Prophylactic antibiotics in uncomplicated appendicitis during childhood--a prospective randomised study. Peritoneal lavage versus drainage for perforated appendicitis in children 
Open and laparoscopic appendectomy are equally safe and acceptable in children
 Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. Antibiotic prophylaxis in non-perforated appendicitis of childhood: tetracycline lavage compared with peroperative intravenous cefuroxime and metronidazole. Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial. A double-blind controlled trial of metronidazole suppositories in children undergoing appendicectomy. Perioperative prophylaxis with sulbactam and ampicillin compared with metronidazole and cefotaxime in the prevention of wound infection in children undergoing appendectomy. Should prophylactic antibiotics be given perioperatively in acute appendicitis without perforation? Antibiotic management of complicated appendicitis. Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prospective Multicenter Randomized Controlled Trial Ertapenem versus standard triple antibiotic therapy for the treatment of perforated appendicitis in pediatric patients: a prospective randomized trial. Peritoneal taurolidine lavage in children with localised peritonitis due to appendicitis Prospective, randomized, controlled trial comparing a tissue adhesive (Dermabond™) with adhesive strips (Steri-Strips™) for the closure of laparoscopic trocar wounds in children. Selective reporting bias of harm outcomes within studies: findings from a cohort of systematic reviews Comparison of post operative morbidity between laparoscopic and open appendectomy in children. A randomized clinical trial of ampicillin, gentamicin and clindamycin versus cefotaxime and clindamycin in children with ruptured appendicitis. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. A double-blind study of the efficacy and safety of multiple daily doses of amikacin versus one daily dose for children with perforated appendicitis in Costa Rica. Laparoscopic versus open appendicectomy for complicated appendicitis: A prospective study Early vs interval appendectomy for children with perforated appendicitis. Single‐blind randomized clinical trial of laparoscopic versus open appendicectomy in children Laparoscopic Appendectomy in Children: Evaluation of Different Techniques One-drug versus two-drug antibiotic therapy in pediatric perforated appendicitis: a prospective randomized study. Randomized, Single-blinded Trial of Laparoscopic Versus Open Appendectomy in Children: Effects on Postoperative Analgesia The necessity of prophylactic antibiotics in uncomplicated appendicitis during childhood. Can oral metronidazole substitute parenteral drug therapy in acute appendicitis? A new policy in the management of simple or complicated appendicitis with localized peritonitis: a randomized controlled clinical trial. Are antibiotics necessary in nonperforated appendicitis in children? A double blind randomized controlled trial. Laparoscopy in children with complicated appendicitis. Study of appendicitis in children treated with four different antibiotic regimens. Non-Absorbable Interrupted versus Absorbable Continuous Skin Closure in Pediatric Appendectomies The costs and effects of laparoscopic appendectomy in children. Cefotaxime Lavage in Children Undergoing Appendicectomy Laparoscopic appendectomy: An unnecessary and expensive procedure in children? Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. Small lateral access--an alternative approach to appendicitis in paediatric patients: a randomised controlled trial. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial Imipenem‐cilastatin vs. tobramycin and metronidazole for appendicitis‐related infections Laparoscopic versus open appendectomy in children: a prospective randomised study. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. The utility of peritoneal drains in children with uncomplicated perforated appendicitis Hospital cost analysis of a prospective, randomized trial of early vs interval appendectomy for perforated appendicitis in children. Topical ampicillin in the prevention of wound infection after appendicectomy Irrigation of the peritoneal cavity for appendicitis in children: a double-blind study. Patient and parental scar assessment after single incision versus standard 3-port laparoscopic appendectomy: long-term follow-up from a prospective randomized trial. Single Incision Versus Standard 3-Port Laparoscopic Appendectomy: A Prospective Randomized Trial Comparative trial of four antibiotic combinations for perforated appendicitis in children. Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. A controlled trial of intraperitoneal cephaloridine administration in peritonitis. Driving up the Quality and Relevance of Research Through the Use of Agreed Core Outcomes A preliminary report of ticarcillin and clavulanate versus triple antibiotic therapy in children with ruptured appendicitis. Antibiotic therapy of perforated appendicitis in children: a comparison of amoxycillin/clavulanate with a combination of benzylpenicillin, netilmicin and metronidazole. Ceftazidime/metronidazole versus netilmicin/metronidazole in the treatment of perforated appendicitis in children. Delayed primary wound closure using skin tapes for advanced appendicitis in children. A prospective, controlled study. Warm, Humidified Carbon Dioxide Gas Insufflation for Laparoscopic Appendicectomy in Children: A Double-Blinded Randomized Controlled Trial
544 children operated upon for uncomplicated appendicitis were r and omised into three groups . Group I received no antibiotics , patients in Group II were administered one single pre-operative dose of metronidazole ( 10 mg/kg ) and patients in Group III received both both metronidazole ( 20 mg/kg ) and cefuroxime ( 50 mg/kg ) in a single preoperative dose . The rate of infectious complications in Group I was 6.3 % but only 2.1 and 2.3 in Groups II and III , respectively . Among patients with a normal appendix or patients with simple appendicitis there was no difference in the rate of post-operative infections between the three different groups . However , in patients with gangrenous appendicitis the rate of postoperative infections was significantly lower in the two groups who received preoperative antibiotics ( 1.8 % and 3.0 % respectively ) than in the group receiving no prophylactic antibiotics ( infection rate 14 % ) . It is concluded that a single preoperative dose of metronidazole significantly decreases the rate of postoperative infectious complications in children with appendicitis . No further improvement could be demonstrated if cefuroxime against aerobic organisms was added A total of 231 children with acute appendicitis were treated at our hospitals during the 10 years between 1984 and 1993 , 53 of whom had a perforated appendix . These 53 patients were r and omly assigned to two groups at the time of surgery according to the different procedures performed . Thus , 29 children were managed by appendectomy followed by peritoneal lavage using a large amount of saline , and intravenous antibiotic therapy consisting of aminoglycoside and cephem ( lavage group ) , while the other 24 children were treated by appendectomy with silicon tube drainage and the same systemic antibiotic therapy ( drainage group ) . The mean length of hospitalization , and the mean duration s of fever and the need for fasting after laparotomy in the lavage group were significantly less than those in the drainage group : 10.1 versus 18.8 days , 2.8 versus 7.7 days , and 1.8 versus 3.5 days , respectively . The operation wounds healed well in the lavage group due to the fact that there was no drain . Wound infections occurred in two children from the lavage group and six from the drainage group . Intra-abdominal abscesses occurred in two children from the drainage group . Accordingly , peritoneal lavage appears to be superior to intraperitoneal tube drainage for the management of perforated appendicitis in children Background : The aim of this study was to evaluate prospect ively whether laparoscopic ( LA ) and open appendectomy ( OA ) are equally safe and feasible in the treatment of pediatric appendicitis . Methods : A total of 517 children with acute appendicitis were r and omly assigned to undergo LA or OA appendectomy , based on the schedule of the attending surgeon on call . Patient age , sex , postoperative diagnosis , operating time , level of training of surgical resident , length of postoperative hospitalization , and minor and major postoperative complications were recorded . Chi-square analysis and the Student t-test were used for statistical analysis . Results : In all , 376 OA and 141 LA were performed . The two groups were comparable in terms of patient demographics and the incidence of perforated appendicitis . The operative time was also similar ( 47.3 ± 19.7 vs 49.9 ± 12.9 min ) . The overall incidence of minor or major complications was 11.2 % in the OA group and 9.9 % in the LA group . Conclusion : Pediatric patients with appendicitis can safely be offered laparoscopic appendectomy without incurring a greater risk for complications . Nevertheless , a higher ( but not significantly higher ) abscess rate was found in patients with perforated appendicitis who underwent laparoscopy BACKGROUND For decades , urgent operation has been considered the only appropriate management of acute appendicitis in children . The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children . STUDY DESIGN A prospect i ve nonr and omized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy  was performed . The primary result was 30-day success rate of nonoperative management . Secondary outcomes included comparisons of disability days , missed school days , hospital length of stay , and measures of quality of life and health care satisfaction . RESULTS Seventy-seven patients were enrolled during October 2012 to October 2013 ; 30 chose nonoperative management and 47 chose surgery . There were no significant differences in demographic or clinical characteristics . The immediate and 30-day success rates of nonoperative management were 93 % ( 28 of 30 ) and 90 % ( 27 of 30 ) . There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed . Compared with the surgery group , the nonoperative group had fewer disability days ( 3 vs 17 days ; p < 0.0001 ) , returned to school more quickly ( 3 vs 5 days ; p = 0.008 ) , and exhibited higher quality of life scores in both the child ( 93 vs 88 ; p = 0.01 ) and the parent ( 96 vs 90 ; p = 0.03 ) , but incurred a longer length of stay ( 38 vs 20 hours ; p < 0.0001 ) . CONCLUSIONS Nonoperative management of uncomplicated acute appendicitis in children is feasible , with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores . Additional follow-up will allow for determination of longer-term success rate , safety , and cost effectiveness Eighty-four cases of non-perforated appendicitis in children were r and omly allocated to receive either oxytetracycline lavage alone or oxytetracycline lavage plus peroperative intravenous metronidazole and cefuroxime . The wound infection rate with the oxytetracycline lavage alone was 4.4 % compared with 7.7 % when metronidazole and cefuroxime were added . These rates were not significantly different . This study supports the use of oxytetracycline lavage alone as effective prophylaxis against wound infection in non-perforated appendicitis of childhood PURPOSE The current study examined the impact of immediate laparoscopic surgery vs nonoperative initial management followed by interval appendectomy for appendicitis with abscess on child and family psychosocial well-being . METHODS After obtaining Internal Review Board approval , 40 patients presenting with a perforated appendicitis and a well-formed abscess were r and omized to surgical condition . Parents were asked to complete child quality of life and parenting stress ratings at presentation , at 2 weeks postadmission , and at approximately 12 weeks postadmission ( 2 weeks postoperation for the interval appendectomy group ) . RESULTS Children in the interval arm experienced trends toward poorer quality of life at 2 and 12 weeks postadmission . However , no group differences in parenting stress were observed at 2 weeks postoperation . At 12 weeks postadmission , participants in the interval condition demonstrated significant impairment in both frequency and difficulty of problems contributing to parenting distress . CONCLUSION Families experience significant parenting distress related to the child 's functioning and disruption in the child 's quality of life that may be because of the delay in fully resolving the child 's medical condition . In addition , parents experience negative consequences to their own stress as a result of the delay before the child 's appendectomy A total of 133 children , aged 16 months to 15 years ( mean 6.7 years ) , with presumptive acute appendicitis , was included in a double-blind , placebo-controlled trial of the short-term ( 72 hour ) use of metronidazole suppositories as prophylaxis against post-operative infection . There was no significant difference in the incidence or severity of wound infection or post-operative intra-abdominal sepsis between the metronidazole-treated and placebo groups . It is suggested that intra-rectal metronidazole , when used exclusively , is not sufficient for effective prophylaxis for appendicitis in childhood Sulbactam is a beta-lactamase inhibitor , which when administered with ampicillin , increases the latter agents antibacterial activity against beta-lactamase producing organisms . One hundred children between the ages of 5 and 14 undergoing emergency appendectomy were entered into a prospect i ve r and omized trial comparing sulbactam and ampicillin ( SA ) with metronidazole and cefotaxime ( MC ) as prophylaxis against postoperative wound infection .  Patients in whom the appendix was perforated or gangrenous received a 72-hour course of antibiotics , others received a single dose only . The overall wound infection rate was 8 % ( 14 % in patients with perforation or gangrene and 4 % in those without ) . There was no difference in infection rate between the two antibiotic groups ; there were three wound infections and one subphrenic abscess in patients receiving SA and four wound infections in patients receiving MC . SA , therefore , appears to be a suitable antibiotic combination for use as prophylaxis in appendicitis in children The authors question the need to give prophylactic antibiotics perioperatively in all cases of acute appendicitis without perforation to reduce the rate of wound infection . A retrospective study of 82 patients showed a wound infection rate of 4.8 % ; 3 of 53 patients who did not receive antibiotics  had a wound infection compared with 1 of 29 patients who received antibiotics . A prospect i ve double-blind clinical trial was performed comparing the results of perioperative administration of cefam and ole and placebo . One of 21 patients who received the placebo had a wound infection ; none of the 21 patients given cefam and ole had infection . Thus , the authors conclude that , although reports in the literature suggest that antibiotics given perioperatively decrease the rate of wound infection  in acute appendicitis without perforation , the incidence of such infection is too low to warrant routine administration . They suggest that such antibiotic use be reserved for those suspected of having more serious disease A prospect i ve , r and omized , double-blind clinical trial was undertaken comparing gentamicin , ampicillin , and clindamycin ( GAC ) to gentamicin , ampicillin , and placebo ( GAP ) in children with complicated appendicitis . Of the 64 patients enrolled in this study , 33 were assigned to the GAC group and 31 received GAP . A single GAC patient ( 3 % ) was considered a therapeutic failure in comparison to seven children ( 23 % ) in the GAP group ( P less than 0.05 ) . Duration of fever was significantly prolonged in the GAP patients ( 4.7 + /- .8 days versus 2.9 + /- .5 days ) when compared to the clindamycin treated children ( P less than 0.05 ) . Duration of leukocytosis was 3.2 + /- .4 days for GAC patients and 4.9 + /- .9 days for those on the GAP protocol ( P = 0.08 ) . On the basis of this experience the routine use of gentamicin , ampicillin , and clindamycin is recommended for all children with complicated appendicitis Background Appendectomy has been the treatment for acute appendicitis for over 120 years . Antibiotic treatment has occasionally been used in small uncontrolled studies , instead of operation , but this alternative has never before been tried in a multicenter r and omized trial . Patients and Methods Male patients , 18–50 years of age , admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study . No women were enrolled by decision of the local ethics committee . If appendectomy was planned , patients were asked to participate , and those who agreed were r and omized either to surgery or to antibiotic therapy . Patients r and omized to surgery were operated on with open surgery or laparoscopically . Those r and omized to antibiotic therapy were treated intravenously for 2 days , followed by oral treatment for 10 days . If symptoms did not resolve within 24 hours , an appendectomy was performed . Participants were monitored at the end of 1 week , 6 weeks , and 1 year . Results During the study period 252 men participated , 124 in the surgery group and 128 in the antibiotic group .  The frequency of appendicitis was 97 % in the surgery group and 5 % had a perforated appendix . The complication rate was 14 % in the surgery group . In the antibiotic group 86 % improved without surgery ; 18 patients were operated on within 24 hours , and the diagnosis of acute appendicitis was confirmed in all but one patient , and he was suffering from terminal ileitis . There were seven patients ( 5 % ) with a perforated appendix in this group . The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14 % during the 1-year follow-up . Conclusions Acute nonperforated appendicitis can be treated successfully with antibiotics . However , there is a risk of recurrence in cases of acute appendicitis , and this risk should be compared with the risk of complications after appendectomy BACKGROUND The primary objective of this study was to compare triple therapy with ertapenem treatments in pediatric patients with perforated appendicitis , especially in terms of postoperative infectious complications . The secondary objective of this study was to assess the relative impact of therapy with ertapenem and triple antibiotic regimen on the emergence of resistant bacteria in bowel flora in the patients . MATERIAL S AND METHODS Children aged 3 months to 17 years with perforated appendicitis were r and omized 1:1 to receive ertapenem or triple therapy . Serial rectal cultures were obtained from participants enrolled in the study , allowing assessment of the relative impact of therapy with ertapenem and triple therapy on bowel colonization by resistant bacteria . RESULTS In this study , 107 patients were included . No difference existed in time to full oral intake and regular diet , the length of antibiotic therapy , the length of the postoperative hospitalization , or the length of hospital stay between the two groups . Patients in the triple-therapy group were more likely to suffer from a postoperative infectious complication than those in the ertapenem group ( 6/54 vs. 2/53 , p > 0.05 ) . Bowel colonization with resistant organisms at the end of therapy in the triple-therapy group was significantly different than in the ertapenem group ( 35.2 vs. 11.3 % , p < 0.05 ) . CONCLUSIONS Bowel colonization with resistant bacteria was less likely to occur after ertapenem treatment than triple therapy . The results of this trial suggest that ertapenem may be a useful option that could eliminate the need for combination and /or multidosed antibiotic regimens for the empiric treatment of perforated appendicitis in children Despite aggressive surgical treatment , rational antibiotic therapy , and modern intensive care , generalised peritonitis remains a major threat in the paediatric age group . Several adjuvant strategies such as peritoneal saline lavage and peritoneal drainage have been utilised . Taurolidine , derived from the amino acid taurine , has bactericidic , antiendotoxic , and antiinflammatory properties . It has been introduced previously for intraoperative peritoneal lavage in treating peritonitis in adults . The aim of our study was to evaluate the effect of peritoneal taurolidine lavage on the clinical course and serological inflammation markers in children with perforated appendicitis and localised peritonitis . A series of 27 children presenting with appendicitis between January 1999 and July 2001 were included in the study after parental informed consent . All patients underwent open appendectomy .  Taurolidine peritoneal lavage was applied in 15 r and omly selected children ( eight girls and seven boys ; mean age 10 years and 10 months ) . Twelve children received saline peritoneal lavage and served as the control group ( six girls and six boys ; mean age 9 years and 7 months ) . Blood was taken preoperatively and on postoperative days 1 , 3 , 7 , and 14 . Full blood cell count , C-reactive protein , endotoxin , interleukin-1 , interleukin-6 , soluble interleukin-2 receptor , tumour necrosis factor α , and procalcitonin were investigated to evaluate the serological course of inflammation . Both groups initially presented with severe inflammation as evidence d clinical ly and serologically . The clinical postoperative course was uneventful in 13/15 patients in the treatment group and 10/12 patients in the control group . The remaining patients presented complications : intraperitoneal abscess or early postoperative bowel obstruction . With regard to the serological inflammatory parameters , no significant differences were found between the two groups except for the soluble interleukin-2-receptor on the 7th postoperative day . In conclusion , the expected reduction of endotoxin levels and inflammatory activity in the treatment group was not evident . A significant advantage of adjuvant peritoneal taurolidine lavage in the surgical therapy of children with localised peritonitis due to appendicitis could not be shown in our study BACKGROUND 4 methods are used in pediatric laparoscopic surgery to close trocar wounds . While tissue adhesives or adhesive strips have been shown to produce fewer wound complications and a better cosmetic result compared to trans- or only subcutaneous sutures , the choice of technique is still often based on the surgeon 's personal experience . Thus , the objective of this trial was to assess the impact of tissue adhesives ( Dermabond ™ ) compared to adhesive strips ( Steri-Strip ™ ) on potential complications of wound healing , wound pain , cosmetic outcome , and patient satisfaction after laparoscopic appendectomy in children . METHODS 49 patients undergoing laparoscopic appendectomy were enrolled in this prospect i ve r and omized trial . In every patient , two 5-mm and one 10-mm port-site incision was closed either with Dermabond ™ or Steri-Strip ™ after placing subcuticular absorbable sutures ( 4 - 0 Vicryl ™ ) . Postoperative complications , pain , and patient satisfaction with scars were evaluated at follow-up on day 10 and day 90 after the operation using a question naire and a visual analogue scale ( VAS ) . Photographs of scars taken on day 90 were evaluated on a VAS by 2 pediatric surgeons blinded to the closure method used . RESULTS According to the surgeons ' evaluation of the cosmetic outcome , a significant difference between the 2 groups with regard to the cosmetic score was found on day 90 of follow-up , favoring Steri-Strip ™ wound closure ( p < 0.05 ) . On day 10 and 90 there were no statistical differences between the 2 methods as regards the result of patient evaluations ( p > 0.05 ) . Only one wound infection ( 4 % ) was observed in the Steri-Strip ™ group ( n = 25 ) on day 10 . At follow-up on day 90 two patients ( 9.1 % ) in the Dermabond ™ group and one ( 4.8 % ) in the Steri-strip ™ group complained of wound pain ( p = 0.52 ) . CONCLUSIONS Both tissue adhesives and adhesive strips are excellent " no needle " alternatives for the closure of laparoscopic port-site incisions in children . As regards cosmetic outcome  , Steri-Strip ™ wound closure seems to be the most suitable and is also the less expensive technique Objective To determine the extent and nature of selective non-reporting of harm outcomes in clinical studies that were eligible for inclusion in a cohort of systematic review s. Design Cohort study of systematic review s from two data bases . Setting Outcome reporting bias in trials for harm outcomes ( ORBIT II ) in systematic review s from the Cochrane Library and a separate cohort of systematic review s of adverse events . Participants 92 systematic review s of r and omised controlled trials and non-r and omised studies published in the Cochrane Library between issue 9 , 2012 and issue 2 , 2013 ( Cochrane cohort ) and 230 systematic review s published between 1 January 2007 and 31 December 2011 in other publications , synthesis ing data on harm outcomes ( adverse event cohort ) . Methods A 13 point classification system for missing  outcome  data on harm was developed and applied to the studies . Results 86 % ( 79/92 ) of review s in the Cochrane cohort did not include full data from the main harm outcome of interest of each review for all of the eligible studies included within that review ; 76 % ( 173/230 ) for the adverse event cohort . Overall , the single primary harm outcome was inadequately reported in 76 % ( 705/931 ) of the studies included in the 92 review s from the Cochrane cohort and not reported in 47 % ( 4159/8837 ) of the 230 review s in the adverse event cohort . In a sample of primary studies not reporting on the single primary harm outcome in the review , scrutiny of the study publication revealed that outcome reporting bias was suspected in nearly two thirds ( 63 % , 248/393 ) . Conclusions The number of review s suspected of outcome reporting bias as a result of missing or partially reported harm related outcomes from at least one eligible study is high . The declaration of important harms and the quality of the reporting of harm outcomes must be improved in both primary studies and systematic review This prospect i ve comparative study was conducted in the department of Pediatric Surgery , Dhaka Shishu ( children ) Hospital during the period of June 2007 to September 2008 with the children of < 12 years , diagnosed as acute Appendicitis . Patient selection was done by simple r and om technique by means of lottery . For open Appendectomy ( OA ) conventional method & for Laparoscopic Appendectomy ( LA ) 3 trocher technique was applied . Data was analyzed with the help of SPSS version 10 . In this study 60 cases with acute Appendicitis including both gender were studied by two groups , group-A include 30 cases for laparoscopic and group-B include 30 cases for open appendectomy .  Postoperative pain was assessed in both groups by using FLACC scale and compared at 1st 6-hours , 24 hours , 72 hours , 96 hours & at day 7 . At 1st 6-hours , most of the children 24(80 % ) of group A had moderate pain whereas 17(56.7 % ) children of group B had severe pain ( p<0.001 ) . At 24 hours most of the patient 17(56.7 % ) of group A had mild pain compared to 27 ( 90 % ) patients of group B had moderate pain ( p<0.0001 ) . At 48 hours in group A most of the children 23(76.7 % ) had mild pain compared to moderate pain in 18(60 % ) children of group B ( p<0.0001 ) . Subsequently at 72 hours and at 96 hours most of the patients of LA group were free of pain compared to OA group . At final follow-up on day 7 , 29(96.7 % ) children of group A had no pain compared to 26(86.7 % ) of group B. Regarding analgesics requirement both qualitative & quantitative requirements of analgesics were less in LA group than OA group . About post operative wound infection in group A only 1(3.3 % ) case had developed post operative wound infection whereas in group B 7(23.3 % ) cases had . The mean ( + /-SD ) of post operative length of hospital stay was 52.00+/-11.62 ( range 48 - 96 ) hours for group A and 76.00+/-12.74 ( range 48 - 96 ) hours for group B children ( p<0.001 ) . Laparoscopic Appendectomy is more effective , preferable & superior procedure than that of open Appendectomy to reduce the post operative morbidity in children undergone appendectomy for acute appendicitis This prospect i ve , r and omized , double-blind study compares the efficacy , safety and cost-effectiveness of ampicillin , gentamicin and clindamycin ( AGC ) or cefotaxime and clindamycin ( CC ) for the treatment of children with complicated appendicitis . Ninety-seven children were r and omized . Forty-seven were assigned to the AGC regimen and 50 received CC . Forty-two patients in the AGC group had an appropriate therapeutic outcome , whereas 48 of 50 children who received CC completed the trial successfully ( p = NS ) . There were no differences between the groups with reference to the duration of antibiotic administration , fever , leukocytosis or length of hospitalization . Complications of therapy were uncommon and neither regimen demonstrated a significant advantage from an economic st and point . We concluded that , in childhood , complicated appendicitis can be treated with either CC or AGC with equal efficacy OBJECTIVE The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children . METHODS A pilot r and omized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children . Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were r and omized either to treatment with antibiotics or to surgery . Follow-up was for 1 year . RESULTS Fifty patients were enrolled ; 26 were r and omized to surgery and 24 to nonoperative treatment with  antibiotics . All children in the surgery group had histopathologically confirmed acute appendicitis , and there were no significant complications in this group . Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis . Another 6 patients have had an appendectomy due to recurrent abdominal pain ( n = 5 ) or parental wish ( n = 1 ) during the follow-up period ; none of these 6 patients had evidence of appendicitis on histopathological examination . CONCLUSIONS Twenty-two of 24 patients ( 92 % ) treated with antibiotics had initial resolution of symptoms . Of these 22 , only 1 patient ( 5 % ) had recurrence of acute appendicitis during follow-up . Overall , 62 % of patients have not had an appendectomy during the follow-up period . This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted BACKGROUND There is evidence that aminoglycosides given in a single daily dose ( once daily dose , ODD ) are as effective and safe as multiple daily doses ( MDD ) . However , the published pharmacokinetic and pharmacodynamic data are overly representative of pediatric population s in Europe and the USA , and not representative of low or middle-income countries such as Costa Rica , in which the patient population might differ from those in higher income setting s. METHODS A double-blind , r and omized clinical trial of the efficacy and safety of ODD vs. MDD amikacin therapy was conducted for children aged 2 - 12 years with an intraoperative diagnosis of perforated appendicitis . One hundred patients were r and omized following a one-to-one r and omization to receive either amikacin 7.5 mg/kg every 8 h ( MDD ) or 22.5 mg/kg as a single dose ( ODD ) . Patients in both groups were given clindamycin 10 mg/kg every 6 h. Efficacy was evaluated by the occurrence of intra-abdominal abscesses , documented by abdominal ultrasound , and therapeutic failure . Safety was determined by the presence of renal or cochlear toxicity . RESULTS Fifty patients were enrolled in each group . There were no statistically significant differences in the incidence of intra-abdominal abscesses or therapeutic failures , or in the occurrence of cochlear or renal toxicity , between the MDD and ODD treatment groups . CONCLUSIONS In this patient population of Costa Rican children with perforated appendicitis , we found that amikacin ODD is as safe and effective as the MDD regimen . This could have implication s for national health systems such as that in Costa Rica , as ODD is presumably a more economic option and may reduce the cost of antibiotic treatment in patients with perforated appendicitis . This would need to be confirmed through an economic analysis , which is outside the purview of this paper Aims : The purpose of this study was to compare open versus laparoscopic appendicectomy ( LA ) in complicated appendicitis . Material s and Methods : We prospect ively analyzed all children over a 2-year period who underwent appendicectomy in a single institution and found 30 cases of complicated appendicitis diagnosed on the table and confirmed by histopathology . These children were allocated r and omly into Group 1 if they had LA and Group 2 if they had open appendicectomy ( OA ) , solely based on surgeon assessment . The parameters assessed were duration of symptoms before surgery , use of postoperative parenteral analgesia , timing of initiation of feeds after surgery , postoperative complications and duration of postoperative stay . Results : Of the 30 patients with complicated appendicitis , 12 patients in Group 1 underwent LA and 18 patients in Group 2 underwent OA . The two groups were comparable for age and sex . Children in Group 1 were found to need less parenteral analgesia ( two out of 12 versus six out of 18 ) . Postoperatively , feeds were started earlier in Group 1 than in Group 2 ( 2.5 days versus 3.7 days ) . The average postoperative hospital stay was 5 days in Group 1 and 7.5 days in Group 2 . There were only minor wound infections in Group1 as against two major complications in Group 2 . There was no mortality in either group . Conclusions : In complicated appendicitis , laparoscopic approach carries definite advantages with less postoperative morbidity and hospital stay . It is a feasible and better alternative than the open approach in complicated appendicitis OBJECTIVE To compare the effectiveness and adverse event rates of early vs interval appendectomy in children with perforated appendicitis . DESIGN Nonblinded r and omized trial . SETTING A tertiary-referral urban children 's hospital . PATIENTS A total of 131 patients younger than 18 years with a preoperative diagnosis of perforated appendicitis . INTERVENTIONS Early appendectomy ( within 24 hours of admission ) vs interval appendectomy ( 6 - 8 weeks after diagnosis ) . MAIN OUTCOME MEASURES Time away from normal activities ( days ) . Secondary outcomes included the overall adverse event rates and the rate of predefined specific adverse events ( eg , intra-abdominal abscess , surgical site infection , unplanned readmission ) . RESULTS Early appendectomy , compared with interval appendectomy , significantly reduced the time away from normal activities ( mean , 13.8 vs 19.4 days ; P < .001 ) . The overall adverse event rate was 30 % for early appendectomy vs 55 % for interval appendectomy ( relative risk with interval appendectomy , 1.86 ; 95 % confidence interval , 1.21 - 2.87 ; P = .003 ) . Of the patients r and omized to interval appendectomy , 23 ( 34 % ) had an appendectomy earlier than planned owing to failure to improve ( n = 17 ) , recurrent appendicitis ( n = 5 ) , or other reasons ( n = 1 ) . CONCLUSIONS Early appendectomy significantly reduced the time away from normal activities . The overall adverse event rate after early appendectomy was significantly lower compared with interval appendectomy . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00435032 Appendicectomy is the most common emergency surgical operation in children . The aim of this study was to compare recovery after  appendicectomy  using either a laparoscopic or an open technique in children Patients and surgeons frequently opt for laparoscopic appendectomy for treatment of acute appendicitis . Clinical studies have shown this approach to be a reasonable alternative to open appendectomy . The objective of the current study was to assess the outcome of laparoscopic appendectomy using three different techniques . The study sample consisted of 150 children with acute appendicitis who underwent surgery at Al-Azhar University Hospitals , Cairo , Egypt , and at Al Mishary Hospital in Riyadh , Saudi Arabia , between October 1997 and October 1999 . The patients were allocated to undergo extracorporeal laparoscopic appendectomy , Endoloop laparoscopic appendectomy , or EndoGIA ( Ethicon Endo-surgery , Inc. , Cincinnati , OH , USA ) laparoscopic appendectomy . All patients were assessed for the severity of the disease at baseline using clinical and hematologic indicators . The ages of the children ranged from 7 to 14 years , with a mean of 10 years ( SD , 2.14 years ) . Of the children , 55.3 % were female . The results showed that children who underwent laparoscopic appendectomy using the EndoGIA had statistically significant shorter operating times , did not have complications , and had the shortest duration of hospital stay ( although duration of hospital stay did not reach the statistically significant level of P > 0.05 ) . Therefore , the study showed that laparoscopic appendectomy using the EndoGIA is the procedure that is most recommended , except for the relatively high cost of the disposable material s. Endoloop laparoscopic technique was the second most preferable procedure , and the least preferred procedure was extracorporeal laparoscopically assisted appendectomy . The major drawback of the last technique is the high frequency of complications .  Endoloop laparoscopic appendectomy with a purse-string suture can be performed safely if the EndoGIA is not available A prospect i ve r and omized study was undertaken to compare the use of the combination of gentamicin and clindamycin with single agent , cefoxitin , in the treatment of perforated appendicitis in the pediatric patient . In a 3-year period from 1986 to 1989 , 56 patients with perforated appendicitis were r and omized . Twenty-nine patients received cefoxitin , and 27 patients received gentamicin and clindamycin . Antibiotics were started before operation and continued for a minimum of 6 days after operation . Skin and subcutaneous tissues were left open at surgery and closed secondarily after day 3 , if they appeared to be clean . Wounds were considered infected if they developed increased purulence with positive wound cultures . Age range was similar in both groups , with a mean of 9 years ( range , 1 to 17 years ) ; 28 were boys and 28 were girls . No changes in antibiotics were required for reasons of susceptibility . No adverse drug reactions occurred in either group . The most common organisms were Escherichia coli in 35 cases ( 62 % ) and Bacteroides species in 26 cases ( 46 % ) . No difference was noted in infection complications in the two groups nor in length of hospital stay . Therefore , no difference is evident in the use of cefoxitin versus gentamicin and clindamycin in the treatment of perforated appendicitis in terms of disease or drug-related complications Background The benefit of laparoscopy to patients has been clearly established in adults undergoing cholecystectomy . Results are less clear for appendectomy . The current study was undertaken to compare the respective 3-day postoperative periods after laparoscopic and open appendectomy in children . Methods Sixty-three children ( aged 8 - 15 yr ) scheduled for appendectomy were r and omly assigned to two groups : open and laparoscopic . Postoperative evaluation included delay of postoperative recovery ( walking and feeding ) , pain assessment by visual analog scale during the 3 subsequent days , amount of nalbuphine administered via a patient-controlled analgesia system during the first 48 h and responses by children , parents , and nurses on the overall quality of analgesia . Results There was no difference between groups for demographic data ( particularly macroscopic aspect of appendix ) , analgesia , sedation , delay before eating and walking , incidence of urinary retention , nausea , vomiting . Operative time was longer ( P less or equal to 0.05 ) in the laparoscopic group ( 54+/-17 min ) than in the open group ( 39 + /-18 min ) . Thirty five percent of the children had pain at the shoulder in the LAP group versus ten percent in the open group ( P less or equal to 0.05 ) . Conclusions Laparoscopy did not improve analgesia and postoperative recovery after appendectomy in children A prospect i ve , r and omized , clinical study was done to evaluate the place of  prophylactic antibiotics  in uncomplicated childhood appendicitis . One hundred patients with uncomplicated appendicitis were r and omly assigned to one of four groups , each consisting of 25 cases . Group 1 patients did not receive prophylactic antibiotic . Group 2 , group 3 , and group 4 patients received ornidazole , penicillin plus tobramycin , and piperacillin , respectively . The use of prophylactic antibiotics did not yield better results than the use of placebos . The rarity of infectious complications after uncomplicated appendicectomy may be unique for children . Although the need for antibiotic prophylaxis is well documented in adults , the rarity of infectious complications makes it highly question able in the treatment of uncomplicated appendicitis in children To demonstrate the efficacy of oral metronidazole ( OM ) in simple or complicated appendicitis with localized peritonitis , a r and omized prospect i ve study was carried out in 1083 patients , ranging in age from 4 to 50 years ( mean age , 21.38 ) . The patients were r and omly divided into two groups . The study group ( SG ) ( 524 patients ) received OM ( 500 mg for adults , 7 - 10 mg/kg if less than 15 years ) 2 - 3 hours before operation . The drug was continued 4 to 5 hours after operation , every 8 hours , for three doses if the appendix was mild to severely inflamed . In the case of complicated appendicitis ( 114 patients ) , the same dose was given for 3 to 6 days , depending on the absence or presence of pus . Ceftizoxime was administered to the control group ( CG ) ( 559 patients ) 2 to 3 hours before operation and then postoperatively every 6 hours for three doses if the appendix was mild to severely inflamed . The complicated cases in the CG ( 120 patients ) received a combination of penicillin , chloramphenicol , and gentamicin for 3 to 6 days , depending on the absence or presence of pus . The serum concentration of metronidazole  measured in 43 patients was at bactericidal level in 40 ( mean + /- SD st and ard deviation , 10.65 + /- 4.89 microg/mL ) . The rate of wound infection was not significantly different in the SG and the CG with the same degree of pathology ( 3.17 % vs 2.96 % if uncomplicated ; 15.78 % vs 14.16 % if complicated , respectively ) . Pelvic collection occurred in four adults and one child in the CG with perforated appendicitis ( 4.16 % ) . The same complication developed in two adults and two children in the SG with perforated appendicitis ( 3.5 % ) . All six adults and one of the children in the SG had to be re-explored , whereas the remaining two children responded to conservative management  ( OM and gentamicin ) . In uncomplicated cases , hospital stay and hospital charge were both almost the same in both groups . However , length of hospitalization was nearly 1 day shorter and hospital cost per day was about 30 per cent less in complicated cases in the SG as compared with the CG . Conclusively , OM may not only substitute parenteral antibiotics in acute appendicitis as a prophylactic agent , but it may also be used as a cost-effective drug and is more convenient to the patient BACKGROUND The use of antibiotics in uncomplicated appendicitis in children , remains the area of controversy . The aim of the study was to assess the necessity of antibiotic administration in nonperforated appendicitis in children . MATERIAL AND METHODS The design of the study was a double blind r and omized controlled trial , with a follow-up of 4 to 20 months . SETTING Surgical Department in a University Pediatric Hospital . PATIENTS One hundred and eighty seven out of 249 children subjected to emergency appendectomies met the inclusion criteria , with 35 eligible but not included in the study . The remaining 152 patients were r and omized ; 41 had complicated appendicitis , 3 other diagnosis , 108 were analyzed within 3 study groups : 1 ( n = 31 ) no antibiotic , 2 ( n = 41 ) one dose , 3 ( n = 36 ) 5-day course . Open appendectomy was a surgical procedure and Ceftriaxone 1.0 g i.v . was administered . Investigated parameters were : body temperature , WBC , bowel sounds , wound healing , recovery and morbidity . RESULTS Valid outcome data were available for 90 of 108 r and omized patients . Protocol s of 18 children due to fever > 39 degrees C , upper airway infection or allergy were disclosed . In the remaining 90 children , there were no differences in WBC and oral feeding between groups 1 ( n = 24 ) , 2 ( n = 35 ) and 3 ( n = 31 ) . Group 1 and 2 had a higher mean temperature on day 1 post-op , without any clinical significance . A higher mean temperature was noted on day 5 post-op in group 1 , due to wound infection in one patient . There were no intraabdominal abscesses . The only other complications were 2 adhesion small bowel obstructions ( in groups 1 and 2 each ) . CONCLUSION Routine use of antibiotics in nonperforated appendicitis in children is not necessary BACKGROUND / PURPOSE Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children . The role of laparoscopy in complicated acute appendicitis is more controversial . The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis . METHODS A total of 102 children with suspected acute appendicitis were selected r and omly to undergo either a laparoscopic or an open appendectomy . The outcomes of 25 children with complicated appendicitis , 13 in the laparoscopic group and 12 in the open appendectomy group , were analyzed . Children , their parents , and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation . All 25 children completed a 30-day follow-up . RESULTS There were no differences in terms of patients ' age , sex , weight , height , and appendiceal histology between the 2 groups . All laparoscopic procedures were completed without conversion . The mean ( + /-SD ) operating time was 63 ( + /-31 ) minutes in the laparoscopic group and 37 ( + /-18 ) minutes in the open appendectomy group ( mean difference 26 minutes , 95 % CI 5 to 47 minutes , P = .02 ) . There were 2 major complications in the laparoscopic group in children with appendiceal masses . One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation . Another child had a pelvic abscess that resolved with antibiotic treatment . Superficial wound infections were encountered in 2 patients in the open appendectomy group . CONCLUSIONS Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis . Good surgical judgement is necessary in patients with an established appendiceal abscess This is a prospect i ve and r and omized study of 100 patients with acute appendicitis who were less than 10 years old , in which four different antibiotic regimens commonly in use against gram-negative and anaerobic bacteria were compared in terms of postoperative septic complications . The antibiotics were begun immediately preoperatively and continued for five days . Ten percent of the patients developed infection complications , with 4 % requiring further surgery . The best results were obtained with cefoxitin ( 4 % of infection ) ,  metronidazole plus amikacin and latamoxef ( 8 % ) , while the regimen of clindamycin plus amikacin was associated with the greatest number of complications ( 20 % ) . On analyzing the main microbiologic findings of the study , we conclude that some sort of antibiotic treatment is indicated in all types of appendicitis , due to the occult presence of bacteria in the peritoneal cavity , even without clinical evidence of gangrene or perforation . Further , we emphasize the significance of Streptococcus faecalis as being responsible , along with Escherichia coli and Bacteroides fragilis , for serious postoperative complications Background and Aims : Appendectomy wounds are still commonly closed with non-absorbable sutures . Stitch removal has financial costs and causes anxiety in children . Our aim was to compare interrupted non-absorbable ( NA ) and continuous intradermal absorbable ( A ) sutures in appendectomy wounds to evaluate whether absorbable suturing increases the risk of complications . Material and Methods : 198 children ( age 4–18 years ) including perforated cases were prospect ively r and omized into two groups ( NA and A skin closure ) . The wounds and inflammatory markers were evaluated on the first two postoperative days . The appearance of the wound was evaluated one week postoperatively by a district nurse . Follow-up data were obtained from 166 patients ( 87 in NA group and 79 in A group ) . Results : In NA group 86 % and in A group 81 % had appendicitis ( 8 % and 15.6 % perforated and 9.3 % and 25 % gangrenous cases in NA and A groups , respectively ) . The total wound infection rate was low , 1.8 % ( 2.3 % in NA Group and 1.3 % in A Group ) . No differences in the inflammatory markers or the appearance of the wound were noted between the groups , but nine children in NA Group ( 10.3 % ) had a partial wound dehiscence after stitch removal . Conclusion : Appendectomy wounds in children can be closed with continuous , absorbable sutures , even in complicated cases BACKGROUND Laparoscopic procedures are performed commonly in children . In general , the cost containment of laparoscopic surgery  in children has not been evaluated . OBJECTIVE To compare the costs of laparoscopic appendectomy with those of open appendectomy . DESIGN Prospect i ve clinical trial between November 1 , 1997 , and April 30 , 2000 . For analysis , cost of supplies , operation room use , and recovery in the hospital and after discharge was evaluated . Costs common to both groups were not determined . SETTING Operations performed in a university hospital . Patients Eighty-seven children aged 4 to 15 years who underwent appendectomy for suspected appendicitis . Patients were r and omized to laparoscopic or open appendectomy .  Intervention Laparoscopic appendectomies performed with the same st and ard set of reusable equipment . MAIN OUTCOME MEASURES Cost surplus of the laparoscopic procedure and recovery after surgery were evaluated , to determine the costs and effects of  laparoscopic appendectomy  compared with those of open appendectomy in children . RESULTS Excess operating and complication costs per procedure were 96 euros ( EUR ) in laparoscopic appendectomy . The increased operative expenses were offset by a shorter hospital stay , result ing in a marginal difference of 53 EUR in itemized total costs between the 2 procedures ( total cost , 1023 EUR in the laparoscopic appendectomy group and 970 EUR in the open appendectomy group ) . After laparoscopic appendectomy , children returned to school and sports earlier than those who had had an open appendectomy . CONCLUSION Laparoscopic appendectomy was marginally more expensive , but it allowed earlier return to normal daily activities than open appendectomy Summary In an attempt to reduce postoperative sepsis , a series of r and omised , double-blind studies was begun in 1982 , using cefotaxime as backbone therapy . Up to 1985 ( stages I and II ) , the best results were obtained using a combination of cefotaxime ( 75 mg/kg intravenously in 3 doses at 12-hourly intervals ) plus metronidazole ( 10 mg/kg intravenously in 3 doses ) , both drugs administered 1 hour before surgery ( preoperatively ) or at anaesthetic induction ( perioperatively ) . In 300 consecutive cases , the wound infection rates were 1 % in uncomplicated acute appendicitis and 5 % in perforated/gangrenous appendices . The present study ( stage III ) reports the findings in 401 consecutive patients : 215 treated with the above regimen , either pre-or perioperatively ( group 1 ) and 186 who additionally had peritoneal lavage with cefotaxime 2 g/L during surgery ( group 2 ) . There were 16 wound infections overall , 2 among patients administered prophylaxis preoperatively and 14 in those administered prophylaxis perioperatively . All produced mixed cultures , with Escherichia coli , Streptococcus milleri and Bacteroides fragilis predominating . The overall figures for postoperative sepsis are 12/215 ( 5.6 % ) in the non-lavage group and 8/186 ( 4.3 % ) in the lavage group . Among patients with a perforated and /or gangrenous appendix , the wound infection rate was 8/72 ( 11.1 % ) in the non-lavage group ( group 1 ) and 4/66 ( 6.1 % ) in the lavage group ( group 2 ) . Each group had 2 cases of pelvic abscess BACKGROUND / PURPOSE Laparoscopic Appendectomy ( LA ) is a safe procedure in adults result ing in shorter hospitalization and sooner return to activity . The relative merits of LA and open appendectomy ( OA ) are evaluated in this first prospect i ve and r and omized study in children . METHODS A total of 129 children with appendicitis were included . Forty-three boys and 45 girls , age 1 to 16 years , were enrolled . R and omization was determined by sealed assignment card . OA utilized a 3- to 4-cm right lower quadrant , muscle-splitting incision . Wounds were closed without drains . Antibiotics , when used , consisted of gentamycin , clindamycin , and ampicillin . LA was performed by experienced surgeons utilizing a 3-trocar technique with reusable instruments . Twenty-one children ( 24 % ) were perforated . Patients were discharged as soon as they were taking a diet and afebrile . Statistical comparisons were by Fisher 's Exact and Wilcoxon rank-sum tests . RESULTS There were no differences in postoperative analgesia , resumption of oral intake , length of hospitalization , return to normal activities , or morbidity .  Laparoscopic appendectomy was associated with longer operating times and increased cost . CONCLUSIONS Laparoscopic appendectomy  in children is not associated with the same advantages reported in adults . LA is a more expensive alternative and offers no advantages related to pain relief , length of stay , return to normal activities , or morbidity INTRODUCTION Appendicitis is the most common emergency condition in children . Historically , a 3-drug regimen consisting of ampicillin , gentamicin , and clindamycin ( AGC ) has been used postoperatively for perforated appendicitis . A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole ( CM ) to be a more simple and cost-effective antibiotic strategy . Therefore , we performed a prospect i ve , r and omized trial to compare efficacy and cost-effectiveness of these 2 regimens . METHODS After internal review board approval ( IRB no. 04 12 - 149 ) , children found to have perforated appendicitis at appendectomy were r and omized to either once daily dosing of CM ( 2 total doses per day ) or st and ard dosing of AGC ( 11 total doses per day ) . Perforation was defined as an identifiable hole in the appendix . The operative approach ( laparoscopic ) , length of antibiotic use , and criteria for discharge were st and ardized for the groups . Based on our retrospective analysis using length of postoperative hospitalization as a primary end point , a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82 . RESULTS One hundred patients underwent laparoscopic appendectomy for perforated appendicitis . On presentation , there were no differences in sex distribution , days of symptoms , temperature , or leukocyte count . There was no difference in abscess rate or wound infections between groups . The CM group result ed in significantly less antibiotic charges then the AGC group . CONCLUSIONS Once daily dosing with the 2-drug regimen ( CM ) offers a more efficient , cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen INTRODUCTION In a previous prospect i ve r and omized trial , we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient , cost-effective treatment for children with perforated appendicitis . In this study , we evaluated the safety of discharging patients to complete an oral course of antibiotics . METHODS Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study . Perforation was defined as a hole in the appendix or fecalith in the abdomen . Patients were r and omized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days ( intravenous [ IV ] arm ) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet ( IV/PO arm ) to complete 7 days . RESULTS One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis . On presentation , there were no differences in age , weight , sex distribution , days of symptoms , maximum temperature , or leukocyte count between the 2 groups . There was no difference in the postoperative abscess rate between the two treatment groups . Discharge was possible before day 5 in 42 % of the patients in the IV/PO arm . CONCLUSIONS When patients are able to tolerate a regular diet , completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation BACKGROUND Conventionally the appendix is removed through a right lower quadrant transverse incision or a gridiron incision approximately 5 cm in length . In this modern era of minimally invasive surgery , there is a lot of emphasis on cosmesis and early recovery . We performed a prospect i ve , double blind , r and omised trial to evaluate a new incision for appendectomy to compare with conventional appendectomy . METHODS One hundred and twenty patients , aged between 3 and 18 years , were r and omized to receive either small access appendectomy ( SAA ) ( n=60 , 53 acute appendicitis and 7 interval appendectomy ) or conventional appendectomy ( CAP ) ( n=60 , 55 acute appendicitis and 5 interval appendectomy ) .  SAA was performed through an incision in the lateral 1/3 of the spino-umbilical line , lateral to McBurney 's point . The caecum along with the appendix could be delivered through this small incision easily as the ileal loops did not interfere with the delivery . All patients suspected of acute appendicitis were evaluated by the modified Alvarado 's system to reduce the rate of negative appendectomies .  Patients with diffuse peritonitis were excluded . RESULTS The demographic data for the two groups were similar . The SAA group required less analgesics ( p<0.001 ) , had earlier ambulation and shorter hospital stay ( p<0.001 ) , and better cosmetic score ( p<0.001 ) , but the operation took longer ( p<0.001 ) compared to the CAP group . CONCLUSION We conclude that SAA can be done safely without the need for any special equipment , with definite advantages over conventional appendectomy BACKGROUND Research ers have suggested that antibiotics could cure acute appendicitis . We assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendicectomy for treatment of patients with uncomplicated acute appendicitis . METHODS In this open-label , non-inferiority , r and omised trial , adult patients ( aged 18 - 68 years ) with uncomplicated acute appendicitis , as assessed by CT scan , were enrolled at six university hospitals in France . A computer-generated r and omisation sequence was used to allocate patients r and omly in a 1:1 ratio to receive amoxicillin plus clavulanic acid ( 3 g per day ) for 8 - 15 days or emergency appendicectomy . The primary endpoint was occurrence of postintervention peritonitis within 30 days of treatment initiation . Non-inferiority was shown if the upper limit of the two-sided 95 % CI for the difference in rates was lower than 10 percentage points . Both intention-to-treat and per- protocol analyses were done . This trial is registered with Clinical Trials.gov , number NCT00135603 . FINDINGS Of 243 patients r and omised , 123 were allocated to the antibiotic group and 120 to the appendicectomy group . Four were excluded from analysis because of early dropout before receiving the intervention , leaving 239 ( antibiotic group , 120 ; appendicectomy group , 119 ) patients for intention-to-treat analysis . 30-day postintervention peritonitis was significantly more frequent in the antibiotic group ( 8 % , n=9 ) than in the appendicectomy group ( 2 % , n=2 ; treatment difference 5·8 ; 95 % CI 0·3 - 12·1 ) . In the appendicectomy group , despite CT-scan assessment , 21 ( 18 % ) of 119 patients were unexpectedly identified at surgery to have complicated appendicitis with peritonitis . In the antibiotic group , 14 ( 12 % [ 7·1 - 18·6 ] ) of 120 underwent an appendicectomy during the first 30 days and 30 ( 29 % [ 21·4 - 38·9 ] ) of 102 underwent appendicectomy between 1 month and 1 year , 26 of whom had acute appendicitis ( recurrence rate 26 % ; 18·0 - 34·7 ) . INTERPRETATION Amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis . Identification of predictive markers on CT scans might enable improved targeting of antibiotic treatment .  FUNDING French Ministry of Health , Programme Hospitalier de Recherche Clinique 2002 The efficacy of imipenem-cilastatin was compared with that of tobramycin and metronidazole for the treatment of appendicitis-associated abdominal infections in children in an open , r and omized trial . Two hundred eighteen patients between 2.5 and 16.8 years of age hospitalized for appendectomy because of suspected acute appendicitis were allocated to 5 treatment groups . The appendix was perforated in 54 ( 33.8 % ) of the 160 cases with appendicitis . All patients responded favorably to treatment . Infection in the wound coccurred in 15 of 125 ( 12.0 % ) of those without preoperative 43 children between the ages of 7 and 15 years with clinical symptoms of acute appendicitis were r and omised to an open appendectomy ( OA ) or a laparoscopic appendectomy ( LA ) . There were 15 acute cases of appendicitis and 5 perforated appendices in the OA group and 17 acute appendicitis , 3 cases of perforated appendices and 3 other diagnoses in the LA group . The operative time was a little shorter in the OA group . There were no differences in hospital stay or the postoperative course of the patients . In the LA group , there were two minor complications , no other complications were seen . When comparing the two surgical methods in the consistent group of patients with non-perforated acute appendicitis no statistical differences were seen in the operative time , hospital stay or in the recovery of the patients between the OA and the LA groups . We conclude that LA has no significant benefit over OA in routine use . In paediatric patients we recommend an open approach for clinical ly typical acute appendicitis , but there should be no hesitation to choose laparoscopic approach when the clinical diagnosis is unclear HYPOTHESIS For children with perforated appendicitis , the use of a prolonged course of intravenous ( i.v . ) antibiotics is equivalent to a short course of i.v . antibiotics followed by sequential conversion to oral ( PO ) antibiotics . DESIGN Prospect i ve , r and omized , clinical trial . SETTING Multicenter study in tertiary children 's hospitals . PATIENTS Children ( aged 5 - 18 years ) with perforated appendicitis found at laparotomy . INTERVENTION Children were r and omized after appendectomy either to a 10-day course of a combination of i.v . ampicillin , gentamicin sulfate , and clindamycin ( n = 10 ) ; or to a short course of a combination of i.v . ampicillin , gentamicin , and clindamycin , followed by conversion to a combination of p.o . amoxicillin and clavulanate potassium plus metronidazole ( n = 16 ) . MAIN OUTCOME MEASURES The primary outcome measure was clinical success , which was rated as complete , partial , or failure . Secondary outcome measures included return of oral intake , duration of fever , return of normal white blood cell count , and patient charges . Treatment equivalence was determined using confidence interval analysis . RESULTS We found treatment equivalence between the i.v . and i.v./p.o . groups , with 6 ( 60 % ) complete and 4 ( 40 % ) partial successes for the 10 patients in the i.v . group and 15 ( 94 % ) complete and 1 ( 6 % ) partial successes for the 16 patients in the i.v./p.o . group ( P < or = .05 ) . There was no difference in return of oral intake , duration of fever , or return of normal white blood cell count between the groups . Conversion to oral therapy results in savings of approximately $ 1500 per case . CONCLUSION There is treatment equivalence between prolonged i.v . therapy and i.v . therapy followed by conversion to oral antibiotic therapy in children with perforated appendicitis Peritoneal drainage in children with uncomplicated perforated appendicitis ( UPA ) is still controversial . Many pediatric surgeons prefer not to drain the peritoneal cavity in such cases . However , there is no r and omized controlled study performed in children . We aim ed to study the effects of peritoneal drainage in children with UPA in a r and omized prospect i ve trial . One hundred and forty consecutive patients with UPA were divided r and omly into 2 groups . Group I ( 70 patients ) consisted of cases with peritoneal drainage , and group II ( 70 patients ) without drainage . UPA is defined as perforated appendicitis with no more discoloration of peritoneal fluid after peritoneal wash out . Cases with localized abscess in the peritoneum were excluded from the study . In all patients , the ages , duration of symptoms , nasogastric drainage and hospitalization , and complications after surgery were recorded . The duration of hospitalization and nasogastric draining time were significantly lower in patients without peritoneal drainage . There was no difference in postoperative complications between the two groups . The onset of oral intake after surgery was significantly earlier in group II patients . Placing drains in the peritoneum does not improve outcome in UPA . Therefore , we do not recommend routine drainage of children with UPA BACKGROUND The methods of surgical care for children with perforated appendicitis are controversial . Some surgeons prefer early appendectomy ; others prefer initial nonoperative management followed by interval appendectomy . Determining which of these two therapies is most cost-effective was the goal of this study . STUDY DESIGN We conducted a prospect i ve , r and omized trial in children with a preoperative diagnosis of perforated appendicitis . Patients were r and omized to early or interval appendectomy .  Overall hospital costs were extracted from the hospital 's internal cost accounting system and the two treatment groups were compared using an intention-to-treat analysis . Nonparametric data were reported as median ± st and ard deviation ( or range ) and compared using a Wilcoxon rank sum test . RESULTS One hundred thirty-one patients were r and omized to either early ( n = 64 ) or interval ( n = 67 ) appendectomy . Hospital charges and costs were significantly lower in patients r and omized to early appendectomy . Total median hospital costs were $ 17,450 ( range $ 7,020 to $ 55,993 ) for patients treated with early appendectomy vs $ 22,518 ( range $ 4,722 to $ 135,338 ) for those in the interval appendectomy group . Median hospital costs more than doubled in patients who experienced an adverse event ( $ 15,245 vs $ 35,391 , p < 0.0001 ) . Unplanned readmissions also increased costs significantly and were more frequent in patients r and omized to interval appendectomy . CONCLUSIONS In a prospect i ve r and omized trial , hospital charges and costs were significantly lower for early appendectomy when compared with interval appendectomy .  The increased costs were related primarily to the significant increase in adverse events , including unplanned readmissions , seen in the interval appendectomy group The effect of topical ampicillin on the rate of wound infection after emergency appendicectomy  was studied in a prospect i ve controlled trial of 200 patients . Sixteen per cent of patients in the control group developed a wound injection compared with 3 per cent of those receiving ampicillin powder in the wound ( P<0.01 ) . When patients with peritonitis were considered , 64 per cent of the 14 patients in the control group developed a wound infection compared with 13 per cent of the 15 patients in the ampicillin group INTRAPERITONEAL ANTIBIOTICS have been used for over 30 Deyr . spite numerous experimental and clinical investigations , their role in clinical peritonitis has not been clarified . A number of retrospective studies have included patients of varying ages with peritonitis of diverse origins . Appendicitis , with generalized peritonitis in children is still a major clinical problem . The benefits of systemic antibiotics in these cases remains controversial and the use of intraperitoneal antibiotics has not been widely reported . At the Children 's Memorial Hospital we have carried out a double-blind controlled study of the effects of intraperitoneal and wound irrigation with kanamycin in cases of perforated appendicitis . METHODS Children with perforated appendicitis and established peritonitis undergoing operation from April 1969 to July 1974 were included in this study . Cultures of peritoneal fluid or pus were obtained on each patient . The use of systemic antibiotics and ~.eritoneal or wound drainage was left to the discretion of the surgeon . Kanamycin and placebo solutions were supplied in numerically coded vials , previously r and omized by Bristol Laboratories . These were added to identically coded 500 ml bottles of normal saline by the hospital pharmacy prior to use . Before closure of the peritoneum the peritoneal cavity and the wound were irrigated with either a 0.25 % solution of kanamycin or with normal saline . No attempt was made to suction all of the irrigant . A volume of 20 ml/kg of body weight was used up to a maximum of 500 ml . Irrigation with the kanamycin solution delivered 50 mg of drug/kg body weight . Each patient was specifically observed during the intraoperative and postoperative periods for signs of respiratory depression . None exhibited any sign of depression or other evidence of drug toxicity . The postoperative courses of 79 patients with perforated appendicitis were analyzed . This patient population included 37 boys and 42 girls . Nineteen were black , 59 white , and one oriental . Forty-eight per cent were between six and 10 yr of age ; 24 % were 13 mo to 5 yr ; and 28 % , 11 - 16 yr .  Wound infections that necessitated the drainage of a primarily closed wound or prevented a planned delayed primary closure were distinguished from wounds showing only prolonged or purulent drainage at sites of peritoneal or wound drains . Localized intra-abdominal abscesses requiring operative drainage have been listed separately from presumed pelvic phlegmons that resolved spontaneously BACKGROUND Single site laparoscopy for appendectomy is a technique with several case series suggesting a cosmetic advantage , but without prospect i ve comparative data . We conducted a prospect i ve , r and omized trial comparing single site laparoscopic appendectomy to the st and ard 3-port approach , including scar assessment at early and long-term follow-up . METHODS Enrolled patients over 12years old and parents of patients less than 12years old were asked to complete the vali date d  Patient Scar Assessment Question naire ( PSAQ ) at early follow-up around 6weeks and by phone after 18months . The PSAQ consists of 4 scored subscales : Appearance , Consciousness , Appearance Satisfaction , and Symptom Satisfaction . Each subscale has a set of questions with a 4-point categorical response ( 1=most favorable , 4=least favorable ) . The sum of the scores quantifies each subscale . RESULTS Early question naires were obtained from 98 3-port and 100 single-site patients with the single-site approach producing superior overall scar assessment ( P=0.003 ) . By telephone follow-up , question naires were completed by 49 3-port and 56 single-site patients at a median of 25 ( 18 - 32 ) months . In this longer-term follow-up , overall scar assessment was not significantly different between groups ( P=0.06 ) . CONCLUSION Patients or parents express superior scar assessment with the single site approach at early follow-up , but this difference disappears in the long-term Background : Laparoscopic appendectomy through a single umbilical incision is an emerging approach supported by several case series . However , to date , prospect i ve comparative data are lacking . Therefore , we conducted a prospect i ve , r and omized trial comparing single site umbilical laparoscopic appendectomy to 3-port laparoscopic appendectomy . Methods : After Internal Review Board approval , patients were r and omized to laparoscopic appendectomy via a single umbilical incision or st and ard 3-port access .  The primary outcome variable was postoperative wound infection . Using a power of 0.9 and an alpha of 0.05 , 180 patients were calculated for each arm . Patients with perforated appendicitis were excluded . The technique of ligation/division of the appendix and mesoappendix was left to the surgeon 's discretion . There were 7 participating surgeons dictated by the call schedule . All patients received the same preoperative antibiotics and postoperative management was controlled . Results : There were 360 patients were enrolled between August 2009 and November 2010 . There were no differences in patient characteristics at presentation . There was no difference in wound infection rate , time to regular diet , length of hospitalization , or time to return to full activity . Operative time , doses of narcotics , surgical difficultly and hospital charges were greater with the single site approach . Also , the mean operative time was 5 minutes longer for the single site group . Conclusion : The single site umbilical laparoscopic approach to appendectomy produces longer operative times result ing in greater charges . However , these small differences are likely of marginal clinical relevance . The study was registered with clinical trials.gov at the inception of enrollment ( NCT00981136 ) OBJECTIVE To compare the therapeutic efficacy of four antibiotic regimens : penicillin , tobramycin , and clindamycin ; penicillin , tobramycin , and ornidazole ; piperacillin alone ; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis . DESIGN Prospect i ve r and omised study . SETTING Teaching hospital , Turkey . SUBJECTS 200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were r and omly assigned to one of four groups each consisting of 50 patients . INTERVENTIONS Preoperative antibiotics given intravenously , peritoneal drainage by Penrose drains without irrigation , appendicectomy with the inversion of the stump by a purse string , taking peritoneal swabs , and primary skin closure . MAIN OUTCOME MEASURES Comparability of the groups , duration of fever , leucocytosis , antibiotic treatment , stay in hospital , nasogastric intubation , and drainage , as well as results of cultures and complications . RESULTS There were no significant differences between the groups for any variable studied . The predominant bacterial species were Escherichia coli , Klebsiella spp , Pseudomonas spp , Fusobacteria , and Peptostreptococci which were appropriately covered by all the antibiotic regimens . Fourteen patients had complications including wound infections ( n = 10 ) , prolonged ileus ( n = 2 ) and intra-abdominal abscess ( n = 2 ) all of which were treated conservatively . There was no mortality and no major complications . All regimens had the same clinical and bacteriological efficacy . CONCLUSION There is no gold st and ard for antimicrobial chemotherapy in perforated appendicitis . Different antibiotic combinations or a single broad spectrum antibiotic , which include both aerobic and anaerobic coverage , can safely be used in children with perforated appendicitis Background Single-incision laparoscopic surgery ( SILS ) is a novel area of minimally invasive surgery that uses a single incision to minimize all ports to one site . The end result is an incision that can be strategically placed in the umbilicus for a perceived scarless abdomen . The authors rationalized that a r and omized controlled trial was important given the rapid popularization of this approach . Methods An institutional review board-approved prospect i ve r and omized trial compared patients undergoing SILS ( SILS-A ) and conventional laparoscopic ( LAP-A ) appendectomy at a free-st and ing children ’s hospital during a median follow-up period of 2.2 years . Results A total of 50 patients ( 50 % boys and 67 % Hispanics ) were r and omized equally to SILS-A and LAP-A. The patients ranged in age from 3 to 15 years without a difference between the two groups . Half ( 50 % ) of these patients were younger than 8 years . The technique for SILS-A involved a single supraumbilical curvilinear skin incision with three fascial incisions . Ports were inserted to varying depths to minimize restriction of instrument movement . Coaxial visualization was improved by the use of a 30 ° scope . To achieve technical comparability with the LAP-A , a stapler device was used , which required upsizing a 5 mm port to a 12 mm port . The mean duration of the operation was 46.8 ± 3.7 min ( range , 22–120 min ) compared with 34.8 ± 2.5 min ( range , 18–77 min ) for st and ard LAP-A ( p = 0.010 ) . No conversions occurred , and the two groups did not differ in hospital length of stay . The postoperative complications consisted of one wound seroma in the SILS-A group ( nonsignificant difference ) , and no hernias were seen . No difference in readmissions , diet tolerance , fever , or postoperative pain was noted between the two groups . Conclusions The findings show the SILS approach to be feasible in the pediatric population despite the limited abdominal domain in younger children . Although SILS operating room times currently are longer than for LAP-A , they are comparable , and no other outcomes differed appreciably between the two techniques at the time of hospitalization or during the follow-up period INTRODUCTION Perforated appendicitis is a common condition in children , which , in a small number of patients , may be complicated by a well-formed abscess . Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy . Although this strategy has become well accepted , there are no published data comparing initial nonoperative management ( drainage/interval appendectomy ) to appendectomy upon presentation with an abscess . Therefore , we conducted a r and omized trial comparing these 2 management strategies . METHODS After internal review board approval ( # 06 11 - 164 ) , children who presented with a well-defined abdominal abscess by computed tomographic imaging were r and omized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess  ( when possible ) , followed by interval laparoscopic appendectomy approximately 10 weeks later . This was a pilot study with a sample size of 40 , which was based on our recent volume of patients presenting with appendicitis and abscess . RESULTS On presentation , there were no differences between the 2 groups regarding age , weight , body mass index , sex distribution , temperature , leukocyte count , number of abscesses , or greatest 2-dimensional area of abscess in the axial view . Regarding outcomes , there were no differences in length of total hospitalization , recurrent abscess rates , or overall charges . There was a trend toward a longer operating time in patients undergoing initial appendectomy ( 61 minutes versus 42 minutes mean , P = .06 ) . CONCLUSIONS Although initial laparoscopic appendectomy trends toward a requiring longer operative time , there seems to be no advantages between these strategies in terms of total hospitalization , recurrent abscess rate , or total charges From a controlled therapeutic trial extending for more than 2 yr and involving 69 patients with appendicitis and peritonitis a clear-cut statistically significant result emerged . There was a major reduction in the incidence of intraperitoneal abscesses using cephaloridine by the intraperitoneal as opposed to the systemic route . After r and omized selection into treatment and control groups , cephaloridine , 25 mg/kg was given by injection every 6 hr for 48 hr to the treatment group by i.p . installation and to the control group by systemic injection . Both groups received initial intraoperative peritoneal lavage with normal saline and also continued systemic injections of cephaloridine on postoperative days 3 , 4 , and 5 . Only one out of 36 patients in the treatment group developed a residual intraperitoneal abscess , as opposed to six abscesses developing in 33 patients in the control group . Technical problems and complications of the method were trivial and have not prevented us from continuing and extending the applications of the method There is a growing recognition that insufficient attention has been paid to the selection of the outcomes to measure in clinical trials and clinical audit . Outcomes need to be relevant to patients , clinicians , purchasers and policy-makers if the findings of research are to influence practice and future research . In addition , st and ardization of outcomes is needed to combine data from different studies to allow evidence synthesis and to compare data sets . Inconsistent choice of outcome measures means that many meta-analyses are unable to include data from all the relevant studies . For example , the five most accessed Cochrane review s in 2009 , together with the top cited review in that year , all described inconsistencies in the outcomes reported in eligible trials . A call for the st and ardization of outcomes is a regular conclusion of systematic review s. Furthermore , outcome reporting bias , defined as the bias arising from selecting outcomes for publication based on the results , affects many r and omized trials and ‘ is an under-recognized problem that affects the conclusions in a substantial proportion of Cochrane review s ’ . That bias is likely to affect systematic review s more widely as well as affecting individual studies when considered on their own . Similar problems occur with clinical audit , highlighting the importance of establishing national audits that use and report the same outcomes for all participants . All these issues could be addressed with the development and application of agreed st and ardized sets of outcomes that have been termed ‘ core outcome sets ’ . These should be measured and reported , as a minimum , in all relevant clinical trials and national clinical audits for a specific condition . Adopting a core outcome set does not imply that a particular study , review or audit should be restricted to only those outcomes . Rather , the expectation is that , as a minimum , core outcomes will always be collected and reported to allow the results of trials to be compared , contrasted and combined as appropriate . The adoption of core outcomes would have implication s across all areas of research in health and health care , reduce heterogeneity between trials , and lead to research that is more likely to have measured relevant outcomes . Importantly , they would enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable information . In addition , they will increase the efficiency and value of research . An important rationale for core outcome sets is that outcomes currently reported for trials do not consistently reflect endpoints that are meaningful for patients . Examples exist where trials failed to include all outcomes important to patients and where involvement of patients has identified an outcome that might not have been considered by practitioners on their own . Despite increasing recognition of the importance of incorporating patients ’ opinions , their involvement has been limited . Recent regulatory guidance in the USA requires documented evidence of patient input during the development of instruments to measure  patient reported outcomes ( PROs ) . However , measurement of PROs in clinical trials is hampered by the multiplicity and heterogeneity of tools currently available . Many generic , disease and domain-specific instruments have been developed and vali date d , each containing multiple scales and items . As a result , synthesis of PRO data from trials is difficult and review s aim ing to summarize treatment effect according to PROs may fail . There is synergy between the development of core outcome sets for trials and work to select up to seven outcomes that are important to patients for inclusion in Summary of Findings tables in systematic review s. Developed by the GRADE group ( http://www . grade workinggroup.org ) , Cochrane review s have featured such tables since 2008 , and they play a key role in presenting research in guidelines , such as those produced by the World Health Organization ( WHO ) . The development of core outcome sets needs to be accelerated and undertaken in ways that maximize efficiency . The COMET ( Core Outcome Measures in Effectiveness Trials , http://www.comet-initiative.org ) Initiative in the UK brings together research ers interested in the development and application of core outcome sets . These include key participants in a collaboration of research ers in rheumatology who have done the most notable work to date in this area . The COMET Initiative was launched in January 2010 , with a second meeting in July 2011 . Attendees included trialists , systematic review ers , patients , clinicians , journal editors , research funders , policy-makers , people responsible for trials registries and regulators . Data on individual studies , both published and ongoing , are being included in a free , publically available internet-based re source . This will be up date d periodically , to minimize the risk of duplication . Seventy-eight published or ongoing studies have already been entered into the repository . In addition , published review s of outcomes used in clinical trials or studies examining patients ’ views , will be entered St and ard therapy for childhood ruptured appendicitis includes combination antibiotic therapy with ampicillin , gentamicin and clindamycin . Complicated dosing schedules and the possibility of aminoglycoside toxicity make alternatives desirable . One such alternative is Timentin ( a combination agent of ticarcillin disodium and clavulanate potassium ) . This agent has a more convenient dose schedule than st and ard therapy and eliminates the possibility of aminoglycoside ototoxicity and nephrotoxicity . It is active in vitro against most pathogens associated with ruptured appendicitis in children . The preliminary results of an ongoing prospect i ve , open label , r and omized trial comparing ticarcillin and clavulanate with ampicillin , gentamicin and clindamycin in childhood ruptured appendicitis are reported herein . While further evaluation is necessary , we have found single agent therapy with ticarcillin and clavulanate to be equivalent in safety and efficacy to st and ard combination therapy . Also discussed are the relative merits of immediate versus delayed primary closure of the abdominal wound after appendectomy This multicentre trial compared the clinical efficacy of amoxycillin/clavulanate used as a single-agent therapy with that of the three-agent combination usually prescribed in the post-operative period for appendicular peritonitis in children . Only bacteriologically documented peritoneal infections were included . Sixty-four patients were r and omly distributed between two groups : Group A ( 29 cases ) treated with amoxycillin/clavulanate , first administered iv ( 100 mg/kg/day ) followed by conversion to the oral route ( 50 mg/kg/day ) once the patient had been afebrile for 48 h ; Group B ( 35 cases ) first treated by the iv route with benzylpenicillin ( 100,000 IU/kg/day ) plus netilmicin ( 5 mg/kg/day ) plus metronidazole ( 30 mg/kg/day ) followed by conversion to the oral route for metronidazole ( 30 mg/kg/day ) . In both groups , the total duration of parenteral and oral treatment was not less than five days . A total of 180 bacterial strains were recovered from peritoneal fluid sample s obtained during surgery ; 86 % of these were sensitive to amoxycillin/clavulanate .  Clinical efficacy , assessed on the basis of time until return to normal temperature and gut transit and duration of hospitalization , was identical in both groups , with follow-up monitoring on day 30 showing recovery in all cases . Cure was obtained without any problems of infection in 25/29 patients in group A and in 34/35 patients in group B ( non-significant difference ) . Tolerance was excellent and identical in the two groups with the exception of three cases of thrombophlebitis which occurred in group B. The results of this study suggest that amoxycillin/clavulanate may be useful as single-agent therapy as a first-line curative treatment for appendicular peritonitis in children One hundred children with peritonitis result ing from a perforated appendix were treated with ceftazidime or netilmicin . Metronidazole was added to both groups to treat the anaerobic organisms commonly associated with the infecting aerobic organisms in peritonitis . Escherichia coli was the most common aerobe found in peritoneal pus . Wound infection occurred in nine patients of the netilmicin group and in none treated with ceftazidime ( P less than 0.01 ) . No bacterial resistance was evident in the ceftazidime group , but gram-positive streptococci found in eight patients were resistant to netilmicin . Thus it is recommended that an antibiotic of the penicillin group be added if netilmicin is used to treat peritonitis . The results indicate that ceftazidime was more effective than netilmicin in the treatment of children with peritonitis result ing from a perforated appendix In a 3-year period , 63 consecutive patients with advanced perforated ( n=53 ) and gangrenous ( n=10 ) appendicitis were allocated to undergo either immediate wound closure or delayed primary wound closure after emergency appendectomy . The incidence of wound infection between delayed primary wound closure and immediate wound closure was similar ( 24.0 % and 21.1 % , respectively ) . The duration for complete healing of infected wounds was slightly shorter in the group undergoing delayed primary wound closure ( mean + /- SD , 24.3 + /- 9.2 days ) than in the group undergoing immediate wound closure ( mean + /- SD , 32.6 + /- 16.5 days ) , but the difference was not significant . However , healing of noninfected wounds was significantly prolonged in the group undergoing delayed primary wound closure ( mean + /- SD , 19.3 + /- 10.1 days ) compared with the group undergoing immediate wound closure ( mean + /- SD , 7.0 + /- 0 days ) . The latter had been shown to associate with more nonseptic wound complications and therefore required longer rehabilitation . Our study showed that delayed primary closure did not offer additional advantage over immediate closure in the treatment of wounds associated with advanced appendicitis in children Objective : To investigate clinical benefits of warm , humidified carbon dioxide ( CO2 ) insufflation for acute laparoscopic appendicectomy on  postoperative pain and recovery in children ( age 8–14 years ) . Background : Conventional CO2 insufflation leads to desiccation-related peritoneal inflammation and injury , which is preventable with warm , humidified CO2 gas . We hypothesized that reduced peritoneal desiccation would improve patient-centered outcomes in children after laparoscopic appendicectomy . Method : A double-blinded , r and omized controlled trial was conducted . Intervention group participants received warm ( 37 ° C ) , humidified ( 98 % relative humidity ) CO2 gas insufflation , whereas control participants received st and ard room temperature ( 20 ° C ) gas with 0 % relative humidity . Perioperative analgesia and anesthesia were st and ardized . Postoperative opiate usage was converted to morphine equivalent daily dosages ( MEDD ) for comparison , and pain intensity at rest and on moving was rated by participants using visual analog scales . Postoperative recovery and return to normal activities was assessed using a question naire on day 10 . Results : Between February 2010 and March 2011 , a total of 190 participants were r and omized . Both intervention and control groups were matched at baseline . Postoperative MEDD and pain scores were also similar . There were no differences in postoperative recovery parameters . Conclusions : Warm , humidified CO2 insufflation for acute laparoscopic appendicectomy has no short-term clinical benefits on postoperative outcomes in pediatric patients ( Clinical Trials.gov trial identifying code : NCT01027455 )
Background Acute appendicitis is the most common surgical emergency in children .
Despite this , there is no core outcome set ( COS ) described for r and omised controlled trials ( RCTs ) in children with appendicitis and hence no consensus regarding outcome selection , definition and reporting .
We aim ed to identify outcomes currently reported in studies of paediatric appendicitis .