Transcript Appendicitis Current Management

Appendicitis:
Current Management
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, MO
Appendicitis
History
Examination
Imaging -
Abdominal film?
Ultrasound?
CT scan?
Laparoscopic Appendectomy
•
Since 2002, used exclusively
•
Perforated, non-perforated, abscess
•
Why:
1.
Definitely fewer wound problems c/o open
operation
2.
Less small bowel obstruction
Laparoscopic Appendectomy
Personnel/Port Positions
Laparoscopic Appendectomy
Technique
• Window in
mesoappendix
• Vascular stapler
across
mesoappendix
Laparoscopic Appendectomy
Technique
• Regular stapler across
base of appendix
• Extract through 12
mm umbilical cannula
• Bag used selectively
Acute Appendicitis
(No Perforation)
• April 2003 – Nov 2006
• 609 Pts
• 3 post-op abscesses
(0.49%)
Acute Appendicitis Contained Perforation
• Perforated appendicitis (3 - 5 day hx)
• Evacuation/irrigation
• Controlled spillage
• Wound problems minimized
Acute Appendicitis Free Perforation
Hemodynamically Stable
Laparoscopic appendectomy
• reduced discomfort
• selectively
irrigate/evacuate pus
• lyse adhesions
• few wound problems
• often NGT not needed
Perforated Appendicitis
Acute Appendicitis Free Perforation
Hemodynamically Unstable
• IVF Resuscitation
• Antibx/NGT
• Open appendectomy
• Lower midline incision
• RLQ incision
• Prolonged (10 - 14 days) hospitalization
• Rare patient
Acute Appendicitis –
Definite Abscess on CT
Hemodynamically Stable
1) 5 - 7 day history
2) IVF
3) Percutaneous drainage
(radiology)
4) PICC line - antibx
5) Discharge day 3-5 if stable
6) Antibx con’t 10 - 14 days at
home
7) Return 8-10 wk. for interval
appendectomy - overnight
hospitalization
Interval Appendectomy
Why?
Levels Of Evidence
5 – Expert opinion, or applied principles from
physiology, basic science, or other conditions
4 – Case series or poor quality case control and
cohort studies
3 – Case control studies
2 – Review of case control or cohort studies with
agreement or poor quality randomized trial
1 – Prospective, randomized controlled trials
Appendectomy Studies at
Children’s Mercy
1.
Postoperative Antibiotic Regimen
for Perforated Appendicitis
• Prospective,
randomized trial
• AGC vs CM
• 50 pts each arm
• Definition of
perforation
• Hole in appendix
• Fecalith in abdomen
AAP, 2007
1.
Postoperative Antibiotic Regimen
for Perforated Appendicitis
• No difference b/w groups re: weight, gender, days of
symptoms, temperature, WBC count on admission
Table 1 – Outcomes: CM vs AGC
CM
AGC
P
Value
Time to Regular Diet (Hours)
75 +/- 48
79 +/- 41
0.68
Length of Post-Op Hospitalization (Days)
6.0 +/1 2.4
6.1 +/- 2.5
0.94
Post-Operative Abscess
15.9%
17.8%
0.81
Narcotic Charges
$258 +/- $150
$361 +/- $247
0.02
Antibiotic Charges
$1,246 +/- $490
$1,919 +/- $648
<0.001
0
1
NS
Post-Operative Wound Infection
AAP, 2007
1.
Postoperative Antibiotic Regimen
for Perforated Appendicitis
Conclusion:
Ceftriaxone(Rocephin) and metronidazole(Flagyl) offers a
more efficient, cost-effective antibiotic regimen than
ampicillin, gentamicin, clindamycin for children with
perforated appendicitis. Also, it may allow earlier
resolution of symptomatic peritoneal irritation as reflected
by lower narcotic needs.
AAP, 2007
Postoperative Antibiotic Protocol
For Perforated Appendicitis
(Without Preoperative Abscess)
Normal WBC,
Afebrile
Discharge
ROCEPHIN/FLAGYL
(5 Days)
WBC or
Febrile
Normal WBC
Afebrile
2 More Days
Antibx
WBC or
Febrile
CT
Abscess
Drain, PICC
Line – 2 Wks,
Antibx
No abscess
3 More
Days
Antibx
2.
IV vs IV/Oral Antibiotics for
Perforated Appendicitis
• Perforation defined as hole in appendix or fecalith in
abdomen
• Power analysis (alpha 0.05, power 0.8) – 75 patients
each arm
• Control: IV Ceftriaxone/Metronidazole (CM) – 5 days
minimum
• Experimental:
• Initiate CM
• If tolerating regular diet, on oral analgesics & afebrile 12 hrs,
discharge on Augmentin to complete 7 day course
• Primary endpoint:
formation
incidence of postoperative abscess
3.
Resource Utilization and Outcomes From
Percutaneous Drainage and Interval
Appendectomy for Perforated Appendicitis
with Abscess
• Retrospective study
• June 00 – Dec 06
• 52 pts
• Attempted
percutaneous drainage,
interval appendectomy
*
AAP, 2007
3.
Resource Utilization and Outcomes From
Percutaneous Drainage and Interval
Appendectomy for Perforated Appendicitis
with Abscess
Mean age –
9.0 +/- 3.9 yrs
Mean weight Mean symptoms -
34.4 +/ 18.8 kg
8.4 +/- 7-6 days
Mean volume fluid -
76.3 +/1 81.1 cc
Mean time to interval appy –
61.9 +/- 25.2 days
1.4 +/- 1.4 days
Mean post-op hosp. after interval lap appy Drain complications –
1) ileal perforation
2) colon perforation
3) bladder perforation
4) buttock/thigh abscess
AAP, 2007
3.
Resource Utilization and Outcomes From
Percutaneous Drainage and Interval
Appendectomy for Perforated Appendicitis
with Abscess
Outcome Variables
Number of CT scans
Total hospital days
Total days of drainage
Number of healthcare visits
Total charges (thousands of $)
Recurrent abscess
Repeat drainage
Mean +/- Std Dev
3.5 +/- 2.0
7.0 +/- 3.9
6.4 +/- 7.0
7.6 +/- 2.8
54.3 +/- 55.2
17.3 %
11.5%
AAP, 2007
4.
Adhesive Small Bowel Obstruction After
Appendectomy in Children: Comparison
Between the Laparoscopic and Open
Approach
Jan 98-June 05: 1105 Appendectomies-447 Open, 628 Lap.
AAP 2006
J Pediatr Surg 42:939-942, 2007
4.
Laparoscopic versus Open
Appendectomy
(1105 Patients)
Laparoscopic (n = 628)
Open (n = 477)
P Value
11.0 +/- 3.7
9.2 +/- 5.1
p > 0.05
Gender (M/F)
355/273
301/176
p > 0.05
SBO
1 (0.2%)
7 (1.5%)
p = 0.01
186
192
8 days
58 days
3.5 (0.8 – 6.5)
4.9 (0.9 – 8.3)
Age (years)
Perforated appendicitis
Mean time to SBO
Median follow-up (years)
AAP 2006
J Pediatr Surg 42:939-942, 2007
4.
SBO After Perforated Appendicitis
(1105 Patients)
Perforated appendicitis
SBO
Laparoscopic
Open
186
192
1 (0.5%)
6 (3.1%)
p value
p = 0.03
AAP 2006
J Pediatr Surg 42:939-942, 2007
5.
Prospective Randomized Trial
• Patients presenting with an abscess
• IR drainage with IV antibiotics followed
by laparoscopic interval appendectomy
vs laparoscopic appendectomy and
evacuation of abscess on admission
• Pilot study: 30 patients
Evolution in Timing of Operation
1) IV CM on admission
2) Will operate that day/night until 9-10 pm
3) If present after 9-10 pm, operate next
day (1 pm or earlier)
Conclusions
• Lap appendectomy is our preferred
approach for all forms of appendicitis
• Lap appendectomy can be performed for
perforated appendicitis and for patients
presenting with an abscess
• Lap appendectomy results in fewer
wound problems and less SBO
? ? ?
www.centerforprospectiveclinicaltrials.com
www.cmhcenterforminimallyinvasivesurgery.com