Early Surgery for Ruptured Appendix in Children Best
The most common gastrointestinal condition in children to require urgent surgery in the United States is appendicitis. While there is no question acute, nonperforated appendicitis is requires urgent appendectomy, there has been a debate over the approximately 30% of patients who present with perforated appendicitis.
A study’s findings reported online February 21, 2011 in Archives of Surgery definitively favors early appendectomy.
For years there have been two commonly used surgical treatment options for children with perforated appendicitis: early appendectomy and interval appendectomy, but no good randomized studies that compared the two strategies until now.
Martin L. Blakely, M.D., M.S., from University of Tennessee Health Science Center, Memphis, Tenn., and colleagues evaluated the surgical outcomes of 131 patients under the age of 18 who had a preoperative diagnosis of perforated appendicitis between October 2006 and August 2009. The patients were randomized into two groups: 64 were in the early appendectomy group and 67 were in the interval appendectomy group.
The researchers used time away from normal activities and overall adverse event rates (such as, intra-abdominal abscess, surgical site infection, unplanned readmission) as the main outcome measures.
In both treatment strategies, the patients are resuscitated with intravenous fluids and given broad-spectrum intravenous antibiotics.
With early appendectomy, the patient undergoes an urgent appendectomy within the first 24 hours of hospitalization and any intra-abdominal abscess is drained during the operation.
With interval appendectomy, the appendectomy is planned for 6 to 8 weeks after the initial diagnosis, after the patient has been discharged and is back to normal activities. The potential advantage of the interval appendectomy approach is to perform the operation at a time when peritoneal contamination has resolved, potentially resulting in fewer intraoperative and/or postoperative complications.
The study showed early appendectomy, compared with interval appendectomy, significantly reduced the time away from normal activities (average, 13.8 vs. 19.4 days).
The overall adverse event rate was 30% for early appendectomy compared to 55% for interval appendectomy.
The total length of hospital stay was also reduced by an average of more than two days for patients receiving the early appendectomy compared to those who received the interval appendectomy. Some of the patients in the interval group (23 patients or 34 percent) had an appendectomy earlier than planned because of failure to improve (17 patients), recurrent appendicitis (five patients), and other reasons (one patient).
"We found that those treated with early appendectomy return to normal activities an average of five days earlier. Because a child's time away from normal activities limits parents' abilities to work, we believe it is an important outcome from a patient and family perspective," the authors remark. "The overall adverse event rate after early appendectomy was significantly lower compared with interval appendectomy," the authors conclude.
Martin L. Blakely; Regan Williams; Melvin S. Dassinger; James W. Eubanks, III; Peter Fischer; Eunice Y. Huang; Elizabeth Paton; Barbara Culbreath; Allison Hester; Christian Streck; S. Douglas Hixson; Max R. Langham, Jr; Early vs Interval Appendectomy for Children With Perforated Appendicitis; Arch Surg. 2011;0(2011):archsurg.2011.6.