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? 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)

Jan 98-June 05: 1105 Appendectomies-447 Open, 628 Lap. 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) Open (n = 477) P value Age (years) 11.0 +/- 3.7 9.2 +/- 5.1 p > 0.05 Gender (M/F) 355/273 301/176 SBO 1 (0.2%) 7 (1.5%) p = 0.01 Perforated appendicitis 186 192 Mean time to SBO 8 days 58 days Median follow-up (years) 3.5 (0.8 – 6.5) 4.9 (0.9 – 8.3) AAP, 2006 J Pediatr Surg 42:939-942, 2007

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

Impact of Strict Definition of Perforation on Abscess Rate 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) After definition (388 Pts) Acute appendicitis Abscess rate 1.7% 0.8% (131 Pts) (161 Pts) Perforated appendicitis 14.0% 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 These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line Exclusion Criteria Known allergy to one of the medications 11

Results Outcomes 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 Therefore we were comparing about 3.5 yrs experience against 1.5 yrs experience Abscess (%) 20.4% 16.3% 0.79 AAP, 2007 J Pediatr Surg 43:79-82, 2007 12

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 Therefore we were comparing about 3.5 yrs experience against 1.5 yrs experience AAP, 2007 J Pediatr Surg 43:981-985, 2008 13

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) 10.1 +/- 4.2 8.8 +/- 4.2 .31 Weight (kg) 37.0 +/- 16.2 37.1 +/- 20.8 .98 Body mass index (kg/cm2) 18.0 +/- 4.5 19.5 +/- 5.5 .39 White blood cell count 17.4 +/- 6.6 16.9 +/- 6.8 .84 Maximum temperature 37.8 +/- 1.0 37.7 +/- 0.9 .95 Maximum axial area of abscess (cm2) 29.2 +/- 29.7 26.2 +/- 21.1 .75 APSA, 2009 J Pediatr Surg 45:236-240, 2010

Prospective Randomized Trial Initial non-operative management Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess Initial operation (n = 20) Initial non-operative management P value Operation time (min) 62.1 +/- 38.7 42.0 +/- 45.5 .06 Total length of hospitalization (d) 6.5 +/- 3.8 6.7 +/- 6.6 .92 Recurrent abscess after initial treatment 20% 25% 1.0 Doses of narcotics 9.7 +/- 4.0 7.1 +/- 15.8 .47 Total health care visits 2.8 +/- 1.1 4.1 +/- 1.0 <.001 No. of CT scans 1.5 +/- 0.7 2.1 +/- 1.1 0.4 Total charges $44,195 +/- $19,384 $41,687 +/- $18,483 .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) IV/PO (n=50) P value Mean age (years) 9.7 +/-4.2 10.1 +/- 4.6 0.63 Mean weight (kg) 41.2 +/-23.3 43.2 +/- 24.1 0.88 Male (%) 60 0.62 Mean maximum temperature on admission (oC) 37.9 +/- 1.0 38.1 +/- 1.0 0.53 Mean duration of symptoms (days) 2.6 +/- 1.3 3.0 +/- 1.5 0.36 AAP, 2009 Accepted, J Pediatr Surg

Prospective Randomized Trial Clinical Outcomes IV (n=52 IV/PO (n=50 P value Mean operative time (min) 41:06+/-15:36 46:30+/-19:42 0.13 Mean time to regular diet (min) 68:00+/-35:06 61:42+/-32:12 0.36 Mean length of stay after operation (min) 6:06+/-2:00 4:48 +/-2:36 0.01 Total visits 3.1 +/-1.4 3.1+/-1.2 1.0 Postoperative abscess rate (%) 19 20 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 www.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com 24