RETRACTED ARTICLE: Conservative Management of Acute Appendicitis Abdominal Drainage Following Appendectomy and Cholecystectomy Nonperforative appendicitis: a continuing surgical dilemma. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis Wound infection following appendicectomy: The effect of extraperitoneal wound drainage and systemic antibiotic prophylaxis The efficacy of postoperative oral antibiotics in appendicitis: a randomized prospective double-blinded study. Antibiotic Prophylaxis in Acute Nonperforated Appendicitis: The Danish Multicenter Study Group 111 The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Acute appendicitis in children. Is abdominal cavity culture of any value in appendicitis? [Antibiotic treatment of perforated appendicitis in childhood--a prospective study]. Acute nonperforating appendicitis. Efficacy of brief antibiotic prophylaxis. Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Laparoscopic Appendectomy Using Endoloops: A Prospective, Randomized Clinical Trial Syringe Pressure Irrigation of Subdermic Tissue after Appendectomy to Decrease the Incidence of Postoperative Wound Infection [Prospective study on the prevention of wound infections after appendectomy for acute appendicitis].
Background The acute appendicitis is the most common abdominal emergency , and the primary treatment has been appendicectomy . Antibiotics are started preoperatively and continued postoperatively as needed . Methods This prospect i ve study was carried out at Sher-i-Kashmir Institute of Medical Sciences , Soura , Srinagar , Kashmir , India to determine the role of antibiotics as the only treatment in acute appendicitis and the analgesic consumption needed . Total of 80 patients were included in the study with a duration of abdominal pain less than 72 h. Out of 80 patients , 40 patients received antibiotics intravenously for 2 days followed by oral treatment for 7 days , while another 40 patients considered as controls were r and omized to surgery . Results Patients managed conservatively were discharged within 3 days except for two— patients who required surgery after 12 and 24 h , respectively , because of peritonitis due to perforated appendicitis . Four patients were readmitted within 1 year as a result of recurrent appendicitis and had to undergo surgery when appendicitis was confirmed . The diagnostic accuracy within the operated group was 90 % . Two patients had perforated appendicitis at operation . Conclusion Our conclusion is that antibiotic treatment in the patients with acute appendicitis is quite effective , and these patients may not need surgery . The patients managed conservatively with antibiotics alone experience less pain and require less analgesia but have high recurrent rate 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 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 In a prospect i ve controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated . Of 40 patients admitted with a duration of abdominal pain of less than 72 h , 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were r and omized to surgery . All patients treated conservatively were discharged within 2 days , except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis . Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery , when appendicitis was confirmed . The diagnostic accuracy within the operated group was 85 per cent . One patient had perforated appendicitis at operation .  Antibiotic treatment  in patients with  acute appendicitis was as effective as surgery . The patients had less pain and required less analgesia , but the recurrence rate was high The value of extraperitoneal wound drainage and a 3‐day course of prophylactic systemic cephaloridine used both separately and together have been assessed in a prospect i ve controlled r and omized trial involving 246 patients undergoing appendicectomy at the Leicester Royal Infirmary .  Extraperitoneal wound drainage was shown to reduce significantly the incidence of post‐operative wound infection in patients with a gangrenous or perforated appendix ( P<0·025 ) . Prophylactic cephaloridine significantly reduced the overall incidence of wound infection ( P<0·02 ) and was also effective when the appendix was gangrenous or perforated ( P<0·01 ) . A highly significant reduction in wound infection was achieved when the appendix was gangrenous or perforated by the addition of wound drainage to the antibiotic regimen ( P<0·001 ) 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 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 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 A prospect i ve study was conducted on 344 children aged from 3 months to 16 years with acute appendicitis . Most children presented with typical features of acute appendicitis ( 70 % ) or peritonitis ( 28 % ) . Atypical presentation was uncommon and occurred only in seven young children , masquerading as intestinal obstruction , gastroenteritis or urinary tract infection . Prolonged delay in surgery was associated with a rise in incidence of late appendicitis ( gangrenous and perforated appendicitis ) . This rise was especially marked 37 h after onset of symptoms . The main causes of delay were inability of the parents and primary care medical practitioners to recognize the disease early . Surgeons contributed very little to the delay . High risk factors for postappendectomy sepsis were young children under 6 years old , late appendicitis , obese patients , inferior systemic antibiotic regimes and inexperienced surgeons . Young children had high postoperative sepsis mainly because of the high incidence of late appendicitis due to their inability to express their symptoms properly . They were not especially prone to postappendectomy sepsis ; they had the same degree of appendicitis compared with older children . Measures to decrease the postappendectomy morbidity are suggested 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 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 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 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 OBJECTIVE The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children . METHODS A pilot r and omized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children . Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were r and omized either to treatment with antibiotics or to surgery . Follow-up was for 1 year . RESULTS Fifty patients were enrolled ; 26 were r and omized to surgery and 24 to nonoperative treatment with  antibiotics . All children in the surgery group had histopathologically confirmed acute appendicitis , and there were no significant complications in this group . Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis . Another 6 patients have had an appendectomy due to recurrent abdominal pain ( n = 5 ) or parental wish ( n = 1 ) during the follow-up period ; none of these 6 patients had evidence of appendicitis on histopathological examination . CONCLUSIONS Twenty-two of 24 patients ( 92 % ) treated with antibiotics had initial resolution of symptoms . Of these 22 , only 1 patient ( 5 % ) had recurrence of acute appendicitis during follow-up . Overall , 62 % of patients have not had an appendectomy during the follow-up period . This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted Background 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 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 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
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 ?