[Drainage of the abdominal cavity and complications in perforating appendicitis in children].

INTRODUCTION: Controversies regarding drainage and irrigation with antibiotics following perforated appendicitis still exist in literature. Some authors concluded that undrained patients treated with systemic antimicrobial therapy, adequate fluid resuscitation, emergency appendicectomy, peritoneal lavage and primary abdominal wall closure are less exposed to complications. On the other hand, Lund and Murphy and Schwartz and Tapper are still advocating transperitoneal drainage. In that context the aim of this study was to contribute to the current debate with its original results and conclusions.

MATERIAL AND METHODS: A series of 56 children, who were operated on for perforated appendicitis during 1996 in Children's Hospital Podgorica and Pediatric Surgery Department of Hospital in Novi Sad, are reviewed. The average age of children in this series was 9.8 years (range, 2-14 years). All children were divided in two groups: patients included in the first group (n = 36) were treated with aggressive fluid resuscitation, preoperative triple antibiotic therapy, peritoneal lavage, avoidance of transperitoneal drains except those used for well-localized abscesses, primary wound closure and postoperative antibiotic therapy for seven to ten days. In the second group, children were managed in the same way, but silicon tube drainage after appendicectomy was included as well. Patients in both groups were given the same antibiotic therapy: intravenous metronidazole combined with gentamicin and ampicillin.

RESULTS: Perforated appendicitis most frequently occurred in the age group between 8 and 15 years (77%), with highest incidence in male children (61%) of all children observed. Positive cultures were obtained from peritoneal swabs from 32 children (57%), of which all had pure growth of aerobes (Escherichia coli and Pseudomonas aerugionosa, mixed or pure). 36 children were managed by appendectomy followed by peritoneal lavage using a large amount of saline, and intravenous antibiotic therapy (undrained group), while the other 20 children were treated by appendectomy with silicon tube drainage and the same systemic antibiotic therapy (drained group). A minor complication rate was 43%; this includes 20 cases of wound infection and 4 cases of wound dehiscence. Major complications rate was 5%, which includes 3 cases of ileus. The mortality rate was zero. A comparison of the group that underwent drainage with undrained group showed a relative rate of wound infection to be 19% (undrained) vs. 65% (drained). According to the x2 test, this can be considered a significant difference, with Yates' correction. Wound dehiscence and ileus were more frequent in the drained group: 10% vs. 6% and 19% vs. 3%, respectively.

DISCUSSION: The principal factors contributing to perforation of appendix are: age of children, delays of surgical intervention, family anamnesis, social group and late recognition of symptoms of appendicitis. Fast and adequate surgical intervention followed by adequate antibiotic therapy successfully resolve the cases of perforated appendicitis. The rate of serious post-appendectomy complications of 5-10% established by this study, can be considered as acceptable based on standards presented in the relevant literature. Regarding the reduction of wound infections following perforated appendicitis in children, aggressive therapy consisting of aminoglycosides combined with metronidazole have proven to be very efficient. Complications developed more frequently in the group of drained patients. Our results are in accordance with that achieved by authors cited in introduction: undrained patients are less prone to complications in comparison to drained patients.

CONCLUSION: We achieved our lowest rate of serious complications following surgery for pediatric perforated appendix with the use of broad-spectrum antibiotic therapy, primary wound closure and without drainage. Regarding our results, we could propose the same treatment protocol to all in