Transcript Appendicitis: Challenges in Management

Appendicitis:
Challenges in Management
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, MO
Questions
• Laparoscopy vs open for acute appendicitis?
• Laparoscopy vs open for perforated
appendicitis?
• How do we define perforation?
• Optimal antibiotic management for perforated
appendicitis?
• Management of patient presenting with
abscess?
• SSULS appendectomy vs 3 port laparoscopic
appendectomy?
Laparoscopy vs Open Appendectomy
Acute Appendicitis
• Less wound infx with laparoscopy
• Stapler vs cautery/endo loop technique
Laparoscopy vs Open Appendectomy
Perforated Appendicitis
• Far fewer (almost none)
wound infx with
laparoscopic approach
• Allows surgeon to
suction/irrigate under
direct visualization
• Less small bowel
obstruction (SBO)
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
Laparoscopic versus Open Appendectomy
(1105 Patients)
1998-2005
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
SBO After Perforated Appendicitis
(1105 Patients)
1998-2005
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
How Do We Define Perforation?
Hole in appendix
Stool in abdomen
Definition of Perforated Appendicitis
(Hole in appendix, fecalith in abdomen)
Impact of Strict Definition of Perforation on Abscess Rate
(2003-2007)
Before definition
(292 Pts)
Acute appendicitis
Perforated appendicitis
Abscess rate
1.7%
After definition
(388 Pts)
Abscess rate
0.8%
Before definition
(131 Pts)
After definition
(161 Pts)
Abscess rate
14.0%
Abscess rate
18.0%
PAPS, 2008
J Pediatr Surg 43:2242-2245, 2008
What is the Optimal Antibiotic
Management for Perforated
Appendicitis?
Prospective Randomized Trial
Ceftriaxone/Metronidazole vs AGC
• Under 18 years of age
• Perforated appendicitis at the time of
appendectomy
 Stool in the abdomen
 Hole in the appendix
Exclusion Criteria
• Known allergy to one of the medications
Results
Outcomes
CM
AGC
P value
WBC (x103)
9.4 +/- 3.9
9.9 +/- 4.4
0.56
LOS (Days)
6.27 +/- 2.5
6.20 +/- 3.2
0.85
IV Tx (Days)
6.0 +/- 1.5
6.2 +/- 1.1
0.48
Abscess (%)
20.4%
16.3%
0.79
AAP, 2007
J Pediatr Surg 43:79-82, 2007
Conclusions
• There is no difference in infectious
complications, recovery or defervescence
after perforated appendicitis between
Ceftriaxone/Metronidazole and AGC
• Ceftriaxone/Metronidazole is more cost-
effective than AGC
AAP, 2007
J Pediatr Surg 43:981-985, 2008
How do we manage the child presenting
with an abscess due to ruptured
appendicitis?
Prospective Randomized Trial
Initial Laparoscopic Appendectomy vs Initial Non-operative
Management for Patients Presenting with Appendicitis and Abscess
Patient Characteristics at the Time of Admission
Initial
operation
(n = 20)
Initial non-operative
management (n = 20)
P value
Age (y)
10.1 +/- 4.2
8.8 +/- 4.2
.31
Weight (kg)
37.0 +/- 16.2
37.1 +/- 20.8
.98
Body mass index (kg/cm2)
18.0 +/- 4.5
19.5 +/- 5.5
.39
White blood cell count
17.4 +/- 6.6
16.9 +/- 6.8
.84
Maximum temperature
37.8 +/- 1.0
37.7 +/- 0.9
.95
Maximum axial area of abscess (cm2)
29.2 +/- 29.7
26.2 +/- 21.1
.75
APSA, 2009
J Pediatr Surg 45:236-240, 2010
Prospective Randomized Trial
Initial Laparoscopic Appendectomy vs Initial Non-operative Management for
Patients Presenting with Appendicitis and Abscess
Initial operation
(n = 20)
Initial non-operative management
(n = 20)
P value
62.1 +/- 38.7
42.0 +/- 45.5
.06
6.5 +/- 3.8
6.7 +/- 6.6
.92
20%
25%
1.0
Doses of narcotics
9.7 +/- 4.0
7.1 +/- 15.8
.47
Total health care visits
2.8 +/- 1.1
4.1 +/- 1.0
<.001
No. of CT scans
1.5 +/- 0.7
2.1 +/- 1.1
0.4
$44,195 +/$19,384
$41,687 +/- $18,483
.68
Operation time (min)
Total length of
hospitalization (d)
Recurrent abscess after
initial treatment
Total charges
APSA, 2009
J Pediatr Surg 45:236-240, 2010
Prospective Randomized Trial
Conclusion
There is no difference in outcomes b/w
initial laparoscopic operation vs initial
non-operative management followed by
laparoscopic interval appendectomy for
patients presenting with a well-defined
abscess due to perforated appendicitis.
APSA, 2009
J Pediatr Surg 45:236-240, 2010
Can patients with perforated
appendicitis be discharged prior to
postoperative day 5?
Discharge Criteria
• Afebrile x 24 hrs.
• Regular diet
Prospective Randomized Trial
• IV vs IV/PO antibiotics for
perforated appendicitis
• 102 patients
• Definition of perforated
appendicitis
• IV/PO arm of study (7 days)
vs minimum IV antibiotics of
5 days
Prospective Randomized Trial
Patient Demographics
IV (n=52)
IV/PO (n=50)
P value
Mean age (years)
9.7 +/-4.2
10.1 +/- 4.6
0.63
Mean weight (kg)
41.2 +/-23.3
43.2 +/- 24.1
0.88
60
60
0.62
Mean maximum
temperature on
admission (oC)
37.9 +/- 1.0
38.1 +/- 1.0
0.53
Mean duration of
symptoms (days)
2.6 +/- 1.3
3.0 +/- 1.5
0.36
Male (%)
AAP, 2009
Accepted, J Pediatr Surg
Prospective Randomized Trial
Clinical Outcomes
IV (n=52
IV/PO (n=50
P value
Mean operative time (min)
41:06+/-15:36
46:30+/-19:42
0.13
Mean time to regular diet (min)
68:00+/-35:06
61:42+/-32:12
0.36
6:06+/-2:00
4:48 +/-2:36
0.01
3.1 +/-1.4
3.1+/-1.2
1.0
19
20
1.0
Mean length of stay after
operation (min)
Total visits
Postoperative abscess rate (%)
AAP, 2009
Accepted, J Pediatr Surg
Conclusion
42% (42/100) of patients in the
IV/PO antibiotic group could be
discharged before day 5 using
discharge criteria of afebrile and
tolerating a regular diet.
SSULS Appendectomy
QUESTIONS
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