Dr. Krysta Sutyak - Best of the Best in Pediatric Surgery 2025

Uh we're going to now move on to the second paper from PEPS. Um, Dr. Christa Sujak who is talking about uh well she's from the University of Texas Health Science Center at uh Houston, Texas. And she's going to be talking about the safety evaluation of the use of providone iodine irrigation for perforated appendicitis. Let's hear it. Thank you. We have nothing to disclose. Appendicitis is the most common diagnosis requiring urgent surgical treatment in the pediatric population. 34% of the almost 34,000 children who underwent appendectomy in the United States from 2019 to 2021 were found to have perforation. Perforated appendicitis increases the risk for post-operative intraabdominal abscess with 10 to 30% of patients with perforation developing an abscess. The development of a post-operative abscess leads to increased morbidity, often requiring subsequent drainage procedures, increased hospital length of stay and readmission rates and increased healthcare costs. We looked at the overall cost of post-operative abscess at our institution from 2013 to 2019 and found that the development of an abscess was associated with a length of stay increase of 6.1 days and an estimated incremental cost increase of $11,809 US per patient. Providone iodine has bactericidal properties, matching the pathogen profile seen most commonly in perforated appendicitis and abscess formation. In 2016, we performed a pilot randomized control trial investigating the use of providone iodine irrigation or PVI in pediatric perforated appendicitis. Patients in the intervention arm received irrigation of the right lower quadrant and pelvis with PVI solution containing 0.1% available iodine compared to usual care in the control arm. This resulted in an 89% probability that PVI reduced the rate of abscess and a 96% probability of decreased length of stay. In the secondary cost analysis, we identified a mean cost difference between the PVI group and the usual care group of $1,954 US. Overall, this reflected a 95% based in probability of reduced 30-day hospital costs. For all the participants in this trial, or 50 patients, this was an estimated hospital cost savings of $98,000. PVI irrigation in this setting is a novel therapy. Theoretical concerns about its use intraabdominally include potential adhesive disease, gastrointestinal effects or thyroid dysfunction. The long-term outcomes of PVI intraabdominally are unknown. We aim to identify any potential adverse events. A retrospective review was performed of the 100 patients who participated in the trial from the time of discharge to December of 2023. The EMR was reviewed for the presence of any inpatient or outpatient encounters. Diagnosis were reviewed for any gastrointestinal issues, including constipation, diarrhea or chronic abdominal pain. Thyroid related conditions, treatment visits and lab results were also assessed. All abdominal imaging was noted and reviewed for any mention of unusual findings. The operative reports of any subsequent operations were reviewed for abnormal findings or the presence of increased adhesive disease. Of the trial participants, 60% were male with a median age at the time of surgery of 9.5 years. All 100 trial participants were reviewed with 51% having subsequent encounters within the electronic medical record, including 50% of those who received PVI therapy and 52% of those who received usual care. The median follow-up time was 7.3 years. There was no statistically significant difference in gender or age at surgery between the two groups. Only seven of the 100 patients had an ED visit related to their appendicitis diagnosis with five in the usual care group and two in the PVI group. Three patients had a related readmission, all from the usual care group, and two patients had a related post-operative visit outside of the specified routine follow-up, both of whom were in the usual care group. When assessing the medical records for visits outside of the pediatric surgery department, zero patients were identified as being diagnosed with chronic abdominal pain, diarrhea or small bowel obstruction. Five patients had encounters related to constipation with one from the usual care group and four from the PVI group. No other diagnostic trends were observed. Two patients were identified as having thyroid related diagnosis since the time of surgery. One patient from the PVI group was diagnosed with thyroiditis after positive TPO antibodies were identified in the initial screening for the trial. This was determined by pediatric endocrinology to be unrelated to the PVI use. One patient from the usual care group was diagnosed with papillary thyroid carcinoma 7.5 years later at the age of 22. Children after PVI irrigation for perforated appendicitis did not demonstrate any adverse events, unexpected outcomes or differences in rates of biologically plausible conditions related to PVI. Both thyroid conditions identified were unrelated to the use of PVI. Long-term outcomes of our RCT demonstrate safety in the use of PVI and support further investigation with a multi-center trial. Thank you very much. So, Chris, thank you for that. Here's the problem. Whenever you present about appendicitis, you're going to get a million questions. So uh. Absolutely. Dan and I are fighting here. We want to go go ahead Dan. And then we have a question from the audience. it never ceases to amaze me that we're still trying to figure out how to take care of appendicitis. So so just a basic question about the the structure of your trial, you usual care was there any irrigation and how do you segment out whether this these results were because of the irrigation or because of the iodine? Yeah, I would say for the most part the usual care was no irrigation, but as as within the trial it's usual care. So within our practice though it would typically be no irrigation. So that's the challenge, right? Because we're. Yeah, absolutely. Irrigation to no irrigation. And the struggle I'm having is I keep changing my practice every time I read the latest paper because we had the Kansas City paper that it didn't make a difference then we had a follow up paper that used high volume irrigation. Absolutely. So uh it's hard to make sense of it. I I would love to see even compared to some of the historical papers um comparing just standard irrigation or high volume irrigation just to try to make sense of all of this. Yeah. there's a great question from the chat, um Dr. Si about um impact on infertility in female children and do we expect that and I don't, you know, in comparison to saline or any other irrigation might impact tube function. I think that's an excellent question. I think that's one of the reasons why we were interested in looking at these patients because at the time we did this, the medium follow up was about seven years. That was two years ago, so we're kind of getting a little bit older now. That's not something we saw mentioned, but obviously one of the major limitations of this study is the retrospective nature and that we only had data, although it was equal between groups between 50% of patients. So we're currently prospectively looking at the patients within this trial to to gather some things like that and we can ask more specific questions of the patients and their families than what's written in the EMR. love the long term follow up. That's great. Thank you so much. Great job, great presentation.