Appendicitis Current Management

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The IPEG Annual Congress joins with

• II World Congress of the World Federation of
  Associations of Pediatric Surgeons (WOFAPS)
• VII Congress of the Federation of Pediatric
  Surgical
• Associations of the South Cone of America
  (CIPESUR)

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AppendicitisCurrent Management

• George W. Holcomb, III, M.D., MBA
• Childrens Mercy Hospital
• Kansas City, MO

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Appendicitis

• History
• Examination
• Imaging - Abdominal film?
• Ultrasound?
• CT scan?

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Laparoscopic Appendectomy

• Since 2002, used exclusively
• Perforated, non-perforated, abscess
• Why
• Definitely fewer wound problems c/o open
  operation
• Less small bowel obstruction

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Laparoscopic AppendectomyPort Positions

• 12 mm umbilical port - working port/stapler
• 5 mm LLQ - telescope/camera
• 5 mm L suprapubic region - retraction

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Laparoscopic AppendectomyTechnique

• Window in mesoappendix
• Vascular stapler across mesoappendix

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Laparoscopic AppendectomyTechnique

• Regular stapler across base of appendix
• Extract through 12 mm umbilical cannula
• Bag used selectively

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Acute Appendicitis - Contained Perforation

• Perforated appendicitis (3 - 5 day hx)
• Evacuation/irrigation
• Controlled spillage
• Wound problems minimized

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Acute Appendicitis - Free Perforation
Hemodynamically Stable

• Laparoscopic appendectomy
• reduced discomfort
• selectively irrigate/evacuate pus
• lyse adhesions
• few wound problems
• often NGT not needed

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Acute Appendicitis - Free Perforation
Hemodynamically Unstable

• IVF Resuscitation
• Antibx/NGT
• Open appendectomy
• Lower midline incision
• RLQ incision
• Prolonged (10 - 14 days) hospitalization
• Rare patient

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Acute Appendicitis Contained Perforation
Hemodynamically Stable

1. 5 - 7 day history
2. IVF
3. Percutaneous drainage (radiology)
4. PICC line - antibx
5. Discharge day 3-5 if stable
6. Antibx cont 10 - 14 days at home
7. Return 8-10 wk. for interval appendectomy -
   overnight hospitalization

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Interval Appendectomy

• Why?

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Appendectomy Studies at Childrens Mercy
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Postoperative Antibiotic Regimen for Perforated
Appendicitis

• Prospective, randomized trial
• AGC vs CM
• 50 pts each arm
• Definition of perforation
• Hole in appendix
• Stool in abdomen

AAP, 2007
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Postoperative Antibiotic Regimen for Perforated
Appendicitis

• No difference b/w groups re weight, gender, days
  of symptoms, temperature, WBC count on admission

Table 1 Outcomes CM vs AGC Table 1 Outcomes CM vs AGC Table 1 Outcomes CM vs AGC Table 1 Outcomes CM vs AGC
CM AGC P Value
Time to Regular Diet (Hours) 75 /- 48 79 /- 41 0.68
Length of Post-Op Hospitalization (Days) 6.0 /1 2.4 6.1 /- 2.5 0.94
Post-Operative Abscess 15.9 17.8 0.81
Narcotic Charges 258 /- 150 361 /- 247 0.02
Antibiotic Charges 1,246 /- 490 1,919 /- 648 lt0.001
AAP, 2007
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Postoperative Antibiotic Regimen for Perforated
Appendicitis

• Conclusion
• Ceftriaxone and metronidazole offers a more
  efficient, cost-effective antibiotic regimen than
  ampicillin, gentamicin, clindamycin for children
  with perforated appendicitis. Also, it may allow
  earlier resolution of symptomatic peritoneal
  irritation as reflected by lower narcotic needs.

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Resource Utilization and Outcomes From
Percutaneous Drainage and Interval Appendectomy
for Perforated Appendicitis with Abscess

• Retrospective study
• June 00 Dec 06
• 52 pts
• Attempted percutaneous drainage, interval
  appendectomy

AAP, 2007
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Resource Utilization and Outcomes From
Percutaneous Drainage and Interval Appendectomy
for Perforated Appendicitis with Abscess
Mean age 9.0 /- 3.9 yrs
Mean weight - 34.4 / 18.8 kg
Mean symptoms - 8.4 /- 7-6 days
Mean volume fluid - 76.3 /1 81.1 cc
Mean time to interval appy 61.9 /- 25.2 days
Mean post-op hosp. after interval lap appy - 1.4 /- 1.4 days
Drain complications ileal perforation colon perforation bladder perforation buttock/thigh abscess Drain complications ileal perforation colon perforation bladder perforation buttock/thigh abscess
AAP, 2007
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Resource Utilization and Outcomes From
Percutaneous Drainage and Interval Appendectomy
for Perforated Appendicitis with Abscess
Outcome Variables Outcome Variables
Mean /- Std Dev
Number of CT scans 3.5 /- 2.0
Total hospital days 7.0 /- 3.9
Total days of drainage 6.4 /- 7.0
Number of healthcare visits 7.6 /- 2.8
Total charges (thousands of ) 54.3 /- 55.2
Recurrent abscess 19.2
Repeat drainage 11.5
AAP, 2007
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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 2006 J Pediatr Surg 42939-942, 2007
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Laparoscopic versus Open Appendectomy
Laparoscopic (n 628) Open (n 477) P Value
Age (years) 11.0 /- 3.7 9.2 /- 5.1 p gt 0.05
Gender (M/F) 355/273 301/176 p gt 0.05
SBO 1 (0.2) 7 (1.5) p 0.01
Perforated appendicitis 186 192 p 0.03
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 2006 J Pediatr Surg 42939-942, 2007
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SBO After Perforated Appendicitis
Laparoscopic Open p value
Perforated appendicitis 186 192 p 0.03
SBO 1 (0.5) 6 (3.1) p 0.03
AAP 2006 J Pediatr Surg 42939-942, 2007
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Prospective Randomized Trial

• Patients presenting with an abscess
• IR drainage with IV antibiotics followed by
  laparoscopic interval appendectomy vs
  laparoscopic appendectomy and evacuation of
  abscess on admission
• Pilot study 30 patients

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Conclusions

• Lap appendectomy is our preferred approach for
  all forms of appendicitis
• Lap appendectomy can be performed for perforated
  appendicitis and for patients presenting with an
  abscess
• Lap appendectomy results in fewer wound problems
  and less SBO

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