Appendicitis:Challenges in Management
George W. Holcomb, III, M.D., MBAChildren’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 2006AAP 2006J Pediatr Surg 42:939-942, 2007J Pediatr Surg 42:939-942, 2007
Laparoscopic versus Open Appendectomy(1105 Patients)
1998-2005Laparoscopic (n = 628) Open (n = 477) P value
Age (years) 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
Perforated appendicitis 186 192
Mean time to SBO 8 days 58 days
Median follow-up (years) 3.5 (0.8 – 6.5) 4.9 (0.9 – 8.3)
AAP, 2006AAP, 2006J Pediatr Surg 42:939-942, 2007J Pediatr Surg 42:939-942, 2007
SBO After Perforated Appendicitis (1105 Patients)
1998-2005
Laparoscopic Open P value
Perforated appendicitis 186 192
SBO 1 (0.5%) 6 (3.1%) p = 0.03
AAP, 2006AAP, 2006J Pediatr Surg 42:939-942, 2007J Pediatr Surg 42:939-942, 2007
How Do We Define Perforation?
Stool in abdomenHole in appendix
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)
After definition
(388 Pts)
Acute appendicitis Abscess rate
1.7%
Abscess rate
0.8%
Before definition
(131 Pts)
After definition
(161 Pts)
Perforated appendicitis Abscess rate
14.0%
Abscess rate
18.0%
PAPS, 2008PAPS, 2008J Pediatr Surg 43:2242-2245, 2008J Pediatr Surg 43:2242-2245, 2008
What is the Optimal Antibiotic Management for Perforated
Appendicitis?
Prospective Randomized TrialProspective Randomized TrialCeftriaxone/Metronidazole vs AGCCeftriaxone/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
ResultsResultsOutcomes
WBC (x103) 9.4 +/- 3.9 9.9 +/- 4.4 0.56
LOS (Days) 6.27 +/- 2.5 6.20 +/- 3.2 0.850.85
IV Tx (Days) 6.0 +/- 1.5 6.2 +/- 1.1 0.480.48
Abscess (%) 20.4% 16.3% 0.79
CMCM AGCAGC PP value value
AAP, 2007AAP, 2007J Pediatr Surg 43:79-82, 2007J Pediatr Surg 43:79-82, 2007
Conclusions
• There is no difference in infectious complications, recovery or defervescence after perforated appendicitis between Ceftriaxone/MetronidazoleCeftriaxone/Metronidazole and AGC
• Ceftriaxone/MetronidazoleCeftriaxone/Metronidazole is more cost-effective than AGC
AAP, 2007AAP, 2007J Pediatr Surg 43:981-985, 2008J Pediatr Surg 43:981-985, 2008
How do we manage the child presenting with an abscess due to ruptured
appendicitis?
Prospective Randomized TrialInitial Laparoscopic Appendectomy vs Initial Non-operative
Management for Patients Presenting with Appendicitis and Abscess
Patient Characteristics at the Time of AdmissionInitial
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, 2009APSA, 2009J Pediatr Surg 45:236-240, 2010J Pediatr Surg 45:236-240, 2010
Prospective Randomized TrialInitial 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
Operation time (min) 62.1 +/- 38.7 42.0 +/- 45.5 .06Total length of hospitalization (d)
6.5 +/- 3.8 6.7 +/- 6.6 .92
Recurrent abscess after initial treatment
20% 25% 1.0
Doses of narcotics 9.7 +/- 4.0 7.1 +/- 15.8 .47Total health care visits 2.8 +/- 1.1 4.1 +/- 1.0 <.001No. of CT scans 1.5 +/- 0.7 2.1 +/- 1.1 0.4Total charges $44,195 +/-
$19,384$41,687 +/- $18,483 .68
APSA, 2009APSA, 2009J Pediatr Surg 45:236-240, 2010J 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, 2009APSA, 2009J Pediatr Surg 45:236-240, 2010J 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
Male (%) 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
AAP, 2009 AAP, 2009 Accepted, J Pediatr Surg 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
Mean length of stay after operation (min)
6:06+/-2:00 4:48 +/-2:36 0.01
Total visits 3.1 +/-1.4 3.1+/-1.2 1.0
Postoperative abscess rate (%) 19 20 1.0
AAP, 2009 AAP, 2009 Accepted, J Accepted, J Pediatr SurgPediatr 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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