International Abstracts1216

randomised controlled study of incisional bupivacaine versus placebo

in 68 children undergoing open appendectomy. The trial medicine

(0.5 ml/kg) was infiltrated into the subcutis after wound closure. Patients

below 40 kg received bupivacaine 0.25% and children over 40 g 0.5%.

During the first 24 postoperative hours, the patients in the bupivacaine

group needed an average of 0.065 mg/kg morphine and the patients in the

placebo group 0.073 mg/kg, which was statistically not significant. The

patients in the bupivacaine group tended to experience pain relief for a

longer time than patients in the placebo group. However, this difference

was statistically not significant. It was concluded that the use of

subcutaneous infiltration with bupivacaine has no significant effect on

the use of postoperative morphine after appendectomy.

—Thomas A. Angerpointner

Minimum postoperative antibiotic duration in advanced appendicitisin children: a reviewSnelling CMH, Poenaru D, Drover JW. Pediatr Surg Int 2004 (November);

20:838-845.

Antibiotic treatment is standard after appendectomy for gangrenous or

perforated appendicitis, but evidence is limited. A standard regimen should

be characterized by a minimum duration to be cost-effective, prevent

bacterial resistance, minimize toxicities and increase patient compliance. It

was the aim of this review to determine a suitable standard for length of

antibiotic administration.

The objective was to determine if more than 3 days of treatment

improves outcome for advanced appendicitis, relative to 3 days or less.

Additional questions asked for the suitable minimum duration of antibiotic

use, for an appropriate standard for discharge, for a standard for

modification of therapy from intravenous to oral, and for criteria to

discontinue the therapy. The analysis included studies of antibiotic use in

children who had undergone appendectomy for gangrenous or perforated

appendicitis. Data on duration of antibiotic use, on antibiotic vs. placebo,

on two or more antibiotics, on parenteral or oral administration and on

inpatient or outpatient treatment were selected. The studies had to include at

least one key outcome parameter bpostoperative wound infectionQ or

babdominal abscess/infectionQ.Twenty-eight studies published between 1980 and 2002 and meeting the

inclusion criteria were found by Medline search, Cochrane database

analysis, and from bibliographies of recent reviews and personal files.

The studies comprised 2284 children.

Shortest duration of antibiotic therapy was 3 days. An increased

number of infectious complications was not found compared to a longer

treatment period. Antibiotics were stopped based on a protocol (10 studies),

on a variable base (surgeon’s discretion, clinical findings, afebrile; 18

studies) or on leucocytosis (7 studies). These criteria were criticized

because the persistence of signs of inflammation is not an indication to

continue, re-start or change antibiotics. There is no agreement concerning

discharge criteria. Free of medications, afebrile and with a normal white

cell count were mentioned in two papers. No study discharged a child to

outpatient antibiotic therapy earlier than the 4th postoperative day.

Monotherapy with a 2nd generation cephalosporin alone was judged as

less expensive, safe and effective. Therefore, the combination with

aminoglycosides should be reserved for resistant organisms and

nosocomial infections. Peritoneal cultures seemed unnecessary for

guiding therapy.

Limits of the review were that the studies had related, but not

identical purposes. Often dosages of antibiotics were not given. Differ-

ences in operative techniques and topical wound treatment were not

considered. In conclusion, early discharge to a longer oral outpatient

therapy is sensible if cost-effectiveness has priority. Shorter antibiotic

courses, but longer inpatient observation prevent bacterial resistance and

minimizes drug toxicity. It should be stated that unjustified fear of

treatment failure and a noticeable lack of interest with regard to

discerning whether less is better allowed some of the initial questions

to go unanswered.—Peter Schmittenbecher

Ileocaecal valve atresia: our surgical approachCacciari A, Mordenti M, Ceccarelli PL, et al. Eur J Pediatr Surg 2004

(December);14:435-439.

Atresia of the ileocecal valve is the rarest type of intestinal atresia. There are

very few reports on it in the literature, and all cases described to date were

treated by ileocolic resection. The authors present such a case of ileocecal

atresia, the third in the literature, in which a different technical approach

was employed as an alternative to the usual surgical technique. The patient

presented with a complicated intestinal perforation in whom an ileal stoma

was established after an unsuccessful conservative approach. Four months

later the stoma was closed. During this procedure the ileocecal valve atresia

was detected and treated by creating a new ileocecal valve and carrying out

an appendectomy. After a 7-year follow-up no complications have

occurred, and the girl enjoys very good health.

It is concluded that a plasty of Bauhin’s valve is a valid alternative to

intestinal resection.— Thomas A. Angerpointner

Surgery for ulcerative colitis in pediatric patients: functional resultsof 10-year follow-up with straight endorectal pull-throughCerati E, Deganello F, De Peppo F, et al. Pediatr Surg Int 2004 (August);

20:573-578.

The incidence of inflammatory bowel disease is increasing in all

developed countries. The annual incidence of ulcerative colitis is reported

between 1.5 and 2.14 cases per 100.000. Many patients have a long

period of complete remission, but less than 5% remain free from relapse

after 10 years from diagnosis. The aim of the paper was to present a

10 year follow-up of endorectal pull-through (ERPT).

In the 13 year interval from 1988 to 2001, 118 children affected by

ulcerative colitis were treated in the authors division of gastroenterology

and in 28 cases surgical treatment was necessary. The surgical procedure

included total colectomy, rectal mucosectomy and straight ileo-anal

anstomosis. In three cases, an ileal S-pouch was created. A telephone

follow-up asked for stool patterns and urgency periods and calculated an

incontinence score rating items for emission of gas, liquid stools, solid

stools and use of diapers. The quality of life was evaluated in terms of

school and physical activity, emotional status and social life.

Twenty-eight children (23.7%) were operated with an age of 2 to 16 at

time of operation. Mean time between diagnosis and surgery was

27.1 month. Urgent subtotal colectomy with delayed ileoanal anastomosis

for severe rectal bleeding was done in four children, elective ERPT with

temporary ileostomy in 24 patients, three of them with S-shaped pouch.

Ileostomy closure took place about 4 month after surgery. Ten complica-

tions (47%) included 4 local recurrences and two anastomotic leaks. Two

S-pouches were excised because of recurrent pouchitis. The follow-up of

24 children at 6O years after surgery demonstrated regular growth patterns,

no bladder dysfunction and no male impotence. Half of the patients had

more than six stools per day, seven reported loose or liquid stools, and

incontinence was given in 11 children. The emotional status and the social

life were reported to be normal in 72% and 66% respectively.

Ninety percent of children with ulcerative colitis have moderate to

severe disease activity. Ileal reservoir techniques are created to increase the

rectal capacity and to reduce the frequency of bowel movements. According

to that, median stool frequency is reported about four movements/day in

pouches in contrast to seven movements/day in ERPT. Early and long-term

functional results of pouches are superior to straight ERPT. Unfortunately,

the authors do not comment on their unsatisfactory results in pouch

creation. Independent from that, it is mentioned as important to assess the

impact of chronic disease on quality of life. In adults, quality of life scores

were low in inflammatory bowel disease before surgery and improved

postoperatively. The authors conclude that these data justify aggressive

surgical intervention in many patients. They pointed out that most of their

patients experience a satisfactory lifestyle even if fecal incontinence and

high frequency of defecation compromise quality of life. Finally the aspect

of financial implications is discussed with the statement that early surgery