Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: A multicenter case-control study

Hypothesis: The morbidity following treatment for perforated appendicitis in children is significant, with intra-abdominal abscess being one of the more serious complications. This can lead to prolonged hospitalizations and antibiotic administration, multiple computed tomographic scans, and invasive procedures. The purpose of our study was to determine risk factors for developing an intra-abdominal abscess following treatment for perforated appendicitis.Design: Case-control study.Setting: Four tertiary care children\u27s hospitals.Patients: Children aged 1 to 18 years with appendicitis.Intervention: Multivariable logistic regression.Main outcome measures: Development of postoperative abscess, length of hospital stay, presence or absence of fever, and tolerance of diet on postoperative day 3.Results: Thirty-five (13.2%) of 265 children developed an abscess. Ten factors with a bivariate P value \u3c.20 were included in the regression model. The final multivariable model revealed only 2 factors influencing abscess development: an intraoperative fecalith (odds ratio, 8.77 [95% confidence interval, 1.50-51.40]) and diarrhea at presentation. Many factors proposed to be associated with abscess were not, including pain history, type and timing of preoperative antibiotics, abscess at operation, laparoscopic procedure, and length of antibiotics postoperatively. Thiry-seven children were discharged on or before postoperative day 3. Another 21 children were afebrile and tolerating a diet at that time but remained in the hospital. There were no significant differences between the 2 groups. None of the early-discharge group developed an abscess, and 2 of those remaining in the hospital developed an abscess (P = .06).Conclusions: Clinical factors commonly thought to be predictive of abscess formation following perforated appendicitis were not reliable predictors of this outcome. Our results suggest that if children are afebrile and eating on postoperative day 3 they can be discharged with a low rate of abscess development

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 chi2, 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 \u3c .01), fewer abscesses (4% vs 24%, P \u3c .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

Closing gastroschisis: The good, the bad, and the not-so ugly

Purpose: The diagnosis of closing or closed gastroschisis is made when bowel is incarcerated within a closed or nearly closed ring of fascia, usually with associated bowel atresia. It has been described as having a high morbidity and mortality.Methods: A retrospective review of closing gastroschisis cases (n = 53) at six children\u27s hospitals between 2000 and 2016 was completed after IRB approval.Results: A new classification system for this disease was developed to represent the spectrum of the disease: Type A (15%): ischemic bowel that is constricted at the ring but without atresia; Type B (51%): intestinal atresia with a mass of ischemic, but viable, external bowel (owing to constriction at the ring); Type C (26%): closing ring with nonviable external bowel +/- atresia; and Type D (8%): completely closed defect with either a nubbin of exposed tissue or no external bowel. Overall, 87% of infants survived, and long-term data are provided for each type.Conclusions: This new classification system better captures the spectrum of disease and describes the expected long-term results for counseling. Unless the external bowel in a closing gastroschisis is clearly necrotic, it should be reduced and evaluated later. Survival was found to be much better than previously reported.Type of study: Retrospective case series with no comparison group.Level of evidence: Level IV