Current practice patterns in the treatment of perforated appendicitis in children

Current Practice Patterns in the Treatment ofPerforated Appendicitis in ChildrenCatherine Chen, MD, MPH, FACS, Christine Botelho, MPH, Andrew Cooper, PhD,Patricia Hibberd, MD, PhD, Susan K Parsons, MD, MRP

BACKGROUND: The treatment of perforated appendicitis in children often involves a combination of surgicaland medical therapy. The aim of this study was to document the degree of consensus in thecurrent management of perforated appendicitis in children.

STUDY DESIGN: A survey was sent to all practicing pediatric surgeons in North America in April 2000 who weremembers of the American Pediatric Surgical Association for 1999–2000. Survey questionspertained to preoperative, perioperative, and postoperative practice patterns, particularly thoseissues related to use of antibiotic therapy.

RESULTS: Among eligible surgeons, 80.2% completed the survey. Although more than 80% of respon-dents practiced in an academic setting, only 17% of surgeons used a formal clinical practiceguideline to direct care. Responses varied substantially in the duration of postoperative antibi-otic therapy, the use of intravenous or oral agents or both, and the duration of hospitalization.A considerable number of patients are receiving a portion of their intravenous antibiotic therapyas outpatients.

CONCLUSIONS: There is little apparent consensus in the many aspects of perioperative and postoperative care ofperforated appendicitis in children across North America. Only a fraction of surgeons currentlyuses a formal clinical practice guideline for treatment of perforated appendicitis, althoughincreased pressures to develop more cost-effective therapeutic strategies can encourage devel-opment of additional guidelines. Definitive evidence to inform development of such guidelinesand enhance consensus is lacking. Further studies are needed across institutions to better informclinical decisions in light of a changing practice environment and treatment alternatives. ( J AmColl Surg 2003;196:212–221. © 2003 by the American College of Surgeons)

Acute appendicitis is the most common cause for emer-gency abdominal surgery in children, with 60,000 to80,000 cases per year in the United States.1 Acute ap-pendicitis with or without perforation is also a majorcause of hospitalization among children between theages of 1 and 14 years.2 The treatment of acute nonper-forated appendicitis remains a surgical appendectomy,either as an open or laparoscopic procedure. Once anappendix has perforated, potential morbidity increases,and controversy exists regarding many aspects of preop-

erative, perioperative, and postoperative management.Depending on the nature of the perforation, which canmanifest as free peritonitis, phlegmon, or abscess, treat-ment usually incorporates a combination of surgical andmedical therapies in the form of antibiotics.

The literature on this subject is replete with retrospec-tive studies documenting clinical outcomes of childrentreated for perforated appendicitis utilizing protocols inpractice at individual institutions.3-8 Although retro-spective studies are considered a relatively weak form ofevidence to support clinical guidelines, they do provideuseful descriptive information about clinical approacheswithin a given treatment era. More recently, with chang-ing external pressures (eg, fiscal, systems standards andefficiency, consumerism) and practice innovations (eg,intravenous devices,9 home care, oral antibiotics10),there is increasing demand for more rigorous evaluationof clinical alternatives.11 One approach has been theevaluation of clinical outcomes based on the use of stan-

No competing interests declared.

Received May 29, 2002; Revised September 4, 2002; Accepted September 9,2002.From the Department of Surgery (Chen) and Clinical Research Core Pro-gram Office (Cooper), Children’s Hospital (Parsons), Harvard MedicalSchool, Boston, MA; the Clinical Research Institute (Botelho, Hibberd),New England Medical Center, Tufts University School of Medicine, Boston,MA; and the Department of Pediatric Oncology (Parsons), Dana-Farber Can-cer Institute, Boston, MA.Correspondence address: Catherine Chen, MD, MPH, FACS, Departmentof Surgery, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115.

212© 2003 by the American College of Surgeons ISSN 1072-7515/03/$21.00Published by Elsevier Science Inc. doi:10.1016/S1072-7515(02)01666-6

dardized clinical parameters.12 This method relies on theretrospective, individualized evaluation of patient carebased on selected clinical criteria. These clinical criteriaare based on “best available evidence.”

Another approach is the development of formal clin-ical practice guidelines (CPGs) to guide patient care pro-spectively within a select population. The developmentof CPGs is part of a larger trend toward evidence-basedmedicine and quality of care. A clinical practice guide-line is defined as a systematically developed, evidence- orconsensus-based, or both, multidisciplinary plan of carefor a specific patient population that serves as a guide forclinical decision-making and as a method to ensure thatall aspects of the care process are carried out in a timelyfashion to best meet the patient’s needs.13,14 Perforatedappendicitis is an entity that can lend itself clinically toguidelines use because the natural progression of diseasecan be predicted once the diagnosis is suspected. Thesubsequent aspects of perioperative and postoperativemanagement can often be delineated in advance. Todate, most CPGs reflect institution-specific standards ofpractice, relying principally on “expert opinion” ratherthan explicit evidence from the literature to informmany aspects of care for perforated appendicitis.14-16 Thepotential for bias or inadvertent exclusion of other stake-holders (eg, families, other medical personnel) weakensguidelines, particularly those based on expert opinionalone. Given the lack of definitive evidence and the in-herent limitations of guidelines based on expert opinion,we surveyed practicing North American pediatric sur-geons in the year 2000 regarding their current practicepatterns in treating this common entity to determinewhether or not consensus existed in the current manage-ment of perforated appendicitis in children, particularlyrelated to use of antibiotic therapy.

METHODSStudy populationA 28-question survey was mailed on April 10, 2000 tothe complete North American membership of the Amer-ican Pediatric Surgical Association (APSA) for 1999–2000 (see Figure 1, copy of survey). The study was re-

viewed and approved by the Institutional Review Boardat Children’s Hospital, Boston, MA. The study popula-tion included 663 pediatric surgeons across the UnitedStates, Canada, and Puerto Rico. Although the surveywas initially sent to all North American APSA members,143 retired members (as identified by the APSA roster)were deemed ineligible and were excluded from the anal-ysis because the purpose of the study was to elicit infor-mation on current practice. In addition, six surgeonswere deemed to be ineligible because of further special-ization or retirement unknown to APSA. Five hundredfourteen surgeons were deemed eligible for the study andcomprise the “revised eligibles” group. See Figure 2 fordetails on survey respondents.

SurveySurveys were self-administered and were coded with aunique identification number to allow for subsequentmailings but with assurance of confidentiality of re-sponses. Questions concerning each respondent’s site ofpediatric surgery training or current place of employ-ment were not included. Participation was voluntaryand a return was taken as consent. No honorarium wasoffered. The survey was designed to minimize free-textresponses. The only questions that allowed free text werethose with an “other” response, for which space was al-lotted to specify the response. Written responses in themargins and on the back of the survey were discussedand categorized into the existing categories or a new“other” category by Drs Chen and Hibberd before dataentry. A second mailing was sent on May 10, 2000 to alleligible surgeons who had not returned the survey fromthe initial mailing within one month. A third and finalmailing was sent on June 9, 2000 to eligible surgeonswho had not responded to the second survey within twoweeks. Data collection was officially closed on June 30,2000.

Statistical methodsData were entered into an Access database designed bythe Clinical Research Core Programs Office at Chil-dren’s Hospital in Boston and then imported into SASstatistical software (SAS Institute, Cary, NC) for analy-sis. Descriptive statistics were performed for each surveyitem.

Abbreviations and Acronyms

CPG � clinical practice guidelineAPSA � American Pediatric Surgical Association

213Vol. 196, No. 2, February 2003 Chen et al Perforated Appendicitis in Children

Figure 1.

214 Chen et al Perforated Appendicitis in Children J Am Coll Surg

Figure 1. Continued.






RESULTSCompletion ratesThe completion rate from the first mailing was 361 of514 (70.2%). The second mailing increased the comple-tion rate to 406 of 514 (79.0%) with little incrementalgain after the third and final mailing. The final comple-tion rate was 412 of 514 (80.2%). Among the 102 non-respondents, 11 were unable to be reached at the avail-able addresses provided by APSA. Ninety-one surgeonsdid not return a completed survey (Fig. 2).

Description of the sampleThe majority of respondents practiced in an academicsetting, with 49% of surgeons working in academicteaching children’s hospitals and 32% of surgeons work-ing in academic teaching hospitals for both pediatric andadult patients. Only 17% of respondents described theirhealth care facility as a community hospital. Over half(57%) of respondents worked in hospitals with 100 to249 pediatric beds and another 27% of surgeons workedin smaller hospitals with 1 to 99 pediatric beds. Almost

half (47%) of respondents worked in small group prac-tices consisting of 1 to 3 full-time pediatric surgeons,while another 44% of surgeons worked in groups of 4 to7 pediatric surgeons. More than one-third (36%) of re-spondents reported more than 50 cases of perforatedappendicitis at their institution in 1999, 32% of sur-geons reported between 26 to 50 cases, and 26% ofrespondents reported 11 to 25 annual cases.

Guidelines useThe majority of surgeons (59%) base their clinical prac-tices on individual surgeon’s preferences. Another 24%of respondents use informal guidelines based on a con-sensus of surgeons in the practice group. Surprisingly,only 17% of surgeons have formal clinical practiceguidelines to direct care of patients with perforatedappendicitis.

Practice patternsTable 1 summarizes survey results, which address preop-erative and perioperative practice patterns. More than

Figure 2. Survey respondents. APSA, American Pediatric Surgical Association.


half (58.1%) of respondents use abdominal computer-ized tomography as the diagnostic test of choice if nec-essary for diagnosing perforated appendicitis. Abdomi-nal ultrasonography is used by 34.5% of surgeons.During appendectomy for perforated appendicitis,42.8% of responding surgeons routinely culture theperitoneal fluid and the remaining surgeons do not. Themajority of surgeons (81.7%) do routinely irrigate theabdominal cavity and 18.3% do not. The use of perito-neal drains remains controversial, with 8.1% of surgeonsstating they always use peritoneal drains, 51.6% of sur-geons using them only if an abscess is found, and 40.3%of surgeons stating they do not use them at all. Thosesurgeons who do use peritoneal drains are nearly evenlysplit in their choice of type of drain; 45.0% of surgeonschoose closed suction drains such as Jackson-Prattdrains, while 52.1% of surgeons prefer open passivedrains such as penrose drains. The use of subcutaneousdrains is less controversial with the majority of respon-

dents (72.9%) stating they never use such drains. Nearly5% of surgeons state they always use subcutaneousdrains, while 22.5% of surgeons use them for specificindications, such as gross soilage of the wound (13.7%),or obesity (10.8%). Finally, there is little variability re-garding wound management, with 79.7% of surgeonsusing primary closure. More than 10% of surgeons leavethe wound open with packings, and 7.3% perform de-layed primary closure.

Postoperative practice patterns are summarized in Ta-ble 2. Nearly all surgeons (99.8%) prescribe intravenousantibiotics in the postoperative period. Although the

Table 1. Preoperative and Perioperative Management ofPerforated Appendicitis

# usingapproach %

PreoperativeDiagnostic testing (N � 406)

Abdominal ultrasound 140 34.5Abdominal computerized tomography 236 58.1

PerioperativeRoutine culturing of peritoneal fluid (N � 409)

Yes 175 42.8Routine irrigation of abdominal cavity (N � 409)

Yes 334 81.7Use of peritoneal drainage (N � 407) 243

Always 33 8.1Only if abscess 210 51.6

Type of drain used 242Closed suction drain (eg, JP) 109 45.0Open passive drain (eg, penrose) 126 52.1Other 7 2.9

Use of subcutaneous drainage (N � 409)Always 19 4.6Sometimes (answer all that apply) 92 22.5

Gross soilage of wound 56 13.7Obesity 44 10.8

Wound management (N � 409)Primary closure 326 79.7Leave open and pack 42 10.3Delayed primary closure 30 7.3Other 11 2.7

JP, Jackson-Pratt.

Table 2. Postoperative Management of Perforated Appendi-citis

# usingapproach %

IV antibiotic use (N � 409)Yes 408 99.8

Duration of IV antibiotic use (N � 405)1–3 days 13 3.24–5 days 131 32.36–7 days 126 31.18–10 days 47 11.6�10 days 8 2.0Other 80 19.8

Use of home IV therapy (N � 404)Yes 198 49.0

Oral antibiotic use (N � 411)Yes 107 26.0

Duration of oral antibiotic use (N � 106)1–3 days 2 1.94–5 days 28 26.46–7 days 50 47.28–10 days 15 14.2�10 days 6 5.7Other 5 4.7

Initiation of oral antibiotics (N � 106)Immediately after operation 2 1.9Once patient tolerating oral diet 35 33.0After completion of IV antibiotic course 52 49.1At discharge 6 5.7Other 11 10.4

Typical length of hospitalization (N � 410)1–3 days 14 3.44–5 days 207 50.56–10 days 174 42.4�10 days 1 0.2Other 14 3.4

Performance of interval appendectomy (N � 411)Yes 353 85.9


majority of respondents treat patients with postopera-tive intravenous antibiotics according to a predeter-mined length of therapy, there is considerable variabilityin the duration of intravenous antibiotic therapy. Morethan 32% of surgeons treat their patients for 4 to 5 days,31.1% of surgeons treat for 6 to 7 days, and 16% ofsurgeons treat for lengths of time dependent on the pa-tient’s clinical course. Many survey respondents speci-fied the clinical criteria that had to be met before discon-tinuation of intravenous antibiotic therapy. Theseincluded normalization of white blood cell count or dif-ferential or both, absence of fever, and return of bowelfunction with ability to tolerate oral diet. Interestingly,49.0% of surgeons stated they use home intravenoustherapy in the postoperative management of patientswith perforated appendicitis.

In contrast to the universal use of intravenous antibi-otics, only 26.0% of respondents use oral antibioticspostoperatively with considerable variability in the selec-tion of oral regimens (data not shown). Among thoseusing oral antibiotics, both the duration of therapy andtime of initiation also varied. Specifically, 75.5% of re-spondents reported using oral agents a week or less.Nearly half initiated therapy after completion of an in-travenous antibiotic course (49.1%), while 33.0% of thegroup initiate oral therapy once the patient is toleratingan oral diet. Respondents stated the typical length ofhospitalization to be 4 to 5 days in 50.5% of cases, and 6to 10 days in 42.4% of cases. The vast majority of sur-geons (85.9%) perform interval appendectomy in chil-dren initially treated nonoperatively for perforated ap-pendicitis with appendiceal mass. We did not elicitfurther details from respondents regarding initial man-agement of these patients.

DISCUSSIONThis survey of APSA members was designed to docu-ment current practice patterns in the treatment of per-forated appendicitis in children across North Americaand is a first step to understand if there is consensus orvariability in practice patterns among practicing NorthAmerican pediatric surgeons. These results can providean impetus to further examine many of the current prac-tices critically using prospective, multiinstitutional stud-ies. This survey highlights considerable variability in thecare of children with perforated appendicitis acrossNorth America, which might influence clinical out-comes, length of hospitalization, site of medical care,

and patient-centered outcomes, such as quality of life.The full implications of this variability have not beenwell described and are not addressed by this survey.

One of the major limitations of the data is potentialclustering of responses based on common practiceswithin an institution where a respondent was trained oris currently employed. We did not specifically elicit suchdescriptive data to protect confidentiality. Data reportedherein assume that this is an independent sample; thedegree of overstatement from possible clustering is notknown. Given this concern, we elected not to addresspossible differences in practice patterns among surgeonswho use CPGs compared with those who do not, al-though this issue should be addressed in future studies.

Our survey focused on perioperative and postopera-tive practices, but was not designed to inquire about allpossible practice patterns related to the care of childrenwith perforated appendicitis. The survey was purposelydesigned succinctly to encourage a maximal responserate. An emphasis was placed on understanding practicepatterns related to use of intravenous or oral antibioticsor both in the postoperative period with regard to dura-tion of therapy and site of care. Considerable variabilityin initial choice of specific antibiotics was noted becauseof the range of agents (data not shown), though respon-dents were not asked to clarify the timing of use of par-ticular antibiotic regimens. In addition, this survey didnot address the use of laparoscopy to remove the appen-dix, or the role of initial medical therapy with antibioticsrather than immediate appendectomy for perforated ap-pendicitis or the use of percutaneous drainage of periap-pendiceal abscesses, usually by interventional radiolo-gists, in the initial management of this entity. Severalrespondents commented on the need to define “perfo-rated appendicitis,” because management can vary forspecific clinical presentations, including perforationwith generalized peritonitis, perforation with localizedphlegmon, or perforation with localized abscess. Despitethese limitations, our data confirm the considerable vari-ability that exists in preoperative, perioperative, andpostoperative practice patterns, indicating lack ofconsensus.

Despite the prevalence of acute appendicitis, ourstudy confirms that there is little consensus about theextent and appropriateness of care. Virtually every aspectof the clinical management of these children has beencontroversial. One potential mechanism to evaluatepostoperative care would be with CPGs. Surprisingly,


only 17% of respondents in this survey used a formalCPG, though the methods used to inform their devel-opment (ie, expert opinion, consensus, or evidence-based) were not explicitly elicited by the survey. CPGscould standardize care and facilitate prospective analysisof clinical and patient-centered outcomes, providingthey are developed from the highest possible levels ofevidence, such as randomized controlled trials (Level 1evidence) or other experimental studies (Level 2 evi-dence), ideally multiinstitutional in design.17 The con-temporary approach to postoperative antibiotic treat-ment, in particular, given enhanced treatmentalternatives such as the increased availability of broad-spectrum oral antibiotics for children and a changingclinical environment, including the growing trend toreduce hospitalizations, warrants careful prospectiveevaluation, relying on rigorous experimental design.

Author ContributionsStudy conception and design: Chen, Botelho, HibberdAcquisition of data: Chen, BotelhoAnalysis and interpretation of data: Chen, Botelho,

Hibberd, ParsonsDrafting of manuscript: Chen, ParsonsCritical revision: Chen, Botelho, Hibberd, ParsonsStatistical expertise: Cooper, HibberdSupervision: Chen

Acknowledgment: The authors thank Frances Williams forhelp with the mailings of the surveys, James DiCanzio forstatistical support, and Anne-Maria Fiorino and Venee Tub-man for data management.

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Current practice patterns in the treatment of perforated appendicitis in children