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)

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

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

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

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

Laparoscopic Appendectomy Technique Window in mesoappendix Vascular stapler across mesoappendix

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

Acute Appendicitis - Contained Perforation Perforated appendicitis (3 - 5 day hx) Evacuation/irrigation Controlled spillage Wound problems minimized

Acute Appendicitis - Free Perforation Hemodynamically Stable Laparoscopic appendectomy reduced discomfort selectively irrigate/evacuate pus lyse adhesions few wound problems often NGT not needed

Acute Appendicitis - Free Perforation Hemodynamically Unstable IVF Resuscitation Antibx/NGT Open appendectomy Lower midline incision RLQ incision Prolonged (10 - 14 days) hospitalization Rare patient

Acute Appendicitis – Contained Perforation Hemodynamically Stable 5 - 7 day history IVF Percutaneous drainage (radiology) PICC line - antibx Discharge day 3-5 if stable Antibx con’t 10 - 14 days at home Return 8-10 wk. for interval appendectomy - overnight hospitalization

Interval Appendectomy Why?

Appendectomy Studies at Children’s Mercy

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

Postoperative Antibiotic Regimen for Perforated Appendicitis No difference b/w groups re: weight, gender, days of symptoms, temperature, WBC count on admission Table 1 – Outcomes: CM vs AGC CM AGC P Value Time to Regular Diet (Hours) 75 +/- 48 79 +/- 41 0.68 Length of Post-Op Hospitalization (Days) 6.0 +/1 2.4 6.1 +/- 2.5 0.94 Post-Operative Abscess 15.9% 17.8% 0.81 Narcotic Charges $258 +/- $150 $361 +/- $247 0.02 Antibiotic Charges $1,246 +/- $490 $1,919 +/- $648 <0.001 AAP, 2007

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.

Attempted percutaneous drainage, interval appendectomy Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess Retrospective study June 00 – Dec 06 52 pts Attempted percutaneous drainage, interval appendectomy AAP, 2007

Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess Mean age – 9.0 +/- 3.9 yrs Mean weight - 34.4 +/ 18.8 kg Mean symptoms - 8.4 +/- 7-6 days Mean volume fluid - 76.3 +/1 81.1 cc Mean time to interval appy – 61.9 +/- 25.2 days Mean post-op hosp. after interval lap appy - 1.4 +/- 1.4 days Drain complications – ileal perforation colon perforation bladder perforation buttock/thigh abscess AAP, 2007

Resource Utilization and Outcomes From Percutaneous Drainage and Interval Appendectomy for Perforated Appendicitis with Abscess Outcome Variables Mean +/- Std Dev Number of CT scans 3.5 +/- 2.0 Total hospital days 7.0 +/- 3.9 Total days of drainage 6.4 +/- 7.0 Number of healthcare visits 7.6 +/- 2.8 Total charges (thousands of $) $54.3 +/- $55.2 Recurrent abscess 19.2 % Repeat drainage 11.5% AAP, 2007

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 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 p = 0.03 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 Laparoscopic Open p value Perforated appendicitis 186 192 p = 0.03 SBO 1 (0.5%) 6 (3.1%) p = 0.03 AAP 2006 J Pediatr Surg 42:939-942, 2007

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

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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