Abstract:
AIM To describe the pathophysiology and disease morbidity of peritoneal inflammation in childhood appendicitis and to determine whether this understanding can be applied to current management strategies to improve patient outcome. METHODS An observational study was conducted, using multivariate regression modelling, to describe disease morbidity from appendicitis-related secondary peritonitis, identify predictors of patient outcome, and evaluate current treatment strategies. Adequately powered, prospective clinical trials investigated the impact of interventions targeting appendicitis-related peritoneal inflammation and its clinical manifestations . A comparison cohort study investigated the use of clinical criteria representative of resolving peritoneal inflammation to guide postoperative antibiotic duration in appendicitis -related secondary peritonitis. A double-blinded, randomised, controlled trial (RCT) investigated warm humidified gas insufflation during laparoscopic appendicectomy as a means of preventing pneumoperitoneum-related peritoneal desiccation. RESULTS In complicated appendicitis, significant morbidity arises from secondary peritonitis. The observational study of 359 participants found a postoperative complication rate of 25% with intraabdominal infections being the most common complication (44 cases, 12%). Late ( Day 3) postoperative fever was an independent predictor of intraabdominal infections (odds ratio = 0.35, p = 0.016) while duration of postoperative antibiotic therapy was a key predictor of LOS (F = 215.5; partial 2 = 0.48; p < 0.001). The comparison cohort study of 94 participants found that using bedside clinical criteria to determine postoperative antibiotic duration shortened median LOS (5 versus 6 nights, p = 0.010). Compared to a fixed duration of therapy, readmission rates and the incidence and severity of complications were not significantly different, including intraabdominal infections (6 versus 8 cases, p = 0.562). Altering physical features of laparoscopic gas insufflation affects the peritoneal desiccation, acidosis, hypothermia, and hypoxia associated with conventional carbon dioxide pneumoperitoneum. Warm humidified insufflation gas prevents peritoneal desiccation. However, the RCT of 190 participants found no short-term benefits on postoperative opiate consumption, pain scores, and return to normal activities after laparoscopic appendicectomy in children. CONCLUSIONS Childhood appendicitis is accompanied by peritoneal inflammation and injury from secondary peritonitis and laparoscopic surgery. Management strategies that take into account the contributing factors and clinical consequences of peritoneal inflammation can reduce disease morbidity and improve practice efficiency.