Thursday, March 17, 2011

Shifting Appendectomy Consensus

An interesting article from Archives on the optimal treatment of children who present with perforated appendicitis. Previous dogma dictated an initial non-operative approach---- dick around with IV antibiotics, CT guided drains, etc--- and then bring the child back in 6-8 weeks for an "interval appendectomy". This article demonstrates that getting the kid into the OR ASAP leads to better outcomes and a faster return to normal activities.

I've advocated for this approach before. Explore the kid laparoscopically, evacuate any abscess collections, leave a drain in certain cases, and take the damn appendix out. I would even extrapolate from the pediatric population and apply such management to all patients with complex appendicitis.


Paracelsus said...

I'm glad you hold these views as an America surgeon. I think this represents a return to sanity, actually. We speak of observing, antibiotics, CT/US guided drainage, etc. - all of which are nicely summed-up as "dicking around" in these situations. However, these patients suffer. And they suffer longer and harder then they should, it's not just about "faster returning to normal activities". This "new" approach is actually the oldest, in agreement with the fundamental surgical principle of removing all infection and infection sources that are surgically accessible, as soon as the patient is ready. And the majority of patients are readier as they're ever going to be. I mean... perforated appendix.

I think the "dicking around" you speak of is a trait of the well developed healthcare systems (i.e. the American one), which manifest the inherent tendency to rely heavily on the technology at hand and to push things further than necessary or advisable, just to put all that technology to use and, possibly, justify some costs.

Eastern European schools of surgery have been succesfully using this "new" approach for decades, simply because there was no CT-guided drainage alternative at hand. And, beyond evidence-based literature, this approach was and still is the most succesful, if only because appendicectomy, peritoneal lavage and drainage IS the surgical treatment for peritonitis secondary to perforated appendicitis. Why "dick around"?

Bongi said...

i personally take it out. but that's just me. i like to cut.

Anonymous said...

When do you decide that you prefer open to lap?

My last hospital had a rule - no lap appendix under 12. I think a registrar (resident) stuck a trocar into a common iliac.

just some surgery resident said...

Are you concerned about possibly having to do a bigger resection if you find a phlegmon of the cecum by this approach?