Appendicitis:Current Management

George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital

Kansas City, MO

Appendicitis

History

Examination

Imaging - Abdominal film?

Ultrasound?

CT scan?

Laparoscopic Appendectomy

• Since 2002, used exclusively

• Perforated, non-perforated, abscess

• Why:1. Definitely fewer wound problems c/o open

operation

2. Less small bowel obstruction

Laparoscopic AppendectomyPersonnel/Port Positions

Laparoscopic AppendectomyTechnique

• Window in mesoappendix

• Vascular stapler across mesoappendix

Laparoscopic AppendectomyTechnique

• Regular stapler across base of appendix

• Extract through 12 mm umbilical cannula

• Bag used selectively

Acute Appendicitis(No Perforation)

• April 2003 – Nov 2006

• 609 Pts

• 3 post-op abscesses (0.49%)

Acute Appendicitis - Contained Perforation

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

Acute Appendicitis - Free Perforation

Hemodynamically Stable

Laparoscopic appendectomy

• reduced discomfort• selectively

irrigate/evacuate pus

• lyse adhesions

• few wound problems

• often NGT not needed

Perforated Appendicitis

Acute Appendicitis - Free Perforation

Hemodynamically Unstable

• IVF Resuscitation

• Antibx/NGT• Open appendectomy

• Lower midline incision• RLQ incision

• Prolonged (10 - 14 days) hospitalization

• Rare patient

Acute Appendicitis – Definite Abscess on CT

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 con’t 10 - 14 days at home

7) Return 8-10 wk. for interval appendectomy - overnight hospitalization

Interval Appendectomy

Why?

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

Appendectomy Studies at Appendectomy Studies at Children’s MercyChildren’s Mercy

1. Postoperative Antibiotic Regimen for Perforated Appendicitis

• Prospective, randomized trial

• AGC vs CM

• 50 pts each arm• Definition of

perforation• Hole in appendix

• Fecalith in abdomen

AAP, 2007AAP, 2007

1. Postoperative Antibiotic Regimen for Perforated Appendicitis

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

AAP, 2007AAP, 2007

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 <0.001

Post-Operative Wound Infection 0 1 NS

1. Postoperative Antibiotic Regimen for Perforated Appendicitis

Conclusion:

Ceftriaxone(Rocephin) and metronidazole(Flagyl) 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.

AAP, 2007AAP, 2007

Postoperative Antibiotic Protocol For Perforated Appendicitis

(Without Preoperative Abscess)

ROCEPHIN/FLAGYL (5 Days)

Discharge Normal WBC Afebrile

WBC or Febrile

2 More Days Antibx

CT

No abscess

3 More Days

Antibx

Abscess

Drain, PICC Line – 2 Wks, Antibx

Normal WBC, Afebrile

WBC or Febrile

2. IV vs IV/Oral Antibiotics for Perforated Appendicitis

• Perforation defined as hole in appendix or fecalith in abdomen

• Power analysis (alpha 0.05, power 0.8) – 75 patients each arm

• Control: IV Ceftriaxone/Metronidazole (CM) – 5 days minimum

• Experimental:• Initiate CM• If tolerating regular diet, on oral analgesics & afebrile 12 hrs,

discharge on Augmentin to complete 7 day course

• Primary endpoint: incidence of postoperative abscess formation

3. 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, 2007AAP, 2007

*

3. 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 –1) ileal perforation2) colon perforation3) bladder perforation4) buttock/thigh abscess

AAP, 2007AAP, 2007

3. Resource Utilization and Outcomes From Percutaneous Drainage and Interval

Appendectomy for Perforated Appendicitis with Abscess

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 17.3 %

Repeat drainage 11.5%

AAP, 2007AAP, 2007

4. 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

4. 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

4. SBO After Perforated Appendicitis (1105 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

5. 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

Evolution in Timing of Operation

1) IV CM on admission

2) Will operate that day/night until 9-10 pm

3) If present after 9-10 pm, operate next day (1 pm or earlier)

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

? ? ?www.centerforprospectiveclinicaltrials.com

www.cmhcenterforminimallyinvasivesurgery.com