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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

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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



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



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



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


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


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

AAP, 2007


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

AAP, 2007


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 Children: Comparison Between the Laparoscopic and Open Approach(1105 Patients)

AAP 2006

J Pediatr Surg 42:939-942, 2007


Sbo after perforated appendicitis 1105 patients
SBO After Perforated Appendicitis Children: Comparison Between the Laparoscopic and Open Approach(1105 Patients)

AAP 2006

J Pediatr Surg 42:939-942, 2007


Prospective randomized trial
Prospective Randomized Trial Children: Comparison Between the Laparoscopic and Open Approach

  • 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 Children: Comparison Between the Laparoscopic and Open Approach

  • 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 Children: Comparison Between the Laparoscopic and Open Approach

  • 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


? ? ? Children: Comparison Between the Laparoscopic and Open Approach

www.centerforprospectiveclinicaltrials.com

www.cmhcenterforminimallyinvasivesurgery.com


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