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Appendicitis: When Simple Becomes Not So Simple

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Appendicitis: When Simple Becomes Not So Simple Wright State University CORE Scholar Department of Surgery Faculty Publications Surgery 1-26-2010 Appendicitis: When Simple Becomes not so Simple Elizabeth H. Ey Wright State University, [email protected] Jeffrey C. Pence Wright State University, [email protected] Follow this and additional works at: https://corescholar.libraries.wright.edu/surg Part of the Surgery Commons Repository Citation Ey, E. H., & Pence, J. C. (2010). Appendicitis: When Simple Becomes not so Simple. https://corescholar.libraries.wright.edu/surg/678 This Presentation is brought to you for free and open access by the Surgery at CORE Scholar. It has been accepted for inclusion in Department of Surgery Faculty Publications by an authorized administrator of CORE Scholar. For more information, please contact [email protected]. Appendicitis: Appendicitis: When simple becomes not so simple When simple becomes not so simple Elizabeth H. Ey, MD Associate Clinical Professor of Pediatrics Department of Medical Imaging Dayton Children’s Medical Center Jeffrey C. Pence, MD, FACS, FAAP Associate Professor of Surgery Department of Surgery Dayton Children’s Medical Center Learning Objectives Historical Perspectives • To further understand a contemporary approach in • Reginald Fitz (Harvard,(Harvard, 1886) the management of acute appendicitis • Presented ““PerforativePerforative Inflammation of the Vermiform • To acknowledge that appendicitis represents a Appendix with Special Reference to Its Early Diagnosis and Treatment” to the Association of American Physicians continuum of disease • Conclusively demonstrated that “perityphlitis“perityphlitis”” began with • To define “simple” versus “complicated” appendicitis iflinflamma tion o fthf the appendix • To understand the importance of diagnostic and • Suggested immediate surgical intervention (3 days or less) for, therapeutic imaging in appendicitis or to prevent, spreadingspreading peritonitis • To explore alternative therapeutic strategies in Fitz RH: Perforating inflammation of the vermiform appendix: With special complicated appendicitis based upon outcomes reference to its early diagnosis and treatment. Trans Assoc Am Physicians analyses 1:107, 1886 Historical Perspectives Historical Perspectives • Charles McBurney(1889) (1889) • Greatest contributor to the treatment of appendicitis “The seat of greatest pain…has • Published the landmark treatise on the surgical been very exactly between an treatment of appendicitis before rupture inch and a half and two • Su bsequen tltly publi s he d (1894) the exposure o f the inches from the anterior appendix through an incision which now bears his spinous process of the ilium name on a straight line drawn from the process to the McBurney C: Experience with early operative interference in cases of disease umbilicus” of the vermiform appendix. N Y State Med J 50:676, 1889 McBurney C: The incision made in the aabdombdominalinal wall in cases of appendicitis. Ann Surg 20:38, 1894. 1 Introduction Introduction • Most commonly diagnosed surgicalsurgical condition of the • Most commonly misdiagnosed surgical condition of abdomen the abdomen • Approximately 7% of individuals will develop acute • Incidence of perforated appendicitis ranges generally appendicitis in their lifetime from 3030--4545 percent in ppyediatric and elderly populations • 250,000 cases diagnosed annually in United States • Continues to cause significant morbidity and rare • Accounts for >1 million inpatient hospital days mortality annually • Cost of >3 billion US dollars per annum Anatomical Considerations Pathophysiology What’s constant… • Three taeniae coli converge at the LUMINAL OBSTRUCTION junction of the cecum with the Appendicolith (40%) appendix Lymphoid hypertrophy • Relationship of the appendiceal Parasites base to the cecum remains Foreign bodies constant Tumors What’s not constant… • Length of the appendix may vary INTRALUMINAL HYPERTENSION from <1 cm to >30 cm (typically 66-- Ongoing secretion Sympathetic nervous system 9 cm) Bacterial proliferation Vague abdominal pain • Position of the appendiceal tip is Appendiceal dilation markedly variable Pathophysiology A Dichotomous Disease Simple appendicitis: “Early” in time course TRANSMURAL INLAMMATION Somatic nervous system Mild periappendiceal inflammation Localized abdominal pain Nonperforated Periappendiceal inflammation GANGRENE/MICROPERFORATION Complicated appendicitis: “Late” in time course GROSS PERFORATION Generalized peritonitis Significant periappendiceal inflammation Phlegmon Mass Abscess PHLEGMON/ABSCESS 2 The Surgeon’s Dilemma The Surgeon’s Dilemma • Simple appendicitisSimple • Simple appendicitis Operate The Surgeon’s Dilemma • Complicated appendicitis Not so simple USA Today January 19, 2010 The Surgeon’s Dilemma The Surgeon’s Dilemma • Complicated appendicitis Not so simple • Complicated appendicitis Not so simple – How do I distinguish complicated appendicitis? – Do I oppyppperate immediately in complicated appendicitis? – If so, what technique? – If I don’t operate, what should my expectations be? – If conservative management is successful, is interval appendectomy necessary? 3 Contemporary Contemporary The ̂ Surgeon’s Premise The ̂ Surgeon’s Premise • I want to distinguish simple from complicated appendicitis • I believe that complicated appendicitis may harbor increased risks with acute appendectomy Higher risk of intraoperative complications Higher risk of open conversion Prolonged operative time Higher risk of postoperative complications (abscess formation) • I acknowledge that the total length of hospitalization, antibiotic administration, and cost of treatment will be unchanged if I employ initial nonoperative management Results HorwitzHorwitz,, JR, et al. Should Laparoscopic Appendectomy Be Avoided for Complicated Appendicitis in Children? J Pediatr Surg 3232::16011601--16031603,, 1997 • No intraoperativecomplications • 7/34 (20%) required laparoscopic to open conversion • Retrospective review • 15/27 (56%) total complications in laparoscopic group • 2 year period (1994(1994--1996)1996) • 11/27 (41%) formed postoperative intraabdominal • 56 children with complicated appendicitis abscess in laparoscopic group • 34 children underwent initial laparoscopic • 2/11 required laparotomyfor drainage appendectomy • 22 children underwent open appendectomy Conclusions Roach JP, et al. Complicated appendicitis in children: a clear role for drainage • Laparoscopic appendectomy for complicated and delayed appendectomy. appendicitis in children is associated with a notable Am J Surg 194:769194:769--773,773, 2007 increase in the incidence of postoperative intraabdominal abscess formation • Retrospective review • 1106 children undergoing either open or laparoscopic • Early open conversion for complicated appendicitis if appendectomy identified incidentally (intraoperativelyintraoperatively)) • 5 year study period (2000-(2000-2006)2006) 4 Roach JF, et al. Results • 360 (32%) radiographic, operative, or pathologic evidence of perforation (complicated appendicitis) • 92/360 (26%) abscess or phlegmon on preoperative iiimaging • 60/92 (65%) immediate appendectomy • 32/92 (35%) conservative treatment with delayed (interval) appendectomy Conclusions Simillis C, et al. A metameta--analysisanalysis comparing conservative treatment versus acute appendectomy for complicated appendicitisappendicitis (absces(abscesss or phlegmonphlegmon).). • Optimal treatment of children who present with Surgery 147:818147:818--29,29, 2010 greater than 5 days of symptoms and preoperative imaging suggestive of complicated appendicitis is • Database search using Medline, EMBASE, Ovid, and Cochrane through June 22,, 2008 delayed appendectomy • 74 total reports identified • 17 reports evaluated in final metameta--analysisanalysis • Initial nonoperative management is safe and effective • 11//1717 reports was a non-non-randomizedrandomized prospective study with no children failing delayed appendectomy and • 77//1717 reports were pediatric no complications requiring repeat admission Outcomes for analysis Results • Duration of hospital stay Outcome of interest Studies Patients OR* PP--valuevalue – Mean duration of hospital stay during first hospitalization Duration of IV antibiotics 4 321 1.02 0.39 – Overall duration of hospital stay, including IA and complications Duration of initial hospitalization 8 825 0.49 0.76 • Duration of antibiotic administration Overall duration of hospital stay7 319 0.04 0.98 – Excluded oral course completed subsequent to discharge OllliiOverall complications 16 1, 490 0240.24 <0. 001 • Complications Wound infection 10 1,024 0.28 0.001 – Overall Abdominal/pelvic abscess 8 981 0.19 0.003 – Specific, including wound infection and abscess formation IleusIleus/bowel/bowel obstruction 8 946 0.35 0.004 • Reoperations Reoperation 4 363 0.17 0.02 – Postoperative complications after IA or AA *OR <1.0 favored CT group 5 Pediatric Subset Analysis Conclusions (n=7) Conservative management of complicated appendicitis is • No differences in duration of first hospitalization associated with: • CT group had fewer overall complications (OR 0.21; P<0.001) • no change in duration of hospital stay • no change in duration of intravenous antibiotic • CT group had fewer wound infections (OR 0.11; P=0.007) administration • decreased overall complication rate • CT group had significantly less abdominal/pelvic abscess • decreased rate of reoperation formation (OR 0.11; P<0.001) Radiology: The importance and impact of imaging Appendicitis: Imaging
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