Update Course Rewind: Management of Appendicitis 2022

Hello everyone, I'm Sueso Diah Quihena from Cincinnati Children's Hospital. We are summarizing the talks of the Advances in Pediatric Surgery, ChatGPT2. This talk is about management of appendicitis. As a moderator for this talk, we have Dr. Witte Holcomb, and as a speakers, we have doctors Mira Katagal, Sean San Peter and doctor Tolu Ayintesh. In this talk, we are covering three topics: non-perforated appendicitis, perforated appendicitis, and non-surgical treatment for appendicitis. And they started by doing a question. If you're looking at this picture, how would you classify the appendix shown in the picture, perforated, gangrenous, supportive, or it depends? And there's to me, there's no real difference or very little difference between gangrenous and supportive. So it's either perforated or non-perforated. Well, this has been our standard practice um here for over a decade, uh the paper that was published in 2008, which clearly defined perforation depends on whether you have a hole in the appendix or if there's a facalith in the abdomen. So when you classified people based on hole in the appendix or a fecalith, it it impacted your rates of abscess in a way that made logical sense, right? It reduced the rates of abscess amongst the non-perforated patients and it increased the rates of abscess around the perforated patients, so it aligned with what you would expect in clinical care. If you have true gang green of the of the bowel wall and bacteria translocating across that, is that different than perforated or is is that perforated or is that not perforated? Which category does that go into? The the patient with vocal necrosis will typically fall into the group that would uh get sent home. So what they're saying is that from a clinical standpoint, we now classify appendicitis in perforated and not perforated. Perforated means that the appendix has a hole or there's a fecalith in the abdomen. And that is important to know if the patient can be discharged the same day or if they need to be admitted for IV antibiotics. So, gangrenous would be considered non-perforated. Let's look to same day discharge for non-perforated appendicitis. Um so, you know, thinking about how we can move patients with non-perforated appendicitis through their pathway and kind of out of the hospital in a timely fashion and can we do that safely? You know, the initial study with same day discharge was way back in 2013-14. At that time, we had a 28% uh successful discharge. Uh we learned from that and we continue to work on that till this recent study that we we published, which showed that we were successfully, we successfully discharged 87% of the patient. And this has become the normal, the norm for us now. 87%, that is a great rate of same day discharge. So, let's move to the next question, irrigation or no irrigation. Right, so this paper is probably well known and um that was back in 2012 which compared suction to irrigation. And the minimum amount of irrigation in this story was 500 ccs, but the average that was used to about 850 ccs. It showed no difference. So the the benefit of suction if I can call it that is there's no added time to irrigating and also research used. That being said, this is a randomized study, but there's another study that was a retrospective study that looked at more aliqa in 50 ccs and they went as high as two to three liters. Based on the other study said, well, irrigating might also help. That study was 3 to 12 liters in 50 cc aquats. The abscess rate in the um in the patients who were irrigated was 0% in that study compared to 18.9% in the perforated appendicitis population. But again, retrospective study, not randomized. Yeah, 0% I I mean, I struggle with that a little bit, which is why I do think we probably need more data. In our practice, we don't irrigate. We just suction and I don't think we've seen a major difference in abscess rate. There's still some controversy in this topic that many people in the room say they didn't irrigate, they would just use suction. And now the fourth question, if we admitted the patient for IV antibiotics, when do we discharge it? The patient will declare himself or so. If the patient looks is is ready and clear, wants to eat, it doesn't matter if it's day one, day two. If the patient is febrile, good pain control, is toding a diet, the patient can go off. You know, all those things we make a clinical decision based on how the patient's doing and then um get labs at that time to decide about discharge home with antibiotics versus discharge home without antibiotics. Great. So if the patient is okay, they are tolerating food and they have normal evacuations with no diarrhea, they are able to be discharged. But Dr. Tabkonsky was a little bit concerned, so he made a question. Let's hear it. Is I totally get everything you said that usually by day three or four, we know infections take a while to start developing. Day one, they're not going to have an infection yet, it's too soon. So do you really trust 20 less than 24 hours after surgery that they've declared themselves as good to go? I don't think we should focus on the extreme outlier. Uh the more likely scenario, the fastest we typically see is somebody transitions between clears to solids on day one and then we make sure by day two they haven't thrown everything up the next morning. Got it. And it's usually day two breakfast is about the fastest you typically see that we end up getting the white count up. But what's interesting is that we did when we did all these previous uh trials, we saw a 20% abscess rate and that was sort of fixed across whether we used two different types of antibiotics irrigation or whatever. And our abscess rate has finally dropped to about 10% since we stopped treating them like they're sick. So in Cincinnati, we took a different research approach to this using QI techniques and and we tracked their abscess rate. We had a protocol, this exactly the same protocol and then looked at abscess formation or readmission for abscess as a balancing measure and by implementing that exactly that protocol of going home when you meet those criteria, there was no change at the readmission rate for abscess. Okay. So what they are saying is that a patient normally tolerates and can be discharged by day two post up and treated them as healthy patients actually decrease their abscess rate to 10%. So, that is great. Let's go on with this. So so this is an eight-year-old male that presents with 24 hours of abdominal pain, a white count of 12 and ultrasound that demonstrates appendicitis with an appendiceal diameter of 0.9 and a small fecalith and no abscess or flemon. And the poll question is, which one of these findings makes the patient ineligible for non-operative management? They do that in? Let's hear the answer. Um I think two studies really that people should know about in the thinking about non-operative management, one is the adult side, um which was the Kota trial, which was a pragmatic randomized control trial um that was done on the adult side and then there was a child done in the Midwest Pediatric Surgical Consortium looking at this, which was a patient and family choice study. So I think the big things that we see in these patients to be eligible for non-operative management, symptoms less than 48 hours, imaging confirmation with an appendiceal diameter less than 1.1 cm, um no abscess, flemon or fecalith, and then white count somewhere between 5 and 18. So the kids who have a white count of 25,000 were less likely to um think of as non-perforated appendicitis that might improve um with just antibiotics. Great. So non-surgical treatment for appendicitis is it effective? When we designed the multicenter trial, we were designing it as a non-inferiority trial. This is a study that hasn't come out yet. We we had this debate about at what point do you just say that's that's too high. And most of the surgeons landed on around 20%. So that's where we set the mark for the non-inferiority non-inferiority margin. And what we're seeing it the interim analysis is the exact same result. It's around 31, 32% one year fail rate. Not all fail not all failures are the same, you know, if 30% failure means that they will come back, they'll have an operation, when they look at the histology, not not even all of them had appendicitis. So, um, for some people, for some parents, their quality of life it's better, uh, they won't have an overnight operation and even they've they've measured how many days they're absent from school and with non-operative management, there's a non significant like three days uh, uh extra going going to school, so not not all failures are the same. A lot of our patients seem to have an interval app. And that's why we we've actually gone to the outpatient management because we think you can outpatient treat them, they go home. We see them at follow up and have a true discussion and a a significant portion of them will say, let's just have an interval app. Again, you schedule it, it's elective and that will probably be a better quality of life than admitting. Great. So I think we can all agree that non-surgical treatment is not here to overcome surgery. But we must have this tool in our toolbox to treat appendicitis. Great session, right? Let's summarize. First, we should classify appendicitis in perforated or non-perforated. Second, non-perforated appendicitis can be discharged the same day. Third, irrigations or no irrigations are still a controversy. So we don't have an answer to that question yet. Fourth, for perforated appendicitis, if the patient is okay, has normal recreations and tolerates food, he can be discharged after white blood. We typically check a white blood cell counts to determine the need for further antibiotics. Fifth, non-surgical treatment for appendicitis is feasible. But it's not here to overcome surgery. So it's okay to have it in our toolbox, but can replace surgery within. And that was everything for today. Hope you like it. And if you want to see more, go to stay current. 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