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Current Management of Children with Appendicitis CIPESUR Meeting November 18, 2011

Current Management of Children with Appendicitis CIPESUR Meeting November 18, 2011. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri. Three Presentations. Surgical History for Appendicitis (U.S.). 1990 – 2000

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Current Management of Children with Appendicitis CIPESUR Meeting November 18, 2011

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  1. Current Management of Children with AppendicitisCIPESUR MeetingNovember 18, 2011 George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

  2. Three Presentations

  3. 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

  4. 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

  5. Laparoscopic AppendectomyPersonnel/Port Positions

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

  7. Postoperative Appearance3 Port Laparoscopic Appendectomy

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

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

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

  11. 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

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

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

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

  15. 2000 – 2010 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?

  16. 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

  17. Antibiotics Only vs Appendectomy For Non-Perforated Appendicitis • Liu K, Ahanchi S, Pisaneschi M, et al. Can acute appendicitis be treated by antibiotics 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

  18. Early Operation Versus Delayed Operation Abou-Nukta F, Bakhos C, Arroyo K, et al. Effects of delaying appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg 141:504-506, 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

  19. 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

  20. The remaining four questions can be answered from studies at Children’s Mercy

  21. Levels Of Evidence 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

  22. Is There an Optimal Antibiotic Management for Perforated Appendicitis?

  23. 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

  24. Why Not Use Ceftriaxone/Metronidazole?Advantages • Same broad spectrum coverage as triples • The duo of Ceftriaxoneand Metronidazolerequire no serum levels • Ceftriaxoneand Metronidazole has been shown to be safe and effective in once/day dosing • Daily dosing allows easy transition to outpatient IV therapy, if needed

  25. Retrospective 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, 2005 J PediatrSurg 41: 1020-1024, 2006

  26. Retrospective ResultsOutcomes C/M A/G/C P Value 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 CAPS, 2005 J PediatrSurg 41: 1020-1024, 2006

  27. C/M * 38.5 * A/G/C * 38 * Tmax (Degrees Celsius) * 37.5 37 36.5 Admission 1 2 3 4 5 Post-Operative Days 1 - 5 ResultsTemperature Curves * P < 0.001 CAPS, 2005 J PediatrSurg 41: 1020-1024, 2006

  28. ResultsMedication Charges Expense of dose ($ dose) = (drug price + dispensing charge ) Expense of course = ($ dose) x (# doses/day) x (days of treatment) CAPS, 2005 J PediatrSurg 41: 1020-1024, 2006

  29. ResultsMedication Charges Impact Of Nursing Charges Ceftriaxone Dose Charge = ( $19.48 + $28.13 ) Expense of Course = ($47.51) x (1 dose/day) x (7 days) = $332 Ampicillin Dose Charge = ( $0.38 + $28.13 ) Expense of Course = ($28.51) x (4 doses/day) x (7 days) = $798 CAPS, 2005 J PediatrSurg 41: 1020-1024, 2006

  30. ResultsMedication Charges C/M A/G/C $ of Course $546.01 +/- $29.34 $2494.06 +/- $78.44 P Value < 0.0001 CAPS, 2005 J PediatrSurg41:1020-1024, 2006.

  31. 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?

  32. 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?

  33. Prospective 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

  34. 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

  35. ResultsOutcomes C/M A/G/C P Value WBC (x103) 9.4 +/- 3.9 9.9 +/- 4.4 0.56 LOS (Days) 6.27 +/- 2.5 6.20 +/- 3.2 0.85 IV Tx (Days) 6.0 +/- 1.5 6.2 +/- 1.1 0.48 Abscess (%) 20.4% 16.3% 0.79 AAP, 2007 J Pediatr Surg 43:79-82, 2007

  36. ResultsMedication Charges C/M A/G/C P Value Total Meds $3370 $3817 0.20 IV Abx $1412 $1940 <0.001 % of Med Charges 4.5% 6.1% <0.001 AAP, 2007 J Pediatr Surg 43:981-985, 2008

  37. ResultsTemperature Curves Triples C/M 39 38.5 38 Max Temeperature (Degrees Celsius) 37.5 37 36.5 Admission 1 2 3 4 5 Post-Operative Day AAP, 2007 J Pediatr Surg 43:981-985, 2008

  38. 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, 2007 J Pediatr Surg 43:981-985, 2008

  39. How Do We Define Perforated Appendicitis? • 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

  40. J Pediatr Surg 43:2242-2245, 2008

  41. 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

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

  43. 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)

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

  45. 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

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

  47. 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?

  48. Perforated Appendicitis with Abscess • 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

  49. 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 JPediatr Surg 43:981-985, 2008

  50. Perforated Appendicitis with 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 2009 J Pediatr Surg 45:236-240, 2010

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