Invited Commentary

Few issues in surgery generate more debate or elicit more management protocols than the treatment of appendicitis with perforation. Although there has been essentially no change in the incidence of appendiceal perforation in children over the past four decades, morbidity and mortality have markedly improved. The study by Keller et al further supports the improved outcome for these patients. Unfortunately, in this small series, the authors chose to combine their reporting of perforated and gangrenous appendicitis, which diminishes the impact of their conclusions.

The authors' main point of emphasis is the shortened hospitalization and resulting cost savings based on a comparison with the gold standard. This refers, in part, to a protocol I developed that was instituted in 1976.¹ The protocol included a 9-day course of intravenous antibiotics and an additional 24 hours of hospital observation. At that time, the morbidity from perforated appendicitis was high and length of