Dr. Whit Holcomb discusses current concepts and controversies of appendicitis.
Dr. Ponsky: Hi this is Todd Ponsky. I am a pediatric surgeon at Akron Children’s Hospital and one of the editors of "Stay Current” in pediatric surgery, and this is our first episode of "Stay Current” and with us today I have Dr. Whit Holcomb from Kansas City. Dr. Holcomb, are you there?
Dr. Holcomb: I am, thank you.
Dr. Ponsky: Welcome and thank you for doing this today. Before we get started could you tell us a little bit about yourself and where you practice and what you do there?
Dr. Holcomb: Sure, so I’m a pediatric surgeon at the Children’s Mercy Hospital in Kansas City, Missouri. I’ve been here 16 years. I was previously at Vanderbilt Children’s Hospital for 11 years. I am the surgeon and chief at Children’s Mercy Hospital and one of nine pediatric surgeons practicing here at the hospital.
Dr. Ponsky: Perfect. I know today we’re going to be talking about appendicitis, and I know that you’ve built a pretty robust research center there and I think that you’ve been doing quite a bit of outcomes research with appendicitis, is that right?
Dr. Holcomb: Yes and I would like to acknowledge that much of this work has been done, and certainly has been spearheaded, by Dr. Shawn St. Peter who directs our center for prospective clinical trials and it is through his efforts and his leadership that much of the information that we’ll discuss today has come about.
Dr. Ponsky: Perfect. Yeah Shawn has been doing some great work and I think that a lot of the stuff that’s been coming out of there has changed the management around the country. So speaking of that, I want to jump right in Whit, and present to you a classic patient. So, how would you manage a 16 year old male that presents to your emergency department with a one and a half day history of pain that started at his umbilicus and migrated to his right lower quadrant, he’s had some nausea and some vomiting, no diarrhea, and the emergency room checked a white blood cell count which was 14, and a slightly elevated CRP at around 3. He has a low-grade fever, and that’s where he’s at right now. You go down to examine the patient and he has a soft abdomen, but tender specifically at McBurney’s point in the right lower quadrant. His vital signs are stable. How would you approach a patient like this?
Dr. Holcomb: Well that’s an interesting scenario because you really described the classic presentation for acute appendicitis, and so if that case came in and the emergency physicians have not already performed an imaging study, which would be ultrasound usually, initially, at least today, then we would take that patient to the operating room and perform a laparoscopic appendectomy and that is certainly the way things worked 10, 15 years ago before imaging studies became fairly commonplace in children with abdominal pain. Now, having said that, I will say that at least in our hospital, often an imaging study will have been performed but that is at the discretion of the emergency department physicians and not at the discretion of the pediatric surgeons. So I think in this particular case, if we were called initially or if we saw the patient initially, we would just take that patient to the operating room without an imaging study.
Dr. Ponsky: Perfect, now would that decision change if it was a girl?
Dr. Holcomb: No, not in the description that you gave us.
Long duration of symptoms
Dr. Ponsky: Perfect, okay. Now let’s take a patient that maybe isn’t so classic. Let’s say they had a 4 day history of symptoms, everything else was about the same, but instead of 12-24 hours it’s been 4 days. Would that change your management?
Dr. Holcomb: So that patient has a diagnosis that is probable appendicitis but with a 4 day history you’d certainly be worried about perforation. In our hospital we generally use 24 even up to 36 hours, thinking that symptom of duration of that length does not have a perforation, but any symptom duration longer than that length likely has perforation, assuming they have appendicitis and so that patient would receive an imaging study and we would start with an ultrasound.
Dr. Ponsky: Okay, so let’s say the a, let me ask you first before I get into the results of that ultrasound, if it’s 1:00 in the morning, do you have ultrasound techs at your hospital at that time?
Dr. Holcomb: Yes, we do.
Dr. Ponsky: Okay. If you didn’t, because I know a lot of hospitals don’t necessarily have ultrasound techs 24 hours a day, would you get a CAT scan or wait until the morning?
Dr. Holcomb: Well in our particular situation, at least in our experience, the ultrasound may not be completely accurate for lack of a better way of saying it. And so, assuming there’s any concern on the ultrasound reading, that patient will then proceed to getting a CAT scan. If the ultrasound is diagnostic of appendicitis, then we would not proceed with a CAT scan. If we did not have an ultrasound at 1:00 in the morning, then yes we would get a CAT scan.
Dr. Ponsky: Okay. So let’s say you get the CAT scan Whit and I don’t know about your institution, but at my institution we frequently get the reading that there is non-visualization of the appendix. They don’t necessarily remark that they don’t see a normal appendix, but non-visualization. How do you interpret that and what do you do with that result?
Dr. Holcomb: Well at 4 days I believe you should see a visualization of the appendix, but if you don’t then you should see secondary signs of appendicitis and likely perforation. So if you do not see either of those signs, then I think the likelihood that they have appendicitis is low, although not zero, so I would personally probably admit that child, give him some IV fluid, examine in 8-12 hours and see if the symptom complex changes.
Dr. Ponsky: Great and so that has absolutely been something that some of us do differently that a non-visualization in some patients may lead to a CAT scan, and then some of us, we admit and observe in lieu of a CAT scan, so I like that approach. So the next question I want to ask you is, regarding your CAT scan, in a patient you get a CAT scan, do you use IV and oral contrast or even rectal contrast?
Dr. Holcomb: We generally use IV contrast. Occasionally oral contrast is given. We tried to work on a protocol of using rectal contrast, and the ED physicians did not feel that it was the best way to go, so we have stopped, or that protocol had never really started. And so generally we use IV contrast. We also do a limited CT scan, that is we do a more focused CT scan looking for appendicitis as opposed to a general CT scan, and that’s due to the fact that we’re trying to minimize the radiation exposure.
Intermediate duration of symptoms
Dr. Ponsky: So let’s say the patient has had 3 days of symptoms, evidence on ultrasound of a perforated appendix, there’s no rule you have about getting imaging on that patient? You may still take them straight to the OR?
Dr. Holcomb: Well, yes, but practically speaking that patient would have received an imaging study already, and if they had not I probably would’ve gotten one because I would be interested to know if there was a perforation or not. It helps me going in there with my mind set of whether or not there’s a perforation or not, so I probably would at least try to get an ultrasound, although that likely would’ve already been done through our ED physicians.
Dr. Ponsky: That’s a great point, and to reiterate sort of a summary of what you’ve said, a patient with a 3 day history of symptoms, even if you see an abscess, you’re still going to operate so you may not change your management but it gives you a heads up before going into the operating room.
Dr. Holcomb: Right and I think that though this isn’t that important, it does give you the ability to counsel the family too a little bit on what you’re going to expect and the ultrasound is a relatively inexpensive study. I wouldn’t get an ultrasound at 1:00 in the morning for that reason, but I would get one if possible before the operation.
Preoperative antibiotic therapy
Dr. Ponsky: Okay the next thing I want to get into is now we’re going to take that classic appendicitis patient to the operating room. Before I leave the first part of this discussion which was imaging and work-up, was there anything that you wanted to add that we didn’t touch on?
Dr. Holcomb: Nothing except that once the diagnosis is made, we would initiate antibiotics.
Dr. Ponsky: And which antibiotics would you initiate?
Dr. Holcomb: As you may know, our center has written several papers and performed some studies looking at antibiotic administration for appendicitis. We have found that ceftriaxone and metronidazole is the most cost-effective antibiotic duo and it also has similar efficacy to the so-called triple antibiotic regimens. I personally don’t think that everyone has to use ceftriaxone and metronidazole, but I do think that surgeons and their locale should try to figure out which antibiotic works best for them and use that for patients with appendicitis.
Dr. Ponsky: So Whit that’s interesting. There has been a recent publication, I believe from the Journal of the American College of Surgeons, that looked at colon surgery, colorectal surgery in adults and it did find that a cephalosporin with metronidazole seemed to be the most effective, and so you are applying that to appendicitis as well.
Dr. Holcomb: Correct so we’ve been using that particular antibiotic regimen for over 10 years now and we generally use that for colorectal surgery in general and also for acute appendicitis in particular.
Dr. Ponsky: And do you change that regimen depending on if they’re perforated or not, or is it the same for all patients?
Dr. Holcomb: No if it’s non-perforated disease, as identified in the operating room, then the patients do not get another dose of antibiotics. So they just get their single preoperative dose. If it is perforated then we have a separate protocol for that but we use ceftriaxone and metronidazole for that protocol.
Dr. Ponsky: Okay. So the dosing may be different but the antibiotic choice remains the same of ceftriaxone and metronidazole.
Dr. Holcomb: That’s correct.
Dr. Ponsky: Okay
Dr. Holcomb: And if I may make just one point, Todd, the reasons we find that to be a good duo is that it’s a once daily dosing and if the patients go home, say they’re perforated and they go home for some reason need home health care, then it’s an easy transition to home health care, although we don’t do that a whole lot. But it’s quite cost-effective. It does not require serum levels as gentamycin might. It does not have some of the toxicities that gentamycin has and it’s a once daily dosing for each of them, so for those reasons we find this to be a good antibiotic duo to use.
Dr. Ponsky: So Whit that’s fascinating to me. I did not know that because typically the cephalosporins were given every 6-8 hours but you just give it once a day.
Dr. Holcomb: That’s correct. So we performed a prospective randomized trial comparing daily dosing of ceftriaxone and metronidazole to the standard triple antibiotic regimen, and this was published in the Journal of Pediatric Surgery in 2008, and we found very similar efficacy among 100 patients that were randomized, and there was no difference in abscess rate or wound infections between groups, yet the ceftriaxone metronidazole group resulted in less antibiotic charges than the ampicillin, gentamycin, and clindamycin group.
Dr. Ponsky: So I hate to put you on the spot but do you happen to know the dosing for that?
Dr. Holcomb: It was 50 mg/kg of the ceftriaxone and 30 mg/kg of the metronidazole.
Dr. Ponsky: Okay so is that a different dosing than the standard ceftriaxone dosing you do when you give it every 6-8 hours or is it the same dosing?
Dr. Holcomb: Well we actually don’t use ceftriaxone 6-8 hours, we give it once a day in all-comers.
Operative approach for nonperforated disease
Dr. Ponsky: I see. Okay. So you make the diagnosis of appendicitis by ultrasound or just by physical exam, and you decide to take the patient to the OR, you give them the dose of ceftriaxone and flagyl, you take them to the operating room, can you talk to me about the different approaches that you might take or that others may take and how they’ve compared and what you’ve studied?
Dr. Holcomb: Sure, so if we think it is acute appendicitis without perforation, and the patient is relatively thin or lean, then we might try single incision laparoscopic approach through the umbilicus or we might do in some cases what I call a DILS approach, double incision laparoscopic surgery where an incision is made in the umbilicus but also a small 5 mm incision is made in the suprapubic region and the appendix mobilized using an instrument placed through that suprapubic port and then the appendix exteriorized through the umbilicus, and an extracorporeal appendectomy performed. So that’s assuming that the patient is thin and does not have perforation. So we do not use the single incision or even the double incision approach, unless the patient is non-perforated.
Dr. Ponsky: Got it. I have a couple of comments and a question for you. Let me make a comment about that extracorporeal approach. I know that there are many ways of approaching that. I myself have tried using an operative laparoscope, where you can go in and grab the appendix and pull it out. Now I put in a very small 5 mm port and insert a 3 mm grasper just inferior to that fascial incision. Within the same skin incision I insert a 3 mm grasper, grab the appendix and then I divide the fascia between the grasper and the port, and pull it up into an extracorporeal appendectomy—that or the operative laparoscope. When you do the single incision approach, not the DILS but the single incision, is that how you do it?
Dr. Holcomb: Yeah so our single incision approach is very similar. We put a 5 mm port through the center or upper center aspect of the umbilical fascia and then make a stab incision below thagt mm or so fascial defect in which to exteriorize the appendix. I will say, that at least in my opinion, it’s very important to use a locking grasper when you’re bringing the appendix out through the abdominal cavity, because if not I’ve had several occasions where the appendix has slipped off the non-locking grasper and so I think it’s important to place a locking grasper to have a secure grasp of the appendix as it’s being exteriorized.
Dr. Ponsky: Whit, I think that’s a great point about not dropping the appendix. A couple of other points, you mentioned that sometimes it’s stuck. We’ve found that if we grab right where the attachments are to the appendix and almost pull the appendix up to the liver, it just sort of peals that attachment away and allows you to pull it through. And the other point is that you mentioned about the 10 mm fascial incision. We always make sure that we definitely aren’t wimpy on that incision because too small of an incision sometimes is difficult to bring it up through to get down to the base of the appendix. Would you agree with that?
Dr. Holcomb: Yes I would agree because rarely do you grab the tip of the appendix end-on and usually you’re grasping with at least a 5 mm port. I think you may have said you use a 3 mm, but regardless you rarely grab it end-on, and so you grab it close to the end but you create sort of a U shape configuration, which then lengthens the amount of incision you need to exteriorize, and so that’s why I think a 10 mm, a 12 mm incision is need in order to exteriorize the appendix safely without dropping it.
Definition of perforated appendicitis
Dr. Ponsky: Great point. And by the way specifically we now use this gator mini-lap grasper to grab alongside the port. So, Whit, you mentioned something and I know that this is something that you’ve studied, you mentioned that you go in and you look at it and if it’s perforated, you then will do a 3 port, and if it’s not perforated you’ll try the single or double incision. Tell me how you define what is perforated and what is not perforated.
Dr. Holcomb: So there was a very nice study that again was initiated by Dr. St. Peter, and this was around 2006 or 2007, in which he looked at using the definition of perforation as stool in the abdomen or a hole in the appendix. Now that is the definition that we had to come up with when we started our prospective trials on appendicitis because one of the problems with looking at the literature on appendicitis is the word: perforation. Some surgeons use the word "gangrenous” , some say "necrotic”, others just use perforated and they all mean the same, so we had to come up with a definition of perforation, and again we have chosen stool in the abdomen, meaning a fecalith or stool in the abdominal cavity, or a visible hole in the appendix. If you did not have one of those signs, then the patient does not have perforation and so that’s how we make the distinction between perforated and non-perforated.
Dr. Ponsky: Great and I know that surgeons don’t always agree without using those criteria there’s not much agreement on what is the definition, so that was a huge advance for us to be able to finally have criteria.
Dr. Holcomb: Well, as you know Todd, you published a wonderful paper talking about inter-observer variation and the assessment of appendicele perforation in the Journal of Laproendoscopic Advanced Surgical Techniques and I thought that it was a great study and the take-home message was that in your paper among attending surgeons looking at pictures that there was 25% agreement on whether there was perforation or not. And so I think that the take-home message is that you can’t really assess perforation visually without well-defined criteria and that different surgeons will view perforation in a different fashion.
Same-day discharge for nonperforated appendicitis
Dr. Ponsky: Absolutely. And not only your technique, but also your postoperative management changes based on the finding of stool in the abdomen or a hole in the appendix, is that correct?
Dr. Holcomb: That’s correct. So in the last year or so, we have been sending our non-perforated appendix patients home the same day. Now that’s assuming that it’s not 1:00 in the morning or something like that but as a general statement we do not do appendectomies past 7 or 8 o’clock at night, and so if it’s done around 3 or 4 in the afternoon, then they will be sent home that same evening. Now if we do them around 8:00 at night they likely stay overnight just for practical purposes, but anyway the point is that we’re trying to send the non-perforated patients home within around 6 hours of having their appendectomy and yet our standard protocol is that a patient with perforated disease, many of them need 4-5 days with antibiotic therapy at least.
Dr. Ponsky: So Whit I definitely want to pursue the perforated patient, but the title of this podcast is called "Stay Current” and I am absolutely not current after what you just described so I want to dig a little more deep into that. I typically admit my patients overnight and send them home the next day. I know we’ve been toying with the idea of early discharge. Have you studied this yet, the outcomes of sending them home shortly after surgery?
Dr. Holcomb: No, well the data has not been published yet and I’m not sure if one of my colleagues has looked at that. I know that there are plans to look at that when we get a reasonable enough volume, but I would say we’re over 100 patients I’m sure that have been managed in that direction and at least of what I know, I don’t know of many, if any, that have returned with a problem. Again, we do not give them antibiotics after the operation. We just give them antibiotics before the operation so they don’t need to stay for antibiotics. We put local anesthesia in the incisions and send them home with pain medicines. And most of the children want to get home and obviously most of the parents want to get home, so so far so good in terms of our outcomes, but the data have not been analyzed so I can’t answer that question definitively.
Dr. Ponsky: Well, knowing your institution that study will be out shortly and that’s something we’re all eagerly awaiting because I think that that will be one of the bigger changes in the management of appendicitis if we see that there’s not a big bounce-back rate.
Dr. Holcomb: Right and one of the, well there’s several evidences for this. One is patient satisfaction, two is to open beds up in the hospital for patients that need to be in the hospital and three is that at least in my mind the fact that there are reports that some patients may be managed appropriately with antibiotics and so I can see down the line a nice randomized trial of antibiotics versus day surgery appendicitis, if you will, for acute appendicitis. And so we’re sort of gearing up for things like that and trying to make sure that we minimize the hospitalization if they don’t really need it.
Single-port vs 3-port laparoscopy
Dr. Ponsky: Great point there and before we leave the surgical technique, you mentioned the different options. Have you looked at the outcomes comparing single incision to standard 3 port laparoscopy?
Dr. Holcomb: Right, so we published a paper in October of 2011 in the Annals of Surgery that was published at the American Surgical Association meeting. The study period was from August of ’09 to November of 2010. There were 360 patients who were randomized. There were no differences in their patient characteristics preoperatively, and after operation there was no difference in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity between the two groups. Interestingly, the operative time, doses of narcotics, surgical difficulty as defined by the operating surgeon, and hospital charges were greater for the single-site approach and the mean operative time was 5 minutes longer. I don’t think 5 minutes longer is clinically relevant, but it was statistically significant in this study. Now, it’s important to remember that this is only for non-perforated appendicitis patients. If the patients were perforated, then they were not part of this particular study. But at least in this study there was no difference in wound infection rate, which we were concerned about because the appendix is being exteriorized through the umbilicus, but there was also no difference in time returning to full activity or regular diet and other postoperative variables.
Dr. Ponsky: So that’s the key thing and I know that my partners anecdotally are guessing that I have a higher wound infection rate, and it may be related to technique. I know in your study, which I always quote, there was no difference.
Dr. Holcomb: There was a 3.3% infection rate in the 180 patients undergoing the single incision approach and there was a 1.7% difference in patients undergoing the 3 port approach. The p-value for that was .5 so there was no difference statistically between those two groups.
Dr. Ponsky: That’s interesting. And I would guess that my numbers are the same. So maybe that is about right, about 3/100 patients will get a wound infection versus 1-1.5 in the 3 port. And I think it’s an important distinction that you did not use the perforated because we do all-comers and so that may have explained it as well. Speaking of that, Whit, when you do a 3 port laparoscopy for a perforated appendix do you close the skin?
Dr. Holcomb: Well, for the single incision, we close the fascia, we put interrupted plain gut sutures in the umbilical skin. For the 3 port, we do the same for the umbilical incision and then we close the skin of the other two other 5 mm sites with a 5 0 vicryl suture, placed in a U-type fashion.
Dr. Ponsky: So when you do the interrupted sutures, I’m sorry, how do you dress that wound?
Dr. Holcomb: How we dress it, so we have the plain gut sutures in there and then we round up a piece of gauze and put a tegaderm over it, the idea being that if a wound infection does occur, it will drain through the interrupted sutures, yet we do not have to remove the sutures because of their short half-life.
Dr. Ponsky: Okay got it. So that’s a nice way to approach that, and I probably will start doing that as well. Before we leave technique, there are a couple of other questions, what are your thoughts if you go in and you see some murky fluid, what are your thoughts on irrigation? Have you looked at that?
Dr. Holcomb: Right, so again Dr. St. Peter spearheaded a study in which we looked at the need for irrigation at the time of management of perforated appendicitis, so one group received irrigation as well as suctioning, the other group just received suctioning, and interestingly enough there was no difference in abscess rate or abscess location between the two groups—they were both about 20% postoperative abscess development. Now, again, it’s important to realize that the definition, we used a strict definition that’s a hole in the appendix or a fecal that’s in the abdomen, as opposed to just a distended or angry looking appendix, or a necrotic or gangrenous or anything like that. So I think we’re dealing definitely with perforation rather than just a bad acute appendicitis. But anyway, in this study, there was no difference between the use of irrigation and the use of suction without irrigation. I think it’s also an interesting way to look at it is that there was no detriment to using irrigation as well if folks wanted to continue to use irrigation, but at least there’s no advantage of using irrigations, so we thought that it was a pretty useful study.
Dr. Ponsky: Yeah and I know that at our hospital we quote that study quite frequently. Just to reiterate, you tell your patients preoperatively, for those that you believe are perforated, that their risk of getting an abscess is about 20%?
Dr. Holcomb: Right, in all of our appendectomy studies, I think that there are probably 6 or 7 now, for perforated appendicitis, our abscess rate has been between 15 and 20 percent in every study for perforated disease. And so, I tell families 20% and I think that’s also a pretty good ballpark for the development of an abscess. Now, I will say that a lot of surgeons will say their abscess rate is not that high for perforation, and my counterpoint would be that I think you’re treating patients with gangrenous appendicitis or necrotic appendix, i.e. it’s not perforated and you’re lumping them into your group that are perforated and therefore that would lower the abscess rate development.
Dr. Ponsky: That’s a great point, thus reiterating the importance of the study that you did defining that.
Dr. Holcomb: Right.
Dr. Ponsky: One last comment about the technique, I know that some use staplers, some use an endo-loop with cauterization of the mesoappendix, some use energy devices. Are you aware of any study that has compared any of those techniques?
Dr. Holcomb: No I’m not aware of any study that actually looks at the actual technique of removing the appendix. I think it’s really surgeon-preference. I will say that in our institution, we have probably a different billing mechanism than many institutions, and that is we bill by the minute of operating room usage. So, as an example, and the current billing rate is $225/minute. So, but we’ve all been charged for sponges and instruments other than some large disposables and things like that. But the point is that if a stapler costs $600 and it saves you 3 minutes, then it’s cost-effective in terms of patient charges. So, at least in our center we use the stapler for both the mesoappendix and the appendix because at least it can be justified as being cost-effective.
Dr. Ponsky: Does anyone in your institution staple across both at the same time?
Dr. Holcomb: I do not think that’s the case. I think most of us would staple the mesoappendix or the appendix first and then the other one. Also, generally speaking, we use different loads. We generally would use a standard load for the appendix and a vascular load for the mesoappendix so that would be another reason not to staple across both of them at the same time.
Dr. Ponsky: I see. Okay. I know I use a vascular load for both and sometimes I will use an endo-loop and I cauterize the mesoappendix if it’s very stuck down and sometimes difficult to mobilize I will cauterize it. And we did a study, a retrospective study, looking at over 700 cases of using electrocautery, this was with Steve Rothenberg, and found that there was almost no cases of bleeding, there was one patient that had a coagulopathy, a factor 8 deficiency, that had some bleeding, but other than that, it seemed fairly safe. And so I think probably any of these techniques are probably appropriate, and whatever the surgeon feels comfortable with, would you agree?
Dr. Holcomb: Yes I would agree. I will tell you that early on in the development of laparoscopy and laparoscopic appendectomy, when I was still at Vanderbilt, there were 3 children who were brought in, this was in the early 1990s,there were 3 children brought in who had had cautery used and there were adjacent injuries or secondary injuries to the small bowel that required operation and so because of that I got a little aversion to using cautery for appendicitis and the reason for that is that I think you have to be very careful that you’re not having an arc of electricity going to adjacent loops of small bowel, and that it’s easy to do when you’re focused on the appendix and you’re not really watching what’s going on you know on the left side of the abdomen. And so, if you do use cautery I think it’s important to be sure to watch everything that’s going on.
Murky fluid in the abdomen
Dr. Ponsky: That’s a great point. And a random question that’s something I wish I had asked before, when you do the single incision approach and you see a non-perforated appendix but a belly full of murky fluid, how do you get that out with a single incision approach, or do you not care about getting it out?
Dr. Holcomb: Alright so I guess the best way to answer that is that that would be a very unusual finding, at least in our experience with non-perforated disease. Yes you can see some cloudy fluid I would say in the pelvis, which we would try to suction out, although that can be difficult. Murky fluid would cause me concern and I would probably put another port in to get a better view, and put another instrument through that port in order to get a better view of where the murky fluid might be coming from because you have to worry about other things going on. And so, murky fluid, to me, would be an unusual finding and I would investigate that further. Having said that, when you try to suction the pelvis out using the single incision technique it’s important to suction it out before you incise that common bridge between the two small umbilical fascial defects because you won’t be able to suction it out very easily once you’ve taken the appendix out.
Dr. Ponsky: That’s a great point. The point of putting the suction in, you’re sort of doing that blindly without the camera helping you. And I like your point about putting in another port. Let me ask you, if you go in and find a normal appendix, do you then put 3 ports, 2 more ports in, and run the bowel, or what’s your protocol for that situation?
Dr. Holcomb: Well, that’s a good question and the short answer is we usually take a look but it’s different if we’ve had an imaging study then we often times don’t do a full look at the small bowel. If we’ve not had an imaging study, then yes I would do a full look of the small bowel.
Dr. Ponsky: Okay, very good.
Dr. Holcomb: Because the imaging study, by and large, is going to give you ideas about other problems going on.
Postoperative care for perforated appendicitis
Dr. Ponsky: Yeah. Right. Good point. That patient you’ve operated on, 3 day history, they had a perforated appendix, you do a 3 port appendectomy. Tell me your postoperative protocol and how you know when to send them home.
Dr. Holcomb: Right so when we began our foray into prospective randomized trials with appendicitis, our first one was our one I mentioned earlier about comparing ceftriaxone and metronidazole to ampicillin, gentamycin, clindamycin and in performing that trial we had to come up with a protocol. We came up with a protocol of 5 days worth of antibiotics postoperatively for perforated appendicitis, and we thought that was very reasonable dosing length for antibiotics but we had to come up with a protocol for that. And indications for going home were that we drew a white blood cell count on day 5, if that was normal, the patient was not febrile, and the patient was tolerating a regular diet, then they were discharged home without oral antibiotics, so that’s on day 5 of perforated appendicitis. If a leukocytosis was found, that patient received 2 additional days of antibiotics and another white count was performed. If the white count was elevated, they received another 3 days of antibiotics and a CT scan was then obtained to look for the presence of an abscess. In our experience, almost all of the patients who develop an abscess postoperatively develop it in the hospital. So we’ve had very few patients go home and come back with the development of an abscess. So we then followed that study up with a study looking at, well, do all patients need the minimum 5 days of intravenous antibiotics, or can they go home earlier than that? So we did a study randomizing 50 patients to 5 days for sure, versus 50 patients who could go home if they met those same discharge criteria as I mentioned, and they would be discharged to home on oral Augmentin if they were tolerating a regular diet to complete a total of 7 days. So, if they went home on day 3, they would be given 4 more days of Augmentin. If they went home on day 4, they would be given 3 more days on Augmentin. And what we found was that there was no difference in the postoperative abscess rate between these two treatment groups, but we also found that it was possible to discharge patients before day 5 and 40% of the patients in what we call the IV and POR, and so my take-home message is about 40% of patients can go home before that 5 day period with the criteria that I just discussed being afebrile and a normal white count and tolerating a regular diet.
Dr. Ponsky: That’s interesting. I think maybe your next study might be doing the same study but with no home-going antibiotics.
Dr. Holcomb: Right, I agree, and at the same time, going home with a few oral antibiotics is not too terribly bad if you can get out of the hospital earlier.
Perforated appendicitis with abscess
Dr. Ponsky: I agree. Let’s talk about the patient that presents to the emergency department and they had a 4 day history of symptoms and you got your ultrasound and it shows a suggestion of a perforated appendix with a wall-off abscess. How do you manage that patient?
Dr. Holcomb: If there’s a well-defined abscess and the duration is probably at least, I would say it’s probably 5 or 6 days, 4 days we might go ahead and operate and it might be that it’s not as well defined, so you’re still, you’re in the walled-off area but it’s not a well-defined abscess. But, if it’s well-defined and it’s 5 or 6 days, then there are really 2 options. One option is to go ahead and operate on that patient and the other option is to treat that patient non-operatively. Now, we did a study looking at initial laparoscopic appendectomy versus initial non-operative management and interval appendectomy for a well-defined abscess from perforated appendicitis, this was published in the Journal of Pediatric Surgery in 2010. We used a sample size of 40 patients and there was no difference between the two groups regarding their age, their body mass, gender distribution, leukocyte count, number of abscesses, or the greatest 2 dimensional area of the abscess. So, regarding outcomes, there was no difference in length of total hospitalization, recurrent abscess rate, or overall charges. It took longer to do the operation, as you would expect, with the initial appendectomy taking 61 minutes, versus 42 minutes for the interval appendectomy. So the way that we interpreted this study really is that you can do either way. It’s surgeon preference. If you prefer to go ahead and operate on the patients and accept the potential complications from a difficult operation, that’s fine. If you’d rather treat the patient initially non-operatively with drainage and antibiotics and come back for an interval appendectomy then that’s fine as well. And, my personal take-home message was that I prefer the later one; I prefer the initial non-operative management with antibiotics and a return for an interval appendectomy. The main reasons are that having done a number of these operations, they can be quite difficult. The patients are in the hospital seemingly for a long time, although at least in our study there was no real difference in total length of hospitalization between the two groups, they have often a bad ileus, sometimes need a nasogastric tube although we rarely put nasogastric tubes in, and then there’s complications or recurrent abscess. And to me it’s easier on the patient and it’s easier on the surgeon to treat them non-operatively and then allow for the inflammation to go down and return 8-10 weeks later for an interval laparoscopic appendectomy, which again is becoming a day surgery procedure.
Dr. Ponsky: So, a couple points. First of all, I think that study is so important because it does give the surgeon the option, based on the patient, the family, the situation, about what to do. I personally agree with you, Whit. I prefer that approach, but I have two questions about two potential things that may affect my decision and I’m wondering how they might affect yours. One is the presence of a fecalith within the perineal space on evidence on CT scan or ultrasound, and the other would be the duration of their symptoms. Do either of those change your decision on early versus interval appendectomy?
Dr. Holcomb: Well I’ll answer the second question first and I preface on my early remarks when you were describing the case. I think 3 or 4 days, we would operate on the patient. I think 6 or 7 days they would likely have a well-defined abscess and so therefore I would treat them non-operatively. So, the answer to that is yes 3 or 4 days I’d probably operate, 6 or 7 days I wouldn’t, and 5 days is kind of the transition zone where you have to figure out, you know, which one you want to do. The fecalith is an interesting question for me. I do not know any data, and I certainly don’t know from our study that we actually looked at that, but I don’t know of any data to show that that should make a difference. Now, you would think that those patients with a fecalith would be less likely to resolve their abscess initially and then get through 8-10 weeks. I don’t know that there’s data for that, but that would be the initial thinking. Having said that, my approach would be to treat them non-operatively initially, and even if you can get 2 weeks out, to me that operation is a lot easier than going right in there early on and trying to take the appendix out in a sea of dense inflammation and perial material.
Dr. Ponsky: Perfect. I think that’s a great summary of that. The last question that I want to ask you is just something that you had touched on before, and I wanted to get your thoughts on this new, exciting topic of non-operative appendicitis.
Dr. Holcomb: Right. Well there are a number of retrospective reports in the adult literature talking about the management of patients with appendicitis without the need for an operation, and as a general statement, I would say about 2/3 of those patients are treated without the need for an operation and about 1/3 require an operation. And as you know, there’s been some good work performed through our colleagues at Nationwide Children’s Hospital who have looked at this same question and are continuing to look at it, and then there’s some work that’s been done in Finland and other European countries on this matter as well. There’s a prospective randomized trial that’s being performed at Nationwide and there’s another in the planning stages with another group of hospitals. And so, my summary of the data at this time is that it is likely possible that 50-60% of patients can probably be managed non-operatively with antibiotics. Now the devil will be in the details for this. That is, how long does the patient really need to be in the hospital for IV antibiotics versus having an operation and going home that same day? All of these patients, I’m assuming, will likely be patients with non-perforated appendicitis, although it is possible also we know a nice study by Marty Blakely that we can treat some patients with perforated disease non-operatively as well. And so, I think there will be some really good, high-quality studies coming out in the next 5 years that will probably tell us that we can treat a good percentage of patients without the need for an operation. It will be interesting though to follow those patients and figure out whether or not they develop appendicitis 3 years later, 8 years later, 25 years later, and so, do they eventually develop appendicitis, because you can make a good argument that the inflammation surrounding the infection causes scarring in the appendix, which then leads to a closed-loop obstruction, which then leads to recurrent appendicitis. So, we won’t know this answer for sure I dont think for 25 or 30 years, but we’ll have a better handle on the short-term outcome data in the next 5 years.
Dr. Ponsky: So until this data is out, I’m assuming that you’re still taking these children to the operating room.
Dr. Holcomb: Right, and right now I don’t think the data is nearly mature enough to say that we shouldn’t operate on these patients, and especially if we can operate on them and get them home on the same day and then get them back to their routine activities, it would be pretty hard to find more data that will justify the need for not doing that for the next 5 years.
Dr. Ponsky: Perfect. Well, Whit, I think that was a very good summary of some of the new, current themes of management of appendicitis. Most of the literature, which has come out of your institution, definitely some big changes over the past 10-15 years, and I appreciate you giving us a very good summary of that. Is there anything else that I didn’t hit on, before we conclude, that you wanted to touch on?
Dr. Holcomb: Right, and I would just like to touch, and this is sort of follows up with that last question about the need for interval appendectomy for perforated disease that’s initially managed non-operatively. The data as I understand it shows that in one study from Los Angelos that if patients were initially managed non-operatively and did not have an interval appendectomy performed, then about 10% of them subsequently came back for another appendectomy for recurrent appendicitis. The problem with that particular study is the follow up period, as I recall, was only a year or a year and a half maybe, or relatively short-term. And again, I think that we need to get longer-term data to see if those patients come back, you know, in 5 years, 10 years, 20 years, because if they do, then that, to me, justifies taking the appendix out when they’re young so they don’t need to come back and have an operation when they’re older.
Dr. Ponsky: So until that data comes out am I assuming that you’re still operating on all of these patients?
Dr. Holcomb: Right, so our feeling is that we ought to proceed with an interval laparoscopic appendectomy, and frankly, the families would like that as well because they do not want their child coming back for another bout of appendicitis, so so far we’re proceeding with the interval laparoscopic appendectomy.
Dr. Ponsky: Perfect. Any other major points that we’ve missed?
Dr. Holcomb: No, I think that’s great Todd.
Dr. Ponsky: Well, Whit, I appreciate your time. I think that this was very helpful for me and I’m sure it will be helpful for everyone else listening to this. So, have a great day today and hopefully we’ll talk to you soon about another topic.
Dr. Holcomb: Hey, great, listen I’m glad to talk and maybe we can talk about hernia disease next time.
Dr. Ponsky: Perfect. We’ll talk to you then.
Dr. Holcomb: Alright, thanks.
Dr. Ponsky: Okay, bye.
Dr. Holcomb: Alright, bye.