Subcuticular Skin Closure as a Standard Approach to Emergency Appendectomy in Children: Prospective Clinical Trial Acute nonperforating appendicitis. Efficacy of brief antibiotic prophylaxis. Abdominal Drainage Following Appendectomy and Cholecystectomy Are antibiotics necessary in nonperforated appendicitis in children? A double blind randomized controlled trial. Is abdominal cavity culture of any value in appendicitis? Syringe Pressure Irrigation of Subdermic Tissue after Appendectomy to Decrease the Incidence of Postoperative Wound Infection Laparoscopy in children with complicated appendicitis. Safety of incidental appendectomy. Perioperative prophylaxis with sulbactam and ampicillin compared with metronidazole and cefotaxime in the prevention of wound infection in children undergoing appendectomy. Antibiotic Prophylaxis in Acute Nonperforated Appendicitis: The Danish Multicenter Study Group 111 [Prospective study on the prevention of wound infections after appendectomy for acute appendicitis]. Ertapenem Versus Piperacillin/Tazobactam in the Treatment of Complicated Intraabdominal Infections: Results of a Double-Blind, Randomized Comparative Phase III Trial Laparoscopic versus open appendectomy: a prospective randomized comparison Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. Primary appendectomy. The effect of prophylatic cephaloridine on postoperative wound infection. Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. Prophylactic metronidazole in appendectomy: a double-blind controlled trial. Stratified duration of prophylactic antimicrobial treatment in emergency abdominal surgery. Metronidazole-fosfomycin vs. metronidazole-gentamicin in 381 patients. The efficacy of postoperative oral antibiotics in appendicitis: a randomized prospective double-blinded study. Laparoscopic versus open appendectomy in men: a prospective randomized trial Combined topical and systemic antibiotic prophylaxis in acute appendicitis. Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. Appendiceal mass: conservative therapy followed by interval laparoscopic appendectomy. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial) Cefazolin is inferior to cefotetan as single-dose prophylaxis for women undergoing elective total abdominal hysterectomy. Prospective Randomized Trial of Two Wound Management Strategies for Dirty Abdominal Wounds [Antibiotic treatment of perforated appendicitis in childhood--a prospective study]. Delayed primary closure versus primary closure for wound management in perforated appendicitis: A prospective randomized controlled trial Perioperative hyperoxygenation and wound site infection following surgery for acute appendicitis: a randomized, prospective, controlled trial. Prophylaxis with whole gut irrigation and antimicrobials in colorectal surgery. A prospective, randomized double-blind clinical trial. Laparoscopic Appendectomy Using Endoloops: A Prospective, Randomized Clinical Trial Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients. Comparison of rate of surgical wound infection, length of hospital stay and patient convenience in complicated appendicitis between primary closure and delayed primary closure. Nonperforative appendicitis: a continuing surgical dilemma. 
Open and laparoscopic appendectomy are equally safe and acceptable in children
 Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. Evaluating the optimal timing of surgical antimicrobial prophylaxis: study protocol for a randomized controlled trial Antimicrobial Prophylaxis with Ceftriaxone in Laparoscopic Cholecystectomy: a 7-Year Clinical Experience Involving 3,603 Patients. Non-Absorbable Interrupted versus Absorbable Continuous Skin Closure in Pediatric Appendectomies Antimicrobial Prophylaxis with Ceftriaxone in Laparoscopic Cholecystectomy: a 7-Year Clinical Experience Involving 3,603 Patients Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Improving Outcomes After Laparoscopic Appendectomy: A Population-Based, 12-year Trend Analysis of 7446 Patients Prospective randomized study of two different doses of clindamycin admixed with gentamicin in the management of perforated appendicitis. Impact of a focused antimicrobial stewardship program in adherence to antibiotic prophylaxis and antimicrobial consumption in appendectomies. Is peritoneal drainage necessary in childhood perforated appendicitis?--a comparative study. Management of Complicated Appendicitis and Comparison of Outcome with Other Primary Sites of Intra-abdominal Infection: Results of a Trial Comparing Ertapenem and Piperacillin-Tazobactam Risk Factors for Adverse Outcomes After the Surgical Treatment of Appendicitis in Adults Perforated appendicitis: prospective outcome analysis for 150 children. Peritoneal lavage versus drainage for perforated appendicitis in children Comparative trial of four antibiotic combinations for perforated appendicitis in children. Laproscopic versus open appendectomy: a comparative study. Irrigation of the peritoneal cavity for appendicitis in children: a double-blind study. Comparison of post operative morbidity between laparoscopic and open appendectomy in children. Antimicrobial prophylaxis for contaminated head and neck surgery. A Danish multicenter study: Cefoxitin versus ampicillin + metronidazole in perforated appendicitis Laparoscopic versus open appendectomy in children: a prospective randomised study.
Abstract . We evaluated the morbidity associated with primary closure by interrupted subcuticular absorbable sutures  following emergency appendectomy .  In a prospect i ve clinical trial over a 12-month period , 216 children who underwent emergency appendectomy had skin closure using subcuticular interrupted absorbable polyglactin 4 - 0 sutures . Preoperative prophylactic antibiotics consisting of metronidazole alone or in combination with gentamicin were used in patients with suspected phlegmonous appendicitis ; a combination of metronidazole , gentamicin , and ampicillin was used when perforation of the appendix was suspected . Postoperatively , in patients with phlegmonous appendicitis  metronidazole was given for 24 hours , whereas in those with peritonitis the triple antibiotics were continued for 7 to 10 days . All patients were assessed for complications result ing from the technique of wound closure . No intraabdominal abscesses or serious complications were recorded . The overall incidence of wound infection was 1.8 % . Among children with a perforated appendix the rate of superficial wound infection was 5.7 % . There was no difference in the rate of wound infection between patients who received metronidazole alone or metronidazole plus gentamicin preoperatively . All the patients and their families were satisfied with the cosmetic results and with the fact that removal of skin sutures was unnecessary . We conclude that the use of prophylactic antibiotics permits st and ard skin closure by interrupted absorbable subcuticular suture A prospect i ve , r and omized , double-blind clinical study was performed to determine the efficacy of perioperative systemic antibiotics in preventing infection after appendectomy for acute nonperforating appendicitis . One hundred three patients received three doses of either placebo ( saline , n = 52 ) or cefoxitin sodium ( n = 51 ) . The two groups were similar with regard to age distribution , sex ratio , duration of operation , pathologic condition of appendix , and hospital stay . Postoperative wound infections were detected in 9.6 % of the placebo-treated patients , whereas none occurred in the cefoxitin group . All but one infection appeared after discharge . Cost analysis identified a net savings of $ 84 per patient with the use of prophylactic antibiotics . Septic morbidity after appendectomy for nonperforating appendicitis is significantly reduced by systemic antibiotics , and brief administration of a single broad-spectrum agent ( cefoxitin ) is effective prophylaxis Consecutive patients undergoing emergency appendectomy ( 283 ) or urgent cholecystectomy ( 51 ) were prospect ively studied for the development of postoperative incisional or peritoneal sepsis . Severity of the original peritoneal infection was carefully recorded , while use of a Penrose dam to drain the peritoneum was r and omized according to pre-assigned hospital number . Both aerobic and anaerobic cultures were taken from the abdomen at the time of operation as well as from all postoperative infectious foci . Results demonstrated no essential differences in incidence of wound and peritoneal infection following  appendectomy  for simple or suppurative appendicitis ( 187 ) or following  cholecystectomy  for acute cholecystitis ( 51 ) . However , with gangrenous or perforative appendicitis ( 94 ) , incisional and intra-abdominal infection rates were 43 % and 45 % , respectively , when a drain was used ; yet only 29 and 13 % , respectively , without a drain . These latter differences were significant ( p < 0.001 ) . In addition , intra-abdominal abscesses were three times as likely to drain through the incision than along any tract provided by the rubber conduit . Cultures revealed that hospital pathogens accounted for a greater proportion of wound and peritoneal sepsis after cholecystectomy and appendectomy for simple or suppurative appendicitis if a drain had been inserted than if managed otherwise . By contrast , a mixed bacterial flora was responsible for most infections following appendectomy for gangrenous or perforated appendicitis , irrespective as to use of a drain 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 Intraperitoneal culturing during appendectomy is a routine procedure . Significant decrease in the mortality and dramatic improvement in the morbidity were achieved by using antibiotics perioperatively . The value of intraoperative abdominal cavity culture was assessed in our study . METHODS A total of 499 patients formed two groups , those with acute nonperforated appendicitis ( group A ) and those with perforated appendicitis ( group B ) . Intraoperative abdominal cavity culture were taken r and omly in both groups . The perioperative morbidity , the validity , and the impact of positive culture on the antibiotic treatment were examined in both groups . RESULTS Clinical diagnosed perforation was confirmed histologically in 176 patients ( 98.3 % accuracy ) . Intraperitoneal cultures were obtained in 30.1 % of the patients in group A and in 67.1 % of group B. The majority of the patients in group A were treated preoperatively and postoperatively by a single antibiotic agent whereas 58.0 % of the patients in group B were started on triple-agent antibiotics for significantly longer periods ( 22.4 + /- 9.4 versus 5.7 + /- 7.4 doses , respectively ; P < 0.0001 ) . No significant difference was found in both groups in the postoperative complication rate ( wound infection , intra-abdominal abscess and small bowel obstruction ) whether intra-abdominal culture was obtained or not ( 5.9 % versus 4.7 % in group A and 21.2 % versus 21.9 % in group B ; P > 0.05 ) . CONCLUSION Traditional intraoperative abdominal cavity culture can be ab and oned . In perforated appendicitis , colonic flora can be predicted , and antibiotic therapy should begun without any abdominal cavity culture results . This practical approach will save money and reduce laboratory work without affecting the patient 's morbidity To evaluate syringe pressure irrigation of the surgical wound to decrease its infection after appendectomy , we design ed a r and omized control trial at the Emergency Department of Mexico City General Hospital , including 350 patients with acute abdomen suggestive of appendicitis , without any other infection clinical ly evident . The trial was r and omized into 2 groups . Group I patients received prophylactic systemic antibiotics before surgery . Group II patients received the same prophylactic systemic antibiotics plus syringe pressure irrigation of the surgical wound with 300 ml of saline solution using a 20-ml syringe with 19-gauge intravenous ( IV ) catheter to measure the incidence of postoperative wound infection . In our results , 283 patients had appendicitis . Of these , 188 were uncomplicated ( 66.4 % ) and 95 ( 33.6 % ) were complicated . Of the complicated cases , 40 were assigned to group I , and of these , 29 ( 72.5 % ) developed wound infection . In group II there were 55 patients and only 9 ( 16.3 % ) developed wound infection after syringe pressure irrigation [ p= 0.000001 ; 95 % confidence interval ( CI ) = 0.02–0.22 ] . We conclude that syringe pressure irrigation of the surgical wound after appendectomy contributes significantly to decrease the incidence of postoperative wound infection in complicated cases . It is a cheap , safe , and accessible method in any surgical room 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 Reports in the surgical literature are conflicting as to whether appendectomy " in passing " during laparotomy for trauma or for some other disease state does or does not significantly increase patient morbidity or mortality . A chart survey of all appendectomies ( 342 for acute appendicitis and 146 as incidental procedures ) performed on the trauma service of Grady Memorial Hospital over a 40 month period appeared to indicate that the wound infection rate ( 6.8 percent ) was the same as that for acute simple or suppurative appendicitis ( 6.7 percent ) , whereas the intraabdominal sepsis rate ( 17.5 percent ) paralleled that for more advanced gangrenous or perforative appendicitis ( 18.6 percent ) . Since the validity of a retrospective review is always open to question , a prospect i ve , r and omized trial was carried out only on patients with a negative abdominal exploration for trauma over a 22 month interval at the same trauma service . An odd second from the last digit hospital number dictated appendectomy , provided the appendix was readily accessible ; an even digit in the same locus dictated retention of the appendix . In no patient did intraperitoneal sepsis develop , regardless of the procedure chosen . Wound infection rates were 1.8 percent for appendectomy ( 1 of 56 ) , if local anatomic considerations precluded an easy appendectomy ( 0 of 45 ) , and 3.6 percent for the control subjects without appendectomy ( 3 of 83 ) . There were no deaths . These data cast considerable doubt on the reliability of retrospective review s and support the generally accepted dictum that incidental appendectomy , especially in the trauma patient , can be a relatively innocuous procedure 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 In a prospect i ve , block-r and omized , multicenter study , the safety and efficacy of cefoxitin in preoperative prophylaxis were studied . 1735 patients undergoing appendectomy were evaluable , and half of these patients received 2 g of cefoxitin before undergoing operation . The patients were divided into three groups : patients with a normal appendix , patients with an acutely inflamed appendix , and patients with a gangrenous appendix . The study showed for each group a significant reduction of the incidence of wound infection in patients receiving prophylaxis . However , intra-abdominal abscess formation was not influenced by preoperative antibiotic prophylaxis . Consequently , routine preoperative prophylaxis is recommended before appendectomy In the search for an appropriate antibiotic to reduce the rate of  postoperative wound infection in patients with acute appendicitis , we have r and omized 150 patients preoperatively in a prospect i ve 3-arm study . The operation technique was st and ardized for all patients and involved the use of plastic wound protectors . Bacterial contamination was documented by 3 swabs taken during operation . In 2 arms , patients received short-term adjuvant prophylaxis with either cefazolin or clindamycin/tobramycin . The third arm served as a control . Wound contamination ws proven in 33 % of all cases but only 4 % developed a real wound infection . The rate of infection was almost identical in all groups , without a statistically significant difference in the chi2 test . It is concluded that wound infection after appendectomy can not be prevented by prophylactic use of antibiotics . Careful operation technique with local protective steps is quite sufficient . Antibiotics should therefore be reserved for special indications Objective To examine the clinical efficacy and safety of ertapenem , a novel & bgr;-lactam agent with wide activity against common pathogens encountered in intraabdominal infection . Summary Background Data Ertapenem has a pharmacokinetic profile and antimicrobial spectrum that support the potential for use as a once-a-day agent for the treatment of common mixed aerobic and anaerobic infections . Methods This prospect i ve , r and omized , controlled , and double-blind trial was conducted to compare the safety and efficacy of ertapenem with piperacillin/tazobactam as therapy following adequate surgical management of complicated intraabdominal infections . Results Six hundred thirty-three patients were included in the modified intent-to-treat population , with 396 meeting all criteria for the evaluable population . Patients with a wide range of infections were enrolled ; perforated or abscessed appendicitis was most common ( approximately 60 % in microbiologically evaluable population ) . A prospect i ve , expert panel review was conducted to assess the adequacy of surgical source control in patients who were failures as a component of evaluability . For the modified intent-to-treat groups , 245 of 311 patients treated with ertapenem ( 79.3 % ) were cured , as were 232 of 304 ( 76.2 ) treated with piperacillin/tazobactam . One hundred seventy-six of 203 microbiologically evaluable patients treated with ertapenem ( 86.7 % ) were cured , as were 157 of the 193 ( 81.2 % ) treated with piperacillin/tazobactam . Conclusions In this study , the efficacy of ertapenem 1 g once a day was equivalent to piperacillin/tazobactam 3.375 g every 6 hours in the treatment of a range of intraabdominal infections . Ertapenem was generally well tolerated and had a similar safety and tolerability profile to piperacillin/tazobactam . A formal process for review of adequacy of source control was found to be of benefit . 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 intraabdominal infections Background Whether laparoscopy offers a benefit over open surgery in the management of acute appendicitis or not remains a subject of controversy despite the publication of numerous r and omized studies . This study aim ed to compare laparoscopic appendectomy ( LA ) with open appendectomy ( OA ) and to ascertain its therapeutic benefit . Methods Adult patients older than 14 years presenting with signs and symptoms suggestive of acute appendicitis were r and omized to undergo either LA or OA from January 2006 to December 2007 . Comparisons were based on operating time , time until return to a general diet , time until return to normal activity and work , length of hospital stay , billed charges , and postoperative complications . Results The study enrolled 220 patients : 108 to undergo OA and 112 to undergo LA .  The groups were similar in terms of clinicopathologic characteristics . The operating time seemed to be shorter for the OA patients than for the LA patients , but the difference was not significant ( LA , 30 ± 15.2 min vs. OA , 28.7 ± 16.3 min ; p > 0.05 ) . The hospital stay of 4.1 ± 1.5 days for the LA group and 7.2 ± 1.7 days for the OA group , and the difference was statistically significant ( p < 0.05 ) . Laparoscopic appendectomy remained associated with a shorter time until return to a general diet ( LA , 20.2 ± 12.4 h vs. OA , 36.5 ± 10 h ; p < 0.05 ) , to normal activity ( LA , 9.1 ± 4.2 days vs. OA , 13.7 ± 5.8 days ; p < 0.05 ) , and to work ( LA , 21.2 ± 3.5 days vs. OA , 27.7 ± 4.9 days ; p < 0.05 ) . The billed charges appeared to be higher for LA ( LA , 5,720.3 ± 115.7 yuan vs. OA , 5,310 ± 575.4 yuan ) , but this difference failed to be clinical ly important or statistically significant ( p > 0.05 ) . Wound infections were more common after OA ( n = 14 ) than after LA ( n = 0 ) ( p < 0.05 ) . Intraabdominal abscesses occurred for two patients in the LA group and nine patients in the OA group ( p < 0.05 ) . Postoperative ileus occurred with frequencies of 0 % in the LA group and 7.4 % in the OA group ( p < 0.05 ) . The rate for overall complications was significantly lower in the LA group . Conclusion Laparoscopic appendectomy is a useful tool in the treatment of acute appendicitis . Its advantages lie in its minimal invasiveness , its better cosmetic outcome , its lower rate of complications based on surgical expertise and state-of-the-art equipment . It can be recommended as an adoptable method for the routine patient with appendicitis IMPORTANCE An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis . OBJECTIVE To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography ( CT ) . DESIGN , SETTING , AND PARTICIPANTS The Appendicitis Acuta ( APPAC ) multicenter , open-label , noninferiority r and omized clinical trial was conducted from November 2009 until June 2012 in Finl and . The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan . Patients were r and omly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period . INTERVENTIONS Patients r and omized to antibiotic therapy received intravenous ertapenem ( 1 g/d ) for 3 days followed by 7 days of oral levofloxacin ( 500 mg once daily ) and metronidazole ( 500 mg 3 times per day ) . Patients r and omized to the surgical treatment group were assigned to undergo st and ard open appendectomy . MAIN OUTCOMES AND MEASURES The primary end point for the surgical intervention was the successful completion of an appendectomy . The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period . RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group . Of 273 patients in the surgical group , all but 1 underwent successful appendectomy , result ing in a success rate of 99.6 % ( 95 % CI , 98.0 % to 100.0 % ) . In the antibiotic group , 70 patients ( 27.3 % ; 95 % CI , 22.0 % to 33.2 % ) underwent appendectomy within 1 year of initial presentation for appendicitis . Of the 256 patients available for follow-up in the antibiotic group , 186 ( 72.7 % ; 95 % CI , 66.8 % to 78.0 % ) did not require surgery . The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0 % ( 95 % CI , -31.6 % to ∞ ) ( P = .89 ) . Given the prespecified noninferiority margin of 24 % , we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery . Of the 70 patients r and omized to antibiotic treatment who subsequently underwent appendectomy , 58 ( 82.9 % ; 95 % CI , 72.0 % to 90.8 % ) had uncomplicated appendicitis , 7 ( 10.0 % ; 95 % CI , 4.1 % to 19.5 % ) had complicated acute appendicitis , and 5 ( 7.1 % ; 95 % CI , 2.4 % to 15.9 % ) did not have appendicitis but received appendectomy for suspected recurrence . There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients r and omized to antibiotic treatment . CONCLUSIONS AND RELEVANCE Among patients with CT-proven , uncomplicated appendicitis , antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy . Most patients r and omized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period , and those who required appendectomy did not experience significant complications . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01022567 A prospect i ve , r and omized , double-blind study on the effect of cephaloridine prophylaxis in the surgical management of appendicitis was performed . Of the 139 patients studied , 70 received cephaloridine and 69 received placebo prophylaxis . Both groups of patients were well matched with regard to age , sex , operative findings , and bacteria isolated at operation . Postoperative wound infections were detected in 11.6 % of placebo-treated patients and in 1.4 % of cephaloridine-treated patients ( P less than .02 ) . Prophylactic treatment with cephaloridine of patients undergoing surgery for uncomplicated appendicitis result ed in a perceptible reduction in the rate of postoperative wound infection BACKGROUND Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial . We studied the results of initial conservative treatment ( antibiotics and percutaneous drainage if necessary , with or without interval appendectomy ) compared with immediate surgery . METHODS We undertook an observational , retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon , treated in our hospital between January 1997 and March 2009 . Patients younger than 14 , with severe sepsis or with diffuse peritonitis were excluded . A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment . A control group was composed of the other patients , who all underwent  urgent appendectomy  , matched for age and later r and omized 1:1 . The infectious risk stratification was established with the National Nosocomial Infections Surveillance System ( NNIS ) index . Dependent variables were hospital stay and surgical site infection . Analysis was with SPSS , with p < 0.05 considered significant . RESULTS Interval appendectomy  was performed in 7 study group patients . Surgical site infection episodes were more frequent in the control group ( 6 vs. 0 , p < 0.001 ) . A greater percentage of high risk patients ( NNIS ≥ 2 ) was identified in the control group ( 80 vs. 28.7 % , p < 0.03 ) , mostly related with contaminated or dirty procedures in this group ( p < 0.001 ) . No significant difference between groups was found in hospital stay . CONCLUSION Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon Ninety-eight patients with suspected nonperforated acute appendicitis have to date been entered into a continuing , prospect i ve , blinded r and omized trial to determine the role of prophylactic metronidazole in postoperative wound infection . Twenty-six patients were excluded for the following reasons : diagnosis other than acute appendicitis ( 16 ) , perforation of the appendix ( 8) , administration of other antibiotics ( 1 ) , and refusal to enter study ( 1 ) . Seventy-two patients , 47 men and 25 women , with a mean age of 27.5 years ( range 15 to 60 years ) , underwent appendectomy and were studied . Thirty patients received 1 gm intravenous metronidazole preoperatively and five intravenous doses of 500 mg metronidazole postoperatively . Forty-two patients received placebo only . Cultures of the appendiceal stump grew aerobic cultures in 45 ( 62 % ) and anaerobic organisms in 29 ( 40 % ) : Escherichia coli and Bacteroides fragilis , respectively . Six of the 72 patients ( 8.2 % ) developed postoperative wound infections : four of 42 ( 9.5 % ) who received placebo and two of 30 ( 6.6 % ) who received metronidazole ( P = 0.54 by Fisher exact test ) . No toxicity from metronidazole  was observed . The postoperative wound infection rate is insufficient to demonstrate the efficacy of metronidazole for prophylaxis in nonperforated acute appendicitis , although there appears to be a tendency of to assume its efficacy in this regard Consecutive adult patients requiring emergency abdominal surgery were r and omly allocated to preoperative treatment with metronidazole-gentamicin ( M-G ) or metronidazole-fosfomycin ( M-F ) . Postoperative continuation of antibiotics depended on the estimated risk of septic complications . Peroperatively the cases were stratified as group A , acute inflamed appendicitis , or absence of septic disorder -- no postoperative antibiotics , group B , gangrenous appendicitis or cholecystitis or intestinal obstruction without resection , or operations with contamination regarded as minor ( gastrotomy or enterotomy)--three further doses of antibiotics , or group C , perforated appendicitis , perforation of the alimentary tract , generalized peritonitis or gross contamination -- antibiotics continued for 5 days . Assessment for septic complications was made in 381 patients ( 191 M-G , 190 M-F ) . The total incidence was 4.8 % ( M-G 7.8 % , M-F 1.6 % , p less than 0.01 ) . The difference was mainly due to higher infection rate in patients stratified to group C and r and omized to M-G. Stratification thus permitted restricted duration of antibiotic treatment with a low septic complication rate , significantly less with M-F than with M-G regimen The conventional treatment of acute appendicitis is appendectomy followed by intravenous ( IV ) antibiotics until intraabdominal infection has resolved . It is controversial as to whether it is efficacious to add a course of oral antibiotics after cessation of IV antibiotics . All consenting patients who presented to Kern Medical Center between October 2000 and June 2003 with acute appendicitis were entered into the study . Perforated/gangrenous appendicitis was equally represented in the two study arms . After appendectomy , and when IV antibiotics were ready to be discontinued , patients were r and omized to receive a 7-day outpatient course of either placebo ( Group 1 ) or oral antibiotics ( Group 2 ) . Patients were monitored for infectious complications for a minimum of 3 months , and there was no statistical difference ( 11.5 % in Group 1 vs 12.1 % in Group 2 , P = 0.61 ) . The data suggest that adding a course of outpatient oral antibiotics  , after completing a course of IV antibiotics , does not decrease postoperative infectious complications in appendicitis patients Background The role of laparoscopic treatment in acute appendicitis still is unclear . Although some evidence in the literature suggests diagnostic benefits from laparoscopy for young women with suspected acute appendicitis , there is scepticism about the utility of this approach for men . This study aim ed to compare open and laparoscopic appendectomy performed for men with suspected acute appendicitis . Methods All male patients older than 15 years with an American Society of Anesthesiology ( ASA ) classification of 3 or less , no previous abdominal surgery , and no contraindication for pneumoperitoneum were prospect ively r and omized to undergo either open appendectomy ( OA ) or laparoscopic appendectomy ( LA ) . The primary end point was a detected difference in postoperative hospital length of stay , and the secondary end points were detected differences in postoperative analgesia , morbidity , and length of the recovery period . Results In this study , 147 men with suspected acute appendicitis were r and omized to either OA ( n = 75 ) or LA ( n = 72 ) . It took longer to perform LA ( 60 min ; range , 20–120 min vs. 45 min ; range , 20–90 min ; p = 0.0027 ) , and LA did not result in any significant difference for the parameters evaluated . Conclusion The postoperative length of hospital stay did not differ significantly between OA and LA for men .  Laparoscopic appendectomy required more time and did not offer any advantages compared with OA Two hundred forty-six patients with acute appendicitis were r and omly assigned to one of two groups . One group of 120 patients received systemic clindamycin preoperatively . Another group of 126 patients received , in addition to systemic clindamycin , a solution of topical ampicillin applied to subcutaneous tissues . No differences were found in the characteristics of the two groups . Combined prophylaxis with clindamycin and ampicillin significantly reduced wound infection to 4 % , compared with clindamycin alone ( p less than 0.02 ) . A decrease in the surgical wound infection rate in the group treated with clindamycin and ampicillin was mainly observed in patients with advanced ( gangrenous and perforated ) appendicitis ( p less than 0.05 ) . A significant decrease in wound infection rates in patients with positive culture results was also found . We conclude that prophylaxis with a combination of systemic clindamycin and topical ampicillin solution , when compared with clindamycin alone , more effectively prevents wound infection after emergency appendectomy , especially in patients with serious wound contamination PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options 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 BACKGROUND Current therapy of patients with appendiceal abscess or phlegmon is in evolution . Controversial areas include initial conservative therapy , drainage of periappendiceal abscesses , and the role of interval appendectomy . OBJECTIVE To evaluate the safety and efficacy of conservative therapy and of interval laparoscopic appendectomy ( ILA ) . PATIENTS AND METHODS Patients with signs and symptoms of acute appendicitis and a palpable right lower quadrant mass were included . Abscess/phlegmon was documented with ultrasound or computerized tomography . After initial therapy with antibiotics , patients were discharged to home . ILA was performed 6 to 12 weeks later . RESULTS Twelve patients were included . Four patients had phlegmonous appendicitis and eight had an abscess , but only four had percutaneous drainage . All patients improved without surgical exploration and were subjected to ILA . ILA was successful in 11 of 12 patients ; a median hospital postoperative stay of 1 day was required , and no perioperative morbidity was encountered . All patients returned to routine activities within 2 weeks of surgery . CONCLUSIONS 1 ) Initial conservative management of patients with appendiceal abscess/phlegmon is prudent , safe , and effective . 2 ) Interval laparoscopic appendectomy can be performed safely and effectively Background Although the st and ard treatment of acute appendicitis ( AA ) consists of an early appendectomy , there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA . However , the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial . Methods / design The APPAC trial is a r and omized prospect i ve controlled , open label , non-inferiority multicenter trial design ed to compare antibiotic therapy ( ertapenem ) with emergency appendectomy in the treatment of uncomplicated AA . The primary endpoint of the study is the success of the r and omized treatment . In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year ( treatment efficacy ) . Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100 % . Secondary endpoints are post-intervention complications , overall morbidity and mortality , the length of hospital stay and sick leave , treatment costs and pain scores ( VAS , visual analoque scale ) . A maximum of 610 adult patients ( aged 18–60 years ) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and r and omized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem ( 1 g per day ) for three days continued by oral levofloxacin ( 500 mg per day ) plus metronidazole ( 1.5 g per day ) for seven days . Follow-up by a telephone interview will be at 1 week , 2 months and 1 , 3 , 5 and 10 years ; the primary and secondary endpoints of the trial will be evaluated at each time point . Discussion The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75–85 % of patients with uncomplicated AA can be treated with effective antibiotic  therapy avoiding unnecessary appendectomies and the related operative morbidity , also result ing in major cost savings . Trial registration Clinical The purpose of this prospect i ve , r and omized , double-blind clinical trial was to compare the efficacy of 1-g doses of intravenous cefazolin with that of 1-g doses of intravenous cefotetan in preventing major operative site infections after elective abdominal hysterectomy . A major operative site infection requiring parenteral antimicrobial therapy developed in 46 ( 9 % ) of 511 evaluable women : 30 ( 11.6 % ) of 258 women given cefazolin prophylaxis and 16 ( 6.3 % ) of 253 women given cefotetan prophylaxis ( relative risk , 1.84 ; 95 % confidence interval , 1.03 to 3.29 ; P < .05 ) . Risk factors for major operative site infection were younger age , lower postoperative hemoglobin concentration , and a proliferative endometrium . Ten ( 3.9 % ) of 258 women given cefazolin prophylaxis had a postoperative pelvic abscess ; two of these women required additional surgical procedures , compared with two ( 0.8 % ) of 253 women given cefotetan prophylaxis who had an abscess but did not require surgery ( relative risk , 4.9 ; 95 % confidence interval , 1.09 to 22.16 ; P = .04 ) . A greater number of infections and more serious infections occurred following cefazolin prophylaxis ; this treatment result ed in 234 additional hospital days for administration of parenteral antimicrobial therapy Objective To determine the optimal method of wound closure for dirty abdominal wounds . Summary Background Data The rate of wound infection for dirty abdominal wounds is approximately 40 % , but the optimal method of wound closure remains controversial . Three r and omized studies comparing delayed primary closure ( DPC ) with primary closure ( PC ) have not conclusively shown any advantage of one method over the other in terms of wound infection . Methods Fifty-one patients with dirty abdominal wounds related to perforated appendicitis , other perforated viscus , traumatic injuries more than 4 hours old , or intraabdominal abscesses were enrolled . Patients were stratified by cause ( appendicitis vs. all other causes ) and prospect ively r and omized to one of two wound management strategies : E/DPC ( wound packed with saline-soaked gauze , evaluated 3 days after surgery for closure the next day if appropriate ) or PC . In the E/DPC group , wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted . Wounds were considered infected if purulence discharged from the wound , or possibly infected if signs of inflammation or a serous discharge developed . Results Two patients were withdrawn because they died less than 72 hours after surgery . The wound infection rate was greater in the PC group than in the E/DPC group . Lengths of hospital stay and hospital charges were similar between the two groups . Conclusion A strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost A prospect i ve r and omised study ( I ) was carried out on 130 children undergoing laparotomy for perforated appendicitis . The present study evaluates the therapeutic effectiveness of different antibiotic regimens in modifying the rate of post-operative complications ( intraabdominal abscess , ileus , wound infiltration or abscess ) . During the first year of this study two treatment groups were used . Group A consisted of 29 children treated with Sulfometrol/Trimethoprim ; the rate of postoperative complications was 44.8 % . Group B consisted of 36 children treated with mezlocillin , the rate of complications being 13.8 % . However , the same treatment with mezlocillin during the second year of the prospect i ve study showed an increase of this rte to 39 % ( 28 children -- group C ) . The final group of 37 children was treated during the second year with mezlocillin and metronidazole ( group D ) . The postoperative rate of complications was 10.8 % . A retrospective analysis of further 80 children ( study II ) with perforated appendicitis treated with mezlocillin and metronidazole  showed a consistent low rate of postoperative complications at 10.2 % . In 6.8 % of children studied , an operative intervention was necessary ( four cases of ileus , four wound abscesses ) . The mean postoperative hospitalisation period decreased from 22.7 days in group A to 15.2 days in group D and finally to 14 days in study II . The present study shows that an effective and persistent attenuation of the rate of postoperative complications after perforated appendicitis in children depends on an early onset of therapy and on the appropriate choice of antibiotic drugs that are effective against aerobic and anaerobic microorganisms Background : It is still a matter of debate whether delayed primary closure ( DPC ) of contaminated abdominal incisions reduces surgical site infections compared with a primary closure ( PC ) . The aim of this study was to determine the optimal method of wound closure for patients with perforated appendicitis . Methods : A total of 70 patients with perforated appendicitis were included . They were r and omized to have their surgical incisions ( skin and subcutaneous tissue ) either PC or left open with Betadine‐soaked gauze packing for DPC on the fifth postoperative day or later if the wound conditions were inappropriate for closure . A wound was considered infected if pus discharged from the incision site . The main outcome measures were the incidence of wound infection and the length of hospital stay ( LOS ) . Results : In the entire series , wound infection developed after incision closure in 21.4 % of the patients . The PC group had a higher incidence of wound infection ( 38.9 % vs. 2.9 % , p < 0.001 ) and longer LOS ( 8.4 days vs. 6.3 days , p = 0.038 ) . Conclusion : Delayed primary closure is the optimal management strategy for perforated appendicitis wounds . It significantly reduces the wound infection rate and length of stay OBJECTIVE To assess the influence of hyperoxygenation on surgical site infection by using the most homogeneous study population . DESIGN A r and omized , prospect i ve , controlled trial . SETTING Department of surgery in a government hospital . PATIENTS A total of 210 patients who underwent open surgery for acute appendicitis . In the study group , patients received 80 % oxygen during anesthesia , followed by high-flow oxygen for 2 hours in the recovery room . The control group received 30 % oxygen , as usual . INTERVENTION Open appendectomy via incision in the right lower quadrant of the abdomen . MAIN OUTCOME MEASURES Surgical site infection , mainly assessed by the ASEPSIS ( additional treatment , serous discharge , erythema , purulent discharge , separation of deep tissues , isolation of bacteria , and stay in hospital prolonged > 14 days ) system score . RESULTS Surgical site infections were recorded in 6 of 107 patients ( 5.6 % ) in the study group vs 14 of 103 patients ( 13.6 % ) in the control group ( P = .04 ) . Significant differences in the ASEPSIS score were also found . The mean hospital stay was longer in the control group ( 2.92 days ) compared with the study group ( 2.51 days ) ( P = .01 ) . CONCLUSION The use of supplemental oxygen is advantageous in operations for acute appendicitis by reducing surgical site infection rate and hospital stay . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01002365 In a prospect i ve , r and omized double-blind trial , the efficacy of whole gut irrigation as preoperative bowel preparation for elective colorectal surgery was evaluated alone and in combination with two antimicrobial agents in 148 patients . The antimicrobial regimens were metronidazole alone or metronidazole and ampicillin administered systemically preoperatively and continued for 3 days . Whole gut irrigation was completed without any discomfort in 87 percent of the patients . In 3 percent , the irrigation was stopped and the patients were excluded from the study . Abdominal wound infection developed in 32 percent of the patients after whole gut irrigation , and the addition of metronidazole decreased this incidence to 22 percent ( not significant ) . The incidence in wound infections in the group receiving metronidazole as well as ampicillin was 2 percent , and this difference was highly significant compared with both other groups . No significant difference was found for the incidence of intraabdominal abscesses ( p = 0.06 ) , infection of the perineal wound , or anastomotic leakage . No difference in the postoperative infection rate was found between a bowel containing fecal fluid or fecal masses , but when a bowel was clean , significantly fewer infectious complications were found . Whole gut irrigation is a rapid , well-tolerated , easily performed , and safe form of preoperative bowel preparation in elective colorectal surgery if combined with systemic antimicrobial prophylaxis consisting of antimicrobial agents effective against anaerobic and aerobic organisms Background Inadequate closure of the appendix stump can lead to abscess formation or peritonitis . This prospect i ve r and omized clinical trial was performed to evaluate the number of endoloops needed in  laparoscopic appendectomy .  Methods A total of 208 patients were r and omized in two groups : 109 in group 1 using one and 99 in group 2 using two proximal endoloops . The groups were compared in terms of intra- and postoperative complications . Results Postoperative complications were found in five patients ( 4.6 % ) in group 1 , consisting of intraabdominal abscesses ( three patients ) , pulmonary embolism ( one patient ) , and persisting port-site pain ( one patient ) . In group 2 , postoperative complications were found in five patients ( 5.1 % ) , consisting of intraabdominal abscesses ( four patients ) and prolonged percutaneous drainage ( one patient ) . There was no significant difference between the two groups . Discussion In acute appendicitis , a minimal inflamed appendix base can be safely divided using one endoloop OBJECTIVE The aim of the present study is to determine the feasibility and safety of antibiotics for uncomplicated simple appendicitis in pregnancy . METHOD We conducted a 6-year prospect i ve observational study on 20 pregnant women in whom uncomplicated simple appendicitis ( appendiceal diameter ≤11 mm and with no signs of appendicoliths , perforation , or abscess ) was radiologically verified and managed with a 4-day course of antibiotics . Treatment failure rate , defined as the need for an appendectomy during hospitalization and recurrence in the follow-up period ( median 25 months ) , and maternal or fetal complications during the pregnancy were evaluated . RESULTS Mean age of patients was 33.4 years , and gestational age was 17.8 weeks . Three patients failed to respond to antibiotic therapy  during hospitalization and underwent subsequent appendectomy ( 2 suppurative and 1 perforated appendicitis ) . There was 1 wound infection postoperatively . During follow-up , 2 patients during their ongoing pregnancy experienced recurrence at 3 and 6 months post-treatment , and a new course of antibiotics was determined . Patients also experienced recurrence at 8 and 10 months post-treatment and underwent appendectomy . Treatment failure occurred in 5 patients ( 25 % ) with no fetal complications during the pregnancy . CONCLUSIONS Antibiotic therapy for uncomplicated appendicitis in pregnancy may be a feasible treatment option without severe maternal and fetal complications OBJECTIVE To compare the efficacy of laparoscopic appendectomy ( LA ) and open appendectomy ( OA ) in the treatment of acute appendicitis . DESIGN A prospect i ve r and omized trial . SETTING A university teaching hospital . PATIENTS Eighty-one patients with a diagnosis of acute appendicitis were prospect ively r and omized to undergo either LA or OA . The two groups were matched for age and sex . INTERVENTIONS LA or OA . MAIN OUTCOME MEASURES Number of days in hospital and time to full recovery . RESULTS The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA ( p < 0.001 ) . The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group ( p < 0.001 ) . The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group ( p < 0.001 ) . The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA ( p < 0.001 ) . Three patients in the LA group had intra-abdominal abscesses ( p > 0.25 ) . No significant difference in wound infection rates was demonstrated ( p > 0.05 ) . Similarly , pain scores at 7 and 28 days showed no significant difference ( p > 0.05 ) . CONCLUSIONS With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities . LA takes longer to perform and was associated with three intra-abdominal abscesses . In cases of simple acute appendicitis the hospital stay for LA is significantly shorter OBJECTIVE To compare the difference in the rate of surgical wound infection , patient 's convenience and length of hospital stay between Primary Closure and Delayed Primary Closure in cases of complicated appendicitis in adults . METHODS This r and omised control trial was conducted at the Combined Military Hospital , Kharian and Malir from June 5 , 2006 , to September 10 , 2009 . Patients > or = 15 years of both gender who underwent appendectomy through grid iron or Lanz incision and having complicated appendicitis were included . The 100 patients who were included in the study out of the initial size of 393 , were r and omised into two equal groups of 50 each ( Group A : Primary Closure ; Group B : Delayed Primary Closure ) using a computer-generated table . All the surgeries were done by the same surgeon and the operative steps and antibiotic coverage were st and ardised . The rate of surgical wound infection , patient 's convenience ( on visual analogue scale in mm ) and the length of hospital stay were recorded . Data was analysed using SPSS version 11 , and p value was calculated . RESULTS Demographic data , comorbids and medication of both the groups was comparable . There was no significant difference in rate of surgical wound infection ( p > 0.05 ) . The difference in patient 's convenience and length of hospital stay were significant ( p < 0.05 ) , showing superiority of Primary Closure over Delayed Primary Closure with no added morbidity/mortality . CONCLUSION Primary Closure in complicated appendicitis not only reduces the cost of treatment , but is also more convenient and satisfying for the patients , with no added risk of surgical wound infection Acute appendicitis continues as a medical challenge with newer approaches failing to improve diagnostic accuracy . The role of antibiotics in acute nonperforative appendicitis ( NPA ) remains unclear . In 175 patients studied at two hospitals , preoperative guidelines were used to exclude perforative appendicitis . Nevertheless , 14 % of patients were found to have this condition . Surgeon 's reports significantly underestimated the diagnosis when compared with the pathologists ' reports . Antibiotic prophylaxis in 122 patients with NPA was studied prospect ively comparing ceftizoxime ( CTZ ) , cefam and ole ( CFM ) , and placebo ( PLA ) . Ceftizoxime decreased the infection rate compared with PLA ( 0 vs. 8 ; P less than .01 ) . Use of antibiotics ( CTZ or CFM ) result ed in decreased infections when compared with PLA ( 3 vs. 8 ; P less than .01 ) and fewer days of hospitalization ( 3.8 vs. 5.4 d , P less than .005 ) . Analysis of infection risk factors showed no correlations except for failure to administer antibiotics and the finding of a gangrenous appendix . Operative culture results had no predictive value for either infection or pathogen identification . It is recommended that all patients undergoing surgery for NPA be given 1 d of antibiotic prophylaxis 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 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 Background Surgical site infections are the most common hospital-acquired infections among surgical patients . The administration of surgical antimicrobial prophylaxis reduces the risk of surgical site infections . The optimal timing of this procedure is still a matter of debate . While most studies suggest that it should be given as close to the incision time as possible , others conclude that this may be too late for optimal prevention of surgical site infections . A large observational study suggests that surgical antimicrobial prophylaxis should be administered 74 to 30 minutes before surgery . The aim of this article is to report the design and protocol of a r and omized controlled trial investigating the optimal timing of surgical antimicrobial prophylaxis . Methods / Design In this bi-center r and omized controlled trial conducted at two tertiary referral centers in Switzerl and , we plan to include 5,000 patients undergoing general , oncologic , vascular and orthopedic trauma procedures . Patients are r and omized in a 1:1 ratio into two groups : one receiving surgical antimicrobial prophylaxis in the anesthesia room ( 75 to 30 minutes before incision ) and the other receiving surgical antimicrobial prophylaxis in the operating room ( less than 30 minutes before incision ) . We expect a significantly lower rate of surgical site infections with surgical antimicrobial prophylaxis administered more than 30 minutes before the scheduled incision . The primary outcome is the occurrence of surgical site infections during a 30-day follow-up period ( one year with an implant in place ) . When assuming a 5 % surgical site infection risk with administration of surgical antimicrobial prophylaxis in the operating room , the planned sample size has an 80 % power to detect a relative risk reduction for surgical site infections of 33 % when administering surgical antimicrobial prophylaxis in the anesthesia room ( with a two-sided type I error of 5 % ) . We expect the study to be completed within three years . Discussion The results of this r and omized controlled trial will have an important impact on current international guidelines for infection control strategies in the hospital . Moreover , the results of this r and omized controlled trial are of significant interest for patient safety and healthcare economics . Trial registration This trial is registered on Clinical Trials.gov under the identifier NCT01790529 This study is one of the first in the literature with the aim of assessing the effectiveness of antimicrobial prophylaxis with a single preoperative dose of long-acting ceftriaxone in a retrospective analysis of 3,603 patients undergoing laparoscopic cholecystectomy . All patients who underwent laparoscopic cholecystectomy between October 1990 and December 1997 were review ed . Antimicrobial prophylaxis with a single dose of ceftriaxone ( 1 g ) was given intravenously at the induction of anesthesia . Patients were closely monitored for infections until 4 weeks after surgery . Postoperative infections occurred in 44 of the 3,603 patients undergoing laparoscopic cholecystectomy , with an infection rate of 1.22 % . The infectious complications mainly comprised wound infections ( n=13 ) but also included intra-abdominal abscesses ( n=3 ) , pneumonia ( n=9 ) , urinary tract infections ( n=3 ) and other infections ( n=16 ) . The results of this retrospective and non-r and omized study , show that a single-shot regimen containing ceftriaxone may be a cost-effective measure in preventing postoperative infections in patients undergoing laparoscopic cholecystectomy 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 Summary This study is one of the first in the literature with the aim of assessing the effectiveness of antimicrobial prophylaxis with a single preoperative dose of long-acting ceftriaxone in a retrospective analysis of 3,603 patients undergoing laparoscopic cholecystectomy . All patients who underwent laparoscopic cholecystectomy between October 1990 and December 1997 were review ed . Antimicrobial prophylaxis with a single dose of ceftriaxone ( 1 g ) was given intravenously at the induction of anesthesia . Patients were closely monitored for infections until 4 weeks after surgery . Postoperative infections occurred in 44 of the 3,603 patients undergoing laparoscopic cholecystectomy , with an infection rate of 1.22 % . The infectious complications mainly comprised wound infections ( n=13 ) but also included intra-abdominal abscesses ( n=3 ) , pneumonia ( n=9 ) , urinary tract infections ( n=3 ) and other infections ( n=16 ) . The results of this retrospective and non-r and omized study , show that a single-shot regimen containing ceftriaxone may be a cost-effective measure in preventing postoperative infections in patients undergoing laparoscopic cholecystectomy Importance Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis , but long-term outcomes are not known . Objective To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis . Design , Setting , and Participants Five-year observational follow-up of patients in the Appendicitis Acuta ( APPAC ) multicenter r and omized clinical trial comparing appendectomy with antibiotic therapy , in which 530 patients aged 18 to 60 years with computed tomography – confirmed uncomplicated acute appendicitis were r and omized to undergo an appendectomy ( n = 273 ) or receive antibiotic therapy ( n = 257 ) . The initial trial was conducted from November 2009 to June 2012 in Finl and ; last follow-up was September 6 , 2017 . This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone . Interventions Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole . Main Outcomes and Measures In this analysis , prespecified secondary end points reported at 5-year follow-up included late ( after 1 year ) appendicitis recurrence after antibiotic treatment , complications , length of hospital stay , and sick leave . Results Of the 530 patients ( 201 women ; 329 men ) enrolled in the trial , 273 patients ( median age , 35 years [ IQR , 27 - 46 ] ) were r and omized to undergo appendectomy , and 257 ( median age , 33 years , [ IQR , 26 - 47 ] ) were r and omized to receive antibiotic therapy . In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year ( 27.3 % [ 95 % CI , 22.0%-33.2 % ] ; 70/256 ) , 30 additional antibiotic-treated patients ( 16.1 % [ 95 % CI , 11.2%-22.2 % ] ; 30/186 ) underwent appendectomy between 1 and 5 years . The cumulative incidence of appendicitis recurrence was 34.0 % ( 95 % CI , 28.2%-40.1 % ; 87/256 ) at 2 years , 35.2 % ( 95 % CI , 29.3%-41.4 % ; 90/256 ) at 3 years , 37.1 % ( 95 % CI , 31.2%-43.3 % ; 95/256 ) at 4 years , and 39.1 % ( 95 % CI , 33.1%-45.3 % ; 100/256 ) at 5 years . Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis , 76 had uncomplicated appendicitis , 2 had complicated appendicitis , and 7 did not have appendicitis . At 5 years , the overall complication rate ( surgical site infections , incisional hernias , abdominal pain , and obstructive symptoms ) was 24.4 % ( 95 % CI , 19.2%-30.3 % ) ( n = 60/246 ) in the appendectomy group and 6.5 % ( 95 % CI , 3.8%-10.4 % ) ( n = 16/246 ) in antibiotic group ( P < .001 ) , which calculates to 17.9 percentage points ( 95 % CI , 11.7 - 24.1 ) higher after surgery . There was no difference between groups for length of hospital stay , but there was a significant difference in sick leave ( 11 days more for the appendectomy group ) . Conclusions and Relevance Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis , the likelihood of late recurrence within 5 years was 39.1 % . This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis . Trial Registration Clinical Trials.gov Identifier : PURPOSE Although many patients receive antibiotic therapy for uncomplicated appendicitis , the relatively high treatment failure and recurrence rates are problematic . We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm , have better outcomes . The purpose of this prospect i ve non-r and omized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm . METHODS Over 2 years , we enrolled 119 patients who initially received antibiotic therapy .  The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis . Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively . We evaluated the rates of treatment failure , peritonitis , and recurrence . RESULTS Nine patients ( 7.6 % ) failed to respond to initial antibiotic therapy , and 6 had true appendicitis after subsequent surgery . Two patients had complicated appendicitis ( peritonitis ) , but no patient displayed intra-abdominal abscess postoperatively . During a median follow-up period months of 14 months , 14 patients ( 12.7 % ) experienced recurrence . CONCLUSIONS Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm OBJECTIVE Laparoscopic appendectomy for acute appendicitis has become increasingly used over the past decade . The objective of this trend analysis is to assess whether clinical outcomes after laparoscopic appendectomy have improved over the past 12 years . METHODS This analysis is based on the prospect i ve data base of the Swiss Association of Laparoscopic and Thoracoscopic Surgery . All patients undergoing emergency laparoscopic appendectomy for acute appendicitis from 1995 to 2006 were included . The following outcomes were assessed for each of the 12 years : conversion rates , intraoperative complications , surgical postoperative complications , general postoperative complications , rate of reoperations , and length of hospital stay . Unadjusted and risk-adjusted multivariable analyses were performed . Statistical significance was set at a level of P < 0.05 . All statistical tests were 2-sided . RESULTS Data from 7446 patients undergoing laparoscopic appendectomy for acute appendicitis were prospect ively collected . Over the period of observation , the conversion rate decreased significantly from 2.2 % to 1.2 % ( P(trend ) < 0.001 ) , as did intraoperative complications ( from 3.1 % to 0.7 % ; P(trend ) < 0.001 ) , surgical postoperative complications ( from 6.1 % to 1.9 % ; P(trend ) < 0.001 ) , general postoperative complications ( from 4.9 % to 1.5 % ; P(trend ) < 0.001 ) , and rates of reoperations ( from 3.4 % to 0.7 % ; P(trend ) < 0.001 ) . Average postoperative length of hospital stay also significantly decreased from 4.9 to 3.5 days ( P(trend ) < 0.001 ) . CONCLUSIONS Our investigation provides compelling evidence that intraoperative complications , surgical and general postoperative complications , conversion rates , rates of reoperations , and average length of hospital stay have significantly decreased over the past decade in patients undergoing surgery for acute appendicitis . The present trend analysis is the first one in the literature encompassing more than a decade and reporting clinical outcomes after laparoscopic appendectomy for acute appendicitis , which represents an important quality control Septic complications after surgery for enterogenous peritonitis are minimized by adjuvant antibiotics effective against aerobes and anaerobes . Historically , " gold st and ard " therapy included an aminoglycoside plus clindamycin , the latter given at 600 mg intravenous piggyback ( IVPB ) , every 6 hours . Clindamycin pharmacokinetics suggests that it can be given q8h and admixed with gentamicin , thereby markedly reducing the cost of administration . Although this is now common practice , there is no prospect i ve study comparing the efficacy of the two dose schedules in peritonitis . This study was design ed to test the hypothesis regarding the clinical efficacy of the two regimens . One hundred twenty-six patients with gangrenous ( n = 34 ) or perforated appendicitis ( n = 91 ) were r and omized ( 2:1 ) to receive gentamicin admixed with clindamycin 900 mg IVPB every 8 hours ( Group I n = 80 ) or gentamicin IVPB q8h plus clindamycin 600 mg IVPB every 6 hours ( Group II n = 46 ) . Appendectomy was performed , and aerobic and anaerobic cultures were obtained . Twenty-one patients had simultaneous determinations of  clindamycin levels in plasma , peritoneal fluid , and appendix . Outcome analysis revealed no significant differences in postoperative days of fever , days non per os , antibiotic therapy , or hospitalization . There were 6 failures ( 4 abscesses and 2 wound infections ) in Group I and 4 failures ( 1 abscess and 3 wound infections ) in Group II . Both antibiotic regimens provided clinical ly equivalent results in mixed infections due to aerobic and anaerobic bacteria . The admixed clindamycin , administered every 8 hours , results in at least 20 % reduction in costs . This is an important consideration Antibiotic use in appendectomy constitutes a fundamental practice to achieve the clinical outcomes and the prevention of surgical site infection . A prospect i ve interventional study was performed in a community hospital from January 2013 to December 2015 with the aim of determining the effect of a focused antimicrobial stewardship program in the compliance with antibiotic prophylaxis and the antimicrobial consumption in appendectomies . The compliance with the antibiotic prophylaxis was monitored for the timing of administration , the selection and dose and the discontinuation . The monitoring of antimicrobial consumption was performed by a pharmacist using ATC/DDD methodology . The stewardship program includes the education of the staff and the monitoring of the quality of antibiotic prophylaxis and consumption , and feedback . Comparison of the variables over the years was performed using student 's t-test or chi-square test as required . In 603 appendectomies performed the compliance with timely administration was achieved in 72.9 % , 99.6 % and 100 % during 2013 , 2014 and 2015 respectively and the compliance with the discontinuation had an increase from 86.4 % ( 2013 ) to 96.7 % in 2015 . Consumption of antimicrobial was 355.1 DDD/100 procedures ( DDD ) in flemonous , 447.3 DDD in suppurative , 892.8 DDD in gangrenous and 1162.7 DDD in perforated appendectomies . Reduction in consumption for cefuroxime  ( 26.2 % ) ,  metronidazole  ( 12.6 % ) and  ceftriaxone  ( 18.1 % ) was observed . The consumption of antimicrobials in flemonous and suppurated appendectomies achieved the lowest figure in 2015 . The focused antimicrobial stewardship program was effective to improve the timely administration and the proper discontinuation of prophylactic antibiotic , with an important reduction of antimicrobial consumption PURPOSE / BACKGROUND In this study , we aim ed to evaluate the effect of peritoneal drainage ( PD ) on postoperative infective complications in cases with perforated appendicitis . METHOD One hundred nine patients ( with PD ) were evaluated retrospectively and 117 cases ( with no drainage [ ND ] ) were evaluated prospect ively regarding complications like wound infection ( WI ) , intraabdominal abscess ( IAA ) , and small bowel obstruction caused by adhesions ( SBO ) in perforated appendicitis cases . The abdomen was irrigated with isotonic NaCl solution and the wounds were closed primarily in all patients . RESULTS The total number of patients was 226 ( male , 66.4 % ; female , 33.6 % ) , with a mean age of 8.6 + /- 3.4 years ( range , 1 - 15 years ) . The WI rates in PD and ND groups were 28.4 % to 16.2 % , respectively . The ratio of IAA in the PD group was 12.8 % which decreased to 3.4 % in the ND group . The difference was statistically significant ( P < .05 ) . The postoperative hospitalization period in the PD and ND groups were 10.2 + /- 6.5 and 8.3 + /- 3.3 days , duration s of antibiotic use were 9.5 + /- 5.5 and 7.7 + /- 2.7 days , duration s of NG tube usage were 3.2 + /- 1.5 and 2.2 + /- 1.2 days , time to oral feeding was 3.7 + /- 1.7 and 2.5 + /- 1.4 days , and time to normalization of the body temperatures was 3.7 + /- 2.3 vs 2.3 + /- 1.7 days . All differences were statistically significant ( P < .05 ) . The ratio of SBO increased from 2.8 % to 3.4 % in the ND group , but this result was not statistically significant . CONCLUSIONS As a result of this study , we recommend that peritoneal drainage should be ab and oned in childhood appendicitis Abstract A post-hoc analysis of data from a trial of complicated intra-abdominal infection was performed to compare the demographic and disease characteristics of patients with complicated appendicitis to those whose primary infection involved other intraabdominal sites , assess the impact of site of primary infection on outcome , and compare the efficacy and safety of ertapenem 1 g daily with piperacillin-tazobactam 3.375 g every 6 h for treatment of complicated appendicitis . Compared with patients who had primary infection of the colon or another site in the abdomen , patients with complicated appendicitis were younger , had less severe disease ( based on lower APACHE II score and lower proportion with generalized peritonitis ) , and were less likely to be managed by percutaneous drainage of an abscess or to have a postoperative infection . Patients with complicated appendicitis were more likely to have a favorable outcome than were patients with infection of the colon ( OR , 3.02 ; 95 % CI , [ 1.54 - 5.90 ] ; P = .001 ) . At the test-of-cure assessment , 109/123 ( 88.6 % ) microbiologically evaluable patients with complicated appendicitis who received ertapenem and 102/113 ( 90.3 % ) who received piperacillin-tazobactam had a favorable combined clinical and microbiologic outcome . The frequency and severity of drug-related adverse events were similar in the two treatment groups Objective To define risk factors that predict adverse outcomes after the surgical treatment of appendicitis in Department of Veterans Affairs Medical Centers . Summary Background Data Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults are poorly defined . Accurate presurgical assessment of the risk of perioperative complications and death is important in planning surgical therapy . Methods The VA National Surgical Quality Improvement Program contains prospect ively collected and extensively vali date d data on ∼1,000,000 major surgical operations . All patients undergoing surgical intervention for appendicitis from 1991 to 1999 registered in this data base were selected for study . Independent variables examined included 68 putative preoperative risk factors and 12 intraoperative process measures . Dependent variables were 21 specific adverse outcomes , including death . Stepwise logistic regression analysis was used to construct models predicting 30-day morbidity rate and the 30-day postoperative mortality rate . Results There were 4163 patients identified . The mean age was 50 years ; 96 % were male . Sixteen percent of patients had 1 or more complications after surgical intervention . Prolonged ileus , failure to wean from the ventilator , pneumonia , and both superficial and deep wound infection were the most frequently reported complications , accounting for the majority of the morbidity . The 30-day mortality rate was 1.8 % ( 74 deaths ) . For > 50 % of the complications reported , the 30-day mortality rates were significantly higher ( P < 0.01 ) for patients with complications than for those without . Thirty-day mortality rates for several complications exceeded 30 % , including cardiac arrest , coma > 24 hours , myocardial infa rct ion , acute renal failure , bleeding requiring > 4 units of red cells , and systemic sepsis . Four preoperative factors predicted a high risk of 30-day mortality in the logistic regression analysis : “ completely dependent ” functional status , bleeding disorder , steroid usage , and current pneumonia . “ Threat to life ” or “ moribund ” American Society of Anesthesiologists classification and more than a 10 % weight loss in the 6 months before surgery were associated with a high risk of complications . Conclusions Morbidity and mortality rates after the surgical treatment of appendicitis in VA hospitals are comparable with those reported in other large series . Most postsurgical complications are associated with an increased 30-day mortality rate . The models presented here are the most robust available in predicting 30-day morbidity and mortality for VA patients with appendicitis . Furthermore , they provide a starting point for the design of similar models to evaluate non-VA patients with appendicitis using the data the National Surgical Quality Improvement Program is currently gathering from private hospitals BACKGROUND / PURPOSE Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration , operative timing , drain utilization , and wound closure . For 2 decades at the authors ' institution , patients were treated with ampicillin , gentamicin , and clindamycin for 10 inpatient days , with drains in the abdomen , result ing in lower complication rates than most other published series . Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes . In addition , there are little prospect i ve data on clinical outcomes . The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aim ed at decreasing cost and length of stay in our protocol were instituted . METHODS The authors monitored prospect ively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period . Patients received a single antibiotic , piperacillin-tazobactam , intravenously for 10 days . They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met . Other practice s from our earlier protocol were continued , including immediate operation , placement of Penrose drains , and primary wound closure . RESULTS Of 150 patients treated on our protocol , major complications included intraabdominal abscess in 5 ( 3.3 % ) , cecal fistula in 2 ( 1.3 % ) , phlegmon in 3 ( 2.0 % ) , wound infection in 4 ( 2.7 % ) , and no small bowel obstructions requiring operation . None of these complications , nor their aggregate , were significantly more common than those reported in 373 patients treated over 11 years on the authors ' prior protocol ( chi2 , P > .05 ) . CONCLUSIONS Prospect i ve outcome analysis of our protocol shows that a single broad-spectrum antibiotic ( allowing portions of therapy to be delivered less expensively on an outpatient basis ) effectively can treat postoperative appendicitis with very few infectious complications . These outcome data provide baseline against which future protocol s can be compared . All treatment modifications aim ed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised 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 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 OBJECTIVE To compare the results of open with laparoscopic appendectomy in terms of postoperative pain , rate of wound infection and hospital stay . METHODS This quasi-experimental study was conducted in Deprtment of Surgery , Ziauddin University Hospital , Karachi , over a period of six months . Patients undergoing surgery for acute appendicitis were r and omly assigned into one of the two groups ( A or B ) after obtaining written and informed consent . In Group-A patients underwent open appendectomy and in Group B laparoscopic appendectomy was performed . Post operatively pain chart and wound infection was recorded and , at the time of discharge , number of days in hospital was calculated . RESULT Sixty patients ( 38 male , 22 female ) , with clinical diagnosis of acute appendicitis based on Alvarado score of six and above , were included in the study . They were r and omized into 2 groups of A and B with 30 patients in each group . Group-A comprised open appendectomy procedure and Group-B comprised laparoscopic appendectomy .  Mean comparison of postoperative pain by visual analogue scale , was significantly low in Group B , compared with Group A , on day 0 , 1 and 2 . Number of days in Hospital was 4.1 + /- 0.8 days in Group A and 1.5 + /- 0.06 days in Group B. None of the patients in Group B , while 8 ( 26.67 % ) patients in-Group A , developed postoperative wound infection at 1 week follow up . CONCLUSION Laparoscopic appendectomy is safe and effective . Wound infection and postoperative pain is significantly lower after this mode of 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 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 The use of antibiotic prophylaxis in head and neck surgery is controversial . Most surgeons agree that when surgery requires entry into the aerodigestive tract through the skin the wound is by definition contaminated and antibiotic prophylaxis is indicated as it is in other contaminated wounds . There is no general agreement as to which antibiotic or combination of antibiotics to use or what the schedule of dosage administration should be . In order to obtain a meaningful data to help in decision making , a double blind , r and omized study was performed to investigate whether cefazolin alone or a combination of gentamicin and clindamycin was more effective in prophylaxis . All patients entered into the study underwent major oncologic head and neck surgery requiring entry into the upper aerodigestive tract through the skin . Patients were stratified at entry according to the stage of disease , surgical procedure , and the existence of a prior tracheotomy or prior radiation therapy . Subsequently , patients were r and omly assigned to 1 of 4 treatment groups . Group I : Cefazolin 1 day , placebo day 2 to 5 . Group II : Cefazolin days 1 to 5 , Group III : Gentamicin and clindamycin 1 day , placebo days 2 to 5 . Group IV : Gentamicin and clindamycin days 1 to 5 . Drugs were given intravenously beginning 3 hours preoperatively and continued postoperatively every 8 hours , according to the assigned schedule . All wounds were observed daily following surgery and were grade d on a predetermined scale by 3 unbiased observers . Significantly wound infections occurred in 15 % of all patients . Group I , 33 % ; Group II , 20 % ; Group III , 7 % ; Group IV , 4 % . In Group III and Group IV there was a statistically significant ( P less than .05 ) reduction in the rate of postoperative wound infection . Multifactorial analysis demonstrated that patients whose surgery included repair with a regional pectoral flap had a statistically significant increased chance of developing postoperative wound infection ( P less than .05 ) . Patients undergoing laryngectomy , with or without neck dissection , were at less risk of postoperative infection tham patients undergoing oropharyngeal resection ( P less than .05 ) . The preoperative existence of tracheotomy or prior radiation therapy had no demonstrable effect on the incidence of wound infection postoperatively in this study A prospect i ve controlled r and omized‐block multicenter study was carried out in 209 patients undergoing surgery for perforated or ruptured appendicitis . The patients received either cefoxitin or ampicillin + metronidazole for 5 days . The treatment was started peroperatively . In both groups wound infections were found to be less than 10 per cent and no difference could be demonstrated . However cefoxitin was significantly superior to ampicillin + metronidazole in preventing intra‐abdominal abscesses ( P < 0.05 ) . Cefoxitin offers a single drug treatment that adequately reduces postoperative infectious complications in patients undergoing surgery for perforated or ruptured appendicitis 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
The outcome measures of the studies were : Wound infection , intra abdominal abscess , length of stay in hospital , and mortality .
The overall result is that the use of antibiotics is superior to placebo for preventing wound infection and intraabdominal abscess , with no apparent difference in the nature of the removed appendix .
Studies exclusively on children and studies examining topical application reported results in favour to the above , although the results were not significant .
Antibiotic prophylaxis is effective in the prevention of postoperative complications in appendectomised patients , whether the administration is given pre- , peri- or post-operatively , and could be considered for routine in emergency appendectomies
BACKGROUND Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention .
The cause of appendicitis is unclear and the mechanism of pathogenesis continues to be debated .
Despite improved asepsis and surgical techniques , postoperative complications , such as wound infection and intraabdominal abscess , still account for a significant morbidity .
Several studies implicate that postoperative infections are reduced by administration of antimicrobial regimes .
OBJECTIVES This review evaluated the use of antibiotics compared to placebo or no treatment in patients undergoing appendectomy .
Will these patients benefit from antimicrobial prophylaxis ?