MANAGEMENT OPTIONS FOR ACUTE APPENDICITIS.pptx

Management options for acute appendicitis. This is a lecture done at the Levy Mwanawasa University Teaching Hospital

1. MANAGEMENT OPTIONS FOR APPENDICITIS AND ITS COMPLICATIONS Presenter : Dr Letwin Tadyanemhandu Moderator: Dr Felix Michelo Green firm-UTH

2. Outline INTRODUCTION ANATOMY DIAGNOSIS CLASSIFICATION EMERGENCY CARE MANAGEMENT OPTIONS COMPLICATIONS CONTROVERSIES REFERENCES

3. INTRODUCTION Acute appendicitis is characterized by inflammation of the vermiform appendix Most common abdominal surgical emergency in the world, lifetime risk 8.6% males and 6.9% females Open appendectomy was the only standard treatment for appendicitis Contemporary management of appendicitis is more sophisticated and nuanced Numerous knowledge gaps that exist in the management of acute appendicitis decisions on management (surgical versus non-surgical)

4. ANATOMY

5. DIAGNOSIS OF APPENDICITIS Accurate diagnosis is crucial to prevent complications, increases mortality from <0.1% (uncomplicated) to ~5% (perforated) Key Diagnostic Tools: Clinical Scoring Systems: help stratify risk but lack universal adoption Imaging: Ultrasound (US):  First-line in children and pregnant women (low cost, no radiation)  CT Scan:  Gold standard for adults (sensitivity >95%) MRI:  Preferred in pregnancy when US is inconclusive

6. CLASSIFICATION OF APPENDICITIS UNCOMPLICATED : localized appendicitis/non perforated COMPLICATED : perforated/abscess/mass Type: Acute - Marked by severe intolerable abdominal pain, worsens very quickly, usually in hrs. Subacute - Recurrent but mild abdominal pain which starts on its own. Chronic - Clinically characterized by prolonged (>7/7) right lower quadrant pain that may be intermittent and a normal WBC.

7. EMERGENCY DEPARTMENT CARE NPO Intravenous (IV) access Administer crystalloid therapy to patients with clinical signs of dehydration or septicemia-SMART trial Administer parenteral analgesic- acetaminophen/ NSAID/Opioid Antiemetic as needed for patient comfort Intravenous antibiotics- Broad-spectrum gram-negative and anaerobic coverage

8. NON PERFORATED AA MANAGEMENT

9. COMPARISON OF ANTIBIOTICS VERSUS APPENDECTOMY FOR NONPERFORATED APPENDICITIS Antibiotics Appendicectomy Advantages Avoid surgery and anesthesia Shorter duration of disability compared with surgery Not associated with an increased risk of appendix rupturing Appendicitis almost never recurs after appendectomy Lower incidence of subsequent hospitalization than nonoperative management Curative for neoplasm Disadvantages 10 to 20% failure rate at 30 days* 30 to 40% recurrence rate at 1 year* 40 to 50% recurrence rate at 5 years* Small risk of missed neoplasm (mostly in older patients) Requires surgery and anesthesia Longer duration of disability required to recover from surgery

10. URGENT VS EMERGENCY APPENDICECTOMY Landmark DELAY trial “….appendectomy within 12-24 hours of presentation is not associated with an increase in hospital length of stay, operative time, advanced stages of appendicitis, or complications compared with appendectomy performed within 12 hours of presentation” Van Dijk ST, 2018 “..Similar outcomes between when appendicectomy was performed within 24 hours and when it was performed between 24-48 hours” Fair BA, 2015 Additional studies are needed to demonstrate whether initiation of antibiotic therapy followed by urgent appendectomy is as effective as emergent appendectomy for patients with unperforated appendicitis

11. PERI-OPERATIVE MEDICATION Pre-incisional antibiotics reduce bacterial load within the inflamed appendix + reduce contamination Uncomplicated Appendicitis-No role for post op antibiotics Perforated Appendicitis –post operative antibiotics for 3-5 days until clinical and laboratory improvement (APPIC trial)

12. PATIENTS ON ANTIPLATELET OR ANTITHROMBOTIC THERAPY Aspirin/CLOPIDOGREL Direct oral anticoagulants (DOACS) Warfarin

13. MANAGEMENT OF COMPLICATED APPENDICITIS Late presentation: D3 of attack Clinically fever + mass Subject to imaging to ascertain - presence - size

14. PERFORATED ACUTE APPENDICITIS AT UTH Prospective study of Perf AA at UTH-Samuel Phiri 2012 Outcomes : 71 appendicectomies : Perf rate 43.6%, 3-5 days : M/F 2.5:1, Age peak 30-40 yrs : 64.5% generalized peritonitis –Midline incision : Mortality 1.4% Factors contributing: pre Hosp pt delay, use of traditional meds (11%)

15. MANAGEMENT OF ACUTE PERFORATED APPENDICITIS

16. APPENDICULAR MASS Appendix Oedematous Caecum Terminal Ileum Omentum ( Greater Omentum ) Adjacent Peritoneum Ascending Colon

17. MANAGEMENT OF APPENDICULAR MASS Appendicular Lump- Don’t Operate (??) Severe adhesion/ Difficult to separate the part Bloody and dangerous to operate Risk of Faecal fistula Risk of iatrogenic injury

18. OCHSNER- SHERREN REGIMEN NPO & IV Fluid supplements Antibiotics, Analgesics Temp, Pulse( 4 hourly) & Fluid record charting Allow oral liquid on subsequent days If more vomiting- antiemetic &/+ PPI If size of the lump decreases – continue the same After 6-8 weeks = Interval Appendectomy (current literature does not support this view)

19. MANAGEMENT OF APPENDICULAR MASS Criteria for stopping conservative management - Rising pulse/Temp - Increasing/spreading abdominal pain - Increase in size of mass - Vomiting or copious gastric aspirate Failure of mass to resolve should raise suspicion of Ca or Crohn’s disease App 90% resolve with the OS regimen without incident

20. APPENDICULAR ABSCESS Suppuration in an acute appendicitis or in an already formed appendicular mass

21. SURGICAL MANAGEMENT Appendicectomy - laparoscopic - open Diagnostic laparoscopy Laparotomy

22. SURGICAL MANAGEMENT   Open Appendectomy (OA): - Reserved for cases with dense adhesions or generalized peritonitis   Timing of Surgery: - Uncomplicated:  Surgery within 12–24 hours is safe; delays >48 hours increase complications 

23. SURGICAL MANAGEMENT

24. LAPAROSCOPIC APPENDICECTOMY Suitable Indications Uncomplicated appendicitis Appendicitis in pediatric patients Suspected appendicitis in pregnant women Preferred option for : Perforated appendicitis Appendicitis in elderly patients Appendicitis in obese patients

25. LAPAROSCOPIC APPENDICECTOMY Advantages : increased cosmetic satisfaction decrease in the postoperative wound-infection rate shortens the hospital stay Mimimal pain Disadvantages:  increased cost Longer operating time approximately 20 minutes longer than that of an open appendicectomy

26. DRAIN PLACEMENT In general, the use of abdominal drains is based on personal experience rather than strict evidence-based guidelines, as exemplified by the surgical truism, “When in doubt, drain,” first coined by Tait in 1905 Surgical drains disadvantages: drain blockage, hindrance in the healing process, prolonged hospital stay, and increased healthcare expenses Complications: erosion into abdominal viscera, fistula, entrapment, displacement, kinking, or migration Increase the risk of enterocutaneous fistulas (4.2–7.5%) and wound infections (43–85%), IO, Ileus Recent data have cast doubt on its efficacy in preventing postoperative complications

27. COMPLICATIONS AND THEIR MANAGEMENT Wound Infections ( ̴ 20%):  reduced with pre-op antibiotics  Intra-abdominal Abscess (9–20%):  Managed with drainage + antibiotics Paralytic Ileus:  Avoid routine drain placement (increases fistula risk) Fecal fistula Stump Appendicitis:  Rare but possible if residual tissue remains Bleeding/Iatrogenic Injury:  More common in laparoscopic cases Appendicular tumor : < 2cm appendicectomy, > 2cm hemicolectomy Right inguinal hernia(direct )—due to injury to ilioinguinal nerve Respiratory problems and DVT

28. CONTROVERSIES AND FUTURE DIRECTIONS Interval Appendectomy (IA): - Debated necessity; some advocate for IA to rule out neoplasms (28% vs. 1% in immediate surgery) -FINNISH trial Colonoscopy : all Patients above 40/not necessary Emerging Techniques:  Endoscopic appendectomy is under investigation Antibiotic vs No Antibiotic : APPAC III

29. Non-operative management Randomized Control Trial > Br J Surg . 16 May 2022;Volume 109(6):503–509, doi:org /10.1093/bjs/znac086 Antibiotics  versus  placebo in adults with CT-confirmed uncomplicated acute appendicitis (APPAC III): randomized double-blind superiority trial Paulina Salminen  ,  Suvi Sippola  ,  Jussi Haijanen  ,  Pia Nordström  ,  Tuomo Rantanen  ,  Tero Rautio  ,  Ville Sallinen  ,  Eliisa Löyttyniemi  ,  Saija Hurme  ,  Ville Tammilehto  ,  Johanna Laukkarinen  ,  Heini Savolainen  ,  Sanna Meriläinen  ,  Ari Leppäniemi  ,  Juha Grönroos In the APPAC III trial (66 patients),  87 (95 % CI 75-99) per cent for placebo and 97% (92-100) of those tx with antibiotics were successfully treated without surgery within 10 days. The diff was not statistically significant, ( p= 0.142)

30. CONCLUSION Uncomplicated appendicitis:  surgery (preferably laparoscopic) remains gold standard, but NOM is viable for select patients. Complicated cases:  NOM + drainage followed by IA reduces morbidity. Personalized care:  tailor management to patient age, comorbidities, and presentation. Future research needs: Long-term outcomes of NOM vs. surgery. Standardized protocols for IA and antibiotic regimens LMIC: Non-operative treatment for AA has not been widely adopted in LMIC

31. UTH-STATISTICS Jan-2025-Date Complicated : perforated appendicitis - 6 : appendicular mass- 1 : appendicular abscess - 2 Uncomplicated : 17 Sex distribution : M:F 26:3

32. REFERENCES WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis - Salomone Di Saverio1* , Arianna Birindelli2, Micheal D. Kelly3, Fausto Catena4, Dieter G. Weber5, Massimo Sartelli6, Michael Sugrue7, Mark De Moya8, Carlos Augusto Gomes9, Aneel Bhangu10, Ferdinando Agresta11,Ernest E. Moore12, Kjetil Soreide13, Ewen Griffiths14, Steve De Castro15, Jeffry Kashuk16, Yoram Kluger17,Ari Leppaniemi18, Luca Ansaloni19, Manne Andersson20, Federico Coccolini19, Raul Coimbra21, Kurinchi S. Gurusamy22, Fabio Cesare Campanile23, Walter Biffl24, Osvaldo Chiara25, Fred Moore26,Andrew B. Peitzman27, Gustavo P. Fraga28, David Costa29, Ronald V. Maier30, Sandro Rizoli31, Zsolt J Balogh32, Cino Bendinelli32, Roberto Cirocchi33, Valeria Tonini2, Alice Piccinini34, Gregorio Tugnoli34, Elio Jovine35, Roberto Persiani36, Antonio Biondi37, Thomas Scalea38, Philip Stahel12, Rao Ivatury39, George Velmahos40 and Roland Andersson20 https://emedicine.medscape.com/article/773895treatment#:~:text=Patients%20with%20a%20phlegmon%20or,with%20the%20catheter%20in%20place Dahiya, D.S.; Akram , H.; Goyal, A.; Khan, A.M.; Shahnoor , S.; Hassan, K.M.; Gangwani , M.K.; Ali, H.; Pinnam , B.S.M.; Alsakarneh , S.; et al. Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review. J. Clin. Med. 2024, 13, 3034. https://doi.org/ 10.3390/jcm1311303 Abdullatif Mahyoub ., et al. “Non-Operative, Open, and Laparoscopic Management of Non-Perforated Appendicitis in Adults”. EC Microbiology 16.1 (2020): 01-09 Sabiston Text book of Surgery Chapter 50 page 1296. The CODA Collaborative, 2020. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N. Engl. J. Med. 383 1907– 1919. https://doi.org/10.1056/NEJMoa2014320 Talan, D.A., Saverio , S.D., 2021. Treatment of Acute Uncomplicated Appendicitis. N. Engl. J. Med. 385, 1116–1123. https://doi.org/10.1056/NEJMcp2107675 Dahiya, D.S., Akram , H., Goyal, A., Khan, A.M., Shahnoor , S., Hassan, K.M., Gangwani , M.K., Ali, H., Pinnam , B.S.M., Alsakarneh , S., Canakis , A., Sheikh, A.B., Chandan, S., Sohail , A.H., 2024. Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review. J. Clin. Med. 13, 3034. https://doi.org/10.3390/jcm13113034