Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis with abscess

Abstract

Objective-Given the perceived technical demands of laparoscopic appendectomy and the expected postoperative morbidity in patients with a well-defined abscess, initial percutaneous drainage has become an attractive option in this patient population. This strategy allows for a laparoscopic appendectomy to be performed in an elective manner at the convenience of the surgeon. However, the medical burden on the patient and on the quality of patient outcomes has not been described in the literature. Therefore, we audited our experience with initial percutaneous drainage followed by laparoscopic interval appendectomy to evaluate the need for a prospective trial.Methods-After institutional review board approval, a retrospective chart review was performed on all children who presented with perforated appendicitis and a well-defined abscess and were treated by initial percutaneous aspiration/drainage followed by interval appendectomy between January 2000 and September 2006. Continuous variables are listed with standard deviation.Results-There were 52 patients with a mean age of 9.0 ± 3.9 years and weight of 34.4 ± 18.8 kg. The mean duration of symptoms at presentation was 8.4 ± 7.6 days. Percutaneous aspiration only was performed in 2 patients. The mean volume of fluid on initial aspiration/drain placement was 76.3 ± 81.1 mL. The mean time to appendectomy was 61.9 ± 25.2 days. The laparoscopic approach was used in 49 patients (94.2%), of which one was converted to an open operation. The mean length of hospitalization after interval appendectomy was 1.4 ± 1.4 days. A recurrent abscess developed in 17.3% of the patients. Six patients (11.5%) required another drainage procedure. The mean total charge to the patients was $40,414.02. There were 4 significant drain complications (ileal perforation, colon perforation, bladder perforation, and buttock/thigh necrotizing abscess).The child with the ileal perforation after drain placement is the only patient who failed initial nonoperative therapy.Conclusions-The use of initial percutaneous aspiration/drainage of periappendiceal abscess followed by interval appendectomy is an effective approach. However, this management poses complication risks and uses considerable resources. Therefore, this strategy should be compared with early operation in a prospective trial.

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

“…Our previous retrospective report on our experience with initial nonoperative management and interval appendectomy showed some concerning data [6]. In that report, the patients had a 17% rate of recurrent abscess formation, which was about the same as our known rate of abscess development after laparoscopic appendectomy for perforated appendicitis (18%) [8].…”

“…Another concerning finding from our retrospective review was the number of CT scans that were performed with initial nonoperative management [6]. The reason is that these patients were not managed by a standardized protocol, and decisions were made on an individual basis by a large number of caregivers resulting in a mean number of 3.5 CT scans per patient.…”

“…Despite the widespread application of drainage followed by interval appendectomy, there have been little data published describing the expected course for these patients. We recently performed a retrospective review of our experience with attempted drainage, antibiotics, and laparoscopic interval appendectomy and found that drainage complications, persistent symptoms, recurrent abscesses, multiple computed tomographic (CT) scans, numerous home health care visits, and a heavy financial burden may be detriments to this management strategy [6]. However, in this retrospective review, we found that there was not a standardized management strategy among the various surgeons.…”

Dollars and sense of interval appendectomy in children: a cost analysis

“…The optimal management of patients with localized, contained perforated appendicitis is debated [3][4][5]. With improvements in medical management including the use of interventional radiology techniques such as percutaneous drainage of abscesses, there has been a trend toward nonoperative management of localized, perforated appendicitis [6]. If initial nonoperative management is successful, interval appendectomy is typically performed 4 to 12 weeks after the initial presentation [3,7,8].…”

Interval appendectomy for acute appendicitis

“…The increased use of computed tomography or ultrasound imaging in the emergent setting decreases the risk of misdiagnosis and is also helpful to guide drainage interventions. However, it has been shown that delaying definitive surgery is associated with significant resource use, with increased imaging, drainage procedures, and additional admissions [21]. Although the increased use of technology, combined with improvements in antibiotics, makes conservative treatment more attractive and less risky from a misdiagnosis or treatment failure perspective, it highlights the awareness that must be placed on health care system resources.…”