1. Current Management of Children with Appendicitis George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. 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 – 1 st laparoscopic appendectomy

3. Three Presentations Acute appendicitis 60 - 65% Perforated appendicitis 25 - 30% Perforated appendicitis with well- defined abscess (5-7 day history) 5 - 10%

4. 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

5. Surgical History for Appendicitis 2000 – 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

6. Laparoscopic Appendectomy Personnel/Port Positions

7. Laparoscopic Appendectomy Technique Window in mesoappendix Vascular stapler across mesoappendix

8. Postoperative Appearance 3 Port Laparoscopic Appendectomy

9. Acute Appendicitis (No Perforation) April 2003 – Nov 2006 609 Pts – laparoscopic appendectomy 3 post-op abscesses (0.49%)

10. Acute Appendicitis Appendiceal Perforation Perforated appendicitis (3 - 5 day hx)  Evacuation/irrigation of purulent material  Wound problems minimized  20% post-op abscess rate

11. Laparoscopic Appendectomy Please use this link if you experience problems viewing the video above.this link

12. Laparoscopic vs Open Appendectomy Perforated Appendicitis Far fewer (almost none) wound infection with laparoscopic approach Allows surgeon to suction/irrigate under direct visualization Less postoperative SBO

13. 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

14. Laparoscopic versus Open Appendectomy (1105 Patients) Laparoscopic (n = 628)Open (n = 477)P Value Age (years)11.0 +/- 3.79.2 +/- 5.1p > 0.05 Gender (M/F)355/273301/176p > 0.05 SBO1 (0.2%)7 (1.5%)p = 0.01 Perforated appendicitis186192 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 42:939-942, 2007

15. SBO After Perforated Appendicitis (378 Patients) LaparoscopicOpenp value Perforated appendicitis186192 SBO1 (0.5%)6 (3.1%)p = 0.03 AAP 2006 J Pediatr Surg 42:939-942, 2007

16. 2000 – 2012 Questions 1)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?

17. 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

18. 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

19. Visible appendicolith Hole in appendix 3.Definition of Perforation Used in Prospective Randomized Trial

20. 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

21. 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)

22. Results Outcomes NON- Perforated Prior DOP (n=292) After DOP (n=388) Abscess rate1.7%0.8% LOS (days)1.9 +/- 1.31.5 +/- 1.5 Perforated Prior DOP (n=131) After DOP (n=161) Abscess rate14.0%18% LOS (days)9.4 +/- 4.27.4 +/- 8.8 PAPS 2008 J Pediatr Surg 43:2242-2245, 2008 J Pediatr Surg 43:2242-2245, 2008

23. 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 2008 J Pediatr Surg 43:2242-2245, 2008

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

25. Perforated Appendicitis Presenting 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

26. Acute Appendicitis 1)5 - 7 day history 2)Dehydrated – needs IVF 3)Percutaneous drainage (interventional radiology) 4)PICC line - antibiotics 5)Discharge day 3-5 if stable 6)Antibiotics con’t 10 - 14 days at home 7)Return 8-10 wk. for interval appendectomy (to prevent recurrent appendicitis) - overnight hospitalization

27. 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, 2007 J Pediatr Surg 43:981-985, 2008

28. Abscess Study Abscess Study Prospective 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 2009 J Pediatr Surg 45:236-240, 2010

29. Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with an Abscess APSA 2009 J 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 ± 4.28.8 ± 4.2.31 Weight (kg)37.0 ± 16.237.1 ± 20.8.98 Body mass index (kg/cm 2 )18.0 ± 4.519.5 ± 5.5.39 White blood cell count17.4 ± 6.616.9 ± 6.8.84 Maximum temperature37.8 ± 1.037.7 ± 0.9.95 Maximum axial area of abscess (cm 2 ) 29.2 ± 29.726.2 ± 21.1.75 Values are expressed as mean ± SD

30. Initial Non-Op Mgmt vs Lap Appendectomy in Children Presenting with an Abscess APSA 2009 J 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 ± 38.742.0 ± 45.5.06 Total length of hospitalization (d)6.5 ± 3.86.7 ± 6.6.92 Recurrent abscess after initial treatment (%) 20%25%1.0 Doses of narcotics9.7 ± 4.07.1 ± 15.8.47 Total health care visits2.8 ± 1.14.1 ± 1.0<.001 No. of CT scans1.5 ± 0.72.1 ± 1.1.04 Total charges$44,195 ± $19,384$41,687 ± $18,483.68 Values are expressed as mean ± SD, unless otherwise indicated

31. 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 2009 J Pediatr Surg 45:236-240, 2010

32. 5.Is there an advantage performing the laparoscopic appendectomy through a single umbilical incision?

33. SSULS Appendectomy

34. Please use this link if you experience problems viewing the video above.this link

35. Postoperative Appearance

36. 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-Port Laparoscopic Appendectomy ASA, 2011 Ann Surg 254:586-590, 2012

37. Patient Characteristics at Operation Single Incision (N=180) 3-Port (N=180) P-value Age (yrs)11.05 ± 3.4711.04 ± 3.410.98 Weight (kg)42.7 ± 18.542.5 ± 17.40.90 Gender (% male)54.4%51.1%0.53 Leukocyte count14.7 ± 5.214.6 ± 5.40.89 ASA, 2011 Ann Surg 254:586-590, 2012

38. Outcome Data Single Incision (N=180) 3-Port (N=180) P- value Wound Infection3.3%1.7%0.50 Operative Time (mins)35.2 ± 14.529.8 ± 11.6<0.001 Postoperative Length of Stay (hours) 22.7 ± 6.222.2 ± 6.80.44 Hospital Charges ($)17.6K ± 4.0K16.5 ± 3.8K0.005 ASA, 2011 Ann Surg 254:586-590, 2012

39. Other Outcomes Single Site (N=180) 3-Port (N=180)P- Value Surgical Difficulty (1 – Easy to 5 – Difficult) 2.3 +/- 1.41.7 +/- 1.0< 0.001 Abscess0.0%0.6%0.99 Time to Liquid Diet (Hours) 4.1 +/- 3.73.7 +/- 3.10.25 Time to Regular Diet (Hours) 7.2 +/- 5.16.9 +/- 5.20.48 Total Doses of Analgesics 9.6 +/- 4.98.5 +/- 4.30.04 ASA, 2011 Ann Surg 254:586-590, 2012

40. Convalescence Following Discharge Single Site (N=104) 3-Port (N=101) P- Value Days of Prescribed Analgesics 3.8 +/- 3.64.0 +/- 5.10.85 Doses of Prescribed Analgesics 6.4 +/- 9.35.1 +/- 6.60.37 Days to Full Activity7.5 +/- 5.88.5 +/- 6.20.33 Days to Return to School4.7 +/- 2.94.9 +/- 3.70.77 ASA, 2011 Ann Surg 254:586-590, 2012

41. 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

42. Technique Comparison For Overweight IPEG 2012

43. Technique Comparison For Obese IPEG 2012

44. 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

45. 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

46. QUESTIONS www.cmhclinicaltrials.com www.cmhmis.com