Hey there, listeners, this is Rod Gerardo, research resident at Cincinnati Children's Hospital. And if you've been listening for the past few weeks, you know that I'm no longer alone. I'm no longer flying solo. I have help. I have another research resident. Hey, this is Ellen and Cisco, a research resident at Cincinnati Children's Hospital too. And it's a good thing Ellen's here today because we need a smarter resident to help me analyze some journal articles. Right. What are we talking about today? They were going through appendicitis. We're reviewing some recently published literature on the management of appendicitis, and we're doing it with a special guest. Yeah, we're doing it with Jose Campos. OK, hello guys. I, I'm Jose Campos. I'm a pediatric surgeon from Chile. I work, work at Sodero del Rio Hospital and I'm also part of a group that is part of The Chilean Society of Pediatric Surgery. I love it. Thank you, Jose. And if listeners haven't already heard the introduction to Jose Campos, back in the winter, we did a podcast that was about your filtering system. We're using articles that came from your group's literature filtration system, specifically that we pulled our favorite ones about appendicitis. So, um, we got a case. 7-year-old boy comes to the emergency department after abdominal pain for a couple of days. Initially, it was perambilical. It radiated down to his right lower quadrant in the last day. He's also been vomiting for the last day. He hasn't been eating since yesterday morning. He's had two episodes of diarrhea this morning. His mom took his temperature, noted it was 102.1 °F at home. So, she brought him into the emergency department. Department to see us. Otherwise, he's healthy. Ellen, you and I are the residents here. What's the first thing you look up? Checking their history and then checking their vitals. Yeah, and this, this kid's vitals, he's a little bit tachycardic. He's in the hundreds. His blood pressure is fine. And then, uh, in the emergency department, they get a temperature. He's 39.8 °C. So you did your chart review. You saw all this note from the emergency medicine resident. And then you're gonna trot down there to the ED. What's the first thing you're gonna do? We'll review the history again and then, and do a physical exam. Exactly. And when we do that physical exam, this little boy's abdomen is soft. He's not distended. He's not tender. You don't feel any masses. So, Ellen, what are we gonna do now? Presumably, the, the ED will have, will have drawn some labs for us already. And sure enough, this kid has a leukocytosis. His white blood cell count is 14.8. He has a left shift. They got a CRP 1.5. Um, so now we're at this impasse, right? So, um, how about from Jose and Todd, talk to me about what your initial thoughts are with this kid and why you are not leaning towards a certain diagnosis. Of course, this podcast is about appendicitis, so we, you know what we're talking about, but we haven't made, the, the, this made up case too clear for you guys. So, uh, to me, the, the history is not completely clear on appendicitis. I would not take this, this patient straight to this child, uh, has a story that doesn't sound that much like appendicitis. He's got diarrhea, and he's got no right lower quadrant tenderness. So this would be a red herring if this was appendicitis. Whether it's red or blue or otherwise, it certainly seems gray, I'll tell you that much. So, if only there was a way that we could stratify these patients and figure out their likelihood of having appendicitis, Jose, talked to us. I'm glad you mentioned it because the first thing we want to discuss is entitled Appendicitis Risk prediction models in Children presented with right iliac fosa pain. This is a study called a RIFT study and they prospectively evaluated 15 different uh clinical prediction models on all of these patients. Just see, that's even more. This group took a bunch of different prediction models calculating the area under the curve and their, uh, failure percent to determine. And how accurate these prediction models are. Yeah, and then they basically said this one, the Shira score, is the best one. It's area under the curve was 0.84 and its failure rate was 3%. I think they highlighted that, that the Shira score was good for ruling out appendicitis. So Jose is like very verbose, so he rambled on about a lot more articles that we're not gonna have time to talk about, but we're gonna give you the links to those articles under the media. Media player. So scroll down. We're gonna give you links to not only the articles we're talking about, but some that we think are worthwhile reads. Ellen, are you going to get an ultrasound on this kid? Yes, we'll get an ultrasound next. Me too. So here, they tell us on the ultrasound that it's equivocal for appendicitis to correlate with the clinical picture. OK, that's why we chose the next article, pediatric appendiceal ultrasound, maintaining accuracy, increasing determining and improving clinical outlook comes following the introduction of a standardized report. Template to to either say this is or this is not and only leave equivocal for a few identified uh situations. So this was a pre and post intervention and the main finding is that the equivocal report was dropped down from 27% to 9%. They dropped the CTUs from 19% to 9%, so they reduced their CTUs by half and this didn't affect clinical outcome because the negative laparotomy. It's exactly the same. Great article, Jose. Thank you for bringing it to us. It seems like with this format, they were more certain that it is or isn't. So, to make sure I understand, they just standardized the protocol. It was more the reporting, how the radiologists reported their results, trying to reduce the amount of times that they said equivocal because every time they say equivocal, we get a CT scan. It's like a, it's like a 123. Yes, they have it. No, they don't have appendicitis or equivocal. So what I understand is that historically, it's been Freeform. So it's really easy for the radiologist to give an equivocal type of result, which then always ends up leading to a CAT scan. By moving to this system, it is making them commit to a score, which then can be used to help decide in a much more specific way who should be getting secondary imaging. That is awesome. All right, so let's say we get the ultrasound and then the report says acute. Complicated appendicitis. So, should we operate or should we treat with antibiotics? What do you got for us, Jose? I'm happy to introduce this article to you. It's called Monoperative treatment versus Appendectomy for acute non-perforated appendicitis in Children. Just to make it quick, uh, it's laparoscopic surgery versus antibiotics. I think this is the best there is, but they all randomized 26 on one side, 24 on the other side. The surgical failure rate, it's 0%. The medical failure rate, failure rate defined as Uh, having a laparoscopic appendectomy during follow-up, it's 45%. So, I'm not sure if I can make a decision on practice based on this, but definitely we can, we can study better, we can inform parents better. Yes, absolutely. The conversation with the parents, I think is shifting. It's a small study. It's an interesting study, but is this one gonna change? Things. I don't think so. This is a pilot study and the authors have been very clear on this, but this is the best we got right now in pediatric surgery. We decided we're going to operate. So now the question is, for preoperative antibiotics, what should we get? And so we have another paper here from Jose. These authors, they published in Annals of Surgery in 2020, a large retrospective core study. Based on the NSQIP database, and they looked at the two most commonly used uh narrow-based antibiotics for non-complicated appendicitis, those being cephalexin versus ceftraoin plus metronidazole. They were able to show after adjusting for multivariate analysis that there's a 90% reduction in A surgical site infection when you use cephstone plus metriazole compared to cephfodixin. Yeah, we use uh ceftriaxin and Flagyl as well. We decided on our antibiotics, we're gonna take this kid for a lap pi. But, you know, you're gonna see different things when you get in there intraoperatively and how do we define those things and that's what this next article is. So this article, I find it very interesting. It's called Development and Implications of an Evidence-based and Public Health relevant definition of complicated appendicitis in children. When we've been treating appendicitis for, I don't know, more than 100 years, we still don't know how to stratify appendicitis correctly. There's a lot of history to trying to figure out. A definition for perforated appendicitis. It goes way back to 2005. Doctor Sean Saint Peter and Whitt Holcomb came up with a definition of a perforated appendicitis, meaning a hole in the appendix or fecal in the abdomen. And then in 2008, they went back and looked at the abscess rates based on that definition. That was the study that clearly showed that it's a hole in the appendix and stool in the abdomen. This one helps to validate that. Again, they use the NSQIP database and this is a retrospective core study and they took 5000 patients and they individualized all the intraoperative findings. So single intraoperative findings were correlated whether they had more adverse events postoperatively or not. They found actually only 4 variables that correlate with complicated postoperative course for appendicitis, and those are a visible hole, an abscess, a fecal leaf, and diffuse fibrino purulent exudate outside the right iliac fossa or pelvis, and all of these, um, all of these 44 factors, after adjusting for all variables, they had higher adverse effect. They had higher length of stay, higher emergency visits. And higher use of hospital and patient resources, so I would. I would definitely use this definitions in the future. And the only thing that's different in here, that's different than the Saint Peter's study, is that this study said that pus in the abdomen is a predictor of abscess, because in Sean's study, that was not a predictor of abscess. So, after we do our appendectomy, the next question we ask ourselves is, should we be giving patients post-op antibiotics? Afterward, it was a simple, uncomplicated appendicitis. A randomized controlled trial, this one, this time was a double-blinded trial. I think the methodology is quite good. It's entitled Our Postoperative intravenous antibiotics indicated after laparoscopic vasectomy for simple appendicitis. They ended up recruiting 243 patients and they were randomly assigned to either 2 doses of. antibiotics or placebo. They did find a significant reduction in skin infection rate from 6.6 to 0.8. My only comment to this is, this is a really well designed study, but having a baseline 6% infection rate for simple appendicitis seems a bit too high to me. My issue with this study is when I think of What am I worried about with uh uncomplicated appendectomy that's gonna bite me in the butt? It's not a surgical site infection. It's, did I have it wrong and this kid's gonna come back with a postoperative abscess. That's not even what they looked at. I don't know what their postoperative abscess rate was, but they're saying that, hey, you should do more antibiotics afterwards so that they don't get a skin infection. That wasn't even on my radar because we've been talking about abscesses. What do you do for non-complicated appendicitis? Do you Give antibiotics post aversively or not, no, no, and, and this paper wouldn't change your management either. No. And so the next question we have, so, you know, we get to the, do the surgery, they've recovered, and so at, at discharge, what do we typically use for pain control? Do we use narcotics or just um other things like Tylenol? We, we, we picked an article um that's called Eliminating OPTA Prescribing for Children after non-perforated Appendectomy. So, What these authors have done is they did a pre-imposed intervention investigation and they completely eliminated prescription after appendectomy and they did some phone interviews and surgical outpatient follow-up and they asked the patient if they had any pain at all with this new postoperative medication and there was absolutely no increase in self-reported pain. Nor in um extra medication use after they were discharged from the hospital. Nail on the head here, Jose, is that this is a, a very US centric problem that we need to come up with a way to decrease our opioid use. This has been one of the hardest things for me to adjust to out of all the things you brought up today because I, I really felt like these patients need opiates. And once I started converting to Tylenol and or Motrin, They're fine. And it, it totally surprised me, and patients really do not come back asking for opiates. In summary, this hypothetical patient, they came in with right lower quadrant pain, and the story was gray for whether or not they had appendicitis, right? Right. So then we talked about different scoring systems and whether or not they're good or not. And then we talked about ultrasound. One method for reducing the, the rate of getting a CT scan is For radiologists to help us out by being a little more decisive, right, because they're always hedging. They always want to clinically correlate. No, just tell us if you think this is appendicitis or not. So we talked about non-operative management and the antibiotics for that and how effective that is. Then we talked about if we are going to operate, which antibiotics do we want to use, and then we talked about if you go in and it looks perforated, what does perforated even mean? And then we talked about. Post-operative antibiotics, and if we need those, then we all decided we don't typically use them for simple appendicitis. We don't, we don't need to. In the United States. Sometimes these patients go home with opioids and maybe they shouldn't, right? OK, right. At least one institution cut them out of their practice successfully. So maybe everyone else could, yeah, I could think about it as a reminder. There's more literature for you to read. There's more homework. For you to scroll down and click the links and, and check it out and we're gonna keep doing these if you like them, we'll keep making these, uh, but in the meantime, if you want more controversial literature, debates or discussions, or you want to hear from Jose because you didn't hear enough from him, what can they do? They can tune in for an update course coming up soon on August twenty-seventh. Alternatively, download the Stay Current pediatric Surgery app. Yeah, it's in the Apple App Store. It's in the Google Play Store. I'm Rod Gerardo from Cincinnati Children's, and I'm Ellen Ncisco, also from Cincinnati Children's. And remember, knowledge should be free.
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