Delayed Primary Wound Closure Using Skin Tapes for Advanced Appendicitis in Children A Tat M.
Prospective, Controlled Study
Tsang, MBBS, FRCSE;
Paul K. H. Tam, MBBS,
period, 63 consecutive patients with advanced (n perforated = 53) and gangrenous (n 10) appendicitis were allocated to undergo either immediate wound closure or delayed primary wound closure after emergency appendectomy. The incidence of wound infection between delayed primary wound closure and immediate wound closure was similar (24.0% and 21.1%, respectively). The duration for complete healing of infected wounds was slightly shorter in the group undergoing delayed primary wound closure (mean\m=+-\SD,24.3\m=+-\9.2days) than in the group undergoing immediate wound closure (mean\m=+-\SD,32.6\m=+-\16.5days), but the difference was not significant. However, healing of noninfected wounds was significantly prolonged in the group undergoing delayed primary wound closure (mean\m=+-\SD,19.3\m=+-\10.1days) compared with the group undergoing immediate wound closure (mean\m=+-\SD,7.0\m=+-\0 days). The latter had been shown to associate with more nonseptic wound complications and therefore required longer rehabilitation. Our study showed that delayed primary closure did not offer additional advantage over immediate closure in the treatment of wounds associated with advanced appendicitis in children. \s=b\ In a 3-year
=
(Arch Surg. 1992;127:451-453)
medical advances, wound sepsis remains Despite frequent complication of perforated gangrenous 25% 50% a
or
in most reported to appendicitis, amounting to series.1 Open wound treatment for advanced appendici¬ tis was recommended as long ago as 1931 as a method of reduction of wound sepsis but there is no general agree¬ ment on its efficacy.2 It has been claimed that delayed primary wound closure (DPC) consisting of open wound treatment for the few days immediately after surgery, followed by wound closure with skin tapes offers the
publication September 7, 1991. Department of Surgery, University of Hong Kong, Queen Mary Hospital (Drs Tsang and Saing), and Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, England (Dr
Accepted
for
From the
Tam).
Presented at the 19th International Congress of Pediatrics, Paris, July 27, 1989. Reprint requests to Department of Surgery, University of Hong
France,
Kong, Queen Mary Hospital, Hong Kong (Dr Saing).
ChM, FRCSE;
Htut
Saing, MBBS,
FRCSE
combined advantages of reduced wound sepsis and good wound healing. Wound closure with skin tapes is particularly suitable for pediatrie patients, and is an established practice in pediatrie surgery. We, therefore, undertook a prospec¬ tive, controlled study to compare the wound infection rate and healing time of DPC with those of immediate closure (IC) of wounds in the treatment of perforated and gangrenous appendicitis in children. PATIENTS AND METHODS During the 3-year period from luly 1984 to June 1987, 63 con¬ secutive children with advanced appendicitis were treated in the
Division of Pediatrie Surgery, Department of Surgery, Univer¬ sity of Hong Kong, Queen Mary Hospital. Fifty-three had per¬ forated appendicitis and 10 had gangrenous appendicitis con¬ firmed at operation. There were 34 boys and 29 girls, with a mean age of 7.6 years (range, 2 to 12 years). Based on their hospital numbers, they were allocated to either one of the following two methods of wound treatment: DPC for patients with even num¬ bers and IC for those with odd numbers (Table 1). Informed consent was obtained for entry into the controlled trial. The study was approved by the ethical committee of Queen Mary Hospital. The small patient population studied could have accounted for the uneven distribution in the two groups. All patients underwent appendectomy through a right lower quadrant transverse or oblique muscle-splitting incision with the stump of the appendix buried. Peritoneal lavage was performed using normal saline. No drain or topical antibiotic was used during closure of wound. In the IC group, the wound was closed in layers using continuous chromic catgut for the peritoneum and muscles and interrupted nylon for the skin. In the DPC group, peritoneum and abdominal muscles were similarly closed, but the skin and subcutaneous tissue were kept open with a saline dressing that was changed daily to prevent exces¬ sive collection of reactionary exúdate till day 4 after surgery. Skin tapes (Steri-Strip, Medical-Surgical Division/3M, St Paul, Minn) were then applied to appose the skin wound at bedside without the use of anesthesia. Complete wound healing time was defined as the duration from the time of operation to when the wound showed total apposition of the edges with ceasing of further nursing care. Wound infection was defined as the pres¬ ence of gross purulent discharge with or without a positive bac¬ terial culture. All patients received preoperative prophylactic antibiotics, gentamicin sulfate, and metronidazole, and com¬ pleted the 7-day postoperative course. The difference in the incidence of wound infection between
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
Table 1. —Demographic Features of 63 Patients Randomized for Either Immediate Wound Closure (IC) or Delayed Primary Wound Closure (DPC) After Emergency Appendectomy Variable No. M/F
Age,
y Mean
Range Appendicitis,
IC (n = 38)
DPC (n = 25)
21/17
13/12
8.4 4.0-11.5
6.5 2.0-11.0
31 7
22 3
No.
Perforated
Gangrenous
Table 2. —Incidence of Wound Infection in Patients Undergoing Immediate Closure (IC) and Delayed Primary Closure (DPC) Wound Infection* -1
Appendicitis
IC (n = 38)
DPC (n = 25)
Perforated
8
6
Gangrenous
0
0
8(21%) 6(24%) Total *Differences between the two groups were not significant
analysis.
by 2
Table 3. —Mean Healing Time of Noninfected and Infected Wounds in Patients Undergoing Immediate Closure (IC) and Delayed Primary Closure (DPC) Mean ± SD
Appendectomy Wound
IC(n 38) =
7.0 + 0.0 Noninfected 32.6±16.5 Infected •Student's test. NS indicates not
Healing Time, d DPC(n = 25) 19.3±10.1
.001
24.3±9.2
NS
significant.
the two groups was tested using the 2 test. Two-tailed Student's t test was used for the analysis of the differences in the healing time and the hospital stay. Differences were considered signif¬ icant at P
Prospective, Controlled Study
Tsang, MBBS, FRCSE;
Paul K. H. Tam, MBBS,
period, 63 consecutive patients with advanced (n perforated = 53) and gangrenous (n 10) appendicitis were allocated to undergo either immediate wound closure or delayed primary wound closure after emergency appendectomy. The incidence of wound infection between delayed primary wound closure and immediate wound closure was similar (24.0% and 21.1%, respectively). The duration for complete healing of infected wounds was slightly shorter in the group undergoing delayed primary wound closure (mean\m=+-\SD,24.3\m=+-\9.2days) than in the group undergoing immediate wound closure (mean\m=+-\SD,32.6\m=+-\16.5days), but the difference was not significant. However, healing of noninfected wounds was significantly prolonged in the group undergoing delayed primary wound closure (mean\m=+-\SD,19.3\m=+-\10.1days) compared with the group undergoing immediate wound closure (mean\m=+-\SD,7.0\m=+-\0 days). The latter had been shown to associate with more nonseptic wound complications and therefore required longer rehabilitation. Our study showed that delayed primary closure did not offer additional advantage over immediate closure in the treatment of wounds associated with advanced appendicitis in children. \s=b\ In a 3-year
=
(Arch Surg. 1992;127:451-453)
medical advances, wound sepsis remains Despite frequent complication of perforated gangrenous 25% 50% a
or
in most reported to appendicitis, amounting to series.1 Open wound treatment for advanced appendici¬ tis was recommended as long ago as 1931 as a method of reduction of wound sepsis but there is no general agree¬ ment on its efficacy.2 It has been claimed that delayed primary wound closure (DPC) consisting of open wound treatment for the few days immediately after surgery, followed by wound closure with skin tapes offers the
publication September 7, 1991. Department of Surgery, University of Hong Kong, Queen Mary Hospital (Drs Tsang and Saing), and Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, England (Dr
Accepted
for
From the
Tam).
Presented at the 19th International Congress of Pediatrics, Paris, July 27, 1989. Reprint requests to Department of Surgery, University of Hong
France,
Kong, Queen Mary Hospital, Hong Kong (Dr Saing).
ChM, FRCSE;
Htut
Saing, MBBS,
FRCSE
combined advantages of reduced wound sepsis and good wound healing. Wound closure with skin tapes is particularly suitable for pediatrie patients, and is an established practice in pediatrie surgery. We, therefore, undertook a prospec¬ tive, controlled study to compare the wound infection rate and healing time of DPC with those of immediate closure (IC) of wounds in the treatment of perforated and gangrenous appendicitis in children. PATIENTS AND METHODS During the 3-year period from luly 1984 to June 1987, 63 con¬ secutive children with advanced appendicitis were treated in the
Division of Pediatrie Surgery, Department of Surgery, Univer¬ sity of Hong Kong, Queen Mary Hospital. Fifty-three had per¬ forated appendicitis and 10 had gangrenous appendicitis con¬ firmed at operation. There were 34 boys and 29 girls, with a mean age of 7.6 years (range, 2 to 12 years). Based on their hospital numbers, they were allocated to either one of the following two methods of wound treatment: DPC for patients with even num¬ bers and IC for those with odd numbers (Table 1). Informed consent was obtained for entry into the controlled trial. The study was approved by the ethical committee of Queen Mary Hospital. The small patient population studied could have accounted for the uneven distribution in the two groups. All patients underwent appendectomy through a right lower quadrant transverse or oblique muscle-splitting incision with the stump of the appendix buried. Peritoneal lavage was performed using normal saline. No drain or topical antibiotic was used during closure of wound. In the IC group, the wound was closed in layers using continuous chromic catgut for the peritoneum and muscles and interrupted nylon for the skin. In the DPC group, peritoneum and abdominal muscles were similarly closed, but the skin and subcutaneous tissue were kept open with a saline dressing that was changed daily to prevent exces¬ sive collection of reactionary exúdate till day 4 after surgery. Skin tapes (Steri-Strip, Medical-Surgical Division/3M, St Paul, Minn) were then applied to appose the skin wound at bedside without the use of anesthesia. Complete wound healing time was defined as the duration from the time of operation to when the wound showed total apposition of the edges with ceasing of further nursing care. Wound infection was defined as the pres¬ ence of gross purulent discharge with or without a positive bac¬ terial culture. All patients received preoperative prophylactic antibiotics, gentamicin sulfate, and metronidazole, and com¬ pleted the 7-day postoperative course. The difference in the incidence of wound infection between
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
Table 1. —Demographic Features of 63 Patients Randomized for Either Immediate Wound Closure (IC) or Delayed Primary Wound Closure (DPC) After Emergency Appendectomy Variable No. M/F
Age,
y Mean
Range Appendicitis,
IC (n = 38)
DPC (n = 25)
21/17
13/12
8.4 4.0-11.5
6.5 2.0-11.0
31 7
22 3
No.
Perforated
Gangrenous
Table 2. —Incidence of Wound Infection in Patients Undergoing Immediate Closure (IC) and Delayed Primary Closure (DPC) Wound Infection* -1
Appendicitis
IC (n = 38)
DPC (n = 25)
Perforated
8
6
Gangrenous
0
0
8(21%) 6(24%) Total *Differences between the two groups were not significant
analysis.
by 2
Table 3. —Mean Healing Time of Noninfected and Infected Wounds in Patients Undergoing Immediate Closure (IC) and Delayed Primary Closure (DPC) Mean ± SD
Appendectomy Wound
IC(n 38) =
7.0 + 0.0 Noninfected 32.6±16.5 Infected •Student's test. NS indicates not
Healing Time, d DPC(n = 25) 19.3±10.1
.001
24.3±9.2
NS
significant.
the two groups was tested using the 2 test. Two-tailed Student's t test was used for the analysis of the differences in the healing time and the hospital stay. Differences were considered signif¬ icant at P
