appendicitis cuba 2010

8/3/2019 Appendicitis Cuba 2010

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Appendicitis:

Challenges in Management

George W. Holcomb, III, M.D., MBA

Childrens Mercy Hospital

Kansas City, MO


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Questions

Laparoscopy vs open for acute appendicitis?

Laparoscopy vs open for perforatedappendicitis?

How do we define perforation? Optimal antibiotic management for perforated

appendicitis?

Management of patient presenting withabscess?

SSULS appendectomy vs 3 port laparoscopicappendectomy?


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Laparoscopy vs Open Appendectomy

Acute Appendicitis

Less wound infx with laparoscopy

Stapler vs cautery/endo loop technique


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Laparoscopy vs Open Appendectomy

Perforated Appendicitis

Far fewer (almost none)wound infx with

laparoscopic approach

Allows surgeon tosuction/irrigate underdirect visualization

Less small bowelobstruction (SBO)


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Adhesive Small Bowel Obstruction AfterAppendectomy in Children: Comparison

Between the Laparoscopic and Open Approach

Jan 98-June 05: 1105 Appendectomies-447 Open, 628 Lap.

AAP 2006

J Pediatr Surg 42:939-942, 2007


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Laparoscopic versus Open Appendectomy(1105 Patients)

1998-2005

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 (0.86.5) 4.9 (0.98.3)

AAP, 2006J Pediatr Surg 42:939-942, 2007


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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, 2006

J Pediatr Surg 42:939-942, 2007


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How Do We Define Perforation?

Stool in abdomenHole in appendix


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


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What is the Optimal Antibiotic

Management for Perforated

Appendicitis?


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Prospective Randomized Trial

Ceftriaxone/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


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Results

Outcomes

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

CM AGC P value

AAP, 2007

J Pediatr Surg 43:79-82, 2007


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Conclusions

There is no difference in infectiouscomplications, recovery or defervescenceafter perforated appendicitis between

Ceftriaxone/Metronidazole and AGC

Ceftriaxone/Metronidazole is more cost-

effective than AGC

AAP, 2007

J Pediatr Surg 43:981-985, 2008


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How do we manage the child presentingwith an abscess due to ruptured

appendicitis?


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Prospective Randomized TrialInitial Laparoscopic Appendectomy vs Initial Non-operative

Management for Patients Presenting with Appendicitis and Abscess

Patient Characteristics at the Time of Admission

Initial

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, 2009

J Pediatr Surg 45:236-240, 2010


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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 .06

Total length of

hospitalization (d)

6.5 +/- 3.8 6.7 +/- 6.6 .92

Recurrent abscess after

initial treatment20% 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


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Conclusion

There is no difference in outcomes b/w

initial laparoscopic operation vs initialnon-operative management followed bylaparoscopic interval appendectomy forpatients presenting with a well-defined

abscess due to perforated appendicitis.

APSA, 2009

J Pediatr Surg 45:236-240, 2010


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Can patients with perforatedappendicitis be discharged prior to

postoperative day 5?Discharge Criteria

Afebrile x 24 hrs.

Regular diet


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IV vs IV/PO antibiotics forperforated appendicitis

102 patients

Definition of perforatedappendicitis

IV/PO arm of study (7 days)vs minimum IV antibiotics of5 days


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Prospective Randomized TrialPatient 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 onadmission (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, 2009Accepted, J Pediatr Surg


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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

Accepted, J Pediatr Surg


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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.


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SSULS Appendectomy


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QUESTIONS

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appendicitis cuba 2010

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