RIVALRY IN TREATING APPENDICITIS By: Ron Winslow Updated: Feb. 22, 2011 12:01 a.m.

ET About 80,000 children in the U.S. undergo appendectomies each year, making the procedure the most common emergency operation in kids. Still, in the 100 or so years the surgery has been performed, there has been little rigorous scientific research to guide its use. Now, a new study looks at two competing surgical approaches to treating the most dangerous form of appendicitiswhen a child arrives at the emergency room with an appendix that has already ruptured, which happens about 30% of the time. When the appendix bursts, it spills its contents, loaded with toxic bacteria, into the abdominal cavity, potentially leading to systemic infections such as sepsis and to the failure of kidneys and other organs. For these patients, surgeons have been sharply divided for years on what course to take. Some doctors administer an antibiotic infusion followed by immediate surgery to remove the appendix. Others prefer initially to give antibiotics alone, and then wait six or more weeks to perform the appendectomy. In the study, the immediate-surgery approach, which is the more traditional treatment, won out. Although both surgical approaches are effective, an immediate appendectomy was better for kids and their families, the researchers said. The approach allowed the child to return to routine activities, such as school and sports, nearly six days sooner, according to the study, published online Monday in the Archives of Surgery. "Even Grandma knows that you ought to take the appendix out," says Martin Blakely, a pediatric surgeon at Bonheur Children's Hospital and the University of Tennessee Health Science Center, Memphis, and lead author of the study. Still, he says: "There are plenty of pediatric surgeons who don't agree with that." Despite fears of life-threatening complications from a ruptured appendix, the availability in recent decades of powerful antibiotics and other improvements in treatment have made death from appendicitis rare. In 2007, the most recent year for which data are available, 21 people age 19 and under died of appendicitis, a level that has been steady for many years, according to the National Center for Health Statistics. When a child has what's known as acute appendicitis, in which the appendix is inflamed but hasn't ruptured, pediatric surgeons agree that the best treatment is to take it out before it bursts. It is done laparoscopically, with instruments inserted into the abdomen through small incisions. Complications are rare and kids typically spend just one night in the hospital.

The appendix is an appendage about the size of a finger in the lower right quadrant of the abdomen that extends from the large intestine near its junction with the small intestine. Its purpose has long been debated. In 2007, William Parker, an immunologist at Duke University Medical Center, and his colleagues proposed that the appendix once had a role as a kind of "safe house" for the good bacteria the body needs for digestion. But in a "post-industrial society, it's no longer used for what it was evolved to do," he says. Now, "it's like a teenager with nothing to do and it's going to cause trouble." Why the appendix becomes inflamed isn't well understood. When it ruptures and contaminates the surrounding area, abscesses, or pockets of pus, can form nearby. Hefty doses of intravenous antibiotics are required to neutralize the bacteria while catheters and suction devices are used to drain the abscesses and remove toxic matter. A hospital stay typically lasts seven to 10 days. Some kids end up in the intensive-care unit. "When you do an operation on these kids with an abscess, it's a mess," says Edward Livingston, chairman of gastrointestinal and endocrine surgery at University of Texas Southwestern Medical Center, Dallas. "They get really sick after the operation." Surgeons have disagreed in recent years over when is the optimal time to remove a ruptured appendix. Proponents of immediate, or "early," removal say that among other benefits, it eliminates the need for a second hospital admission. It also effectively prevents a recurrence of appendicitis, after the antibiotics have stopped the initial inflammation, which happens in about 8% to 10% of cases in which the appendectomy is delayed. But other doctors say that immediate surgery for a ruptured appendix could spread bacteria and other toxins around the abdomen and increase the risk of surgical-wound and other infections. These doctors say that waiting several weeks for medicines to clear the abdominal cavity of contamination could reduce such complications and make the appendectomy surgery much easier on both patient and surgeon, according to the argument for that approach. In the latest research, Dr. Blakely and his colleagues enrolled 131 patients in their study. The results showed that children who underwent an early appendectomy were unable to participate in regular activities such as going to school or playing sports for an average of 13.8 days. That compared to 19.4 days for those who had the surgery six to eight weeks after their initial hospitalization. Complication rates among the early-appendectomy patients were relatively high at 30%, but still lower than the 55% among those who had the surgery later. The findings differ from those of a separate, 40-patient study last year by researchers from The Children's Mercy Hospital, Kansas City, Mo. That study, which involved patients with a

somewhat more advanced form of appendicitis, found no significant difference in outcome between early or later appendectomies after a ruptured appendix. Researchers measured length of hospital stays, total monetary charges and recurrence of abscesses, among other things. Oliver Soldes, a pediatric surgeon at Cleveland Clinic Children's Hospital, who wasn't involved with either study, says he welcomes randomized studies of the issue. But he says they don't provide a definitive answer about which approach is better. Both studies were done at a single center, and it isn't certain how generalizable the findings are to other centers. Dr. Soldes also says he considers the benefit to children of "returning to school or soccer" a few days sooner as relatively small. Parents facing choices for a child with appendicitis "don't have time to comparison shop," Dr. Soldes adds. But they can be reassured that "both are reasonable treatment strategies." Dr. Blakely, who guided the latest study, agrees that kids will do well with either surgical approach. "The question is, when?" he says. With the early appendectomy, there was a nearly six-day improvement in recovery time. "We felt that was clinically meaningful," Dr. Blakely says. Source: http://online.wsj.com/news/articles/SB10001424052748703610604576158602281260810

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March 15, 2014