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Appendicitis presents choices around diagnosis and management

OCTOBER 22, 2018
Clinical Congress Daily Highlights, Monday First Edition


A wide-ranging panel discussion on Monday around the diagnosis and management of appendicitis in pediatric and adult patients covered the latest strategies for treating a condition that has declined in incidence since the 1940s, now affecting 1.1 people per 1,000 annually. The topics ranged from different imaging modalities for diagnosis, treatment of acute and perforated appendicitis, and treatment in a rural setting.

Shawn St Peter, MD, FACS, Children’s Mercy Hospital, Kansas City, MO, kicked off the panel with a discussion of current management strategies for perforated appendicitis in children. He said there is little difference between early and delayed, also referred to as interval, appendectomy when patients present with an abscess, but that stress affecting parents and children is magnified with delayed appendectomy. He concluded that surgeons performing interval appendectomies should consider the ability for families to cope with stress.

Peter Minneci, MD, FACS, Nationwide Children’s Hospital, Columbus, OH, discussed the rationale for using only antibiotics to treat children with acute appendicitis, and summarized current clinical data on the safety and effectiveness of this strategy. He argued that the wide availability of diagnostic imaging and broad-spectrum oral antibiotics make it feasible to treat these patients with antibiotics alone and that nonoperative management of acute appendicitis is safe and effective. He concluded that treatment should involve a choice between surgery and antibiotics alone, using a shared decision-making process between patients and their families.

Brian David Kenney, MD, MPH, FACS, Nationwide Children’s Hospital, Columbus, OH, outlined the main imaging strategies for pediatric appendicitis including CAT scan (CT), ultrasound (US), and magnetic resonance imaging (MRI). He argued that most patients benefit from imaging, the most common being CT, with low rates of negative appendectomy. However, he said CT scans are too heavily relied on and listed cost and radiation exposure as downsides of this modality. He argued that instead, US is a more cost-effective option and should be used preferentially over CT. Lastly, he mentioned that use of MRI is rare, but should be explored and potentially used more often in the future.  

Shawn Jason Rangel, MD, MSCE, FAAP, FACS, Boston Children’s Hospital, Boston, MA, discussed various ancillary and adjunct treatment strategies for complicated pediatric appendicitis including parenteral nutrition (PN), postoperative diagnostic imaging, and giving oral antibiotics fol/p>ing discharge. He said that PN use in children is not associated with improved outcomes, that delaying postoperative imaging to Day 7 compared to Day 5 may decrease CT utilization, and that most patients don’t need oral antibiotics following appendectomy, but those with severe disease may benefit.

Glenn Levine, MD, FACS, Coquille Valley Hospital, Coquille, OR, rounded out the panel by discussing how to balance resources, expectations, and expertise for pediatric appendicitis patients in critical access hospitals in rural areas. “It’s my opinion that what can be done safely in most critical access hospitals in America is routine laparoscopic appendectomy in children. Appendicitis with complications, chronically ill children with routine appendicitis, cases with questionable examinations and diagnoses, all are best cared for by pediatric surgeons,” he said.

Additional Information

The Panel Session, Current Controversies in the Diagnosis and Management of Appendicitis, was held October 22 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast, and audio information is available online at facs.org/clincon2018.

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