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

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

3. 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

4. Laparoscopic Appendectomy Personnel/Port Positions

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

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

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

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. Perforated Appendicitis

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

12. Acute Appendicitis – Definite Abscess on CT 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 10 - 14 days at home 7)Return 8-10 wk. for interval appendectomy - overnight hospitalization

13. Interval Appendectomy Why?

14. 5 – Expert opinion, or applied principles from physiology, basic science, or other conditions 4 – Case series or poor quality case control and cohort studies 3 – Case control studies 2 – Review of case control or cohort studies with agreement or poor quality randomized trial 1 – Prospective, randomized controlled trials Levels Of Evidence

15. Appendectomy Studies at Children’s Mercy

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

17. 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 +/- 4879 +/- 410.68 Length of Post-Op Hospitalization (Days)6.0 +/1 2.46.1 +/- 2.50.94 Post-Operative Abscess15.9%17.8%0.81 Narcotic Charges$258 +/- $150$361 +/- $2470.02 Antibiotic Charges$1,246 +/- $490$1,919 +/- $648<0.001 Post-Operative Wound Infection01NS

18. 1. Postoperative Antibiotic Regimen for Perforated Appendicitis Conclusion: Ceftriaxone(Rocephin) and metronidazole(Flagyl) 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. AAP, 2007

20. 2. IV vs IV/Oral Antibiotics for Perforated Appendicitis Perforation defined as hole in appendix or fecalith in abdomen Power analysis (alpha 0.05, power 0.8) – 75 patients each arm Control: IV Ceftriaxone/Metronidazole (CM) – 5 days minimum Experimental: Initiate CM If tolerating regular diet, on oral analgesics & afebrile 12 hrs, discharge on Augmentin to complete 7 day course Primary endpoint: incidence of postoperative abscess formation

21. 3. 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 *

22. 3.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 – 1) ileal perforation 2) colon perforation 3) bladder perforation 4) buttock/thigh abscess AAP, 2007

23. 3.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 abscess17.3 % Repeat drainage11.5% AAP, 2007

24. 4. 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

25. 4. 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

26. 4. SBO After Perforated Appendicitis (1105 Patients) LaparoscopicOpenp value Perforated appendicitis186192 SBO1 (0.5%)6 (3.1%)p = 0.03 AAP 2006 J Pediatr Surg 42:939-942, 2007

27. 5. 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

28. Evolution in Timing of Operation 1)IV CM on admission 2)Will operate that day/night until 9-10 pm 3)If present after 9-10 pm, operate next day (1 pm or earlier)

29. 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

30. ? ? ? www.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com