It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis

Background/Purpose

Appendicitis is the most common surgical emergency in children. However, management varies widely. The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis.

Methods

Data were collected prospectively for 3 successive cohorts:

Group A, before introduction of pathway;

Group B, after introduction of pathway;

Group C, after modification of pathway.

All patients operated for suspected appendicitis were included. The pathway was modified after interim analysis of group B data. P < .05 was significant.

Results

Six hundred patients were included. When compared with group A, group C patients were more likely to receive preoperative antibiotics (P < .0001), undergo formal pain assessment (P < .0001), and be operated before midnight (P = .025). There was a significant decrease in readmission rates from 10.0% to 4.2% (P = .023) despite an increase in cases of gangrenous and perforated appendicitis (P = .010).

Conclusions

The introduction of a care pathway resulted in improved compliance with antibiotic regimens, more frequent pain assessment, and fewer post-midnight operations. Postappendicectomy readmission rates were reduced despite an increase in disease severity. This was achieved by critical reevaluation of outcomes and pathway redesign where appropriate.     

Histologic features of the portal plate in extrahepatic biliary atresia and their impact on prognosis—a Danish study

Background/Purpose

The aims of this study are as follows:

1.

To evaluate the outcome of the patients with extrahepatic biliary atresia (EHBA), operated at the Rigshospitalet, Denmark, during the last 24 years.

2.

To relate the histologic findings of the portal plate to the outcome.

3.

To compare the histologic findings in the portal plate of children affected by EHBA with those found at the porta hepatis in age-matched children dead from other causes.

Method

From 1979 to 2003, 57 children have been operated by the Kasai procedure. Only 40 of these have had their portal plate removed for histologic examination. We divided the patients according to clinical outcome into a successful and a failure group and compared the histologic features of the portal plates in the 2 groups. Afterward, the portal plate histology from EHBA was compared with the porta hepatis area from patients dead from other causes.

Results

A significant difference between the success and the failure group was found with regard to the number of bile ducts, the maximal length measurable in any direction for bile duct structures, and the proliferation, but not for any type of diameter. The normal portal plate was different from the portal plate of children with biliary atresia by always having 2 large biliary structures and the cells being mucinous and columnar in the largest bile ducts. Only 1 of 4 normal portal plates showed signs of proliferation. There was no significant difference between the normal and the success group with respect to the number, maximal length, and proliferation of the bile ducts. A difference in the diameter between the normal group and the entire EHBA group was significant for the maximal internal diameter but not for the other types of diameter measurements.

Conclusion

The present study shows the following:

1.

In portal plates from patients with EHBA, the longest measurable length of the bile duct structures, the number of bile duct structures, and less proliferation are positively correlated to prognosis.

2.

Patients with EHBA have a more favorable prognosis when the histology of the portal plate resembles the normal portal plate regarding the number of bile ducts, proliferation, and maximal measurable length.

     

Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures

Aim

The ultrasound-guided percutaneous technique of Hickman line insertion has not been widely adopted in pediatric surgical practice. We wished to review our own experience of using this technique for insertion into the internal jugular vein.

Methods

Our vascular access team consists of a consultant surgeon and 2 consultant anesthetists. All procedures were prospectively recorded on a database and were either performed or directly supervised by our team.

Results

Five hundred consecutive Hickman lines were inserted between June 2004 and October 2006. Patients' ages ranged from 14 days to 19 years (median, 44 months). Patients weighed between 600 g to more than 100 kg. Lines inserted were all tunneled silicone Hickman lines with a Dacron cuff (size 2.7F-10F, with 1-3 lumens), of which 60% were 7F double-lumen lines. Successful cannulation occurred in 99.8%. Perioperative complications (within 30 days) occurred in 12 patients (2.4%) and were all treated conservatively with no need for either blood transfusion or chest drain. Catheter-related sepsis rate was 3.16 per 1000 line days.

Discussion

1.

The technique of ultrasound-guided percutaneous insertion of Hickman line to the internal jugular vein is safe and is applicable to all children regardless of size, age, or diagnosis.

2.

Pediatric surgeons and anesthetists can learn this technique without specific training in interventional radiology.

3.

A learning curve does exist, and we recommend concentrating pediatric vascular access procedures to a specialist team.

     

A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial

Introduction

In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics.

Methods

Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days.

Results

One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm.

Conclusions

When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.     

Implantation of a cone-shaped double-fixed patch increases abdominal space and prevents recurrence of large defects in congenital diaphragmatic hernia

Background

Large defects in patients with congenital diaphragmatic hernia (CDH) are frequently closed with a polytetrafluoroethylene patch (PTFE). Intraoperative problems include lack of abdominal domain for the reduction of organs and closure of the abdominal wall. Main surgical postoperative complication is the recurrence of the hernia. We suggest a new and easy method of patch implantation, improving these problems, and report first follow-up results.

Methods

In our clinic, 103 children with CDH were treated, and 87 children underwent reconstruction of the diaphragm in the 5 years between 1998 and 2002. In 52 patients, a patch implantation had to be performed. We have been optimizing our complete pediatric and surgical procedure and present a new standardized technique of preparation and implantation of a PTFE patch. The flat patch is folded to a 90° cone. The cone is fixed in its form with few single stitches. It is implanted with an overlapping border of 1 cm circumferentially. The border is separately fixed with absorbable single stitches to keep from rolling up. The rough side of the patch points toward the rim of the diaphragm to enable ingrowth of the connective tissue.In a 1-year follow-up study, the recurrences in the 3 following groups of PTFE patches were studied: conventional implantation (simple patch without overlapping border), patch with separately fixed overlapping border, and cone-shaped patch with overlapping separately fixed border.

Results

Thirty-three patients were included in the study. After conventional PTFE-patch implantation, 6 (46%) of 13 patients developed reherniation. After PTFE-patch implantation with separately fixed overlapping border, 1 (11%) of 9 patients had a recurrent hernia. In the group with the PTFE-cone implantation, 1 (9%) of 11 patients developed a recurrence. Meanwhile, another 20 CDH patients received implantation of a cone-shaped patch, and no further recurrence occurred up to now. With the additional space (20 mL) provided by the cone-shaped patch, the closure of the abdomen was easier, and the fundus had intraoperatively a physiological position.

Conclusion

This optimized patch implantation technique in large diaphragmatic defects offers considerable advantages especially regarding recurrence of the hernia and closure of the abdomen, which are currently the most challenging surgical problems.

1.

The cone-shaped 3-dimensional patch increases abdominal capacity.

2.

Redundant chest capacity is reduced, and the reconstructed diaphragm shows a physiological shape.

3.

The dome of the patch allows a physiological position of the gastric fundus and a normal Hiss angle, thus preventing gastroesophageal reflux.

4.

Additional safety of the implantation is achieved by separate fixation of the overlapping border of the cone, preventing recurrence.

     

Fetal intervention for mass lesions and hydrops improves outcome: a 15-year experience

Purpose

The natural history of certain prenatally diagnosed masses is well known. Large thoracic mass lesions can evolve one of 2 ways, either to regress and cause minimal morbidity, or to progress and enlarge, often resulting in hydropic changes in the fetus. This nonimmune hydrops carries a dismal prognosis, with nearly all fetuses expiring before or shortly after birth. However, hydrops associated with fetal mass lesions can be halted and even reversed with fetal intervention and treatment of the underlying defect. We examined our patients with fetal mass lesions to evaluate survival after intervention.

Methods

Institutional approval was obtained by the Committee on Human Research. A retrospective review was performed of 294 fetuses evaluated over 15 years with large mass lesions. All patients were evaluated for evidence of fetal hydrops using ultrasound criteria. Patients were divided according to type of intervention. Primary outcome measure was 30-day survival after birth.

Results

(1)

Patients without fetal hydrops did not undergo fetal intervention and survived to 30 days after birth (167/172, 97%).

(2)

Patients with fetal mass lesions that developed hydrops fared poorly with no intervention (1/33 survival, 3%), whereas fetuses undergoing prenatal intervention fared much better (15/30 open, 50%; 3/10 percutaneous, 30%).

(3)

Four patients with hydropic congenital cystic adenomatoid malformation (n = 3) or pulmonary sequestration (n = 1) received steroids in preparation for surgery but underwent no intervention, and the patients survived the neonatal period.

Conclusion

Fetuses with prenatal diagnoses of masses not associated with hydrops have excellent prognosis with survival higher than 95%. Nonimmune hydrops associated with prenatal diagnosis of a fetal mass is a devastating complication with less than 5% survival. Open resection of a mass causing hydrops resulted in 50% survival, with reversal of hydrops in a group with near-uniform fatality. Further investigation is warranted regarding the use of minimally invasive prenatal therapies including steroid administration for hydropic fetuses.     

Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

Introduction

The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure.

Methods

Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval.

Results

Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001).

Conclusion

Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.     

Dollars and sense of interval appendectomy in children: a cost analysis

Purpose

Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy.

Methods

Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates.

Results

Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios.

Conclusion

Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.     

Mycophenolate, clinical pharmacokinetics, formulations, and methods for assessing drug exposure

This article summarizes part of a consensus meeting about mycophenolate (MPA) therapeutic drug monitoring held in Rome under the auspices of The Transplantation Society in November 2008 (Clin J Am Soc Nephrol. 2010;5:341-358). This part of the meeting focused on the clinical pharmacokinetics of MPA and included discussion on how to measure MPA (active drug) exposure and the differences between the currently available formulations.

Summary points

•

Because of variability in the dose-concentration relationship, MPA exposure should be measured and doses should be adjusted accordingly to achieve optimal clinical outcomes.

•

Suggested therapeutic exposures derived for MPA from mycophenolate mofetil (MMF) may differ to those that could be useful for MPA from enteric-coated mycophenolate sodium (EC-MPS), particularly if limited sampling strategies or single concentration, especially trough concentrations, is used, as the concentration-time profiles of MPA from the 2 formulations are quite different. The 2 MPA formulations cannot be considered as bioequivalent.

•

The area under the concentration-time curve (AUC_0-12) is considered the criterion standard for monitoring of MPA, which is a reflection of exposure to the drug over the entire dosing period. If a limited sampling protocol coupled with multilinear regression or Bayesian estimation is used to estimate this parameter, it should be used only for the population in which the model has been developed and should preferably include at least one time point after 4 hours (preferably around 8 or 9 hours after MMF dosing). If a single time point is to be used as a surrogate for an AUC_0-12, trough concentration of MPA may be the most practical but, from a pharmacokinetic standpoint, is not the most informative time point to choose.

•

Because limited sampling strategies to estimate MPA exposure from EC-MPS have not yet been well developed and fully evaluated, nor have accurate Bayesian estimators been reported, AUC_0-12 measurement is still necessary to obtain reliable estimates of MPA exposure in patients treated with EC-MPS. The measurement of MPA trough concentrations should not be used at all for MPA exposure assessment following administration of EC-MPS.

•

Lower (or higher) than expected total MPA exposure in patients with severe renal impairment may still indicate sufficient free MPA exposure. Mycophenolate free exposure measurement/estimation is likely to be beneficial in patients with severe renal impairment (creatinine clearance <25 mL/min) to guide dosage estimation, especially because renal function changes over time after transplant, while recognizing that robust prospective studies to show the clinical advantage of measuring free MPA exposure are still required.

•

Lower total measured MPA exposure in patients with hypoalbuminemia may still indicate sufficient free MPA exposure. Mycophenolate free concentration measurement and estimation of exposure are likely to be beneficial in patients with a serum albumin less than or equal to 31 g/L to guide interpretation of MPA exposure.

•

A 1.5-g twice-daily starting dose of MMF rather than a 1-g twice-daily starting dose of MMF is more likely to achieve the minimum target MPA exposure in adult transplant recipients receiving concomitant cyclosporine therapy. Because the cyclosporine dose is progressively tapered following transplantation, MPA exposure should be measured repeatedly and MMF should be doses adjusted accordingly to achieve optimal clinical outcome.

•

Mycophenolate exposure should be measured in the first week after transplant, then each week for the first month, each month until month 3, and subsequently every 3 months up to 1 year with appropriate dosage adjustment, as AUC is likely to increase over time. After 1 year, if dosage requirement has stabilized, MPA exposure can be assessed each time the immunosuppressive regimen is changed or a potentially interacting drug is introduced or withdrawn.

•

Assessment of UGT1A9 single nucleotide polymorphisms (−275T>A, −2152C>T, −440C>T, −331T>C) should be considered before transplantation to assist in dosing decisions to achieve optimal MPA exposure immediately after transplant.

Consideration of the points summarized above should lead to more effective dosage adjustment based on sound applied pharmacokinetic and pharmacodynamic principles.     

Perforated appendicitis in children: is there a best treatment?

Purpose

This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors’ hospital.

Methods

This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital.

Results

The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management.

Conclusions

Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm³. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.     

Factors influencing prognosis in perforated peptic ulcer

1.

1. Two hundred ten patients underwent operation for perforated peptic ulcer over a ten year period with a 10 per cent immediate mortality.     

Routine interval appendectomy in children is not indicated

Background

This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis.

Methods

A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay.

Results

The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis.

Conclusion

Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.     

Diagnostic imaging of cervical spine injuries following blunt trauma: A review of the literature and practical guideline

-

Patients with a (potential) cervical spine injury can be subdivided into low-risk and high-risk patients.

-

With a detailed history and physical examination the cervical spine of patients in the ‘low-risk’ group can be ‘cleared’ without further radiographic examinations.

-

X-ray imaging (3-view series) is currently the primary choice of imaging for patients in the ‘low-risk’ group with a suspected cervical spine injury after blunt trauma.

-

For patients in the ‘high-risk’ group because of its higher sensitivity a computed tomography scan is primarily advised or, alternatively, the cervical spine is immobilised until the patient can be reliably questioned and examined again.

-

For the imaging of traumatic soft tissue injuries of the cervical spine magnetic resonance imaging is the technique of choice.

     

Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience

Purpose

The purpose of the study was to determine and evaluate the incidence of postoperative bowel obstruction (PBO) after laparoscopic and open appendectomy in children.

Material and Methods

The medical files of children who have undergone an appendectomy, either via the laparoscopic or open approach, at our department from 1992 until 2007 were reviewed. Collected data included age at appendectomy, initial surgical approach, time interval to PBO, and type of definitive treatment. The incidences of PBO after laparoscopic and open appendectomy were compared with the χ² analysis.

Results

From the 1684 children who were found, 1371 had nonperforated appendicitis and 313 had perforated appendicitis. Laparoscopic appendectomy was performed in 954 patients of the nonperforated group and in 221 of the perforated group. Open appendectomy was performed in 417 and 92 patients of the 2 groups, respectively. Overall, the incidence of PBO development was 2.2%. In the laparoscopic appendectomy population, a significantly low incidence of 1.19% of PBO development was detected, compared with the 4.51% of the open appendectomy group (P < .0001).

Conclusion

Laparoscopic appendectomy diminishes the potential of PBO development. The overall incidence of PBO is not related to the severity of the disease but only to the initial operative approach.     

Is portal venous outflow better than systemic venous outflow in small bowel transplantation? Experimental study in syngeneic rats

Background/Purpose

Blood drainage of the graft into the recipient portal vein reestablishes the physiological venous outflow after small bowel transplantation (SBT). However, although this approach is likely beneficial for the host, it may be technically more demanding making portocaval venous drainage the preferred arrangement during human SBT. The aim of this study was to examine in a syngeneic model of SBT the possible benefits of portoportal anastomosis (PPA) vs portocaval anastomosis (PCA) in terms of body and organ weights and bacterial translocation.

Methods

Syngeneic SBT was carried out in 25 Brown-Norway male rats weighing 249 ± 17.5 g using either PPA (n = 13) or PCA (n = 12). Half the animals in each group were killed, respectively, on postoperative day 2 or 7. Liver, spleen, and lungs were weighed and under sterile conditions the regional lymph nodes were excised. The nodes and venous samples from the cava and portal veins were cultured for aerobes and anaerobes. Bacterial components were detected in blood by polymerase chain reaction. The findings in both groups were compared by χ² or Mann-Whitney U tests.

Results

Mean postoperative body weight change was −3.6% ± 1.5% in PPA and −6.0% ± 1.2% in PCA animals (ns) on day 2 and −6.5% ± 2.6% and −8.0% ± 5.0% (ns) on day 7. Liver, spleen, and lung weights were not significantly different between both groups on either end point. Gram-negative enteric bacteria were found in 3 of 7 PCA animals and 2 of 6 PPA animals at day 2 (ns) and in 1 of 6 and 4 of 6 on day 7 (ns). Aerobic gram-positive bacteria were found in 1 of 7 and 1 of 6 (ns), 3 of 6 and 3 of 6 (ns), respectively, in the 4 groups. Most positive cultures corresponded to portal blood and lymph node samples. There were no anaerobic growths.

Conclusions

-

No body or organ weight change suggesting significant functional advantages of one technical alternative over the other could be demonstrated.

-

Bacterial translocation in the absence of rejection was frequent after SBT independently of the variety of venous outflow used. No difference in bacterial translocation between both anastomosis could be demonstrated.

-

Orthotopic venous drainage did not seem to be advantageous in the present experimental setting.

     

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

Introduction

Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies.

Methods

After internal review board approval (#06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess.

Results

On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06).

Conclusions

Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges.     

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

Background

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

Methods

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using χ², Fisher exact, and Student t tests.

Results

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain).We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 ± 5.7 vs 8.8 ± 6.7 days, P = .08).

Conclusions

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.     

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

Introduction

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.

Methods

After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an α of .5 and a power of 0.82.

Results

One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.

Conclusions

Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.