Appendectomies Sometimes Can Wait, Even After Perforation
SAN FRANCISCO — A perforated appendix in a child need not mean an immediate appendectomy, Hanmin Lee, M.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.
Some clinicians say that some children do better by being sent home with IV antibiotics for a few weeks, followed by an elective appendectomy.
“It's thought by some folks that there are fewer operative complications overall, because you're dealing with a less angry appendix,” said Dr. Lee of UCSF. “Essentially, after 2 months it looks like a normal appendix, and the operation is very easy.”
Another argument for an “interval appendectomy” is that it may decrease total hospital time. An immediate appendectomy on a child with a perforated appendix typically means 2–3 weeks in the hospital. But if the child is treated in the hospital for several days with IV antibiotics and then sent home with a central line or a PIC (peripherally inserted catheter) line, the appendix may well quiet down.
After a couple of months the appendix will look normal, and the child may be able to go home the day after an elective appendectomy.
On the other hand, immediate surgery may involve less total sick time. With an interval appendectomy, “you're committing these kids to essentially 2 months of being kind of sick,” Dr. Lee said. “If you do an immediate appendectomy, they may be in the hospital for up to 2 or 3 weeks, but then they're usually cured of their disease. There may [also] be a slightly decreased incidence of overall complications.”
About a quarter of the patients fail in the interval, becoming sicker and losing their appetite, and they must be brought back in for immediate surgery.
Unfortunately, there have been no good prospective studies comparing interval appendectomy with immediate appendectomy, Dr. Lee said. But there are a number of clues indicating when a patient may do well to wait, and when he or she should get immediate surgery. A patient who has been diagnosed within 3 days of the onset of symptoms should be treated like one with acute appendicitis and should get immediate surgery. But it's possible that a patient diagnosed 4 days or more after symptom onset can wait.
A patient who appears to be doing well (no fever and able to eat) about a week after the onset of symptoms may have a well-formed, walled-off abscess that can be drained by an interventional radiologist. Such a patient may be a good candidate for interval appendectomy.
On the other hand, if the patient is sick with continued fever and anorexia, that's an indication that there's a diffuse process and that immediate appendectomy is warranted, Dr. Lee said.
