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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. History Examination Imaging - Abdominal film? Ultrasound? CT scan?. Laparoscopic Appendectomy. Since 2002, used exclusively

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Appendicitis: Current Management

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

  2. Appendicitis History Examination Imaging - Abdominal film? Ultrasound? CT scan?

  3. Laparoscopic Appendectomy • Since 2002, used exclusively • Perforated, non-perforated, abscess • Why: • Definitely fewer wound problems c/o open operation • Less small bowel obstruction

  4. Laparoscopic AppendectomyPersonnel/Port Positions

  5. Laparoscopic AppendectomyTechnique • Window in mesoappendix • Vascular stapler across mesoappendix

  6. Laparoscopic AppendectomyTechnique • Regular stapler across base of appendix • Extract through 12 mm umbilical cannula • Bag used selectively

  7. Acute Appendicitis(No Perforation) • April 2003 – Nov 2006 • 609 Pts • 3 post-op abscesses (0.49%)

  8. Acute Appendicitis -Contained Perforation • Perforated appendicitis (3 - 5 day hx) • Evacuation/irrigation • Controlled spillage • Wound problems minimized

  9. Acute Appendicitis - Free Perforation Hemodynamically Stable Laparoscopic appendectomy • reduced discomfort • selectively irrigate/evacuate pus • lyse adhesions • few wound problems • often NGT not needed

  10. Perforated Appendicitis

  11. Acute Appendicitis - Free Perforation Hemodynamically Unstable • IVF Resuscitation • Antibx/NGT • Open appendectomy • Lower midline incision • RLQ incision • Prolonged (10 - 14 days) hospitalization • Rare patient

  12. 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

  13. Interval Appendectomy Why?

  14. 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

  15. Appendectomy Studies at Children’s Mercy

  16. 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

  17. Postoperative Antibiotic Regimen for Perforated Appendicitis • No difference b/w groups re: weight, gender, days of symptoms, temperature, WBC count on admission AAP, 2007

  18. 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

  19. 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

  20. 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

  21. Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess AAP, 2007

  22. Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess AAP, 2007

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

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

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

  26. 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

  27. 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)

  28. 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

  29. ? ? ? www.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com

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