A 20-Year


Study of 1,640 Children County (Illinois) Hospital

Joseph S. Janik, MD, Hugh



Firor, MD

acute appendicitis treated at Cook County (Illinois) Hospital between Jan 1,1957, and Dec 31,1976, 35% had appendiceal perforation. Overall morbidity was 12.8% and mortality was 0.24%. Antibiotics, transperitoneal drainage, and delayed wound closure were used routinely in children with appendiceal perforation. Antibiotics and transperitoneal drains did not appreciably alter the incidence of intra\x=req-\ abdominal abscess formation. Delayed wound closure in patients with appendiceal perforation reduced the incidence of wound infection by 75%. \s=b\ Of

1,640 children with

(Arch Surg 114:717-719, 1979) age group, appendicitis is the most condition requiring abdominal surgery. De¬ spite a century of clinical experience, the morbidity and mortality of appendicitis continue to be appreciable and more than 100 children still die of appendicitis each year in the United States.1 Advances in fluid resuscitation and anesthesia are large¬ ly responsible for the 75% reduction in mortality during the past 25 years.2 The role of antibiotics, intraperitoneal drains, and delayed wound closure is less clearly defined. i"6 It is our purpose to describe a 20-year experience of managing this condition and to test the efficacy of the plan of management that has been followed.







Between Jan 1,1957, and Dec 31,1976,1,763 children underwent surgery for acute appendicitis at Cook County (Illinois) Hospital. The records of 1,640 (93%) children were available for review. No child who underwent incidental appendectomy or interval appen¬ dectomy has been included in the study. All charts from children for publication Oct 17, 1978. From the Division of General Surgery, Cook County Hospital, Chicago (Dr Janik), and the Division of Pediatric Surgery, Texas Tech University, Lubbock (Dr Firor). Dr Janik is now with The Hospital for Sick Children, Toronto. Read in part before the annual meeting of the American Pediatric Surgical Association, Hot Springs, Va, May 4, 1978. Reprint requests to Department of Surgery, Cook County Hospital, 1825 W Harrison St, Chicago, IL 60612 (Olga Jonasson, MD).


who died after their conditions were diagnosed as appendicitis were scrutinized. The number of deaths from appendicitis was verified using autopsy and death records. Of the 1,640 children, 1,089 were boys (66.4%) and 551 were girls (33.6%). Ages ranged from 6 weeks to 15 years (mean, 10 years); 136 (8.3%) were younger than 6 years, and eight (0.5%) were younger than 2 years of age.



A history of abdominal pain, vomiting, and persistent right lower quadrant tenderness, usually with fever and leukocytosis, formed the data base for the diagnosis of acute appendicitis. The duration of symptoms before admission averaged 2.0 days. Mean temperature on admission to the hospital was 38.2 °C; the mean preoperative WBC count was 14,845/cu mm. The mean duration of hospitalization from admission to discharge was 9.3 days (range, two to 65 days) and from operation to was 9.1 days (range, two to 65 days).



All children underwent preoperative resuscitation with intrave¬ nous fluids and antipyretics. The objectives of therapy were to establish an adequate urinary output and to reduce the heart rate to less than 130 beats per minute and the temperature to lower than 38.8 °C. Preoperative antibiotics were administered when clinical findings indicated a possible appendiceal perforation. Resuscitation was usually accomplished within four to eight hours. The conduct of the operation was according to the guidelines established at Cook County Hospital in 1907 by Davison.' A muscle-splitting incision was used. When possible, the appendix was removed and the stump inverted. When an appendiceal perforation was found, transperitoneal drainage of the right lower quadrant and pelvis was instituted with two Penrose drains, one to the site of the appendix and one into the pelvis, and delayed wound closure of the skin and the subcutaneous tissue was instituted. The majority of the children were managed in this fashion, with only occasional changes in this routine. Postoperative antibiotic therapy was continued only in children with proved perforation. Open wounds were irrigated with a variety of agents (normal saline, half-strength Dakin's solution, and hydrogen peroxide) and redressed at least once a day. Wounds were allowed to heal by secondary intention or were closed with sterile adhesive strips on the fourth postoperative day.

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Table 1


.—Postoperative Morbidity No.

(%) Patients 118 (49.0) 60 (25.0) 24 (10.0) 13 (5.4) 26(10.6) 241 (100.0) (12.8)

Complications Wound infections Pelvic abscess Other abdominal abscess Intestinal obstruction Other Total Overall complication rate

Table 2.—Incidence of Wound Infection No. of Patients 158


appendix Nonperforated

909 573 135 438


Primary wound closure Delayed wound closure Wound complications

No. (%) of Wound Infection

5(3.1) (4.3) (12.9) (31.9) (7.1) 118 (7.2) 39 74 43 31

Table 3.—Incidence of Intra-abdominal Abscess

No. of

appendix Nonperforated Normal

Perforated With drainage Without drainage

Patients 158 909 573 525 48

No. of Patients With Intra-abdomi-

nal Abscess

No. of Patients

With Pelvic Abscess

12 68

64 4

complications were recorded in 210 chil¬ dren, a frequency of 12.8%. Wound infections accounted for A total of 241

51 48 3


A total of 1,640 children underwent exploratory laparo¬ tomy, 1,621 (98.8%) had appendectomy, and 19 (1.2%) had

drainage of an abscess without appendectomy. Thirty-five percent of the patients (573 children) had histologie evidence of perforation of the appendix, 55.4% (909 chil¬ dren) had acute nonperforated appendicitis, and 9.6% (158 children) had a normal appendix. A total of 55% of the children younger than 6 years old had appendiceal perfora¬ tion. Although the protocol dictated that children with perforation should be managed with antibiotics, transperi¬ toneal drainage, and delayed wound closure, 92.7% received antibiotics, 91.6% had transperitoneal drainage, and only 76.4% had delayed wound closure. Penicillin G potassium, tetracycline hydrochloride, streptomycin sulfate, or some combination of these three drugs were used in 65% of patients, while 11.6% of them received an aminoglycoside sulfate in combination with penicillin or clindamycin hydrochloride hydrate. The antibiotics used and the percent usage were as follows: penicillin-streptomycintetracycline (singly or in combination, excluding penicillinstreptomycin), 52.9%; penicillin-streptomycin, 12.4%, aminoglycoside-penicillin, 9.2%; aminoglycoside-clindamycin, 2.4%; cephalothin sodium (singly or in combination), 7.2%; other, 8.6%; none, 7.3%.

49% of the complications, intra-abdominal abscesses for 35%, and the remaining 16% included intestinal obstruc¬ tion, pneumonia, urinary tract infection, and thrombophle¬ bitis (Table 1). The incidence of complications was uniformly distributed throughout the 20-year period. Wound infection occurred most frequently among children with appendiceal perforation (Table 2). The rate of wound infection in children with perforation was 7.1% when delayed wound closure was used and 31.9%- when the wound closed primarily. Intra-abdominal abscess also was occurred most frequently among children with appendiceal perforation (Table 3). Transperitoneal drainage was used in the management of 91.6% of the children with perfora¬ tion and was not used in 8.4%. The incidence of intraabdominal abscess was approximately the same in these two groups. Antibiotics were given to 92.7% of children with appen¬

diceal perforation. Analysis of the various antibiotics failed to reveal any superior antibiotic or antibiotic combi¬ nation. No antibiotic, used singly or in combination, was associated with fewer than one complication per five patients. Fewer than 10% of the children with perforation received no antibiotics, and the complication rate in this small sample was 4.8%. The percentage of complications from appendiceal perforation in relation to antibiotic therapy was as follows: penicillin-streptomycin-tetracycline (singly or in combination, excluding penicillin-strep¬

tomycin), 21.8%; penicillin-streptomycin, 21.1%; aminoglycoside-penicillin, 22.6%; aminoglycoside-clindamycin, 35.7%; cephalothin (singly or in combination), 39.0%; other, 61.2%;

none, 4.8%.

Mortality Four deaths occurred during this 20-year period, a mortality of 0.24%. No death occurred in a child younger than 9 years old or in any child with a nonperforated appendicitis. There have been no deaths in the last 870 consecutive appendectomies performed since 1964. All deaths resulted from uncontrolled postoperative sepsis among children with appendiceal perforation. The mean preadmission duration of symptoms was 3.5 days. The principles of delayed wound closure and transperitoneal drainage were not followed in three of these four children. Wound and intra-abdominal abscesses developed in all four children. COMMENT

During the last 20 years (1957-1976), 1,640 children admitted to Cook County Hospital with appendicitis have been managed with (1) intensive preoperative resuscita¬ tion, (2) abdominal exploration using a muscle-splitting incision, (3) removal of the appendix with stump inversion, (4) administration of antibiotics preoperatively when perforation was suspected and postoperatively when perfo¬ ration was confirmed at exploration, and (5) insertion of transperitoneal drains and delayed closure of the wound

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findings of perforation. Preoperative resuscitation is essential to prevent mortal¬ ity from anesthesia, hyperpyrexia, convulsions, and dehy¬ dration.2 The treatment of choice for nonperforated appen¬ dicitis is appendectomy without drainage or antibiotics, and primary wound closure. In this series, minimal morbid¬ ity and no mortality were associated with this plan. Controversy persists, however, in optimal management of the perforated appendix. The majority of the compli¬ cations and all of the mortality in this series occurred as a consequence of appendiceal perforation. In 1941, Miller et al8 recorded a 13% childhood mortality for perforated appendicitis at Cook County Hospital, whereas in 1973, Haller et al3 calculated that the continuing childhood mortality for perforated appendicitis was approximately 5%. Nonetheless, despite the serious nature of appendiceal perforation, the childhood mortality at Cook County Hospi¬ tal during the last 20 years has been reduced to less than with

is drained. This issue remains unresolved. John B. Murphy, MD,1" former attending surgeon at Cook County Hospital, pointed out in 1894 that the only proved means of reducing mortality from appendicitis are early diagnosis, prompt surgical intervention, and recognl· tion and treatment of residual septic foci. Nearly a century later, these measures, together with appropriate preopera¬ tive resuscitation, remain the mainstay of treatment.



0.7% and has been nil for the last 12 years. These results are comparable to reports from other major children's hospi¬ tals,5"·1""14 and have occurred even though the average child appears at Cook County Hospital with evidence of advanced disease as described by Stone,1'' ie, duration of symptoms longer than 1.5 days, temperature higher than 38.0 °C, and a WBC count greater than 13,000/cu mm, findings indicative of gangrene or perforation. Analysis of the incidence of complications in children with appendiceal perforation treated with antibiotics revealed that morbidity occurred regardless of the anti¬ biotic regimen used and that no antibiotic regimen was clearly superior. The now-obsolete penicillin-streptomycin combination was associated with as low an incidence of complications as the newer drug combinations. Children with appendiceal perforation who did not receive antibiot¬ ics had fewer infections, although this group was too small to constitute a statistically significant sample. These results agree with those of Shandling et al,5 who found no appreciable difference between series reported from hospi¬ tals that used antibiotics routinely and those that used antibiotics selectively. The incidence of postoperative wound infection after appendiceal perforation was substantially reduced by delayed wound closure. The advantages of transperitoneal drainage are less apparent. In the present series, where transperitoneal drains were routinely used for perforation, the incidence of intra-abdominal abscess was approximate¬ ly the same as that reported in series where drains were used more discriminately.'·5·612 The deaths recorded in the prospective analysis of transperitoneal drainage by Haller et al1 occurred in children on whom drainage was performed. In contrast, three of the four deaths in the present series occurred in children with perforation on whom drainage was not performed. Haller et al concluded that transperitoneal drainage of appendiceal perforation offers no advantage, thus implying that uncontrolled appendiceal sepsis can be fatal regardless of whether the

CONCLUSIONS The results of this study indicate the following: (1) Resuscitation with intravenous fluids and early operation is effective and successful in reducing operative mortality in appendicitis. (2) Delayed wound closure is an effective means of reducing the incidence of wound infection after appendiceal perforation. (3) Antibiotics and transperitone¬ al drainage did not appreciably reduce the incidence of intra-abdominal abscess formation after appendiceal


Until 1970, John G. Raffensperger, MD, directed the care of many of the children studied. Lynn Olufs, RN, MPH, and Harry Levine, MA, provided technical assistance.


Name and Trademark of


Cephalothin sodium—Keflin. References 1. Vital Statistics of the United States, 1950-1976. Rockville, Md, National Center for Health Statistics. Dept of Health, Education, and Welfare, Public Health Service. 2. Pledger HG, Buchan R: Deaths in children with acute appendicitis. Br Med J 4:466-470, 1969. 3. Haller JA, Shaker IJ, Donahoo JS, et al: Peritoneal drainage versus nondrainage for generalized peritonitis from ruptured appendicitis in children. A prospective study. Ann Surg 177:595-600, 1973. 4. Otherson HB, Truluck TB, Loadholt CB: Ruptured appendicitis in children: Continuing controversy over antibiotic combinations. J Pediatr

Surg 11:405-409, 1976. 5. Shandling B, Ein SH, Simpson JS, et al: Perforating appendicitis and antibiotics. J Pediatr Surg 9:79-83, 1974. 6. Stone HH, Sanders SL, Martin JD: Perforated appendicitis in children. Surgery 69:673-679, 1971. 7. Davison C: The surgical treatment of appendicitis at Cook County Hospital. Surg Gynecol Obstet 4:227-230, 1907. 8. Miller EM, Fell EH, Brock C, et al: Acute appendicitis in children: A clinical study of more than 1,000 cases. JAMA 115:1239-1242, 1941. 9. Boles ET Jr, Ireton RJ, Clatworthy HW Jr: Acute appendicitis in children. Arch Surg 79:447-454, 1959. 10. Hudson HW, Chamberlain JW: Acute appendicitis in childhood.

J Pediatr 15:408-425, 1939. 11. Lansden FT: Acute appendicitis in children. Am J Surg 106:938-942, 1963. 12. Longino LA, Holder TM, Gross RE: Appendicitis in childhood. Pediatrics 22:238-246, 1958. 13. Martin LW: Appendicitis, in Mustard WT, Ravitch MM, Snyder WH (eds): Pediatric Surgery, ed 2. Chicago, Year Book Medical Publisher Inc, 1972, pp 948-959. 14. Scott HW, Ware PF: Acute appendicitis in childhood. Arch Surg 50:258-268, 1945. 15. Stone HH: Bacterial flora of appendicitis in children. J Pediatr Surg 11:37-42, 1976. 16. Murphy JB: Appendicitis with original report, histories, and analysis of 141 laparotomies for that disease under personal observation. JAMA 22:302-308, 347-352, 387-389, 423-427, 1894.

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Pediatric appendicitis. A 20-year study of 1,640 children at Cook County (Illinois) Hospital.

Pediatric Appendicitis A 20-Year Cook Study of 1,640 Children County (Illinois) Hospital Joseph S. Janik, MD, Hugh V. at Firor, MD acute appe...
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