Current Management of Children with Appendicitis

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

Surgeon-in-ChiefChildren’s Mercy Hospital

Kansas City, Missouri

Surgical History for Appendicitis• Reginald Fitz: pathologist

1886 – Described pathology of the appendix- Termed the disease: appendicitis

• Charles McBurney: surgeon 1889 – Described classical sign for appendicitis

• Kurt Semm: gynecologist and engineer 1981 – 1st laparoscopic appendectomy

Three Presentations

• Acute appendicitis 60 - 65%

• Perforated appendicitis 25 - 30%

• Perforated appendicitis with well-defined abscess (5-7 day history)

5 - 10%

Surgical History for Appendicitis

1990 – 2000• Slow adoption for laparoscopic approach

• Why – Relatively small open incision (c/w splenectomy,

fundoplication, cholecystectomy)

Many cases done middle of night – OR crews not used to laparoscopy

Benefits were not well appreciated

Surgical History for Appendicitis2000 – 2010

• Laparoscopic approach now favored (exclusively used at many centers including CMH) for all conditions: acute, perforated, abscess

• Why Operative times improved – closure faster Significantly fewer wound infections (almost none) Improved cosmesis, esp if infection develops

Laparoscopic AppendectomyPersonnel/Port Positions

Laparoscopic AppendectomyTechnique

• Window in mesoappendix

• Vascular stapler across mesoappendix

Postoperative Appearance3 Port Laparoscopic Appendectomy

Acute Appendicitis(No Perforation)

• April 2003 – Nov 2006

• 609 Pts – laparoscopic appendectomy

• 3 post-op abscesses (0.49%)

Acute Appendicitis Appendiceal Perforation

• Perforated appendicitis (3 - 5 day hx) Evacuation/irrigation of purulent material Wound problems minimized 20% post-op abscess rate

Laparoscopic Appendectomy

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Laparoscopic vs Open AppendectomyPerforated Appendicitis

• Far fewer (almost none) wound infection with laparoscopic approach

• Allows surgeon to suction/irrigate under direct visualization

• Less postoperative 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 2006J Pediatr Surg 42:939-942, 2007

Laparoscopic versus Open Appendectomy(1105 Patients)

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 p > 0.05

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 2006J Pediatr Surg 42:939-942, 2007

SBO After Perforated Appendicitis(378 Patients)

Laparoscopic Open p value

Perforated appendicitis 186 192

SBO 1 (0.5%) 6 (3.1%) p = 0.03

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

2000 – 2012 Questions1) Do we operate in the middle of the night?

2) Is there an optimal antibiotic regimen for perforated appendicitis?

3) How do we define perforated appendicitis?

4) How do we manage the patient presenting with an abscess?

5) Which is better: SSULS or 3 port appendectomy?

1. When to Operate?Current Practice at CMH

• Patients identified with appendicitis are booked for laparoscopic appendectomy• All receive a dose of rocephin (50mg/kg) and flagyl

(30mg/kg)• This antibiotic regimen was shown to be most cost

effective in PRT• If patients present at night, the operations are scheduled

for the ‘surgeon of the week’ the next day (8 am or 1 pm start)

• Appendectomies rarely occur after 10 PM at night

Operation at Presentation Versus The Following Day

Yardeni D, Hirschl RB, Drongowski RA, et al: Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J Pediatr Surg 39:464-469, 2004.

• Retrospective comparison in children (Level 3 study) between operation < 6 hrs after presentation or the following day• 126 patients (38 early vs 88 late)• No differences in operating time, perforation rate,

or complications

Visible appendicolithHole in appendix

3. Definition of Perforation Used in Prospective Randomized Trial

Post-operative Antibiotic Regimen For Perforated Appendicitis In Children: A

Prospective Randomized Trial

• April 2005 - November 2006

• 100 patients

• To ensure accurate data, the two groups had to be equal and a definition had to be created

Hypothesis• A correct definition of perforation (DOP) is important

because Provides us with the information to safely and efficiently treat

patients Allows us to better identify which patients are at risk for

developing postoperative complications

• If our definition of perforation was correct There should be no increase in abscess rate in the cohort of

patients treated as non-perforated appendicitis after the definition was used

• If our definition of perforation was incorrect There should be an increase in abscess rate in the cohort of

patients treated as non-perforated appendicitis after the definition was used (b/c of under-treatment)

Results Outcomes

NON-Perforated

Prior DOP(n=292)

After DOP(n=388)

Abscess rate 1.7% 0.8%

LOS (days) 1.9 +/- 1.3 1.5 +/- 1.5

Perforated Prior DOP(n=131)

After DOP(n=161)

Abscess rate 14.0% 18%LOS (days) 9.4 +/- 4.2 7.4 +/- 8.8

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

Conclusions• Our strict DOP (either a visible hole in the appendix or

appendicolith in the abdomen) has been shown to be safe No increase in abscess rate for non-perforated patients No detectable risk of under treating patients defined as non-

perforated

• This DOP will improve overall care for children with appendicitis Eliminate unnecessary antibiotic treatment Improve cost management Simplify treatment protocols Improve the integrity of clinical data Allow for ongoing clinical research

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

4. How do we manage the child presenting with an abscess due to

ruptured appendicitis?

Perforated AppendicitisPresenting With Abscess

• Open operation for abscess is difficult• Percutaneous drainage has been described and

applied• Laparoscopy is being used to treat perforated

appendicitis and abscess• Which is better?

History

Acute Appendicitis

1) 5 - 7 day history2) Dehydrated – needs IVF3) Percutaneous drainage

(interventional radiology)4) PICC line - antibiotics5) Discharge day 3-5 if stable6) Antibiotics con’t 10 - 14 days

at home7) Return 8-10 wk. for interval

appendectomy (to prevent recurrent appendicitis) - overnight hospitalization

Retrospective Experience with Interval Appendectomy

• 52 patients – 2000-2006

• Total hospital days = 7.0 +/- 3.9

• Total healthcare visits = 7.6 +/- 2.8

• Total number of CT scans = 3.5 +/- 2.0

• Recurrent Abscess = 10 pts (19.2%)

AAP, 2007J Pediatr Surg 43:981-985, 2008

Abscess StudyProspective Trial

• Drainable abscess

• OR for laparoscopic appendectomy vs percutaneous drainage as initial management

• Drain groups undergoes laparoscopic appendectomy at 10 weeks.

• Quality of life surveys at admission, at 2 weeks and at 12 weeks

• Pilot study – 40 patients

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

Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting

with an Abscess

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

Patient Characteristics at the Time of Admission

Initial operation (n=20)

Initial nonoperative management (n=20)

P

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

Values are expressed as mean ± SD

Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with

an Abscess

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

Outcomes Comparing Initial Operation and Initial Abscess Drainage Followed by Interval Appendectomy

Initial operation (n = 20)

Initial nonoperative management (n = 20)

P

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 .04

Total charges $44,195 ± $19,384 $41,687 ± $18,483 .68

Values are expressed as mean ± SD, unless otherwise indicated

Prospective Randomized Trial

• Conclusion – There is no difference b/w initial laparoscopic operation vs initial non-operative management followed by laparoscopic interval appendectomy

• Management can be determined by the surgeon’s preference and experience

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

5. Is there an advantage

performing the laparoscopic

appendectomy through a single

umbilical incision?

SSULS Appendectomy

SSULS Appendectomy

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Postoperative Appearance

Prospective Randomized Trial

• 360 total patients• Acute non-perforated appendicitis• August 09 – November 10• Primary outcome variable – postoperative wound

infection• Standardized pre and postoperative management• Quality of life surveys at 6 weeks and 6 months

Single Umbilical Incision vs 3-PortLaparoscopic Appendectomy

ASA, 2011Ann Surg 254:586-590, 2012

Patient Characteristics at OperationSingle Incision

(N=180)3-Port

(N=180)P-value

Age (yrs) 11.05 ± 3.47 11.04 ± 3.41 0.98

Weight (kg) 42.7 ± 18.5 42.5 ± 17.4 0.90

Gender (% male) 54.4% 51.1% 0.53

Leukocyte count 14.7 ± 5.2 14.6 ± 5.4 0.89

ASA, 2011Ann Surg 254:586-590, 2012

Outcome DataSingle

Incision (N=180)

3-Port (N=180)

P-value

Wound Infection 3.3% 1.7% 0.50

Operative Time (mins) 35.2 ± 14.5 29.8 ± 11.6 <0.001

Postoperative Length of Stay (hours) 22.7 ± 6.2 22.2 ± 6.8 0.44

Hospital Charges ($) 17.6K ± 4.0K 16.5 ± 3.8K 0.005

ASA, 2011Ann Surg 254:586-590, 2012

Other OutcomesSingle Site (N=180)

3-Port (N=180) P-

ValueSurgical Difficulty (1 – Easy to 5 – Difficult)

2.3 +/- 1.4 1.7 +/- 1.0 < 0.001

Abscess 0.0% 0.6% 0.99Time to Liquid Diet (Hours)

4.1 +/- 3.7 3.7 +/- 3.1 0.25

Time to Regular Diet (Hours)

7.2 +/- 5.1 6.9 +/- 5.2 0.48

Total Doses of Analgesics

9.6 +/- 4.9 8.5 +/- 4.3 0.04

ASA, 2011Ann Surg 254:586-590, 2012

Convalescence Following Discharge

Single Site(N=104)

3-Port (N=101)

P-Value

Days of Prescribed Analgesics

3.8 +/- 3.6 4.0 +/- 5.1 0.85

Doses of Prescribed Analgesics

6.4 +/- 9.3 5.1 +/- 6.6 0.37

Days to Full Activity 7.5 +/- 5.8 8.5 +/- 6.2 0.33Days to Return to School 4.7 +/- 2.9 4.9 +/- 3.7 0.77

ASA, 2011Ann Surg 254:586-590, 2012

Subset Analysis

• BMI% for age & gender: overweight 85-95%, obese >95%

• Compared normal to overweight and normal to obese within each group

• Compared single site to 3 port within each body habitus classification

IPEG 2012

OVERWEIGHT SINGLE (N=26) 3 PORT (N=25) P-Value

Operating Time (Minutes) 34.1 ± 11.9 31.4 ±12.6 0.44

Surgical Difficulty (1 – Easy to 5 – Difficult)

2.6 ± 1.4 1.6 ± 1.0 0.006

Wound Infection (%) 7.7 0 0.08

Doses of Narcotics 5.6 ± 3.7 4.6 ± 3.2 0.32

LOS after Operation (Hours) 24.1 ± 6.7 20.6 ± 5.0 0.04

Hospital Charges ($) 18.5K ± 3.9K 17.2K ± 2.9K 0.20

Technique Comparison For Overweight

IPEG 2012

OBESE SINGLE (N=19) 3 PORT (N=16) P-Value

Operating Time (Minutes) 45.4 ± 20.1 29.3 ± 20.1 0.006

Surgical Difficulty (1 – Easy to 5 – Difficult)

2.5 ± 1.4 1.5 ± 0.6 0.014

Wound Infection (%) 10.5 0 0.11

Doses of Narcotics 7.6 ± 0.15 6.2 ± 4.4 0.42

LOS after Operation (Hours) 25.4 ± 8.1 21.8 ± 5.4 0.14

Hospital Charges ($) 20.3K ± 4.7K 17.1K ± 4.1K 0.04

Technique Comparison For Obese

IPEG 2012

Conclusions• Obesity increases operating time, postoperative

length of stay, doses of narcotics, and hospital charges with single site lap appendectomy

• Obesity has no impact in 3 port appendectomy

• Clinically significant increase in wound infection in overweight and obese patient undergoing single site lap appendectomy

• We do not recommend single site laparoscopic appendectomy in obese patients

IPEG 2012

Summary• There have been significant changes in

the surgical management of appendicitis• These changes have revolved around

timing of surgery and the almost exclusive use of the laparoscopic approach

• Unclear if appendicitis will be a surgical disease in the future

QUESTIONS

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