Antibiotic Therapy and Interval Appendectomy for Perforated Appendicitis in Children: A Selective Approach

Abstract

The role of initial nonoperative treatment in pediatric perforated appendicitis remains controversial. We examined our outcomes after using this approach in a selective manner. Children with perforated appendicitis treated during a 28-month period were retrospectively reviewed. Antibiotics and delayed appendectomy were used if there were more than 3 days of symptoms, absence of bowel obstruction, absence of diffuse peritonitis, and an appendiceal mass. Of 221 patients with perforated appendicitis, 32 (14%) were treated with this approach. Average age was 7.4 ± 4.2 years. Twenty-eight patients (88%) were successfully managed and 26 (81%) underwent appendectomy 8.6 ± 4.2 weeks after first presentation. Two patients did not respond completely, and underwent appendectomy during the same admission. Two patients initially responded, but had recurrent symptoms necessitating earlier appendectomy. There were no complications. Average total hospital stay was 7.2 ± 3.0 days. Initial nonoperative treatment is highly successful in selected children who meet specific criteria. Failure is not associated with increased morbidity.

Failure of First-Line Antibiotics in Nonoperative Management of Appendiceal Mass, toward a Second-Line Instead of Surgery?

“…The second-line antibiotics did not increase postoperative complications (p ¼ 0.99) or recurrence (p ¼ 0.99). These data are consistent with a previous report that failure of medical treatment did not increase morbidity 7 and discordant with another. 8 In our experience, nonoperative management of appendiceal mass and abscess decreased the rate of postoperative intra-abdominal abscess from 18 to 3% (2/64) and we recommend it.…”

“…As a result of this protocol, the nonoperative management was achieved in 94% of children which is one of the highest success rates reported. [7][8][9]13,17 Despite this second-line antibiotics, the mean lengths of hospitalization and antibiotherapy were not increased and seem acceptable to us. The mean length of stay after ILA was 1 day (range, 1-8 days) and in 16 cases (25%) the surgeon did not notice any residual inflammation inside abdominal cavity.…”

“…3 Conservative approach for complicated appendicitis has been gradually adopted by a growing number of centers. Even if there is a lack of consensus about the management of perforated appendicitis, 4 this approach seems to decrease postoperative morbidity in adult 5,6 and pediatric [7][8][9] populations with the rate of success ranging from 62 to 93%.…”

“…9,12 The majority of authors considers a lack of improvement after initial antibiotherapy as an operative indication. 7,8,10,13 There is no protocol using a second-line antibiotics as an alternative to emergency appendectomy reported. After analysis of the levels of antibiotic resistance in our institution, we identified Pseudomonas aeruginosa and Enterococcus as possible sources of failure of nonoperative treatment.…”

Acute Appendicitis: Controversies in Diagnosis and Management

“…132,134 Recent evidence has shown that acute appendicitis can be treated successfully nonoperatively in adults and children. 58,[140][141][142] Two meta-analyses have demonstrated that conservative treatment with antibiotics only is associated with a lower risk of complications without differences in length of hospitalization. 68,143 However, the success of initial nonoperative treatment of complicated appendicitis has stimulated some surgeons to question the need for subsequent interval appendectomy.…”