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.

Fig. 1

This operative photograph, taken at the time of laparoscopic interval appendectomy, shows that the appendix (dotted arrow) is completely disconnected from the cecum (solid arrow). Such a finding emphasizes the need for interval appendectomy in patients initially treated nonoperatively.