Appendicitis current management
This presentation is the property of its rightful owner.
Sponsored Links
1 / 30

Appendicitis: Current Management PowerPoint PPT Presentation


Appendicitis: Current Management. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO. Appendicitis. History Examination Imaging-Abdominal film? Ultrasound? CT scan?. Laparoscopic Appendectomy. Since 2002, used exclusively

Download Presentation

Appendicitis: Current Management

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Appendicitis current management

Appendicitis:Current Management

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

Children’s Mercy Hospital

Kansas City, MO


Appendicitis

Appendicitis

History

Examination

Imaging-Abdominal film?

Ultrasound?

CT scan?


Laparoscopic appendectomy

Laparoscopic Appendectomy

  • Since 2002, used exclusively

  • Perforated, non-perforated, abscess

  • Why:

    • Definitely fewer wound problems c/o open operation

    • Less small bowel obstruction


Laparoscopic appendectomy personnel port positions

Laparoscopic AppendectomyPersonnel/Port Positions


Laparoscopic appendectomy technique

Laparoscopic AppendectomyTechnique

  • Window in mesoappendix

  • Vascular stapler across mesoappendix


Laparoscopic appendectomy technique1

Laparoscopic AppendectomyTechnique

  • Regular stapler across base of appendix

  • Extract through 12 mm umbilical cannula

    • Bag used selectively


Acute appendicitis no perforation

Acute Appendicitis(No Perforation)

  • April 2003 – Nov 2006

  • 609 Pts

  • 3 post-op abscesses (0.49%)


Acute appendicitis contained perforation

Acute Appendicitis -Contained Perforation

  • Perforated appendicitis (3 - 5 day hx)

    • Evacuation/irrigation

    • Controlled spillage

    • Wound problems minimized


Acute appendicitis free perforation hemodynamically stable

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

Perforated Appendicitis


Acute appendicitis free perforation hemodynamically unstable

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

Acute Appendicitis – Definite Abscess on CT Hemodynamically Stable

  • 5 - 7 day history

  • IVF

  • Percutaneous drainage (radiology)

  • PICC line - antibx

  • Discharge day 3-5 if stable

  • Antibx con’t 10 - 14 days at home

  • Return 8-10 wk. for interval appendectomy - overnight hospitalization


Interval appendectomy

Interval Appendectomy

Why?


Appendicitis

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


Appendectomy studies at children s mercy

Appendectomy Studies at Children’s Mercy


Postoperative antibiotic regimen for perforated appendicitis

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, 2007


Postoperative antibiotic regimen for perforated appendicitis1

Postoperative Antibiotic Regimen for Perforated Appendicitis

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

AAP, 2007


Postoperative antibiotic regimen for perforated appendicitis2

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, 2007


Iv vs iv oral antibiotics for perforated appendicitis

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


Appendicitis

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


Appendicitis

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

AAP, 2007


Appendicitis

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

AAP, 2007


Appendicitis

Adhesive Small Bowel Obstruction After Appendectomy in Children: Comparison Between the Laparoscopic and Open Approach

AAP 2006

J Pediatr Surg 42:939-942, 2007


Laparoscopic versus open appendectomy 1105 patients

Laparoscopic versus Open Appendectomy(1105 Patients)

AAP 2006

J Pediatr Surg 42:939-942, 2007


Sbo after perforated appendicitis 1105 patients

SBO After Perforated Appendicitis (1105 Patients)

AAP 2006

J Pediatr Surg 42:939-942, 2007


Prospective randomized trial

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

Evolution in Timing of Operation

  • IV CM on admission

  • Will operate that day/night until 9-10 pm

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


Conclusions

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


Appendicitis

? ? ?

www.centerforprospectiveclinicaltrials.com

www.cmhcenterforminimallyinvasivesurgery.com


  • Login