UPDATE COURSE REWIND- WHO TO SEND HOME FROM THE OR: LAPAROSCOPIC APPENDECTOMY FOR A NON-PERFORATED APPENDICITIS PART 2

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Cecilia Jijena, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held this past August. In this session, the surgeons discussed in roundtable fashion, who can go home from the OR on the same day of the procedure. Today, we are talking about laparoscopic appendectomy for non-perforated appendicitis. Here, we have a 12-year-old with two days of abdominal pain, and ultrasound confirmed appendicitis. Patient underwent a straightforward appendectomy and the appendix was not perforated. You can save a lot of transfers. You get patients from all over the region, from out of state, that technically can be discharged from their EDs and follow up with you in clinic, and then you can have that discussion of an interval appendectomy, which many will choose not to have. Non-operative management of appendicitis was popular during the acute phase of the COVID-19 pandemic. But is this still the trend? Counsel every family member. So we give people the option and we explain what the data show. So, you think that's where it's going to be right now? That's like we're done with the pendulum. I think if be honest about the fact that there's a 30% recurrence rate and that we know that recurrence rate. So we tend not to to offer it to people with appendicalis because we know the likelihood of recurrence is much higher in those patients. Are there specific patients that are more likely to choose non-operative management? It's variable. We'll often see with athletes maybe that are about to enter their season that they'll pick to not have the operation because they don't want to miss time. In Los Angeles, two thirds chose non-operative management, and of those almost probably more than half of those were able to send home from the ED. And then in Seattle, 95% choose surgery, if not more. Share decision-making is an important part of this outcomes. Provided the patient and parents with accurate data allows them to make the best decision for management, whether it's surgical or non-operative. I don't want to pass over the point you made, which is that this could be used to avoid transfer. That patients that are at outlining facilities, you give them antibiotics and this could be treated another time. I think that's a very important topic. If patients present to an ED and there is no surgeon who can operate, it's reasonable to treat them with antibiotics and follow up with a surgeon as an outpatient to discuss interval appendectomy. So what did the surgeons decide for sending patients home on the same day of their procedure? A third would send them home from the PACU. A third would send them home from the floor, and a third would send them home on the following day. Okay, wonder what all that something else is. Yeah, any anything to chat about what the something else is? Ours is really system related. So, I think many of us done these patients are from the PACU, which we can do if they have not yet made it to the floor. So, if they've been admitted to the floor, then we're not allowed to discharge them from the PACU, in which case I would send them back to the floor and discharge them. If they have come straight from the emergency department to the OR, then we can discharge them from the PACU. So it's a system problem. And what does the Nquip data show? In a study out of Buffalo, New York, looking at post-appendectomy discharges from 2012 to 2015, 22% of acute appendicitis was discharged the same day and was not associated with increased risk of readmissions or complications. In subsequent Nquip reviews, we have seen the needle starting to move. So, in the original time period, it was 22%. And then this is up to a mid-30%. And then you can go ahead to the most recent one covering 2017 up to 2021, we're up to 43%. In the final paper that was reviewed, a healthcare system that lacked pediatric beds implemented same day discharges for uncomplicated appendectomies. The race went from 45.5 to 84.4 with no difference in three-day readmission or ED visit. So I think if you implement this and get the right players involved, you can really see a substantial increase in same day discharge. Pediatric surgeons from around the globe discuss the safety and incidence of same day discharge for laparoscopic appendectomy in non-perforated appendicitis. Nearly a third to half of surgeons are already sending their patients home on the same day. Setting expectations with the family prior to the procedure has helped with acceptance of same day discharges. And there are very few patients who come back within 24 hours of procedure. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.