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Acute Appendicitis Current Issues and Controversies (Malen MD) PDF
Acute Appendicitis Current Issues and Controversies (Malen MD) PDF
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)
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 %
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
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
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.
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.
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
NOTES
Natural orifice translumenal endoscopic surgery (NOTES) Transgastric Transrectal Transvaginal
NOTES - Transvaginal
Summary
Thank you