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Appendicitis: Challenges in Management. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO. Questions. Laparoscopy vs open for acute appendicitis? Laparoscopy vs open for perforated appendicitis? How do we define perforation?

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appendicitis challenges in management

Appendicitis:Challenges in Management

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

Children’s Mercy Hospital

Kansas City, MO

questions
Questions
  • Laparoscopy vs open for acute appendicitis?
  • Laparoscopy vs open for perforated appendicitis?
  • How do we define perforation?
  • Optimal antibiotic management for perforated appendicitis?
  • Management of patient presenting with abscess?
  • SSULS appendectomy vs 3 port laparoscopic appendectomy?
laparoscopy vs open appendectomy acute appendicitis
Laparoscopy vs Open AppendectomyAcute Appendicitis
  • Less wound infx with laparoscopy
  • Stapler vs cautery/endo loop technique
laparoscopy vs open appendectomy perforated appendicitis
Laparoscopy vs Open AppendectomyPerforated Appendicitis
  • Far fewer (almost none) wound infx with laparoscopic approach
  • Allows surgeon to suction/irrigate under direct visualization
  • Less small bowel obstruction (SBO)
slide5
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 1998 2005
Laparoscopic versus Open Appendectomy(1105 Patients)1998-2005

AAP, 2006

J Pediatr Surg 42:939-942, 2007

sbo after perforated appendicitis 1105 patients 1998 2005
SBO After Perforated Appendicitis (1105 Patients)1998-2005

AAP, 2006

J Pediatr Surg 42:939-942, 2007

how do we define perforation
How Do We Define Perforation?

Stool in abdomen

Hole in appendix

definition of perforated appendicitis hole in appendix fecalith in abdomen
Definition of Perforated Appendicitis(Hole in appendix, fecalith in abdomen)

PAPS, 2008

J Pediatr Surg 43:2242-2245, 2008

prospective randomized trial ceftriaxone metronidazole vs agc
Prospective Randomized TrialCeftriaxone/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
results outcomes
ResultsOutcomes

CM

AGC

P value

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

AAP, 2007

J Pediatr Surg 43:79-82, 2007

conclusions
Conclusions
  • There is no difference in infectious complications, recovery or defervescence after perforated appendicitis between Ceftriaxone/Metronidazole and AGC
  • Ceftriaxone/Metronidazole is more cost-effective than AGC

AAP, 2007

J Pediatr Surg 43:981-985, 2008

prospective randomized trial
Prospective Randomized Trial

Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess

APSA, 2009

J Pediatr Surg 45:236-240, 2010

slide16

Prospective Randomized Trial

Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess

APSA, 2009

J Pediatr Surg 45:236-240, 2010

prospective randomized trial1
Prospective Randomized Trial

Conclusion

There is no difference in outcomes b/w initial laparoscopic operation vs initial non-operative management followed by laparoscopic interval appendectomy for patients presenting with a well-defined abscess due to perforated appendicitis.

APSA, 2009

J Pediatr Surg 45:236-240, 2010

can patients with perforated appendicitis be discharged prior to postoperative day 5
Can patients with perforated appendicitis be discharged prior to postoperative day 5?

Discharge Criteria

  • Afebrile x 24 hrs.
  • Regular diet
prospective randomized trial2
Prospective Randomized Trial
  • IV vs IV/PO antibiotics for perforated appendicitis
  • 102 patients
  • Definition of perforated appendicitis
  • IV/PO arm of study (7 days) vs minimum IV antibiotics of 5 days
prospective randomized trial patient demographics
Prospective Randomized TrialPatient Demographics

AAP, 2009 Accepted, J Pediatr Surg

prospective randomized trial clinical outcomes
Prospective Randomized Trial Clinical Outcomes

AAP, 2009 Accepted, J Pediatr Surg

conclusion
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.

questions1
QUESTIONS

www.centerforprospectiveclinicaltrials.com

www.cmhcenterforminimallyinvasivesurgery.com