Appendicitis: Challenges in Management

George W. Holcomb, III, M.D., MBA Childrens Mercy Hospital Kansas City, MO

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
Less wound infx with laparoscopy

Stapler vs cautery/endo loop technique

Laparoscopy vs Open Appendectomy Perforated Appendicitis

Far fewer (almost none) wound infx with laparoscopic approach Allows surgeon to suction/irrigate under direct visualization Less small bowel obstruction (SBO)

Adhesive Small Bowel Obstruction After Appendectomy in Children: Comparison Between the Laparoscopic and Open Approach
Jan 98-June 05: 1105 Appendectomies-447 Open, 628 Lap.

AAP 2006 J Pediatr Surg 42:939-942, 2007

Laparoscopic versus Open Appendectomy

(1105 Patients) 1998-2005
Laparoscopic (n = 628)
Age (years) Gender (M/F) SBO Perforated appendicitis Mean time to SBO Median follow-up (years) 11.0 +/- 3.7 355/273 1 (0.2%) 186 8 days 3.5 (0.8 6.5)

Open (n = 477)
9.2 +/- 5.1 301/176 7 (1.5%) 192 58 days 4.9 (0.9 8.3)

P value
p > 0.05 p > 0.05 p = 0.01

AAP, 2006 J Pediatr Surg 42:939-942, 2007

SBO After Perforated Appendicitis

(1105 Patients) 1998-2005
Laparoscopic Perforated appendicitis 186 Open 192 P value

SBO

1 (0.5%)

6 (3.1%)

p = 0.03

AAP, 2006 J Pediatr Surg 42:939-942, 2007

How Do We Define Perforation?

Hole in appendix

Stool in abdomen

Definition of Perforated Appendicitis

(Hole in appendix, fecalith in abdomen)
Impact of Strict Definition of Perforation on Abscess Rate (2003-2007)
Before definition (292 Pts) Acute appendicitis Abscess rate 1.7% Before definition (131 Pts) Perforated appendicitis Abscess rate 14.0% After definition (388 Pts) Abscess rate 0.8% After definition (161 Pts) Abscess rate 18.0%

PAPS, 2008 J Pediatr Surg 43:2242-2245, 2008

What is the Optimal Antibiotic Management for Perforated Appendicitis?

Prospective Randomized Trial

Ceftriaxone/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
CM
WBC (x103) 9.4 +/- 3.9

AGC
9.9 +/- 4.4

P value
0.56

LOS (Days)
IV Tx (Days) Abscess (%)

6.27 +/- 2.5

6.0 +/- 1.5 20.4%

6.20 +/- 3.2

6.2 +/- 1.1 16.3%

0.85
0.48 0.79

AAP, 2007 J Pediatr Surg 43:79-82, 2007

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

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

Prospective Randomized Trial

Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess
Patient Characteristics at the Time of Admission
Initial operation (n = 20) Initial non-operative management (n = 20) P value

Age (y)
Weight (kg)

10.1 +/- 4.2

37.0 +/- 16.2

8.8 +/- 4.2

37.1 +/- 20.8

.31
.98

Body mass index (kg/cm2)

White blood cell count Maximum temperature Maximum axial area of abscess (cm2)

18.0 +/- 4.5

17.4 +/- 6.6 37.8 +/- 1.0 29.2 +/- 29.7

19.5 +/- 5.5

16.9 +/- 6.8 37.7 +/- 0.9 26.2 +/- 21.1

.39
.84 .95 .75

APSA, 2009 J Pediatr Surg 45:236-240, 2010

Prospective Randomized Trial

Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess
Initial operation (n = 20) Operation time (min) Total length of hospitalization (d) Initial non-operative management (n = 20) P value

62.1 +/- 38.7 6.5 +/- 3.8

42.0 +/- 45.5 6.7 +/- 6.6

.06 .92

Recurrent abscess after initial treatment

Doses of narcotics Total health care visits

20%
9.7 +/- 4.0 2.8 +/- 1.1

25%
7.1 +/- 15.8 4.1 +/- 1.0

1.0
.47 <.001

No. of CT scans
Total charges

1.5 +/- 0.7

$44,195 +/$19,384

2.1 +/- 1.1

$41,687 +/- $18,483

0.4
.68

APSA, 2009 J Pediatr Surg 45:236-240, 2010

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?

Discharge Criteria
Afebrile x 24 hrs. Regular diet

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
IV (n=52)
Mean age (years) Mean weight (kg) Male (%) Mean maximum temperature on admission (oC)
Mean duration of symptoms (days)

IV/PO (n=50)
10.1 +/- 4.6 43.2 +/- 24.1 60 38.1 +/- 1.0

P value
0.63 0.88 0.62 0.53

9.7 +/-4.2 41.2 +/-23.3 60 37.9 +/- 1.0

2.6 +/- 1.3

3.0 +/- 1.5

0.36

AAP, 2009 Accepted, J Pediatr Surg

Prospective Randomized Trial Clinical Outcomes

IV (n=52
Mean operative time (min) Mean time to regular diet (min) Mean length of stay after operation (min) Total visits Postoperative abscess rate (%) 41:06+/-15:36 68:00+/-35:06 6:06+/-2:00 3.1 +/-1.4 19

IV/PO (n=50
46:30+/-19:42 61:42+/-32:12 4:48 +/-2:36 3.1+/-1.2 20

P value
0.13 0.36 0.01 1.0 1.0

AAP, 2009 Accepted, J Pediatr Surg

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.

SSULS Appendectomy

QUESTIONS

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