Update Course Rewind: Perforated Appendicitis 2019

Hey there, listeners. It's Rod from Cincinnati Children's. Have you downloaded the new version of the stay current pediatric surgery app? It's got new features, and new layout, a lot of new content. The reason I bring it up here is because when Whitt Holcomb is talking about different articles, I'm gonna link them under the media player, so you can just click on them, open them up while you're listening to the podcast. And on top of that, you can look at other videos about appendicitis, if you want to. It's all in the app. So download it now, it's in the Apple App Store, it's in the Google Play Store. But until then, enjoy the episode. The appendectomy is the most common surgical procedure that pediatric surgeons are performing. But the problem is, let's say the kid gets to the hospital a little bit too late, the appendix is a little bit too bloated, and it perforated. Well, that brings on a slew of questions. I mean, do you aspirate, do you irrigate? Who of these patients is gonna get an abscess, if any? What even is your definition of perforated appendicitis? These nebulous questions are still kind of floating around in the literature, and hopefully, we can help answer some of them. In today's update course, rewind, we're gonna go back to a 2019 session with Witt Holcomb, where he's gonna throw the literature at you, throw the evidence in your face, and say, hey, look, here's what we know so far, here's what we can do, and I think you're gonna love it. So, enjoy today's update course rewind on perforated appendicitis. So I'm gonna present on the uh mundane topic of perforated appendicitis. That's Whitt Holcomb from Children's Mercy Hospital in Kansas City. So you see a 12-year-old child with signs and symptoms of appendicitis. Uh, he's been symptomatic for 36 hours. You think his appendix may have perforated and, and decide to order a CT scan. Now, I know what you're thinking. You would probably just get an ultrasound, but for the purposes of this discussion in this case, let's say that we get a CT scan. So the question is, how accurate is the CT scan in diagnosing perforated appendicitis? So go ahead and think to yourself, do you think it's 50, 70%, or 90% accurate? And while you're thinking about that, scroll down under the media player. There's an article link there. The first one is this article that Doctor Holcomb is gonna talk about. And so what the paper's about is there were 200 CT scans who were reviewed uh by um 6 surgeons, 2 of whom were fellows and 2 radiologists, so 8 people. The 200 scans excluded ones that had Appendiceal abscesses, but they basically have the reviewers look at these scans and say, hey, is this perforated or non-perforated? And guess what? We are terrible at telling whether or not an appendix is perforated or non-perforated on a CT scan. The reviewers were only right 72% of the time. That's not even 3 out of 4. Kind of makes you think. I mean, how many images of an appendix are you looking at in a given week? Probably more than 4. You're probably not reading them all right. Now, let's say we're gonna move on with the case, and you decide to operate. You operate on this child and think he has perforated appendicitis. In the operating room, how accurate is your visualization of the appendix in determining if it has perforated or not? So, again, scroll down under the media player. The second link there is gonna be to an article that hopefully answers that question. And so what uh Doctor Ponsky and his group did was, uh, there were 110 surgeons, uh, involved, 62 attendings and 48 fellows. These were adult surgeons as well as pediatric surgeons. Um, there was a cross section of surgeons that were, uh, you know from university hospitals, community hospitals, and children's hospitals. And among the attendings, the agreement in defining an image. He means like an intraoperative laparoscopic image, not like a CAT scan. Uh, as to whether the appendix was perforated or not was 27%. So not only are we bad at telling whether or not an appendix is perforated or non-perforated, we're not even like the same kind of bad, because we all disagree when it comes to whether or not one is perforated or not. Here's Doctor Ponsky with a little extra bit of analysis from the paper. But the funniest is we took one of the images, turned it upside down, and flipped it to the left, and even people didn't agree with themselves when they saw the same picture later on in the study. So inter and intra-observer variability was close to chance alone. So, maybe we need a standardized definition for perforated appendicitis. Guess what? Scroll down under the media player. There's an article for that too. At our hospital, uh, we identify a perforated appendicitis as a hole in the appendix or a fecal lith in the abdomen. The way Sean explained it to me is in the, it, when they grouped stool in the abdomen or a hole in the appendix, when they took all of those patients that didn't have Either of those, the incidence of abscess was less than 5%. And that's the part we care about, right? Which of these patients will go on to form a postoperative abscess? That's the whole reason we're having this discussion in the first place. Well, in this study, after Doctor Saint Peter's group implemented a standardized definition for perforated appendicitis. They saw their non-perf abscess rate go down, and their perforated abscess rate go up. So what does that mean? That means that before they had a definition for perforated appendicitis, some of their non-perf patients were probably actually perforated. And similarly, some of their perforated patients were probably not really perforated because they didn't have a way to define it until this study. So, Let's say you're in the operating room, you figure out that this patient is for sure perforated. Here's Witt's next question. All right. The next, uh, uh, question is, you find a patient has perforated appendicitis and your resident asked you if irrigation of the abdominal cavity is beneficial. You know the drill. Open up the next article. Uh, in this trial, there were 110 patients in each arm. The surgeon, in the arm in which irrigation was used, the surgeon had to use 500 cc's of irrigation as a, a minimum. The average. Uh, it was about 850 ccs that was used. And what did they find? Well, there was no difference in the postoperative abscess rate between the groups. There also wasn't a difference in length of stay, hospital cost. There's no difference in the operative time. So they concluded that maybe there's no benefit to irrigation for perforated appendicitis. Can I stop you for a second? That's Matt Carbon from Children's Hospital of Buffalo. Some of the criticism that that report has been that the both of the incidences of. Abscess formation are higher than some other studies, the 18 and the 19%. So, any thought about that? I'm sure you've heard that before. Yeah, so I would say that's because of the definition that we used. So keep in mind that not every pediatric hospital was using the same definition that Kansas City was for what is or is not a perforation. Now, because they didn't find any difference in irrigation. That's not to say that every irrigation is the same. Maybe that too could be standardized. And so the study was about a standardized large volume irrigation by one of the surgeons, uh, somewhere between 3 and 12 L, uh, in small focus directed aloquats, uh, comparing that to surgeon preference for the other surgeons for the irrigation. Uh, and the results were that, uh, patients with perforated appendicitis, if you use this, uh, standardized large volume irrigation, the rate of abscess development was 0, versus, uh, about 19%. If, um, if it was surgeon discretion or surgeon preference used. 0 versus 18. True. It changed my practice, the study, and I maybe, what did you have comments about it or no? Yeah, more just um for, uh, in general, I think one of the issues is that no matter how good your data are, you can't beat a good rhyme. That's Alex Gibbons. He's a general surgery resident at the Cleveland Clinic. Um, so the solution to pollution is dilution, you have to come up with something different, so. Uh, my idea was, um, potentially, uh, the inoculation for contamination is aspiration. Yeah, let's put that out there. I guess I should have mentioned that Alex is also a budding rapper, apparently, but he brings up a good point. What about aspiration? Um, for what it's worth, there's a meta-analysis, uh, that came out last year. Don't forget that we're kind of time traveling here. So the article he's talking about, which is linked below, came out in 2018. It was a meta-analysis. They compared suction alone versus irrigation. They looked at children and adults, but they found no difference in the rate of postoperative abscess. So, they're thinking that maybe one isn't necessarily better than the other. That was the last article that Doctor Holcomb was reviewing during this session, and that's when we brought it out to the questions from the audience. So the audience for our update course is both live in person and then also online, so anywhere in the world. I mean, there's a lot here. Do we, so do we irrigate or not? Uh, the answer is we don't have an answer. The, the best quality study said no difference. The more recent study that was, uh, Uh, not as a well-designed study did show a difference. I, I do think it's, it really would behoove all of us if we came up with some standardized definitions. So we're all talking about the, the same disease process. Yeah, well, we'll get there eventually in the next 30 years, OK. So, there you have it. One of our favorite sessions from the 2019 update course about perforated appendicitis. Hopefully, you didn't leave here more confused than you were previously, or if you are, why don't you just download our app, Stay Current Pediatric Surgery, and dive deeper into this. Not only do we have more podcasts like this, we got videos, we have articles. Going into the app every month. So you can keep up to date with any of these issues. You can use our new search feature. Just search perforated appendicitis. Hopefully, you can find the answer you're looking for there. But until next time, I'm Rod Gerardo from Cincinnati Children's, and remember, knowledge should be free.