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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