Interval Appendectomy - SUNY Downstate Medical Center Rounds Appendicitis... · Case Presentation ....

Interval Appendectomy

Downstate Surgery Grand Rounds Jolita Auguste and Cynthia K wong

9/29/2016

www.downstatesurgery.org

Case Presentation

51 F with PMHx of SLE who had been admitted to OSH 6/2016 for perforated appendicitis. Treated conservatively with 10 days of Abx and referred to UHB for GI and Surgery follow up. Repeat CT scan performed on 7/11/2016.


She was referred to GI for colonoscopy. Performed and only positive for a hyperplastic polyp in the rectum. On 8/22 she underwent an interval laparoscopic appendectomy.

Pathology: Chronic appendicitis, appendiceal lumen obliterated by fecalith


Jacopo Berengario da Carpi

1524

Credited for having the first preserved written account of the appendix


Presenter

Presentation Notes

Italian anatomist and professor at the University of Bologna he described an empty small cavity (addentramentum) at the end of the cecum oil on canvas by an Emilian painter of 17th Century. It is displayed in the Museum of the beautiful "Palazzo dei Pio", in the centre of Carpi, Province of Modena

Claudius Amyand

1735

First successful appendectomy


Presenter

Presentation Notes

Thomas Gainsborough, oil on canvas at St. George’s Hospital in London. The patient was an 11-year old boy whose appendix had become perforated by a pin he had swallowed right scrotal hernia and a fistula. He identified the appendix, perforated by a pin within the scrotum, ligated the appendix and then removed it

Reginald Fitz 1886

Coined the term “appendicitis”

Described series of successful drainage of abscesses of the appendix between 1848-1886


Presenter

Presentation Notes

Boston

Charles McBurney

1889

Described the pathologic changes in appendicitis and described the abdominal area of maximal tenderness


Presenter

Presentation Notes

New York surgeon

Kurt Semm

1981

Performed the first laparoscopic appendectomy


Epidemiology

• 250,000 cases annually

• Peak Incidence: 10-30 yo

–Higher rates of perforation in children and elderly

• 7% Lifetime risk in US



Presenter

Presentation Notes

Obstruction is most often secondary to: • Appendicoliths • Lymphoid hyperplasia • Parasite infections • Tumors (carcinoid, metastatic) • Foreign bodies

Alvarado Score (1986)

MANTRELS

• Abdominal pain that migrates to right iliac fossa

• Anorexia

• Nausea and vomiting

• Tenderness in the right lower quadrant (2 pts)

• Rebound tenderness

• Elevated temperature (>99.1F / 37.3C)

• Leukocytosis (>10,000) (2 pts)

• Shift of white cells to the left (>75%)


Presenter

Presentation Notes

A. Alvarado. A practical score for the early diagnosis of acute appendicitis Ann Emerg Med, 15 (1986), pp. 557–564 Score: <4: 96% that diagnosis is NOT appendicitis 4-7: Consider imaging (CT/USS) >7: 58-88% probability that it is appendicitis

Clinical Signs

• Rovsing sign: pain in the right lower quadrant during left-sided pressure

• Dumphy’s sign: increased pain in right lower quadrant with coughing

• Psoas sign: pain with...

– Flexing right hip against resistance, or

– Passive extension of right hip

• Obturator sign: pain with internal rotation of hip while right hip and knee flexed


Presenter

Presentation Notes

Bates Guide to Physical Examination and History Taking

Normal Radiology

Barium Study CT scan

Contrast filled appendix without wall thickening or fat stranding


Presenter

Presentation Notes

Ultrasound: compressible blind ending structure, outer diameter less than 6mm.

Non opacified appendix Presence of fecalith Wall thickening (>6mm in adults, >8mm in children) Periappendical fat stranding

Aperistaltic, noncompressible, dilated (>6 mm outer diameter) Target appearance Distinct appendiceal layers Echogenic prominent pericecal fat Appendicolith

Acute appendicitis www.downstatesurgery.org

Uncomplicated Appendicitis

• Take it out

• Unless you’re Dr. Sulkowski


Appendectomy www.downstatesurgery.org

Presenter

Presentation Notes

Fischer

Complicated

• A result of perforation

• Happens in 7% of cases of acute appendicitis

– Phlegmon/Abscess

– Peritonitis/Free air


Complicated Appendicitis

• Conservative therapy has been shown to have decreased complications compared to immediate appendectomy.

• Antibiotics which cover for intraabdominal flora (Gram negatives, anaerobes)

• Pain control

• +/- Percutaneous drainage

• ???? Interval appendectomy????


Immediate Surgery vs Conservative Management


Presenter

Presentation Notes

Andersson RE. Nonsurgical treatment of appendiceal abscess or phlegmon

Should we perform routine interval appendectomies after complicated appendicitis?


Point-Counterpoint

PRO • Definitive treatment of

disease process; reduce/eliminate recurrence risk.

• Operative risks are minor (wound infections, suture granuloma)

• Risk of underlying malignancy (carcinoid, mucinous neoplasms)

CON

• Operative risk – 9% • Low rate of recurrence and/or

underlying malignancy • Operative costs • No significant difference in

duration of antibiotic use in appendicitis


• Rate of recurrent appendicitis = 11.4%

–Morbidity 12.73%

–Hospital Stay 8.95 days

• Interval appendectomy

–Morbidity 10.5%

–Hospital Stay 5.4 days


Presenter

Presentation Notes

Darwazeh G, Cunningham SC, Kowdley GC. A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See? Am Surg. 2016 Jan;82(1):11-5. 26 retrospective cohorts 21 no interval appendectomy, 5 interval appendectomy Total patients 1943 543 (28%) underwent interval appendectomy Rate of recurrent appendicitis = 11.4% (3-20%) Morbidity 12.73% (3-30%) Unresolved abscess or sepsis requiring surgical intervention (5.3-11.9% of cases) Bowel obstruction (3.1%) Diffuse peritonitis (1.6%) Hospital Stay 8.95 days (2-11) Interval appendectomy Morbidity 10.5% (8-13) SSI, UTI, Bowel obstruction Hospital Stay 5.4 days (5-6)

Recurrence www.downstatesurgery.org

Presenter

Presentation Notes

Liang et al 240,000 pts hospitalized between 2000-2010 for acute appendicitis; 71.4% were between age of 18-65 and 54% were men. 94.1% treated with appendectomy; remaining 5.1% (12,235) treated non operatively. 7.1% (864) patients were readmitted with recurrent disease. Median follow up for study was 6.5years. Median time to recurrence was 7.5 months. Of these pts 14.2% were again treated non operatively; re recurrence was 13% and median time was 4.9 months. (This study purposefully excluded early readmissions <3 months and classified them as primary treatment failure vs IA admissions so as to avoid overestimating the recurrence risk) Risk increases to 9.4% (exclude only 2 months), and 13.1% (excluded only 1 mo) Limited follow up (<2 years in adults, up to age 18 in children)

Morbidity of Interval Appendectomy www.downstatesurgery.org

Presenter

Presentation Notes

126 pts treated with Conservative therapy and interval appendectomy 9% overall postoperative risk for complication: complications included post op abscess, reoperation for bleeding, C diff infection; and superficial wound infections/suture granulomas(⅔ of complications) This study also comments on appendiceal lumens; it has been proposed that the redcued risk in recurrant appendicitis is due to lumen obliteration that occurs during the intial inflammatory process. Here he shows that only 16% of reported appendices had obliterated lumens, and 26% and a retained fecalith.


Presenter

Presentation Notes

Maliginancy in the appendix like small bowel tumors is rare; 0.7-1.7% of all appendectomies. However the most common complaint for appendiceal presentation is RLQ pain/appendicitis. Most common neoplasms include adenocarcinoma, carcinoid, and mucinous neoplasm This study reviewed path of all 18+ appys from year 2006-2010. Out of 376 appys, 17 underwent Interval appendectomy; 5/17 specimens carried neoplasm all of which were mucinous adenocarcinoma or mucinous cystadenoma. In this institution the incidence of neoplasm is 3.7%, and for the subgroup of IA it’s 29%


Presenter

Presentation Notes

Incidence in ths study may be higher than overall incidence due to the fact that prior studies included pediatric pts, where malignancy is quite rare, this chart shows the vast majority of tumors were since in the 40+ age group.

• 6038 patients diagnosed with acute appendicitis

–188 underwent initial non-operative management

• 89 patients underwent interval appendectomy

–12% found to have appendiceal neoplasms

–5 patients required more extensive resections


• 2771 patients followed after nonsurgical management of complicated appendicitis

• Malignant disease detected in 1.2%

• Important benign disease (Crohn’s disease) detected in 0.7%


Questions

A 55-year-old man undergoes an uneventful laparoscopic appendectomy for appendicitis. Final pathology reveals the presence of a 2-cm carcinoid tumor. What would you recommend at the clinic visit?

A. No further intervention

B. Right hemicolectomy

C. Adjuvant interferon alpha

D. Adjuvant octreotide

E. Cecectomy


Questions

An otherwise healthy 16-year-old boy presents with 2 days of abdominal pain, nausea, and anorexia. His physical exam reveals a temperature of 37.4 °C and mild involuntary guarding in the right lower quadrant. Rovsing. obturator. and psoas signs are negative. His white cell count is 12,500/mm3 and C-reactive protein is 18 mg/L. Ultrasound poorly visualizes the cecum: the appendix is not visualized. Which of the following is the next most appropriate step in his management? A. CT abdomen with appendix protocol B. Appendectomy C. Intravenous antibiotics and serial examinations D. Meckel scan with technetium-99 E. Repeat ultrasound and complete blood count in 24 hours


Questions

Compared with open appendectomy, patients undergoing laparoscopic appendectomy have

A.equivalent hospital length of stay

B.equivalent overall morbidity

C.higher rates of septic shock

D.higher rates of wound disruption

E.lower rates of surgical site infection


Questions

After an uncomplicated appendectomy for acute appendicitis, pathologic examination reveals a carcinoid tumor in the specimen. All of the following are indications for repeat operation and right hemicolectomy EXCEPT:

A. tumor size smaller than 1 cm

B. lymphovascular invasion

C. presence of goblet-cell features

D. invasion of appendiceal mesentery

E. tumor location at the base of the appendix


Interval Appendectomy - SUNY Downstate Medical Center Rounds Appendicitis... · Case Presentation ....

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