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 Appendectomy Acute Appendicitis
Less wound infx with laparoscopy
Stapler vs cautery/endo loop technique

4. 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)

5. 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: , 2007

6. 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: , 2007

7. 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: , 2007

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

9. 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
( )
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: , 2008

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

11. 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

12. Results Outcomes CM AGC P value
WBC (x103) / /
LOS (Days) / /
IV Tx (Days) / /
Therefore we were comparing about 3.5 yrs experience against 1.5 yrs experience
Abscess (%) % %
AAP, 2007
J Pediatr Surg 43:79-82, 2007 12

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

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
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: , 2010

16. 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: , 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: , 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 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, Accepted, J Pediatr Surg

21. 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, 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 24