Diagnosis Of Perforated Appendicitis Research Articles

Role of immature granulocytes and total bilirubin values in the diagnosis of perforated appendicitis in patients over 65 years.

The aim of this study was to investigate the effectiveness of immature granulocyte count, immature granulocyte percentage, and total bilirubin value in predicting complicated and perforated appendicitis in patients aged 65 years and older with a diagnosis of appendicitis. In this study, 84 patients, aged 65 years and older, who had appendectomy demographic information, preoperative white blood cell count, neutrophil/lymphocyte ratio, immature granulocyte count and immature granulocyte percentage, operation findings, and pathology results were collected retrospectively. They were grouped into 4 categories: complicated, non-complicated, perforated, and non-perforated, according to the data and surgical findings. Total bilirubin and immature granulocyte count were found to be statistically significant in predicting complicated and perforated appendicitis in patients aged 65 years and older with a diagnosis of appendicitis. The total bilirubin was found to have the following values in differentiating complicated appendicitis: area under the curve=0.883, sensitivity=78.3%, and specificity=88.5%. Total bilirubin had the highest discrimination power with area under the curve=0.804 in differentiating perforation. The immature granulocyte percentage and total bilirubin count are the fast, inexpensive, and reliable parameters that can be used to predict complicated and perforated appendicitis in patients aged 65 years and older.

Perforated Appendicitis Treated By Open Versus Laparoscopic Surgery- A Comparative Study

Background: Acute appendicitis is the most common surgical emergency of the abdomen. Perforated appendicitis often has higher morbidity and mortality. Laparoscopic Appendectomy (LA) is safe and effective procedure for the simple appendicitis compared to Open Appendectomy (OA) but it is not considered as the first line approach in case of perforated appendicitis and its role is still controversial and is under investigation. Hence this study was carried out to compare the outcomes of LA over OA in proven cases of perforated appendicitis.
 Methods: A hospital based comparative study was conducted among 60 patients with the diagnosis of perforated appendicitis who underwent LA and OA, for a duration of 18 months in Manipal Teaching Hospital, Pokhara. Data were collected using semi-structured questionnaire and were analyzed by descriptive and inferential statistics with SPSS version 25.0.
 Results: The study showed no significant statistical difference in operative time in LA compared to OA (66±18.11 minutes vs. 66.67±25.269 minutes, p = 0.9). Moreover it shows less post-operative pain (p = 0.003), shorter length of hospital stay (5.3±1.8 days vs. 7.3±3.31 days, p = 0.005), faster return of peristalsis (1.43±0.504 days vs 1.80±0.805 days, p = 0.037) and faster reinstitution of liquid diet(1.43±0.504 days vs 1.80±0.805 days, p = 0.037), less incidence of wound infection (5 in 30 = 16.66% vs. 12 in 30 = 40%, p = 0.042) and faster subjective full recovery(1.9±0.759 weeks vs. 2.9±0.89 weeks, p ˂ 0.0001) of LA patient compared to OA which is statistically significant.
 Conclusion: LA is safe and effective procedure than OA for perforated appendicitis.

Did the COVID-19 Pandemic Cause a Delay in the Diagnosis of Acute Appendicitis?

BackgroundAppendectomy for acute appendicitis remains one of the most common surgical procedures. This study aims to assess the clinical presentation and delays in diagnosing acute appendicitis during the COVID-19 pandemic.MethodsWe evaluated data of all adult patients who underwent an appendectomy at our hospital between June 1, 2019 and June 1, 2020. Demographic data, admission type to the emergency room, radiological findings, pathological findings, and hospitalization time were noted. Patients were divided into four groups of 3-month periods, pre (Groups 5, 4, 3, 2) and during the pandemic (Group 1). Hospitalization time and perforation status of each group were compared. The hospital admission type and their effect on perforation were also evaluated.ResultsTwo hundred and fourteen patients were included; 135 patients were male, and 57 were female. The median age was 39 years. In Group 1 (pandemic period), 28.8% of patients were referred to us from pandemic hospitals. The median hospitalization time was 7.3 h before pandemics (Group 2–5), 5 h in the pandemic period (Group 1). Perforation rates were 27.8% in Group 1, 23.3% in Group 2, 16.3% in Group 3, 14.0% in Group 4, and 18.6% in Group 5 (0 = 0.58). There was no difference in the patients in Group 1 in the rate of perforated appendicitis in patients who were referred from other pandemic hospitals (29.4) and those admitted via our own emergency room (16.6%) (p = 0.27) during the pandemic period.ConclusionWe did not observe any clear increase in the diagnosis of perforated appendicitis during the pandemic period, even in patients who were transferred from other hospitals.

A Study on the Clinical Factors Associated with Acute Appendicitis and Perforated Appendicitis among Children in a Secondary Medical Centre in Malaysia.

BackgroundAppendicitis complicated with appendiceal perforation is common among children. The delay in diagnosis of appendicitis is due to children’s varied presentations and their difficulty in communicating symptoms. We aimed to identify clinical factors that aid in predicting acute appendicitis (AA) and perforated appendicitis (PA) among children.MethodsThis retrospective study involved 215 children aged 12 years and below with the initial diagnosis of AA and PA. Clinical factors studied were demographics, presenting symptoms, body temperature on admission (BTOA), white cell count (WCC), absolute neutrophil count (ANC), platelet count and urinalysis. Simple and multiple logistic regressions were used to determine the odds ratio of the statistically significant clinical factors. Results: The mean age of the included children was 7.98 ± 2.37 years. The odds of AA increased by 2.177 times when the age was ≥ 8 years (P = 0.022), 2.380 times when duration of symptoms ≥ 2 days (P = 0.011), 2.447 times with right iliac fossa (RIF) pain (P = 0.007), 2.268 times when BTOA ≥ 38 °C (P = 0.020) and 2.382 times when neutrophil percentage was ≥ 76% (P = 0.045). It decreased by 0.409 times with non-RIF pain (P = 0.007). The odds of PA was increased by 4.672 times when duration of symptoms ≥ 2 days (P = 0.005), 3.611 times when BTOA ≥ 38 °C (P = 0.015) and 3.678 times when neutrophil percentage ≥ 76% (P = 0.016). There was no significant correlation between WCC and ANC with AA and PA.ConclusionOlder children with longer duration of symptoms, RIF pain and higher BTOA are more likely to have appendicitis. The risk of appendiceal perforation increases with longer duration of symptoms and higher BTOA.

The Relationship of Perforated Appendicitis with Total and Direct Bilirubin.

IntroductionVery different results have been reported regarding the relationship between bilirubin and perforated appendicitis. We observed this relationship with our own studies.MethodsThe patients, who underwent appendectomy, were retrospectively categorized as perforated and non-perforated based on their files. Those with a total bilirubin (TB) 1.20 mg/dL or less were considered normal whereas those with a 1.21 mg/dL or higher were considered having a high. Those with a direct bilirubin (DB) 0.50 mg/dL or less were considered normal whereas those with a 0.51 mg/dL or higher were considered having a high. The patients were assessed under two groups. Perforated appendicitis (PA) and non-perforated appendicitis (NPA) were analyzed according to the TB in Group 1 and the DB in Group 2.ResultsGroup 1 included 269 patients whose TB were measured. Of those, 218 had NPA and 51 had PA. The rate of patients with high TB among the patients with PA was 1.37 times higher than those with NPA (p ˂ 0.01). Group 2 included 258 patients whose DB values were measured. Of those, 208 had NPA and 50 had PA. The rate of patients with high TB among the patients with PA was 1.71 times higher than those with NPA (p ˂ 0.001).ConclusionIn the diagnosis of PA, both TB and DB show low diagnostic values. In the diagnosis, they can only be considered as a supportive factor to other parameters. However, in the case of a differential diagnosis, we recommend using DB since it has a higher sensitivity and specificity.

Evaluation of disparity in care for perforated appendicitis in a universal healthcare system.

Racial and socioeconomic disparities have been reported in the management of appendicitis. Perforated appendicitis (PA) is used as an index for barriers to care due to delays in treatment. This study evaluates the effect of racial and socioeconomic differences on the likelihood of PA in a universally insured national healthcare system. A retrospective review of pediatric patients enrolled in TRICARE who underwent appendectomy during a 5-year period was performed. Logistic regression was used to examine the association between ethnicity, age, gender, parent, or guardian marital status and deployment status of the active duty parent, type of facility, and type of admission with the odds of perforated appendicitis. A total of 3124 children met inclusion criteria. One-third of children carried the diagnosis of PA. Increased odds of PA was associated with younger age of patient among children of military personnel with enlisted ranks and senior officer ranks. In a universal healthcare system, no disparities across race with regard to presentation of appendicitis were identified. Increased odds of perforated appendicitis were observed in younger patients, but this was demonstrated in families of both high and low socioeconomic status. Universal coverage does appear to eliminate some barriers to healthcare.

1521. Evaluation of the Microbiology of Intraabdominal Infections in Children and Implications for Treatment and Outcomes

BackgroundAcute appendicitis is the most common surgical emergency in pediatric medicine. Pseudomonas aeruginosa has been reported in up to 23% of intraoperative cultures though current recommendations do not specify the need for antipseudomonal coverage for preoperative treatment. Prior to transitioning the empiric antibiotic regimen used in the management of perforated appendicitis from an antipseudomonal agent to a simplified daily antibiotic regimen, we conducted a retrospective review of bacterial cultures obtained from intraabdominal fluid collections and antibiotic regimens in children that underwent surgical treatment of perforated appendicitis and/or intraabdominal abscesses.MethodsA retrospective chart review of electronic medical records was conducted for pediatric patients admitted with a diagnosis of perforated appendicitis and/or intraabdominal abscess between April 1, 2016 and April 30, 2018.ResultsSeventy-two patients met inclusion criteria for the study with abscess identified prior to surgery in 11 patients (42.3%). Intraabdominal cultures were obtained in 48 patients (66.7%). The predominant organisms isolated were Escherichia coli, Bacteroides fragilis, and alpha-hemolytic Streptococcus. P. aeruginosa was identified in 12 (24%) cultures and never as a single organism. The majority of patients received piperacillin/tazobactam empirically (91.7%) with a median duration of 5 days (IQR 2). Forty-four patients (61.1%) received oral antibiotics to continue therapy after discharge and 75% received amoxicillin/clavulanate. Of the 12 patients with P. aeruginosa isolated, all patients received piperacillin/tazobactam empirically and 8 (66.7%) were transitioned to oral antibiotics to complete therapy, of which only two regimens retained antipseudomonal coverage.ConclusionMajority of intraabdominal cultures were polymicrobial and the isolation of P. aeruginosa did not appear to impact the choice of definitive antimicrobial therapy. The predominant organisms identified suggest that a non-antipseudomonal regimen (i.e., cephalosporin with metronidazole) may be considered for empiric antibiotic therapy for cases of perforated appendicitis.Disclosures All authors: No reported disclosures.

Does laparoscopic appendectomy increase the risk of intra-abdominal abscess in children who have perforated appendicitis?

Objective: The aim of this study is to compare the rates of intraabdominal abscesses (IAAs), in laparoscopic appendectomy (LA) and open appendectomy (OA) for perforated appendicitis in children. Methods: A retrospective database search of consecutive cases of children with a diagnosis of perforated appendicitis who underwent OA or LA by the first author or were operated under his supervision diagnosed with appendicitis between 2011 and 2014 and who underwent surgery as treatment was conducted.Results: Seventy-eight patients were included in our study. Forty-two and 36 patients underwent LA and OA, respectively. One case was converted from LA to OA. There was no statistically significant difference at superficial incisional surgical-site infections and IAA between groups but drain placement ratio and length of hospital stay was higher in OA group. Conclusions: The lack of difference in postoperative incidence of IAA supports the idea that LA does not increase the risk of IAA in perforated appendicitis. Although LA for perforated appendicitis in children has been intensely debated, our findings indicate that laparoscopic procedures performed by experienced pediatric surgeons will decrease the risk of complication and conversion to OA. Laparoscopy in children is a safe procedure for perforated, complicated appendicitis.

A RARE CASE OF PERFORATED MECKEL’S DIVERTICULUM”

(1)Meckel’s diverticulum is the most common abnormality of the gastrointestinal tract. It is present in more than 2% of the global human population. (2)Haemorrhage, obstruction and inflammation are the three main possible complications resulting from Meckel’s diverticulum. Spontaneous perforation of Meckel’s diverticulum is very rare and may mimic acute appendicitis. We are reporting the case of a 22 year-old female patient, who presented with a history of five days of acute abdominal pain including on-and-off fever, emesis and vertigo. On physical examination, her abdomen was distended with guarding all over it. A provisional diagnosis of perforated appendicitis with peritonitis or intestinal perforation was made. So CT abdomen with contrast was done. It was reported as sealed perforation with diverticulitis. A diagnostic laparoscopy followed by exploratory laparotomy and subsequent resection and anastomosis of the ileum was performed under general anaesthesia. Meckel’s diverticulitis was confirmed by histopathological findings. This case report is an interesting and unusual case of complications associated with inflamed Meckel’s diverticulum and emphasizes the importance of considering Meckel’s diverticulitis as a differential diagnosis in every patient presenting with acute abdomen.
 Keywords: Meckel’s diverticulum, appendicitis, peritonitis

Hyperbilirubinemia as a Predictor for Appendiceal Perforation: A Systematic Review

Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin may be a useful marker for appendiceal perforation. The purpose of this systematic review was to evaluate studies investigating elevated serum bilirubin as a predictor for appendiceal perforation. Medline, Embase, and Cochrane databases were searched for studies evaluating elevated bilirubin in the diagnosis of perforated appendicitis. Study selection criteria included English language papers evaluating serum bilirubin as a marker of appendiceal perforation in humans. A total of 189 abstracts were screened for eligibility, of which five clinical studies were included in this study. Bilirubin was significantly higher in patients with appendiceal perforation compared with patients with appendicitis without perforation. Elevated serum bilirubin had a sensitivity ranging from 0.38 to 0.77 and a specificity ranging from 0.70 to 0.87 in predicting appendiceal perforation. Elevated serum bilirubin for determining the risk of perforation in appendicitis has low sensitivity but higher specificity. This measure can therefore be used as a supplement in the diagnostic process.

The Laparoscopic Approach for Perforated Appendicitis, Including Cases Complicated by Abscess Formation

Although the laparoscopic approach for perforated appendicitis is commonly performed, there is some controversy over its use because of postoperative complications. These may be associated with various types of disease entities, from gangrenous change to diffuse peritonitis with abscess formation. The aim of the present study was to evaluate the safety and benefits of the laparoscopic approach for perforated appendicitis, including cases complicated by abscess, compared to open. A total of 1747 patients underwent treatment for appendicitis over a period of 3 years. The diagnosis of perforated appendicitis was made by radiology, operative finding, and pathology. Of our five attending surgeons, three performed open surgery for perforated appendicitis, while two performed laparoscopy. There were 474 patients (27%) with perforated appendicitis without abscess (156 underwent laparoscopy, 318 underwent open) and 113 patients (6.4%) with perforated appendicitis and abscess (44 underwent laparoscopy, 69 underwent open). The duration for resumption of diet and hospital stay was shorter in the laparoscopy group than in the open group. There were no significant differences in postoperative complications between patients who had no abscess with laparoscopy and those with open: 5 intra-abdominal abscesses and 10 wound infections versus 11 intra-abdominal abscesses and 25 wound infections (P = 0.88, 0.12), and between patients who had abscesses with laparoscopy and those with open: 4 intra-abdominal abscesses and 3 wound infections versus 6 intra-abdominal abscesses and 6 wound infections (P = 0.94, 0.72). The laparoscopic approach may be a safe, effective treatment for perforated appendicitis, even in the presence of an abscess.

Hiperbilirrubinemia en apendicitis: ¿Es un factor predictivo de perforación?

Hyperbilirubinemia in appendicitis - is a predictive factor of perforation? Background: An elevated total bilirubin level can be a marker for perforated appendicitis. Aim: To assess and compare the predictive value of total bilirubin, C-reactive protein (CRP), white-blood cell count, the lapse of symptoms evolution, and systemic inflammatory response syndrome (SIRS) for the diagnosis of perforated appendicitis. Material and Methods: Prospective study of 134 consecutive patients aged 33 ± 16 years (63 males) operated for acute appendicitis of whom 49 had a perforated appendix. A preoperative blood sample was obtained to measure total bilirubin, C reactive protein and complete blood count. A systemic inflammatory response score was calculated. Results: The lapse of symptoms before operation was higher in patients with perforated appendicitis compared with their counterparts without perforation (105.2 ± 79.3 and 38.6 ± 17.5 hours respectively). C reactive protein values were 176 ± 82.6 and 80 ± 76 mg/l respectively, (p = 0.01). Serum bilirubin values were 0.7 ± 0.3 and 1.0 ± 0.5 mg/dl, respectively (p = 0.05). Sixty five percent of patients with perforated appendicitis had a SIRS score between 3 and 4 points. A C reactive protein over 76.7 mg/l, a lapse of symptoms over 34.5 hours and a SIRS score of three or more had the best performance for the prediction of perforated appendicitis. Conclusions: The diagnosis of perforated appendicitis may be suspected based on CRP, SIRS, and the lapse of symptoms before operation. We do not recommend the use of total bilirubin to predict perforation in appendicitis.

Postoperative antibiotic therapy for children with perforated appendicitis: long course of intravenous antibiotics versus early conversion to an oral regimen

BackgroundAlthough treatment for nonperforated acute appendicitis is usually straightforward, the optimal treatment of patients with perforated appendicitis remains controversial. MethodsOur institution performed a 2.5-year retrospective review of outcomes for postoperative treatment of perforated appendicitis. Patients were treated with either short-term intravenous (IV) antibiotic therapy and conversion to PO antibiotics (PO group) or long-term antibiotic therapy by way of a peripherally inserted central venous catheter (IV group). ResultsOne-hundred forty-nine patients with a diagnosis of perforated appendicitis were reviewed. There were 47 patients in the PO group and 102 patients in the IV group. In the IV group, there were 2 intra-abdominal abscesses (2%) requiring readmission; there were also 2 intra-abdominal abscesses in the PO group (4.2%). Outpatient conversion to PO antibiotics resulted in an average savings of approximately $4,000/patient. ConclusionsInpatient IV antibiotic therapy followed by outpatient conversion to PO antibiotics is a safe and cost-effective treatment of perforated appendicitis.

Perforated and Nonperforated Appendicitis: Defect in Enhancing Appendiceal Wall—Depiction with Multi–Detector Row CT

To retrospectively evaluate the accuracy of multi-detector row helical computed tomography (CT) with intravenous contrast material and without oral contrast material for depiction of perforated appendicitis. This study was approved by the institutional review board; informed consent was waived. CT images in 102 patients (60 male patients, 42 female patients; age range, 4-82 years; mean age, 37.3 years) with surgically and pathologically proved appendicitis who were examined between January 2000 and December 2002 were retrospectively reviewed. Original transverse sections at 3- or 2-mm collimation and 1.5- or 1.0-mm intervals were viewed by using cine mode observation. Two independent observers evaluated five specific findings (defect in enhancing appendiceal wall, abscess, phlegmon, extraluminal air, and extraluminal appendicolith). Sensitivity, specificity, and accuracy of the specific findings in the diagnosis of perforated appendicitis were evaluated. Perforated appendicitis was present in 40 patients, and nonperforated appendicitis was present in 62 patients. A defect in the enhancing appendiceal wall was present in 38 patients in the perforated group. Two patients in the nonperforated group had false-positive findings for a defect in the enhancing appendiceal wall. Sensitivity, specificity, and accuracy of this finding in the diagnosis of perforation were 95.0%, 96.8%, and 96.1%, respectively. Sensitivities for abscess, extraluminal air, and extraluminal appendicolith were 37.5%, 22.5%, and 32.5%, respectively. These three findings were not found in patients with nonperforated appendicitis. Phlegmon was seen in 16 patients in the perforated group and in three patients in the nonperforated group. Sensitivity, specificity, and accuracy of phlegmon in the diagnosis of perforation were 40.0%, 95.2%, and 73.5%, respectively. Multi-detector row CT allows an accurate (96.1%) diagnosis of appendiceal perforation by the depiction of a defect in the contrast material-enhanced appendiceal wall.

Nonoperative Management vs Immediate Appendectomy for Perforated Appendicitis

Surgery| August 01 2007 Nonoperative Management vs Immediate Appendectomy for Perforated Appendicitis AAP Grand Rounds (2007) 18 (2): 19–20. https://doi.org/10.1542/gr.18-2-19 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Nonoperative Management vs Immediate Appendectomy for Perforated Appendicitis. AAP Grand Rounds August 2007; 18 (2): 19–20. https://doi.org/10.1542/gr.18-2-19 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: appendectomy, appendix rupture Source: Henry MC, Gollin G, Illam S, et al. Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis. J Pediatr Surg. 2007,42:19–24; doi:10.1016/j.pedsurg.2006.09.005 Even in the current climate of cost containment and outcomes-based practice, there remains a striking lack of consensus regarding the treatment of many common surgical problems. The optimal treatment for children with complicated appendicitis represents an especially notable example.1,2 The effective use of new broad-spectrum antibiotics and careful patient selection has led some surgeons to advocate nonoperative management for selected patients with perforated appendicitis who do not present with clinical features requiring prompt surgical intervention: ie, are not septic, or toxic, have no evidence of small bowel obstruction, and whose pain can be controlled. Of the patients for whom medical management is an option, at this time there remains little evidence on which to choose between nonoperative versus operative management. This study from Yale University School of Medicine and four other US medical schools has sought to compare these two management options for eligible patients with perforated appendicitis who do not require immediate surgical intervention. The authors collected data from all children between 1 and 18 years of age who presented to one of four academic tertiary care children’s hospitals between May 1998 and June 2003, with a diagnosis of perforated appendicitis on the basis of preoperative CT or ultrasound, operative findings, or postoperative pathology. Cases included all patients treated nonoperatively and controls included patients treated with immediate appendectomy and matched to cases by site and clinical factors. Data were collected for 313 patients. Of the 48 patients treated nonoperatively, five (10.4%) failed medical management and required surgery within three weeks because of persistent fever, abscess, or continued and worsening symptoms. These five patients had mean hospital stays of 18 days (range 6–32 days). Of the remaining 43 patients who were successfully managed nonoperatively, 37 underwent interval appendectomy between 5 and 48 weeks following presentation. Each case was matched to four controls who had undergone immediate appendectomy. The only significant difference between the nonoperative and surgical groups was the duration of pain on presentation: the nonoperative patients had a mean duration of pain of seven days at presentation while the immediate surgical group had a mean of three days of pain at presentation. In order to match for duration of pain, a new control group was randomly generated. This control group of 48 patients was similar to the cases with regard to duration of pain and other clinical characteristics. Compared to this new group of matched controls who had undergone immediate surgery, the nonoperative group had a lower post-treatment recurrent abscess rate (4% vs 24%, P<0.1), shorter length of hospital stay (6.5 vs 8.8 days, P=.08), and fewer complications (19% vs 43%, P<.01). Dr. Cavett has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of a commercial product/device. This commentary does not contain a discussion of an unapproved/investigative use of a commercial... You do not currently have access to this content.

Laparoscopic Appendectomy in Children with Perforated Appendicitis

There is persistent controversy regarding the optimal surgical therapy for children with appendicitis. We have recently adopted laparoscopic appendectomy in lieu of the open technique for children with perforated appendicitis. We hypothesized that laparoscopic appendectomy would be as effective as open appendectomy in preventing postoperative complications. We reviewed the medical records of children admitted to our hospital over a 5-year period with the diagnosis of perforated appendicitis. Patients were divided into two groups based on the operative approach: laparoscopic vs. open appendectomy. Demographic data, duration of presenting symptoms, initial white blood cell (WBC) count, length of stay, and complications were abstracted. Data were compared using appropriate statistical analyses. There was no difference between the laparoscopic (n = 43) and open (n = 77) groups with respect to gender, duration of presenting symptoms, initial WBC, or length of stay. However, patients in the laparoscopic group had a significantly lower complication rate than those in the open group (6/43 vs. 23/77, P = 0.05). Infectious complications were no different between groups. Patients in the laparoscopic group tended to be older than patients in the open group (10.6 +/- 3.3 years vs. 8.5 +/- 4.1 years, P = 0.003). Laparoscopic appendectomy for children with perforated appendicitis has the same infectious complication rate and a lower overall complication rate than open appendectomy. A prospective study with standardized postoperative care would be needed to determine whether laparoscopic appendectomy for children with perforated appendicitis is the treatment of choice, but until then it remains an attractive alternative.

Predictors of Outcome for Children with Perforated Appendicitis Initially Treated with Non-Operative Management

Initial non-operative therapy for children with perforated appendicitis has become increasingly popular with the advent of powerful broad-spectrum antibiotics. However, there is no consensus regarding which patients may be managed effectively with this strategy. We reviewed all children with perforated appendicitis who were treated initially with non-operative therapy to determine those characteristics that may predict a successful outcome. We reviewed the medical records of children admitted to our hospital between January 1, 2000 and May 1, 2003 with the diagnosis of perforated appendicitis. Only those who were treated initially with a single broad-spectrum antibiotic (piperacillin-tazobactam), with the intention of performing an interval appendectomy, were included in this study. Patients were divided into two groups based on whether they were managed successfully with non-operative therapy: Responders and non-responders. Non-responders were defined as patients who either did not improve with antibiotic therapy or who required appendectomy prior to their electively scheduled time (six weeks). Demographic data, duration and type of presenting symptoms, initial white blood cell count (WBC), percent bands, percent neutrophils (PMNs), computed tomography (CT) interpretation, and interventions/operations were abstracted. Categorical data were compared using Chi-square analysis or the Fisher exact test; continuous variables were compared using the Student t-test and the Mann-Whitney U-test. Overall, 26% (19/73) of patients treated initially non-operatively required appendectomy prior to the electively scheduled date. There was no difference between responders (n = 54) and non-responders (n = 19) with respect to age, gender, initial WBC, percent bands, percent PMNs, or duration and type of presenting symptoms. However, responders were more likely to have a phlegmon on CT scan compared to non-responders (11/54 vs. 0/19, p = 0.03). Non-responders were twice as likely to undergo drainage of an abscess by interventional radiology (10/19 vs. 13/54, p = 0.02) compared to responders. Among all patients who required percutaneous drainage, the failure rate of non-operative management was 43% (10/23). Children with perforated appendicitis can be managed effectively with nonoperative therapy, even in the presence of intra-abdominal abscesses. However, the need for abscess drainage increases the failure rate, perhaps due to inadequate source control. Those patients with a phlegmon on CT scan as opposed to an abscess, are most likely to respond to non-operative management. Initial non-operative therapy of perforated appendicitis in children is appropriate under certain clinical circumstances, especially when the body itself or interventional radiology can achieve adequate source control.

A CASE OF PERFORATIVE APPENDICITIS WITH BILATERAL SUBDIAPHRAGMATIC PNEUMOPERITONEUM

A 12-year-old girl was admitted to the hospital with an 8-day history of abdominal pain, nausea and fever. High fever (40°C), marked leukocytosis (12, 700/mm3), and positive CRP (38.1mg/dl) were noted. On physical examination, the abdomen was distended with diffuse tenderness, rebound tenderness and muscle guarding. The maximal tenderness was elicitted in the right lower quadrant. An upright chest X-ray film revealed free air under bilateral diaphragms. Distended small bowel loops were seen on the abdominal X-ray films. There were no leakages of gastrografin on upper GI study. A diagnosis of perforated appendicitis with generalized peritonitis was made. An emergency operation was scheduled. Through a right lower paramedian incision the peritoneum was opened, revealing a considerable amount of purulent exudate which grew out E. coli on culture. Exploration revealed gangrenous appendix with perforation and abscess in the iliocecal area. Appendectomy and drainage of the peritoneal cavity was performed. The postoperative course was uneventful except for the wound abscess. The patient was discharged on the 32th post operative day. It is extremely rare that perforative appendicitis is associated with peritoneal free air, and only 39 cases (35 cases in the world and four cases in Japan) have been reported since 1960. Some bibliographical comments are also presented.

MECKEL'S DIVERTICULUM WITH PERFORATION BY A FISH BONE-A CASE REPORT-

Meckel's diverticulum is usually only detected when complications arise or else is incidentally discovered at laparotomy, since this anomaly is essentially asymptomatic. Among the complications of Meckel's diverticulum, perforation is uncommon and that due to fish bones is particularly rare in Japan. We report this rare case together with a discussion of the relevant literature, including 5 cases reported previously in Japan. A 69-year-old man uncerwent laparotomy with a diagnosis of perforated appendicitis. The patient was found to have a Meckel's diverticulum that had been perforated by a sharp fish bone (mackerel) 1.7cm long. Wedge resection of the diverticulum was performed. Histologically, it was a true diverticulum and contained ectopic pancreatic tissue.