Acute Appendicitis: Current Issues and Controversies

Malen M. Gellido, MD. MHPEd April 6, 2013

Outline
1. Anatomy, Pathophysiology, Epidemiology 1. Diagnosis
Imaging modalities

2. Treatment
Medical vs. Surgical Type of surgery: open or laparoscopic

Appendix
Da Vinci (1492) Vesalius (1543)

Anatomy and Physiology

The base is consistently found at the confluence of the taenia at the base of the cecum The tip is retrocecal in 65% Average length is 9cm An immunologic organ that actively participates in the secretion of immunoglobulins, particularly immunoglobulin A

Reginald Heber Fitz (1886)

Coined the term appendicitis

Pathophysiology of Acute Appendicitis

Incidence of Appendicitis
The most common of the intraabdominal inflammatory disorders, occurring in both genders and in all age groups. The incidence is approximately 233/100,000 population and is highest in the 10 to 19 year-old age group It is also higher among men (male to female ratio of 1.4:1), who have a lifetime incidence of 8.6 percent compared to 6.7 percent for women

Appendicitis in Children
The most common indication for emergent abdominal surgery in childhood. Diagnosed in up to 8% of children evaluated urgently for abdominal pain. Perforation correlates strongly with duration of symptoms:
Neonates 83% Young children (<5 years) 51 to 84 % School-age (5 to 12 years) 11 to 32 % Adolescents (>12 years) 10 to 20 %

Appendicitis during Pregnancy

The most common general surgical problem encountered during pregnancy Acute appendicitis is suspected in 1/600 to 1/1000 pregnancies and confirmed in 1/800 to 1/1500 pregnancies The incidence is slightly higher in the second trimester than in the first and third trimesters or postpartum

Standard management of Acute Appendicitis

Schwartz, Principles of Surgery, 9th Ed

Current Issues
1. The use of imaging modalities 2. Medical versus surgical treatment 3. Open versus laparoscopic surgery

Current Issues
What is the role of imaging technologies in the diagnosis of acute appendicitis?

Current Issues
What is the role of imaging technologies in the diagnosis of acute appendicitis?
Used mainly for equivocal cases Children Pregnant patients Elderly patients

Ultrasound

Ultrasound findings that support the diaganosis of Appendicitis

Noncompressible tubular structure in right lower quadrant Wall thickness of the appendix greater than 2 mm Overall diameter greater than 6 mm Free fluid in the right lower quadrant Thickening of the mesentery Localized tenderness with graded compression Presence of a calcified appendicolith

CT Scan

The appendix is considered abnormal on CT scan when:

It is distended or thickened and greater than approximately 5 to 7 mm in diameter. The wall of the inflamed appendix is circumferentially thickened and may appear as a halo or target. CT findings of periappendiceal inflammation suggest appendicitis; these include:
periappendiceal abscess fluid collections edema phlegmon

MRI

Current Issues
Medical management VS. Surgical Management

Medical Treatment
Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, noninferiority, randomised controlled trial.
Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, Karoui M, Alves A, Dousset B, Valleur P, Falissard B, Franco Lancet. 2011;377(9777):1573.

Medical Treatment
Postoperative peritonitis was significantly more frequent in patients treated with amoxicillin plus clavulanic acid compared with appendectomy (8 versus 2%). Fourteen patients (12%) treated with antibiotics underwent an appendectomy within 30 days of treatment. An additional 30 patients underwent an appendectomy within the year following antibiotic therapy, 26 of whom had confirmed acute appendicitis.

Vons et al, Lancet 2011

Medical Treatment
Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis.
Varadhan KK, Humes DJ, Neal KR, Lobo DN World J Surg. 2010;34(2):199.

Medical Treatment
Among the 350 patients treated with antibiotics alone, 112 (32 percent) failed initial medical therapy and were treated with an appendectomy. In the 238 patients who responded to medical therapy and did not undergo surgery during the acute episode, symptoms recurred in 38 (16 percent) within one year and underwent appendectomy. Histologic findings were available for 35 patients and included phlegmon in 25, perforation in 9, and gangrene in 1. Overall, 58 percent of the initial cohort treated with antibiotics remained asymptomatic at one year of follow-up.
Varadhan et al, World J Surg. 2010

Surgical Treatment
Appendectomy is the gold standard treatment of acute appendicitis. The negative appendectomy rate should be within 10%.

Current Issues
Open surgery VS. Laparoscopic surgery

1894

The first reported case of appendectomy was performed by Claudius Amyand in 1735.

Semm performed the first successful laparoscopic appendectomy in 1982.

Open vs. Laparoscopic Surgery

Laparoscopic versus open surgery for suspected appendicitis.
Sauerland S, Jaschinski T, Neugebauer E Cochrane Database Syst Rev. 2010 A meta-analysis of 56 randomized trials and 11 studies compared the outcomes of approximately 6000 adults and children with suspected acute appendicitis undergoing either laparoscopic appendectomy or conventional open laparotomy

Laparoscopic appendectomy
Advantages
A lower rate of wound infections (odds ratio [OR] 0.43, 95% CI 0.34-0.54) Less pain on postoperative day 1 by the VAS pain score (8 mm, CI 5-11 mm) Shorter duration of hospital stay (1.1 days, CI 0.7-1.5 days) Shorter duration for return of bowel function

Disadvantages
A higher rate of an intraabdominal abscess (OR 1.77, CI 1.14-2.76) A longer operative time (10 minutes, CI 6-15 minutes) Higher operative and inhospital costs

Sauerland et al, Cochrane Database. 2010

NOTES
Natural orifice translumenal endoscopic surgery (NOTES) Transgastric Transrectal Transvaginal

NOTES - Transvaginal

Summary

Schwartz, Principles of Surgery, 9th Ed

Thank you

Treatment: Medical or Surgical?

1735 Claudius Amyand performed the very first appendectomy 1839 Bright and Addison, described signs and symptoms of appendicitis but surgery as treatment was not mentioned 1870 advent of anesthesia and asepsis and antiseptic techniques allowed safer and more tolerable abdominal surgery

But Removal of the appendix was still not widely accepted

Appendectomy Incision: What to use?

Kelly and Hurdon (1905)