Download Current Management of Children with Appendicitis

Current Management of Children
with Appendicitis
CIPESUR Meeting
November 18, 2011
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, Missouri
Three Presentations
• Acute appendicitis
60 - 65%
• Perforated appendicitis
25 - 30%
• Perforated appendicitis with welldefined abscess (5-7 day history)
5 - 10%
Surgical History for Appendicitis
(U.S.)
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
Surgical History for Appendicitis
(U.S.)
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
Laparoscopic Appendectomy
Personnel/Port Positions
Laparoscopic Appendectomy
Technique
• Window in
mesoappendix
• Vascular stapler across
mesoappendix
Postoperative Appearance
3 Port Laparoscopic Appendectomy
Acute Appendicitis
(No Perforation)
• April 2003 – Nov 2006
• 609 Pts – laparoscopic
appendectomy
• 3 post-op abscesses
(0.49%)
Acute Appendicitis
Appendiceal Perforation
• Perforated appendicitis (3 - 5 day hx)
 Evacuation/irrigation of purulent material
 Wound problems minimized
 20% post-op abscess rate
Laparoscopic Appendectomy
Please use this link if you experience problems viewing the video above.
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
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
(1105 Patients)
Laparoscopic (n = 628)
Open (n = 477)
P Value
11.0 +/- 3.7
9.2 +/- 5.1
p > 0.05
Gender (M/F)
355/273
301/176
p > 0.05
SBO
1 (0.2%)
7 (1.5%)
p = 0.01
186
192
8 days
58 days
3.5 (0.8 – 6.5)
4.9 (0.9 – 8.3)
Age (years)
Perforated appendicitis
Mean time to SBO
Median follow-up (years)
AAP 2006
J Pediatr Surg 42:939-942, 2007
SBO After Perforated Appendicitis
(378 Patients)
Perforated appendicitis
SBO
Laparoscopic
Open
186
192
1 (0.5%)
6 (3.1%)
p value
p = 0.03
AAP 2006
J Pediatr Surg 42:939-942, 2007
2000 – 2010 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?
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
Antibiotics Only vs Appendectomy For NonPerforated Appendicitis
Liu K, Ahanchi S, Pisaneschi M, et al. Can acute appendicitis be treated by
antibiotics alone? Am Surg 73:1161-1165, 2007
• Retrospective comparative study (Level 3 study)
in adults found no differences in complications
between appendectomy at presentation or
antibiotic therapy alone
• 5% recurrence rate
Early Operation Versus Delayed Operation
Abou-Nukta F, Bakhos C, Arroyo K, et al. Effects of delaying
appendectomy for acute appendicitis for 12 to 24 hours. Arch Surg
141:504-506, 2006
• Retrospective comparison in adults (Level 3
study) between operation < 12 hrs or > 12
hours after presentation
•
308 patients
•
No differences in OR time, complications, %
with advanced appendicitis, or length of stay
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
The remaining four questions
can be answered from studies
at Children’s Mercy
Levels Of Evidence
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
2. Is There an Optimal Antibiotic
Management for Perforated
Appendicitis?
• Prior to 2000, most pediatric centers in the U.S.
were treating patients with intraabdominal
infections with Ampicillin, Gentamicin and
Clindamycin (Triple Antibiotic Therapy)
• Triple antibx provide good coverage; inexpensive
But
• Gentamicin known to be toxic to hearing and
renal function
• Serum levels recommended for Gentamicin use
Why Not Use
Ceftriaxone/Metronidazole?
Advantages
•
Same broad spectrum coverage as triples
•
The duo of Ceftriaxone and Metronidazole
require no serum levels
•
Ceftriaxone and Metronidazole has been
shown to be safe and effective in once/day
dosing
•
Daily dosing allows easy transition to
outpatient IV therapy, if needed
Retrospective Review
• 250 patients w/perforated appendicitis - 1998 - 2004
• Those treated with Ceftriaxone/Metronidazole were
compared to those treated with triple antibiotic
coverage (Ampicillin, Gentamicin, Clindamycin)
• Retrospective Study (Level 3 study)
• Parameters included temperature curves for the first 5
post-operative days, abscess rate, length of
hospitalization, length of intravenous antibiotic
treatment and medication charges
CAPS, 2005
J Pediatr Surg 41: 1020-1024, 2006
Retrospective Results
Outcomes
C/M
A/G/C
P Value
WBC (x103)
9.8 +/- 0.5
11.6 +/- 0.4
0.10
LOS (Days)
6.8 +/- 0.4
7.9 +/- 0.2
0.03
IV Tx (Days)
7.2 +/- 0.5
8.6 +/- 0.4
0.05
Abscess (%)
8.8%
14.2%
0.37
CAPS, 2005
J Pediatr Surg 41: 1020-1024, 2006
Results
Tmax (Degrees Celsius)
Temperature Curves
C/M
*
38.5
*
A/G/C
*
38
*
*
37.5
37
* P < 0.001
36.5
Admission
1
2
3
4
5
Post-Operative Days 1 - 5
CAPS, 2005
J Pediatr Surg 41: 1020-1024, 2006
Results
Medication Charges
Expense of dose ($ dose) = (drug price + dispensing charge )
Expense of course = ($ dose) x (# doses/day) x (days of
treatment)
CAPS, 2005
J Pediatr Surg 41: 1020-1024, 2006
Results
Medication Charges
Impact Of Nursing Charges
Ceftriaxone Dose Charge = ( $19.48 + $28.13 )
Expense of Course = ($47.51) x (1 dose/day) x (7 days) = $332
Ampicillin Dose Charge = ( $0.38 + $28.13 )
Expense of Course = ($28.51) x (4 doses/day) x (7 days) = $798
CAPS, 2005
J Pediatr Surg 41: 1020-1024, 2006
Results
Medication Charges
C/M
$ of Course
$546.01 +/- $29.34
A/G/C
$2494.06 +/- $78.44
P Value < 0.0001
CAPS, 2005
J Pediatr Surg 41:1020-1024, 2006.
With this information, is there any reason
to perform a prospective randomized trial
comparing Ceftriaxone/Metronidazole to
Triple Antibiotic Therapy (Ampicillin,
Gentamicin, Clindamycin) for perforated
appendicitis?
Why A Prospective, Randomized Trial?
Weaknesses
• Retrospective
• Uneven numbers between groups
• Postoperative care not standardized
• Recent experience vs historical experience creates bias
 Far more laparoscopy in recent cohort (C/M)
 (47% in C/M group vs 2% in A/G/C group)
 Experience w/laparoscopy improved
 Pressures to discharge sooner in recent cohort independent of
medication regimen?
Prospective Randomized Trial
• Ceftriaxone/Metronidazole or A/G/C
• Perforated appendicitis at the time of
appendectomy
 Hole in the appendix
 Visible appendicolith in the abdomen
• Power 0.8; alpha 0.05; sample size 100
Exclusion Criteria
• Known allergy to one of the medications
Standardized Management
• All patients receive 5 days IV antibiotics
• Diet begins after flatus
• WBC drawn on POD 5
• Nl WBC count and tolerating PO’s w/o fever
meets discharge criteria
• If elevated, draw again on POD 7, then if
elevated, draw on POD 10 and obtain CT
• No antibiotics on discharge
Results
Outcomes
C/M
A/G/C
P Value
WBC (x103)
9.4 +/- 3.9
9.9 +/- 4.4
0.56
LOS (Days)
6.27 +/- 2.5
6.20 +/- 3.2
0.85
IV Tx (Days)
6.0 +/- 1.5
6.2 +/- 1.1
0.48
Abscess (%)
20.4%
16.3%
0.79
AAP, 2007
J Pediatr Surg 43:79-82, 2007
Results
Medication Charges
C/M
A/G/C
P Value
Total Meds
$3370
$3817
0.20
IV Abx
$1412
$1940
<0.001
6.1%
<0.001
% of Med Charges
4.5%
AAP, 2007
J Pediatr Surg 43:981-985, 2008
Results
Temperature Curves
Max Temeperature (Degrees Celsius)
Triples
C/M
39
38.5
38
37.5
37
36.5
Admission
1
2
3
4
5
Post-Operative Day
AAP, 2007
J Pediatr Surg 43:981-985, 2008
Conclusions
•
There is no difference in infectious
complications, recovery or defervescence after
perforated appendicitis between
Ceftriaxone/Metronidazole and Triples
(A/G/C)
•
Ceftriaxone/Metronidazole is more costeffective than standard triple antibiotic
therapy
AAP, 2007
J Pediatr Surg 43:981-985, 2008
3. How Do We Define
Perforated Appendicitis?
• The literature is replete with retrospective studies
regarding perforated appendicitis
• All of these studies fail to strictly define perforation

Dependent on surgeon’s definition

“Gangrenous”, “suppurative”, “perforated”
• Therefore, the conclusions from these retrospective
reports must be approached cautiously
J Pediatr Surg 43:2242-2245, 2008
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
Definition of Perforation Used in
Prospective Randomized Trial
Hole in appendix
Visible appendicolith
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)
Results
Outcomes
NONPerforated
Prior DOP
(n=292)
After DOP
(n=388)
Abscess rate
1.7%
0.8%
LOS (days)
1.9 +/- 1.3
1.5 +/- 1.5
Perforated
Prior DOP
(n=131)
After DOP
(n=161)
Abscess rate
LOS (days)
14.0%
9.4 +/- 4.2
18%
7.4 +/- 8.8
PAPS 2008
J Pediatr Surg 43:2242-2245, 2008
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 nonperforated
• 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
4. How do we manage the child
presenting with an abscess due to
ruptured appendicitis?
Perforated Appendicitis
Presenting With Abscess
History
• 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?
Perforated Appendicitis with Abscess
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
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
Perforated Appendicitis with
Abscess
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
Initial Non-Op Mgmt vs Lap
Appendectomy in Children Presenting
with an Abscess
Patient Characteristics at the Time of Admission
Initial operation Initial nonoperative
(n=20)
management (n=20)
P
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
Values are expressed as mean ± SD
APSA 2009
J Pediatr Surg 45:236-240, 2010
Initial Non-Op Mgmt vs Lap
Appendectomy in Children Presenting with
an Abscess
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 ± 38.7
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
.04
Total charges
$44,195 ± $19,384
$41,687 ± $18,483
.68
Values are expressed as mean ± SD, unless
otherwise indicated
APSA 2009
J Pediatr Surg 45:236-240, 2010
Prospective Randomized Trial
• Conclusion – There is no difference b/w
initial laparoscopic operation vs initial
non-operative management followed by
laparoscopic interval appendectomy
• Management can be determined by the
surgeon’s preference and experience
APSA 2009
J Pediatr Surg 45:236-240, 2010
5. Is there an advantage
performing the laparoscopic
appendectomy through a single
umbilical incision?
SSULS Appendectomy
SSULS Appendectomy
Please use this link if you experience problems viewing the video above.
Postoperative Appearance
Prospective Randomized Trial
Single Umbilical Incision vs 3-Port
Laparoscopic Appendectomy
• 360 total patients
• Acute non-perforated appendicitis
• August 09 – November 10
• Primary outcome variable – postoperative wound infection
• Standardized pre and postoperative management
• Quality of life surveys at 6 weeks and 6 months
Patient Characteristics
at Operation
Single Incision
(N=180)
3-Port
(N=180)
P-value
Age (yrs)
11.05 ± 3.47
11.04 ± 3.41
0.98
Weight (kg)
42.7 ± 18.5
42.5 ± 17.4
0.90
Gender (% male)
54.4%
51.1%
0.53
Leukocyte count
14.7 ± 5.2
14.6 ± 5.4
0.89
American Surgical Assn – 2011
Ann Surg 254:586-590, 2011
Outcome Data
Single
Incision
(N=180)
3-Port
(N=180)
Pvalue
3.3%
1.7%
0.50
Operative Time (mins)
35.2 ± 14.5
29.8 ± 11.6
<0.001
Postoperative Length
of Stay (hours)
22.7 ± 6.2
22.2 ± 6.8
0.44
Wound Infection
Hospital Charges ($)
17.6K ± 4.0K 16.5 ± 3.8K
0.005
American Surgical Assn – 2011
Ann Surg 254:586-590, 2011
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
QUESTIONS
www.cmhclinicaltrials.com
www.cmhmis.com