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Current Management of Children with Appendicitis

Current Management of Children with Appendicitis. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri. Surgical History for Appendicitis. Reginald Fitz: pathologist 1886 – Described pathology of the appendix Termed the disease: appendicitis

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Current Management of Children with Appendicitis

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  1. Current Management of Children with Appendicitis George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

  2. Surgical History for Appendicitis • Reginald Fitz: pathologist • 1886 – Described pathology of the appendix • Termed the disease: appendicitis • Charles McBurney: surgeon • 1889 – Described classical sign for appendicitis • Kurt Semm: gynecologist and engineer • 1981 – 1st laparoscopic appendectomy

  3. Three Presentations

  4. Surgical History for Appendicitis 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

  5. Surgical History for Appendicitis 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

  6. Laparoscopic AppendectomyPersonnel/Port Positions

  7. Laparoscopic AppendectomyTechnique • Window in mesoappendix • Vascular stapler across mesoappendix

  8. Postoperative Appearance3 Port Laparoscopic Appendectomy

  9. Acute Appendicitis(No Perforation) • April 2003 – Nov 2006 • 609 Pts – laparoscopic appendectomy • 3 post-op abscesses (0.49%)

  10. Acute Appendicitis Appendiceal Perforation • Perforated appendicitis (3 - 5 day hx) • Evacuation/irrigation of purulent material • Wound problems minimized • 20% post-op abscess rate

  11. Laparoscopic Appendectomy Please use this link if you experience problems viewing the video above.

  12. 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

  13. Adhesive Small Bowel Obstruction After Appendectomy in Children: Comparison Between the Laparoscopic and Open Approach AAP 2006 J PediatrSurg 42:939-942, 2007

  14. Laparoscopic versus Open Appendectomy(1105 Patients) AAP 2006 J PediatrSurg 42:939-942, 2007

  15. SBO After Perforated Appendicitis(378 Patients) AAP 2006 J PediatrSurg 42:939-942, 2007

  16. 2000 – 2012 Questions • Do we operate in the middle of the night? • Is there an optimal antibiotic regimen for perforated appendicitis? • How do we define perforated appendicitis? • How do we manage the patient presenting with an abscess? • Which is better: SSULS or 3 port appendectomy?

  17. 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

  18. Operation at Presentation Versus The Following Day Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J PediatrSurg 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

  19. Definition of Perforation Used in Prospective Randomized Trial Visible appendicolith Hole in appendix

  20. Post-operative Antibiotic Regimen For Perforated Appendicitis In Children: A Prospective 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

  21. Hypothesis • 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)

  22. ResultsOutcomes PAPS 2008 J PediatrSurg 43:2242-2245, 2008

  23. Conclusions • 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 2008 J PediatrSurg 43:2242-2245, 2008

  24. How do we manage the child presenting with an abscess due to ruptured appendicitis?

  25. Perforated AppendicitisPresenting With Abscess History • 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?

  26. Acute Appendicitis • 5 - 7 day history • Dehydrated – needs IVF • Percutaneous drainage (interventional radiology) • PICC line - antibiotics • Discharge day 3-5 if stable • Antibiotics con’t 10 - 14 days at home • Return 8-10 wk. for interval appendectomy (to prevent recurrent appendicitis) - overnight hospitalization

  27. 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, 2007 JPediatrSurg 43:981-985, 2008

  28. Abscess StudyProspective 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 2009 J PediatrSurg 45:236-240, 2010

  29. Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with an Abscess Values are expressed as mean ± SD APSA 2009 J PediatrSurg 45:236-240, 2010

  30. Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with an Abscess Values are expressed as mean ± SD, unless otherwise indicated APSA 2009 J PediatrSurg 45:236-240, 2010

  31. 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 2009 J PediatrSurg 45:236-240, 2010

  32. Is there an advantage performing the laparoscopic appendectomy through a single umbilical incision?

  33. SSULS Appendectomy

  34. SSULS Appendectomy Please use this link if you experience problems viewing the video above.

  35. Postoperative Appearance

  36. Prospective Randomized Trial Single Umbilical Incision vs 3-PortLaparoscopic Appendectomy • 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 ASA, 2011 Ann Surg 254:586-590, 2012

  37. Patient Characteristics at Operation ASA, 2011 Ann Surg 254:586-590, 2012

  38. Outcome Data ASA, 2011 Ann Surg 254:586-590, 2012

  39. Other Outcomes ASA, 2011 Ann Surg 254:586-590, 2012

  40. Convalescence Following Discharge ASA, 2011 Ann Surg 254:586-590, 2012

  41. Subset Analysis • BMI% for age & gender: overweight 85-95%, obese >95% • Compared normal to overweight and normal to obese within each group • Compared single site to 3 port within each body habitus classification IPEG 2012

  42. Technique Comparison For Overweight IPEG 2012

  43. Technique Comparison For Obese IPEG 2012

  44. Conclusions • Obesity increases operating time, postoperative length of stay, doses of narcotics, and hospital charges with single site lap appendectomy • Obesity has no impact in 3 port appendectomy • Clinically significant increase in wound infection in overweight and obese patient undergoing single site lap appendectomy • We do not recommend single site laparoscopic appendectomy in obese patients IPEG 2012

  45. 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

  46. QUESTIONS www.cmhclinicaltrials.com www.cmhmis.com

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