Perforated appendicitis in children continues to be associated with significant morbidity. In 1976, a treatment algorithm was begun at the authors' institution, which included immediate
appendectomy,
antibiotic irrigation of the peritoneal cavity, transperitoneal drainage through the
wound, and 10-day treatment with intravenous
ampicillin,
clindamycin, and
gentamicin. Initial results with this scheme in 143 patients demonstrated a 7.7% incidence of major complications and no deaths. From 1981 through 1991, the authors continued to use this treatment plan in all patients with
perforated appendicitis. Three hundred seventy-three patients with
perforated appendicitis were treated, and the rate of major complications was 6.4%. Infectious complications occurred in 18 patients (4.8%) and included intraabdominal
abscesses (5 patients, 1.3%),
phlegmon treated with an extended course of
antibiotics (6 patients, 1.6%),
wound infections (5 patients, 1.3%), and
enterocutaneous fistula requiring further operations (2 patients, 0.5%). There were six cases of small bowel obstruction (1.6%), which required operative intervention. There were no deaths. The average
length of stay for all patients was 11.4 days (range, 8 to 66 days). Utilization of transperitoneal drainage and choice of
antibiotic therapy continue to be sources of controversy in the surgical literature. However, the treatment plan used in the present study resulted in the lowest complication rate reported to date, and the authors conclude that this scheme is truly the "gold standard" for treatment of
perforated appendicitis. New treatment plans using laparoscopic
appendectomy, different or shorter courses of
antibiotics, or not using drains should have complication rates that are as low as, or lower than this one to be considered as useful alternatives.