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The IPEG Annual Congress joins with: II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) VII Congress of the Federation.

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Presentation on theme: "The IPEG Annual Congress joins with: II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) VII Congress of the Federation."— Presentation transcript:

1 The IPEG Annual Congress joins with: II World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) VII Congress of the Federation of Pediatric Surgical Associations of the South Cone of America (CIPESUR)

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

3 Appendicitis History Examination Imaging-Abdominal film? Ultrasound? CT scan?

4 Laparoscopic Appendectomy Since 2002, used exclusively Perforated, non-perforated, abscess Why: 1. Definitely fewer wound problems c/o open operation 2. Less small bowel obstruction

5 Laparoscopic Appendectomy Port Positions 12 mm umbilical port - working port/stapler 5 mm LLQ - telescope/camera 5 mm L suprapubic region - retraction

6 Laparoscopic Appendectomy Technique Window in mesoappendix Vascular stapler across mesoappendix

7 Laparoscopic Appendectomy Technique Regular stapler across base of appendix Extract through 12 mm umbilical cannula Bag used selectively

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

11 Acute Appendicitis – Contained Perforation Hemodynamically Stable 1)5 - 7 day history 2)IVF 3)Percutaneous drainage (radiology) 4)PICC line - antibx 5)Discharge day 3-5 if stable 6)Antibx con’t days at home 7)Return 8-10 wk. for interval appendectomy - overnight hospitalization

12 Interval Appendectomy Why?

13 Appendectomy Studies at Children’s Mercy

14 1.Postoperative Antibiotic Regimen for Perforated Appendicitis Prospective, randomized trial AGC vs CM 50 pts each arm Definition of perforation Hole in appendix Stool in abdomen AAP, 2007

15 1.Postoperative Antibiotic Regimen for Perforated Appendicitis No difference b/w groups re: weight, gender, days of symptoms, temperature, WBC count on admission AAP, 2007 Table 1 – Outcomes: CM vs AGC CMAGCP Value Time to Regular Diet (Hours)75 +/ / Length of Post-Op Hospitalization (Days)6.0 +/ / Post-Operative Abscess15.9%17.8%0.81 Narcotic Charges$258 +/- $150$361 +/- $ Antibiotic Charges$1,246 +/- $490$1,919 +/- $648<0.001

16 1.Postoperative Antibiotic Regimen for Perforated Appendicitis Conclusion: Ceftriaxone and metronidazole 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.

17 2.Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess Retrospective study June 00 – Dec pts Attempted percutaneous drainage, interval appendectomy AAP, 2007

18 2.Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess Mean age –9.0 +/- 3.9 yrs Mean weight / 18.8 kg Mean symptoms /- 7-6 days Mean volume fluid / cc Mean time to interval appy –61.9 +/ days Mean post-op hosp. after interval lap appy /- 1.4 days Drain complications – 1) ileal perforation 2) colon perforation 3) bladder perforation 4) buttock/thigh abscess AAP, 2007

19 2.Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess Outcome Variables Mean +/- Std Dev Number of CT scans3.5 +/- 2.0 Total hospital days7.0 +/- 3.9 Total days of drainage6.4 +/- 7.0 Number of healthcare visits7.6 +/- 2.8 Total charges (thousands of $)$54.3 +/- $55.2 Recurrent abscess19.2 % Repeat drainage11.5% AAP, 2007

20 3.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

21 3.Laparoscopic versus Open Appendectomy Laparoscopic (n = 628)Open (n = 477)P Value Age (years)11.0 +/ /- 5.1p > 0.05 Gender (M/F)355/273301/176p > 0.05 SBO1 (0.2%)7 (1.5%)p = 0.01 Perforated appendicitis186192p = 0.03 Mean time to SBO8 days58 days Median follow-up (years)3.5 (0.8 – 6.5)4.9 (0.9 – 8.3) AAP 2006 J Pediatr Surg 42: , 2007

22 3.SBO After Perforated Appendicitis LaparoscopicOpenp value Perforated appendicitis186192p = 0.03 SBO1 (0.5%)6 (3.1%)p = 0.03 AAP 2006 J Pediatr Surg 42: , 2007

23 4.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

24 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

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