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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. 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

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  1. Appendicitis:Challenges in Management George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO

  2. 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?

  3. Laparoscopy vs Open AppendectomyAcute Appendicitis • Less wound infx with laparoscopy • Stapler vs cautery/endo loop technique

  4. 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)

  5. Adhesive Small Bowel Obstruction After Appendectomy in Children: Comparison Between the Laparoscopic and Open Approach AAP 2006 J Pediatr Surg 42:939-942, 2007

  6. Laparoscopic versus Open Appendectomy(1105 Patients)1998-2005 AAP, 2006 J Pediatr Surg 42:939-942, 2007

  7. SBO After Perforated Appendicitis (1105 Patients)1998-2005 AAP, 2006 J Pediatr Surg 42:939-942, 2007

  8. How Do We Define Perforation? Stool in abdomen Hole in appendix

  9. Definition of Perforated Appendicitis(Hole in appendix, fecalith in abdomen) PAPS, 2008 J Pediatr Surg 43:2242-2245, 2008

  10. What is the Optimal Antibiotic Management for Perforated Appendicitis?

  11. 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

  12. 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

  13. 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

  14. How do we manage the child presenting with an abscess due to ruptured appendicitis?

  15. 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

  16. 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

  17. 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

  18. Can patients with perforated appendicitis be discharged prior to postoperative day 5? Discharge Criteria • Afebrile x 24 hrs. • Regular diet

  19. 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

  20. Prospective Randomized TrialPatient Demographics AAP, 2009 Accepted, J Pediatr Surg

  21. Prospective Randomized Trial Clinical Outcomes AAP, 2009 Accepted, J Pediatr Surg

  22. 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.

  23. SSULS Appendectomy

  24. QUESTIONS www.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com

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