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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? - PowerPoint PPT Presentation
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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
www.centerforprospectiveclinicaltrials.com
www.cmhcenterforminimallyinvasivesurgery.com