Treatment of Perforated Appendicitis in Children: Focus on Phlegmon
By Chen, Catherine | |
Proquest LLC |
The management of perforated appendicitis in children has been studied extensively but continues to be ac- tively debated regarding the roles of nonoperative management versus immediate appendectomy for this condition.1, 2 Comparisons between studies have al- ways been hampered by variations in the definition of perforated appendicitis and its spectrum of clinical presentation, including the presence of a phlegmon and/or abscess, which many have classified together as ''complicated'' appendicitis. We know of no studies to date that have examined the complicated appendiceal phlegmon independently from abscess, although defi- nitions have been proposed.3 Our study presents a single- institution retrospective review of initial nonoperative management versus immediate appendectomy for a large cohort of pediatric patients treated for perforated appendiceal phlegmon.
We retrospectively identified all patients (n 4 106) who were diagnosed with perforated appendiceal phlegmon and treated at
Patients were treated based on attending pediatric surgeon (n 4 17) preference with either immediate surgery or initial nonoperative management with or without interval appendectomy six to eight weeks later after an initial course of intravenous (IV) antibiotics. At our institution during the study period, the clinical pathway for treatment of perforated appendicitis in- cluded placement of a peripherally inserted central catheter (PICC) line and treatment with at least ten days of IV antibiotics followed by oral antibiotics if needed. Surgical site infections (SSIs) were tabulated based on previously accepted definitions.4 All patients undergoing appendectomy were confirmed to have perforated appendicitis by review of surgical pathology.
During the study period, 99 patients had a free per- foration; all but one of whom was treated with im- mediate surgery, whereas 83 patients presented with an abscess with 74 patients undergoing initial non- operative management (data not shown). We present data on only the patients with phlegmon. The mean age was 9.7 years (standard deviation [SD] 4.4) with 54 per cent males and mean body mass index of 18.8 kg/m2 (SD 3.6). The majority of patients were white (69%) with 7 per cent black and 9 per cent Hispanic/Latino. Seventy-two per cent had private insurance. Presenting symptoms included vomiting (72%), focal right lower quadrant pain (60%), diffuse abdominal tenderness (39%), nausea (26%), and diarrhea (22%). The mean duration of symptoms was 3.7 days (SD 6.0). On ad- mission, the mean temperature was 37.6°C (SD 0.9) and mean white blood cell count was 15.6 (SD 4.9). At presentation, all 106 patients received abdominal im- aging: ultrasound only (nine of 106 [8%]), computed tomography (CT) only (42 of 106 [40%]), and both studies (55 of 106 [52%]).
Sixty per cent (n 4 64) of patients underwent initial nonoperative management with nine patients (14%) eventually requiring an interventional radiology (IR) drainage procedure preoperatively (Table 1), and one requiring two drainage procedures. After com- pletion of the IV antibiotic course through a PICC line in the majority of cases (98%), 58 patients underwent interval appendectomy (97% received pre- operative antibiotics; 97% laparoscopic) with few postoperative complications (Table 2). Two patients received antibiotics during the operative case but after the incision was made.
In contrast, Table 2 shows that those patients un- dergoing immediate surgery (n 4 42 [40%]; 95% laparoscopic) had a significantly increased incidence of postoperative complications. Four patients (10%) developed a postoperative organ/space SSI with three of these patients requiring a single postoperative IR drainage (Table 1), whereas no patients in the initial nonoperative management group developed this com- plication (P 4 0.03). Five patients (12%) developed an ileus requiring total parenteral nutrition (TPN) com- pared with none in the initial nonoperative management group (P 4 0.01). There were no other statistically significant differences in major or minor complications between the two treatment groups (Table 2).
Patients with a phlegmon who were treated with immediate surgery had fewer median hospital admis- sions (one vs two), a shorter total hospital length of stay (LOS; 6.5 vs 9 days), and a shorter total duration of antibiotics (12 vs 15 days) than patients treated with initial nonoperative management (P < 0.01, P 4 0.01, and P < 0.01, respectively). Nearly all patients re- ceived a PICC line regardless of treatment type with four PICC line complications noted in the initial nonoperative management group (two malfunctions, one obstruction, one arteriovenous fistula) and two in the immediate surgery group (two venous thromboses).
The treatment of perforated appendicitis in children remains controversial, particularly the decision re- garding if and when to operate to remove the appendix. Patients who present with a phlegmon continue to be the most challenging to care for because there is no consensus regarding the optimal treatment strategy at our institution. Our study found that initial nonoperative management was associated with minimal postoperative complications, specifically no postoperative organ/space SSI and no postoperative ileus requiring TPN, despite a longer hospital LOS, longer duration of antibiotics, and greater number of hospital admissions compared with immediate surgery. A higher incidence of post- operative organ/space SSI was associated with imme- diate surgery in this group. This finding argues for the benefit of initial nonoperative management for these patients, but the benefit needs to be viewed in the context of a longer hospital LOS and longer duration of antibiotics.
The use of radiologic imaging was universal in this study with the majority of patients receiving an ab- dominal CT scan (92%). Many of these studies were obtained at outside institutions and were available for review during the diagnostic workup. Although current practice now dictates more stringent criteria for im- aging with CT scan as a result of the desire to minimize radiation exposure to the patient, the available radio- logic imaging for this study enabled us to group patients reliably and reproducibly. Since 2009 at our institution, the primary radiologic study, if needed, is abdominal ultrasound with CT reserved only for specific diagnostic challenges. We have found thatultrasoundallowsusto define perforation type as successfully as CT in the past.
At our institution, the treatment strategies for per- forated appendicitis continue to evolve, and we are currently prospectively studying shorter courses of IV antibiotics dictated by resolution of fever and symp- toms. With ongoing changes in antibiotic treatment strategies that may not require home IV therapy with PICC lines, future prospective work should focus on examining costs, both direct and indirect, resource use, and family impact of patients with phlegmon alone.
REFERENCES
1. St Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy versus initial nonoperative management and in- terval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg 2010;45:236-40.
2. Blakely ML, Williams R, Dassinger MS, et al. Early vs in- terval appendectomy for children with perforated appendicitis. Arch Surg 2011;146:660-5.
3. Henry MC, Walker A, Silverman BL, et al. Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: a multicenter case-control study. Arch Surg 2007;142:236-41.
4. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999.
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Clinical Research Program
ACKNOWLEDGMENTS
This study was supported by the
Copyright: | (c) 2014 Southeastern Surgical Congress |
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