Acute Appendicitis Current Issues and Controversies ( Malen MD ).pdf

7/27/2019 Acute Appendicitis Current Issues and Controversies ( Malen MD ).pdf

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Acute Appendicitis:Current Issues and Controversies

Malen M. Gellido, MD. MHPEd

April 6, 2013


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Outline

1. Anatomy, Pathophysiology, Epidemiology

1. Diagnosis Imaging modalities

2. Treatment Medical vs. Surgical

Type of surgery: open or laparoscopic


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AppendixDa Vinci (1492) Vesalius (1543)


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Anatomy and Physiology

The base is consistently foundat the confluence of the taeniaat the base of the cecum

The tip is retrocecal in 65%

Average length is 9cm

An immunologic organ that

actively participates in thesecretion of immunoglobulins,particularly immunoglobulin A


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Reginald Heber Fitz (1886)

Coined the term appendicitis


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Pathophysiology of Acute Appendicitis


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Incidence of Appendicitis

The most common of the intraabdominal inflammatorydisorders, occurring in both genders and in all agegroups.

The incidence is approximately 233/100,000population and is highest in the 10 to 19 year-old agegroup

It is also higher among men (male to female ratio of1.4:1), who have a lifetime incidence of 8.6 percentcompared to 6.7 percent for women


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Appendicitis in Children

The most common indication for emergentabdominal surgery in childhood.

Diagnosed in up to 8% of children evaluated urgently

for abdominal pain. Perforation correlates strongly with duration of

symptoms:

Neonates 83%

Young children (12 years) 10 to 20 %


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Appendicitis during Pregnancy

The most common general surgical problemencountered during pregnancy

Acute appendicitis is suspected in 1/600 to 1/1000pregnancies and confirmed in 1/800 to 1/1500pregnancies

The incidence is slightly higher in the secondtrimester than in the first and third trimesters orpostpartum


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Standard management of

Acute Appendicitis

Schwartz, Principles of Surgery, 9th

Ed


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Current Issues

1. The use of imaging modalities

2. Medical versus surgical treatment

3. Open versus laparoscopic surgery


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Current Issues

What is the role of imaging technologies in the

diagnosis of acute appendicitis?


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Current Issues

What is the role of imaging technologies in the

diagnosis of acute appendicitis?

Used mainly for equivocal cases

Children

Pregnant patients

Elderly patients


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Ultrasound


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Noncompressible tubular structure in right lower quadrant

Wall thickness of the appendix greater than 2 mm

Overall diameter greater than 6 mm

Free fluid in the right lower quadrant

Thickening of the mesentery

Localized tenderness with graded compression

Presence of a calcified appendicolith

Ultrasound findings that support the diaganosis of Appendicitis


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CT Scan


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The appendix is considered abnormal on CT scan

when:

It is distended or thickened and greater than

approximately 5 to 7 mm in diameter.

The wall of the inflamed appendix is

circumferentially thickened and may appear as ahalo or target.

CT findings of periappendiceal inflammation suggest

appendicitis; these include:

periappendiceal abscess

fluid collections

edema

phlegmon


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MRI


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Current Issues

Medical management Surgical ManagementVS.


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Medical Treatment

Amoxicillin plus clavulanic acid versus

appendicectomy for treatment of acute

uncomplicated appendicitis: an open-label, non-

inferiority, randomised controlled trial.Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B,

Karoui M, Alves A, Dousset B, Valleur P, Falissard B, Franco

Lancet. 2011;377(9777):1573.


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Medical Treatment

Postoperative peritonitis was significantly more frequent in

patients treated with amoxicillin plus clavulanic acid

compared with appendectomy (8 versus 2%).

Fourteen patients (12%) treated with antibiotics underwent

an appendectomy within 30 days of treatment.

An additional 30 patients underwent an appendectomy within

the year following antibiotic therapy, 26 of whom had

confirmed acute appendicitis.

Vons et al, Lancet 2011


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Medical Treatment

Antibiotic therapy versus appendectomy for

acute appendicitis: a meta-analysis.

Varadhan KK, Humes DJ, Neal KR, Lobo DN

World J Surg. 2010;34(2):199.


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Medical Treatment

Among the 350 patients treated with antibiotics alone, 112

(32 percent) failed initial medical therapy and were treatedwith an appendectomy.

In the 238 patients who responded to medical therapy and

did not undergo surgery during the acute episode, symptoms

recurred in 38 (16 percent) within one year and underwentappendectomy.

Histologic findings were available for 35 patients and included

phlegmon in 25, perforation in 9, and gangrene in 1.

Overall, 58 percent of the initial cohort treated withantibiotics remained asymptomatic at one year of follow-up.

Varadhan et al, World J Surg. 2010


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Surgical Treatment

Appendectomy is the gold standard treatment

of acute appendicitis.

The negative appendectomy rate should be

within 10%.


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Current Issues

Open surgery Laparoscopic surgeryVS.


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1894


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The first reported case

of appendectomy was

performed by Claudius

Amyand in 1735.


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Semm performed the first

successful laparoscopic

appendectomy in 1982.


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Open vs. Laparoscopic Surgery

Laparoscopic versus open surgery forsuspected appendicitis.

Sauerland S, Jaschinski T, Neugebauer E

Cochrane Database Syst Rev. 2010

A meta-analysis of 56 randomized trials and 11studies compared the outcomes of approximately

6000 adults and children with suspected acuteappendicitis undergoing either laparoscopicappendectomy or conventional open laparotomy


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Laparoscopic appendectomy

Advantages

A lower rate of wound

infections (odds ratio [OR]

0.43, 95% CI 0.34-0.54)

Less pain on postoperativeday 1 by the VAS pain score (8

mm, CI 5-11 mm)

Shorter duration of hospital

stay (1.1 days, CI 0.7-1.5 days)

Shorter duration for return of

bowel function

Disadvantages

A higher rate of an intra-

abdominal abscess (OR 1.77,

CI 1.14-2.76)

A longer operative time (10minutes, CI 6-15 minutes)

Higher operative and in-

hospital costs

Sauerland et al, Cochrane Database. 2010


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NOTES

Natural orifice

translumenal

endoscopic surgery

(NOTES) Transgastric

Transrectal

Transvaginal


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NOTES - Transvaginal


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Summary

Schwartz, Principles of Surgery, 9th Ed


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Thank you


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Treatment: Medical or Surgical?

1735 Claudius Amyand performed the veryfirst appendectomy

1839 Bright and Addison, described signs and symptoms

of appendicitis but surgery as treatment was not mentioned

1870 advent of anesthesia and asepsis and antiseptic techniques

allowed safer and more tolerable abdominal surgery

But Removal of the appendix was still not widely accepted


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Appendectomy Incision: What to use?

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Acute Appendicitis Current Issues and Controversies ( Malen MD ).pdf