current management of children with appendicitis cipesur meeting november 18, 2011 george w....
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Current Management of Children with Appendicitis
CIPESUR MeetingNovember 18, 2011
George W. Holcomb, III, M.D., MBA
Surgeon-in-ChiefChildren’s Mercy Hospital
Kansas City, Missouri
Three Presentations
• Acute appendicitis 60 - 65%
• Perforated appendicitis 25 - 30%
• Perforated appendicitis with well-defined abscess (5-7 day history)
5 - 10%
Surgical History for Appendicitis (U.S.)
1990 – 2000
• Slow adoption for laparoscopic approach
• Why – Relatively small open incision (c/w
splenectomy, fundoplication, cholecystectomy)
Many cases done middle of night – OR crews not used to laparoscopy
Benefits were not well appreciated
Surgical History for Appendicitis (U.S.)
2000 – 2010• Laparoscopic approach now favored
(exclusively used at many centers including CMH) for all conditions: acute, perforated, abscess
• Why Operative times improved – closure faster Significantly fewer wound infections (almost
none) Improved cosmesis, esp if infection develops
Laparoscopic AppendectomyPersonnel/Port Positions
Laparoscopic AppendectomyTechnique
• Window in mesoappendix
• Vascular stapler across mesoappendix
Postoperative Appearance3 Port Laparoscopic Appendectomy
Acute Appendicitis(No Perforation)
• April 2003 – Nov 2006
• 609 Pts – laparoscopic appendectomy
• 3 post-op abscesses (0.49%)
Acute Appendicitis Appendiceal Perforation
• Perforated appendicitis (3 - 5 day hx) Evacuation/irrigation of purulent material Wound problems minimized 20% post-op abscess rate
Laparoscopic Appendectomy
Please use this link if you experience problems viewing the video above.
Laparoscopic vs Open AppendectomyPerforated Appendicitis
• Far fewer (almost none) wound infection with laparoscopic approach
• Allows surgeon to suction/irrigate under direct visualization
• Less postoperative 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)
Laparoscopic (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(378 Patients)
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
2000 – 2010 Questions
1) Do we operate in the middle of the night?
2) Is there an optimal antibiotic regimen for perforated appendicitis?
3) How do we define perforated appendicitis?
4) How do we manage the patient presenting with an abscess?
5) Which is better: SSULS or 3 port appendectomy?
1. When to Operate?Current Practice at CMH
• Patients identified with appendicitis are booked for laparoscopic appendectomy
• All receive a dose of rocephin (50mg/kg) and flagyl (30mg/kg)
• This antibiotic regimen was shown to be most cost effective in PRT
• If patients present at night, the operations are scheduled for the ‘surgeon of the week’ the next day (8 am or 1 pm start)
• Appendectomies rarely occur after 10 PM at night
Antibiotics Only vs Appendectomy For Non-Perforated Appendicitis
Liu K, Ahanchi S, Pisaneschi M, et al. Can acute appendicitis be treated by Liu K, Ahanchi S, Pisaneschi M, et al. Can acute appendicitis be treated by antibiotics alone? Am Surg 73:1161-1165, 2007antibiotics alone? Am Surg 73:1161-1165, 2007
• Retrospective comparative study (Level 3 study) in adults found no differences in complications between appendectomy at presentation or antibiotic therapy alone
• 5% recurrence rate
Early Operation Versus Delayed OperationAbou-Nukta F, Bakhos C, Arroyo K, et al. Effects of delaying Abou-Nukta F, Bakhos C, Arroyo K, et al. Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg 141:504-506, 2006141:504-506, 2006
• Retrospective comparison in adults (Level 3 study) between operation < 12 hrs or > 12 hours after presentation
• 308 patients
• No differences in OR time, complications, % with advanced appendicitis, or length of stay
Operation At Presentation Versus The Following Day
Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J surgery in acute appendicitis: Do we need to operate during the night? J Pediatr Surg 39:464–469, 2004.Pediatr Surg 39:464–469, 2004.
• Retrospective comparison in children (Level 3 study) between operation < 6 hrs after presentation or the following day
• 126 patients (38 early vs 88 late)
• No differences in operating time, perforation rate, or complications
The remaining four questions can be answered from studies
at Children’s Mercy
5 – Expert opinion, or applied principles from physiology, basic science, or other conditions
4 – Case series or poor quality case control and cohort studies
3 – Case control studies
2 – Review of case control or cohort studies with agreement or poor quality randomized trial
1 – Prospective, randomized controlled trials
Levels Of Evidence
2. Is There an Optimal Antibiotic Management for Perforated
Appendicitis?
• Prior to 2000, most pediatric centers in the U.S. were treating patients with intraabdominal infections with Ampicillin, Gentamicin and Clindamycin (Triple Antibiotic Therapy)
• Triple antibx provide good coverage; inexpensive
But• Gentamicin known to be toxic to hearing and
renal function
• Serum levels recommended for Gentamicin use
• Same broad spectrum coverage as triples
• The duo of Ceftriaxone and Metronidazole require no serum levels
• Ceftriaxone and Metronidazole has been shown to be safe and effective in once/day dosing
• Daily dosing allows easy transition to outpatient IV therapy, if needed
Why Not Use Ceftriaxone/Metronidazole?
Advantages
Retrospective ReviewRetrospective Review
• 250 patients w/perforated appendicitis - 1998 - 2004
• Those treated with Ceftriaxone/Metronidazole were compared to those treated with triple antibiotic coverage (Ampicillin, Gentamicin, Clindamycin)
• Retrospective Study (Level 3 study)
• Parameters included temperature curves for the first 5 post-operative days, abscess rate, length of hospitalization, length of intravenous antibiotic treatment and medication charges
CAPS, 2005CAPS, 2005J Pediatr Surg 41: 1020-1024, 2006J Pediatr Surg 41: 1020-1024, 2006
Retrospective ResultsRetrospective Results
Outcomes
WBC (x103) 9.8 +/- 0.5 11.6 +/- 0.4 0.10
LOS (Days) 6.8 +/- 0.4 7.9 +/- 0.2 0.03
IV Tx (Days) 7.2 +/- 0.5 8.6 +/- 0.4 0.05
Abscess (%) 8.8% 14.2% 0.37
C/MC/M A/G/CA/G/C P ValueP Value
CAPS, 2005CAPS, 2005J Pediatr Surg 41: 1020-1024, 2006J Pediatr Surg 41: 1020-1024, 2006
ResultsResultsTemperature Curves
36.5
37
37.5
38
38.5
Admission 1 2 3 4 5
Post-Operative Days 1 - 5
Tm
ax (
Deg
rees
Cel
siu
s)
C/M
A/G/C*
**
**
* P < 0.001
CAPS, 2005CAPS, 2005J Pediatr Surg 41: 1020-1024, 2006J Pediatr Surg 41: 1020-1024, 2006
ResultsResultsMedication Charges
Expense of dose ($ dose) = (drug price + dispensing charge )
Expense of course = ($ dose) x (# doses/day) x (days of treatment)
CAPS, 2005CAPS, 2005J Pediatr Surg 41: 1020-1024, 2006J Pediatr Surg 41: 1020-1024, 2006
ResultsResultsMedication Charges
Ceftriaxone Dose Charge = ( Ceftriaxone Dose Charge = ( $19.48$19.48 + $28.13 ) + $28.13 )
Expense of Course = ($47.51) x (1 dose/day) x (7 days) = Expense of Course = ($47.51) x (1 dose/day) x (7 days) = $332$332
Ampicillin Dose Charge = ( Ampicillin Dose Charge = ( $0.38$0.38 + $28.13 ) + $28.13 )
Expense of Course = ($28.51) x (4 doses/day) x (7 days) = Expense of Course = ($28.51) x (4 doses/day) x (7 days) = $798$798
Impact Of Nursing ChargesImpact Of Nursing Charges
CAPS, 2005CAPS, 2005J Pediatr Surg 41: 1020-1024, 2006J Pediatr Surg 41: 1020-1024, 2006
ResultsMedication Charges
$ of Course
C/M A/G/C
P Value < 0.0001
$546.01 +/- $29.34$546.01 +/- $29.34 $2494.06 +/- $78.44$2494.06 +/- $78.44
CAPS, 2005CAPS, 2005
J Pediatr Surg J Pediatr Surg 41:1020-1024, 2006. 41:1020-1024, 2006.
With this information, is there any reason
to perform a prospective randomized trial
comparing Ceftriaxone/Metronidazole to
Triple Antibiotic Therapy (Ampicillin,
Gentamicin, Clindamycin) for perforated
appendicitis?
Why A Prospective, Randomized Trial?Why A Prospective, Randomized Trial?
Weaknesses• Retrospective
• Uneven numbers between groups
• Postoperative care not standardized
• Recent experience vs historical experience creates bias
Far more laparoscopy in recent cohort (C/M)
(47% in C/M group vs 2% in A/G/C group)
Experience w/laparoscopy improved
Pressures to discharge sooner in recent cohort independent of medication regimen?
Prospective Randomized TrialProspective Randomized Trial• Ceftriaxone/Metronidazole or A/G/C
• Perforated appendicitis at the time of appendectomy Hole in the appendix Visible appendicolith in the abdomen
• Power 0.8; alpha 0.05; sample size 100
Exclusion Criteria• Known allergy to one of the medications
Standardized Management
• All patients receive 5 days IV antibiotics
• Diet begins after flatus
• WBC drawn on POD 5
• Nl WBC count and tolerating PO’s w/o fever meets discharge criteria
• If elevated, draw again on POD 7, then if elevated, draw on POD 10 and obtain CT
• No antibiotics on discharge
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
C/MC/M A/G/C P ValueP Value
AAP, 2007AAP, 2007J Pediatr Surg 43:79-82, 2007J Pediatr Surg 43:79-82, 2007
ResultsResultsMedication Charges
Total Meds $3370 $3817 0.20
% of Med Charges 4.5% 6.1% <0.001
C/MC/M A/G/CA/G/C P ValueP Value
IV Abx $1412 $1940 <0.001
AAP, 2007AAP, 2007J Pediatr Surg 43:981-985, 2008J Pediatr Surg 43:981-985, 2008
Triples
C/M
36.5
37
37.5
38
38.5
39
Admission 1 2 3 4 5
Post-Operative Day
Max
Tem
eper
atu
re (
Deg
rees
Cel
siu
s)
ResultsTemperature Curves
AAP, 2007AAP, 2007J Pediatr Surg 43:981-985, 2008J Pediatr Surg 43:981-985, 2008
Conclusions
• There is no difference in infectious complications, recovery or defervescence after perforated appendicitis between Ceftriaxone/Metronidazole and Triples (A/G/C)
• Ceftriaxone/Metronidazole is more cost-effective than standard triple antibiotic therapy
AAP, 2007AAP, 2007J Pediatr Surg 43:981-985, 2008J Pediatr Surg 43:981-985, 2008
• The literature is replete with retrospective studies regarding perforated appendicitis
• All of these studies fail to strictly define perforation
Dependent on surgeon’s definition
“Gangrenous”, “suppurative”, “perforated”
• Therefore, the conclusions from these retrospective reports must be approached cautiously
3. How Do We Define Perforated Appendicitis?
J Pediatr Surg 43:2242-2245, 2008J Pediatr Surg 43:2242-2245, 2008
Post-operative Antibiotic Regimen For Post-operative Antibiotic Regimen For Perforated Appendicitis In Children: A Perforated Appendicitis In Children: A
Prospective Randomized TrialProspective Randomized Trial
• April 2005 - November 2006
• 100 patients
• To ensure accurate data, the two groups had to be equal and a definition had to be created
Visible appendicolithHole in appendix
Definition of Perforation Used in Prospective Randomized Trial
HypothesisHypothesis• A correct definition of perforation (DOP) is important
because Provides us with the information to safely and efficiently treat
patients Allows us to better identify which patients are at risk for
developing postoperative complications
• If our definition of perforation was correct There should be no increase in abscess rate in the cohort of
patients treated as non-perforated appendicitis after the definition was used
• If our definition of perforation was incorrect There should be an increase in abscess rate in the cohort of
patients treated as non-perforated appendicitis after the definition was used (b/c of under-treatment)
ResultsResults OutcomesOutcomes
NON-Perforated
Prior DOP(n=292)
After DOP(n=388)
Abscess rate 1.7% 0.8%
LOS (days) 1.9 +/- 1.3 1.5 +/- 1.5
Perforated Prior DOP(n=131)
After DOP(n=161)
Abscess rate 14.0% 18%
LOS (days) 9.4 +/- 4.2 7.4 +/- 8.8
PAPS 2008PAPS 2008 J Pediatr Surg 43:2242-2245, 2008J Pediatr Surg 43:2242-2245, 2008
ConclusionsConclusions
• Our strict DOP (either a visible hole in the appendix or appendicolith in the abdomen) has been shown to be safe No increase in abscess rate for non-perforated patients No detectable risk of under treating patients defined as non-
perforated
• This DOP will improve overall care for children with appendicitis Eliminate unnecessary antibiotic treatment Improve cost management Simplify treatment protocols Improve the integrity of clinical data Allow for ongoing clinical research
PAPS 2008PAPS 2008J Pediatr Surg 43:2242-2245, 2008J Pediatr Surg 43:2242-2245, 2008
4. How do we manage the child presenting with an abscess due to
ruptured appendicitis?
Perforated AppendicitisPerforated AppendicitisPresenting With AbscessPresenting With Abscess
• Open operation for abscess is difficult
• Percutaneous drainage has been described and applied
• Laparoscopy is being used to treat perforated appendicitis and abscess
• Which is better?
HistoryHistory
Perforated Appendicitis with Abscess
1) 5 - 7 day history
2) Dehydrated – needs IVF
3) Percutaneous drainage (interventional radiology)
4) PICC line - antibiotics
5) Discharge day 3-5 if stable
6) Antibiotics con’t 10 - 14 days at home
7) Return 8-10 wk. for interval appendectomy (to prevent recurrent appendicitis) - overnight hospitalization
Retrospective Experience with Interval Appendectomy
• 52 patients – 2000-2006
• Total hospital days = 7.0 +/- 3.9
• Total healthcare visits = 7.6 +/- 2.8
• Total number of CT scans = 3.5 +/- 2.0
• Recurrent Abscess = 10 pts (19.2%)
AAP, 2007AAP, 2007JJ Pediatr Surg 43:981-985, 2008Pediatr Surg 43:981-985, 2008
Perforated Appendicitis with Perforated Appendicitis with Abscess Abscess
Prospective Trial• Drainable abscess
• OR for laparoscopic appendectomy vs percutaneous drainage as initial management
• Drain groups undergoes laparoscopic appendectomy at 10 weeks.
• Quality of life surveys at admission, at 2 weeks and at 12 weeks
• Pilot study – 40 patients
APSA 2009APSA 2009J Pediatr Surg 45:236-240, 2010J Pediatr Surg 45:236-240, 2010
Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting
with an Abscess
APSA 2009APSA 2009J Pediatr Surg 45:236-240, 2010J Pediatr Surg 45:236-240, 2010
Patient Characteristics at the Time of Admission
Initial operation (n=20)
Initial nonoperative management (n=20)
P
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
Values are expressed as mean ± SD
Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with
an Abscess
APSA 2009APSA 2009J Pediatr Surg 45:236-240, 2010J Pediatr Surg 45:236-240, 2010
Outcomes Comparing Initial Operation and Initial Abscess Drainage Followed by Interval Appendectomy
Initial operation (n = 20)
Initial nonoperative management (n = 20)
P
Operation time (min) 62.1 ± 38.7 42.0 ± 45.5 .06
Total 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 .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 .04
Total charges $44,195 ± $19,384 $41,687 ± $18,483 .68
Values are expressed as mean ± SD, unless otherwise indicated
Prospective Randomized Trial
• Conclusion – There is no difference b/w initial laparoscopic operation vs initial non-operative management followed by laparoscopic interval appendectomy
• Management can be determined by the surgeon’s preference and experience
APSA 2009J Pediatr Surg 45:236-240, 2010
5. Is there an advantage
performing the laparoscopic
appendectomy through a single
umbilical incision?
SSULS Appendectomy
SSULS Appendectomy
Please use this link if you experience problems viewing the video above.
Postoperative Appearance
Prospective Randomized Trial
• 360 total patients
• Acute non-perforated appendicitis
• August 09 – November 10
• Primary outcome variable – postoperative wound infection
• Standardized pre and postoperative management
• Quality of life surveys at 6 weeks and 6 months
Single Umbilical Incision vs 3-PortLaparoscopic Appendectomy
Patient Characteristics at Operation
Single Incision (N=180)
3-Port (N=180)
P-value
Age (yrs) 11.05 ± 3.47 11.04 ± 3.41 0.98
Weight (kg) 42.7 ± 18.5 42.5 ± 17.4 0.90
Gender (% male) 54.4% 51.1% 0.53
Leukocyte count 14.7 ± 5.2 14.6 ± 5.4 0.89
American Surgical Assn – 2011American Surgical Assn – 2011Ann Surg 254:586-590, 2011Ann Surg 254:586-590, 2011
Outcome Data
Single Incision (N=180)
3-Port (N=180)
P-value
Wound Infection 3.3% 1.7% 0.50
Operative Time (mins) 35.2 ± 14.5 29.8 ± 11.6 <0.001
Postoperative Length of Stay (hours)
22.7 ± 6.2 22.2 ± 6.8 0.44
Hospital Charges ($) 17.6K ± 4.0K 16.5 ± 3.8K 0.005
American Surgical Assn – 2011American Surgical Assn – 2011Ann Surg 254:586-590, 2011Ann Surg 254:586-590, 2011
Summary
• There have been significant changes in the surgical management of appendicitis
• These changes have revolved around timing of surgery and the almost exclusive use of the laparoscopic approach
• Unclear if appendicitis will be a surgical disease in the future
QUESTIONS
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