Update Course Rewind: Management of Appendicitis 2022

Perforation is defined as having a hole in the appendix or a fecalith in the abdomen, based on a 2008 paper that showed this classification impacted abscess rates in a clinically logical way.

Gangrenous appendicitis is classified as non-perforated and patients typically fall into the group that would get sent home.

The initial same-day discharge study in 2013-14 achieved 28% successful discharge rate.

A recent study showed 87% successful same-day discharge rate for non-perforated appendicitis, which has become the norm.

A 2012 randomized study comparing suction to irrigation (minimum 500 ccs, average 850 ccs) showed no difference in outcomes.

A retrospective study using 3 to 12 liters of irrigation in 50 cc aliquots showed 0% abscess rate in irrigated patients compared to 18.9% in perforated appendicitis population.

In Cincinnati's practice using suction without irrigation, no major difference in abscess rate has been observed.

Discharge criteria for perforated appendicitis include patient being afebrile, having good pain control, and tolerating diet.

Patients typically transition from clears to solids on day one, and by day two breakfast is about the fastest discharge timing typically seen.

Previous trials showed a 20% abscess rate that was fixed across different antibiotic regimens and irrigation protocols.

Abscess rate dropped to about 10% after changing practice to treat patients as healthy rather than sick.

Cincinnati implemented a protocol using QI techniques and found no change in readmission rate for abscess when discharging patients by day two post-op.

Eligibility criteria for non-operative management include symptoms less than 48 hours, imaging confirmation with appendiceal diameter less than 1.1 cm, no abscess/phlegmon/fecalith, and white count between 5 and 18.

The Cota trial was a pragmatic randomized control trial on the adult side examining non-operative management.

A patient and family choice study was conducted in the Midwest Pediatric Surgical Consortium examining non-operative management in children.

The multicenter trial was designed as a non-inferiority trial with a non-inferiority margin set at around 20% based on surgeon consensus.

Interim analysis shows approximately 31-32% one-year failure rate for non-operative management.

Not all failures of non-operative management had appendicitis on histology when they eventually had surgery.

Non-operative management showed a non-significant three extra days of school absence compared to surgical management.

Many patients treated non-operatively have an interval appendectomy, which can be scheduled electively and may provide better quality of life than admission.