appendicitis management protocol echazarreta-gallego … · ultrasonography to detect acute...

APPENDICITIS

MANAGEMENT

PROTOCOL

Echazarreta-

Gallego et al.

Surgery Department Hospital Clínico Universitario de Zaragoza

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APPENDICITIS MANAGEMENT PROTOCOL Echazarreta-Gallego et al.

APPENDICITIS MANAGEMENT PROTOCOL

AUTHORS

Echazarreta-Gallego, Estíbaliz. MD

Elía-Guedea, Manuela. PhD

Córdoba-Díaz de Laspra, Elena. PhD

Ramírez-Rodríguez, Jose Manuel. PhD

Gracia-Solanas, Jose Antonio. PhD

Allué-Cabañuz, Marta. MD

Gascón-Domínguez, María de los Ángeles. MD

Millán-Gallizo, Guillermo. MD

Aguilella-Diago, Vicente. PhD

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INDEX

1. Introduction 1.2. HCUZ’S Situation

3 3

2. Protocol’s objectives

4

3. Care process. Diagram

6

4. Protocol development 4.1 Diagnosis 4.2 Treatment

7 7

9

5. Conclusions

17

6.Other references 17

7. Annexes 7.1 Alvarado Score 7.2 AIR Score 7.3 Diagram 7.4 Caprini Score Model 7.5 Apfel Score

18 18

18

19

20

20

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APPENDICITIS MANAGEMENT PROTOCOL

1. INTRODUCTION

Acute appendicitis (AA) is the most common cause of abdominal emergency surgery. The

lifetime risk of developing an AA is approximately 7% with an estimated incidence of 90-10

cases /100,000 inhabitants / year. It can occur in any decade of life, but it is more prevalent in

adolescents and young adults. Surgical management is not free of complications and these

strongly increase the morbidity associated with the process, being the most common:

incisional infection with rates ranging from 3.3-10.3% and organ space infections (9.4%). Today

there is great variability within the surgical management and outcome of AA based on: surgical

approach and technique applied, type of antibiotic used, duration of antibiotherapy, surgical

wound closure, etc. Kelmer1 in 2012 published in Annals of Surgery that the standardization of

cares can achieve significant results in terms of reducing surgical site infection, hospital stay

and patient comfort.

1.2. HCUZ’S SITUATION:

In order to evaluate the results of a common emergency surgical procedure and searching for

improvement areas, we carried out a retrospective review of all patients undergoing surgery

for AA between January 2013 and March 2015 in the Department of Surgery of HCUZ (n = 415).

Of the 415 appendectomy practiced during this period, 85 patients presented postoperative

adverse events (20.5%), being the most common the postoperative ileus in 31 patients (7.5%).

The rate of wound infection was of 4.8% with an incidence of intraabdominal abscess of 4.8%.

We observed an increased frequency of incisional infection in open appendectomy group (OA)

compared with laparoscopic appendectomy (LA) (2% vs 11.7%) being statistically significant (p

<0.000). There was no significant difference in the incidence of intra-abdominal abscess when

analyzing laparoscopic appendectomy (LA) 5.1% vs. open appendectomy (OA) 4.2% (p=0.692)

nor in the presence of ileus (7.8% vs 6.7). The average length of hospital stay in days was of

3.82 days (+/- 3,707).

Table 1: Subgroup analysis in relation to hospitalization (days):

Average length of stay in days: 3.82 (+/- 3,707)

Surgical approach

- Laparoscopic (LA)

- Open (OA)

3,75 days (+/-3,129)

4,01 days (+/-4,855)

Postoperative complications

- Yes

- No

7,49 days (±6,019)

2,88 days (±1,91)

Intraoperative findings

- Complicated appendicitis*

- No complicated appendicitis

5,45 days (+/-4,855)

2,39 days(+/- 1,369)

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* Complicated appendicitis included: gangrenous appendicitis, perforated appendicitis, appendicular “mass” or +/- presence of located or generalized peritonitis.

2. PROTOCOL’S OBJECTIVES

Currently, the goal of clinical practice include quality cares that improve patient`s safety. This

system is based on reducing to an acceptable minimum all the unnecessary procedures or

actions associated with health care that may cause harm. In this point the main aims of this

protocol are:

- Standardizing the management of a common clinical practice, adapting this protocol to

the evidence published in the literature.

- Improving clinical results by reducing postoperative complications. The percentage of

patients who presented complications was 20.5% (n = 85). The most frequent

complications were: postoperative ileus (n=31 patients, 7.5%), wound infection (n= 20,

4.8%) and intra-abdominal abscess (n= 20, 4.8%). Global data about surgical site

infection are similar to those reported in the literature, however if wound infection is

analyzed in specific subgroups we observed it was significantly more frequent (2% vs

11.7%) in the OA versus LA group (p <0.000). On the other hand there was no

significant difference (p 0.692) when analyzing the incidence of intra-abdominal

abscess depending on the surgical approach (5.1% LA vs 4.2% OA). At this point the

purpose of our guide is to reduce the rate of surgical wound infection and intra-

abdominal abscess by encouraging the use of the laparoscopic access and applying the

antibiotic prophylaxis recommendations established by our hospital PROA group.

- Improving length of hospital stay. The average stay is an indicator of effectiveness that

evaluates the time that the hospital needs to perform the diagnosis and treatment of

diseases. The average stay of our series was of 3.82 days (+/- 3.707). Comparing days

of hospitalization in the different subgroups described in table nº 1 we observed

higher hospitalization in OA (4.01 days +/- 4,855) vs 3.75 days +/- 3,129 in LA group;

we also found higher hospital stay in the group of patients who had suffered

postoperative complications (7.49 ± 6.019) vs does who had not undergone

postoperative complications (2.88 ± 1.91), and in those patients defined as

"complicated appendicitis" grouped in the intraoperative finding (5.45 +/- 4,855 days)

vs those described as "no complicated" (2.39 +/- 1.369 days). We consider this

parameter an important value of the clinical effectiveness, since complications and

adverse effects prolong the hospitalization.

In response to these issues, we propose three paths:

Early discharge within 24 hours that has proven to be safe and feasible if

adequate patient selection is made. We consider that this range of action will

benefit patients with non-complicated appendicitis and no comorbidities, even

though nowadays, some series describe a rapid discharged similar to an

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ambulatory process (<12h) with good results in terms of readmission and

morbidity2

Hospitalization increases with postoperative complications, so the

introduction of measures such as: optimization of the patient, appropriate

antibiotic treatment, laparoscopic approach etc. would decrease complications

resulting in a reduction of stay.

In our series comparing with the literature, there was a high rate of AA defined

as complicated appendicitis that is directly related with a longer

hospitalization rate. Another purpose for the implementation of this protocol

is to adequate timings and medical care, decreasing the interval from the

evaluation of the patient to diagnosis by trained personnel at the emergency

department, offering early consultation with the surgical team on guard that

should be prepared to apply a suitable surgical care.

Another parameter we think should be considered to evaluate the quality of care is the costs

of the process. Appendectomy is a surgical procedure with an average cost of 3.106,00€

(SALUD INFORMA). Each day of hospitalization represents 685,00€, a specialized care

consultation 49,00€ and consultation in the emergency department 136,00€. In our series 330

patients (79.5%) showed no postoperative complications with 2.88 (± 1.91) hospitalization

days, in this group of patients, globally 424,974€ could be save, considering a 24 hours

reduction stay. On the other side, it is well known that postoperative complications increases

health spending. So surgical site infection or intaabdominal infection involves additional costs

resulting local treatment, antibiotics, prolonged hospital stay and/or requiring in some cases

reoperation.

Many factors contribute in the pathogenesis of adverse events, some of which are hard-coded

(comorbidities, age, time between beginning of process and consultation), but it is also well

known that many others could contribute to improve a safer clinical practice reducing costs

when applying adequate corrective actions or improvement areas.

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3. CARE PROCESS. DIAGRAM

TIME ACTION RELATED

PERSONNAL

Diagnosis

History and examination + analysis.

- Consider imagining (US or CT)

Patient information and consent form.

Surgeon

Emergency department

Management strategy

- Preoperative period

- Intraoperative period

Antibiotic prophylaxis

Hair removal

Consider thromboembolism prophylaxis on high risk patients. Skin preparation and operative field

Normothermia

Blood glucose

Surgical approach: laparoscopic vs open

- Laparoscopic surgery - Open surgery

Peritonal fluid cultures

Antibiotic prophylaxis dosage repeat during surgery

Irrigation and aspiration of the operation field (OA + AL).

Drains

Local anesthesic infiltration: laparoscopic ports/Abdominal external oblique fascia (OA).

Surgeon

Nurse

Postoperative period

•Oxigenoterapy

•Postoperative antibiotics

•Oral intake

•Analgesia

•Early mobilization

•Thromboembolism prophylaxis

•Respiratory physiotherapy

•Nausea and vomiting treatment. Ileus

Surgeon

Nurse

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prophylaxis

Discharged •Depending on severity:

- Non complicated: 24 h - Complicated appendicitis: once

they tolerate a regular diet and there is no other complication

•Offer care instruction

•Surgical postoperative consultation

appointment

4. PROTOCOL DEVELOPMENT

4.1 Diagnosis

The ideal diagnostic method for appendicitis, which offers high accuracy while avoiding

adverse effects (radiation), has not been achieved yet despite the variety of available tools.

The percentage of negative appendectomies was located historically in the 15% having

reduced to 10% after the introduction of computed tomography (CT) in the diagnosis.

o Physical examination: throughout history, there have been described numerous clinical

signs associated with AA that facilitate the diagnostic, however they lack adequate

sensitivity and specificity.

o Blood analysis: No analytical marker has a sensitivity and specificity adequate to confirm

the diagnosis. The moderate increase of leukocytes with left shift is the most common

finding, present in 80% of patients. Other markers of acute inflammation such as C-

reactive protein CRP or procalcitonin PCT may be useful. It is recommended to perform a

pregnancy test in the differential diagnosis in all women of childbearing age.

o Risk scales: these scales combine different parameters trying to get a more accurate

diagnosis. Among the most widely used scale is Alvarado (Annex 1), several studies have

demonstrated a high sensitivity but low specificity. The latest AIR score (Appendicitis

Inflammatory Response) (Annex 2) has greater precision than the scale of Alvarado.

o Ultrasound: the data that best relates to AA is an image of cecal appendix > 6 mm. The US

in the diagnosis of AA has moderate sensitivity (86%- 95%, CI 83-88) and specificity (81%,

CI 78-84).

Kollar D, McCartan DP, Bourke M, Cross KS, Dowdall J. Predicting acute appendicitis? A comparison of the Alvarado score, the appendicitis inflammatory response score and clinical assessment. World J Surg 2015; 39: 104–09

Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 2004;141: 537–46.

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o TC: image findings suggestive of acute appendicitis is appendiceal thickening greater than

6 mm and / or occlusion of light, appendiceal wall thickening, rarefaction of

periappendiceal fat appendicolith presence (25% of patients). The sensitivity of this

imaging test is 93%.

In this diagram we propose the attitude for diagnostic and therapeutic management in

patients having pain in right lower quadrant. (Annex 3)

PATIENT INFORMATION

Once established the indication for surgery the patient must be informed of the treatment

options available and the possible risks arising. The information provided must be adapted to

the characteristics of the patient.

4.2 TREATMENT

Appendectomy remains the gold standard treatment of appendicitis approved in all clinical

guidelines and recommended by the American College of Surgeons, the Association of

Digestive Tract Surgery and the World Society of Emergency Surgery. The alternative non-

operative approach (conservative antibiotic treatment) has been studied in detail in many

meta-analyzes and systematic reviews, including Cochrane 2011, whose authors concluded

that appendectomy remains the standard treatment and antibiotic treatment would be

relegated to patients or specific conditions in which the surgery is contraindicated.

4.2.1 Preoperative period

4.2.1.1 Antibiotic prophylaxis

Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015 Sep 26;386(10000):1278-87. doi: 10.1016/S0140-6736(15)00275-5.

Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 2007;94:224-31

- Sartelli M, Viale P, Catena F, Ansaloni L, Moore E, Malangoni M, Moore FA, Velmahos G, Coimbra R, Ivatury R, Peitzman A, Koike K, Leppaniemi A, Biffl W, Burlew CC, Balogh ZJ, Boffard K, Bendinelli C, Gupta S, Kluger Y, Agresta F, Di Saverio S, Wani I, Escalona A, Ordonez C, Fraga GP, Junior GA, Bala M, Cui Y, Marwah S, Sakakushev B, Kong V, Naidoo N, Ahmed A, Abbas A, Guercioni G, Vettoretto N, Díaz-Nieto R, Gerych I, TranàC, Faro MP, Yuan KC, Kok KY, Mefire AC, Lee JG, Hong SK, Ghnnam W, Siribumrungwong B, Sato N, Murata K, Irahara T, Coccolini F, Segovia Lohse HA, Verni A, Shoko T. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2013;8(1):3. Epub 2013 Jan 8.

- Flum DR. Clinical practice. Acute appendicitis--appendectomy or the "antibiotics first" strategy. Engl J Med. 2015 May;372(20):1937-43

- Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008359. doi: 10.1002/14651858.CD008359.pub2.

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The administration of prophylactic antibiotics is critical in the prevention of surgical wound

infection and intra-abdominal abscess3. The most common flora in this pathology is the enteric

gram-negative bacilli, anaerobes and enterococci (E. coli, Kleibsiella, Proteus and Bacteroides).

We recommend the following instructions:

* Risk criteria for E. coli or Klebsiella ESBL spp productor: severe / shock sepsis, previous use of quinolones or cephalosporins,

repetive urinary tract infection, urinary catheter, diabetes mellitus

The Cochrane systematic review on "Antibiotic treatment vs placebo in the prevention of

infection postappendectomy" concluded that:

a) Antibiotic prophylaxis in the prevention of postoperative complications in appendectomy is

effective if it is administered pre, per or postoperatively. It should be considered for routine

use in emergency appendectomy.

b) The results of the meta-analysis showed that a single antibiotic dose has the same impact as

multiple doses. In order to reduce costs, toxicity and the risk of developing bacterial resistance

it is desirable to establish the shortest and effective prophylactic regimen to prevent

postoperative complications.

c) In patients in whom perforated appendicitis is suspected, empirical antibiotic treatment will

be administrated following the above recommendations and it must be adjusted if necessary

to culture results.

4.2.1.3 Time intervention

According to the latest "Up to date" recommendation published, once the diagnosis of

appendicitis is established early surgery should be advised in order to prevent progression to

perforation. Prior to surgery, hydration fluid must be provided, and electrolyte disturbances

should be corrected.

Daskalakis K, Juhlin C, Påhlman L. The use of pre- or postoperative antibiotics in surgery for appendicitis: a systematic review. Scand J Surg. 2014 Mar;103(1):14-20. doi: 10.1177/1457496913497433. Epub 2013 Sep 20.

Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of

postoperative infection after appendicectomy. Cochrane Data base Syst Rev. 2005 Jul

20;(3):CD001439.

Papandria D, Goldstein SD, Rhee D, et al. Risk of perforation increases with delay in recognition

and surgery for acuteappendicitis. J Surg Res 2013;184:723—9.

Amoxicillin-clavulanate 2gr ev 5 min (before surgery)

Risk of ESBL*: ertapenem ev 1g

Allergic patients: Clindamicine 600 mg + Gentamicine 2 mg/kg (30 min before anhestesic induction).

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However, some epidemiological studies have found no correlation between a delay of 6-12

hours from the time of hospital admission and surgery with the rate of perforation and / or

postoperative complications.

4.2.1.3 Hair Removal

Hair removal has not been shown to reduce the incidence of surgical infections. In cases where

necessary, clippers are recommended instead of conventional shaving.

4.2.2 INTRAOPERATIVE

4.2.2.1 Preparation of the skin and surgical field

Skin antisepsis must be made in concentric circles around surgical incision with chlorhexidine-

alcohol 1% solution

It is recommended to make skin antisepsis with an agent that contains alcohol unless there is a

contraindication. Alcohol is a powerful bactericide, effective in skin antisepsis but not if used

alone. It could be achieved a quick, effective and cumulative antisepsis in combination with

clorehixidine or iodine-solution.

4.2.2.2 Normothermia

Ingraham AM, Cohen ME, Bilimoria KY, et al. Effect of delay tooperation on outcomes in adults

with acute appendicitis. Arch Surg 2010;145:886—92.

Drake FT, Mottey NE, Farrokhi ET. Time to appendectomy and risk of perforation in acute

appendicitis. JAMA Surg2014;149:837—44.

Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004122.

Lefebvre A, Saliou P, Lucet JC, Mimoz O, Keita-Perse O, Grandbastien B, Bruyère F, Boisrenoult P, Lepelletier D, Aho-Glélé LS; French study group for the preoperative prevention of surgical site infections. Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials. J Hosp Infect. 2015 Oct;91(2):100-8. doi: 10.1016/j.jhin.2015.06.020. Epub 2015 Aug 4.

.

Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for

preventing surgical wound infections after clean surgery.Cochrane DatabaseSyst Rev. 2013 Mar

28;3:CD003949. doi: 10.1002/14651858.CD003949.pub3.

Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, Nyquist AC,

Saiman L, Yokoe DS, Maragakis LL, Kaye KS. Strategies to prevent surgical site infections in acute

care hospitals: 2014 update. Infect Control HospEpidemiol. 2014 Jun;35(6):605-27. doi:

10.1086/676022.

Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS,

Crosby CT, Mosier MC, Alsharif A, Berger DH Chlorhexidine-Alcohol versus Povidone-Iodine for

Surgical-Site Antisepsis. N Engl J Med. 2010 Jan 7;362(1):18-26. doi: 10.1056/NEJMoa0810988.

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Normothermia reduces some surgery related complications as intraoperative bleeding or SSI

(surgical site infection), decreasing the hospital stay. Hypothermia impairs the action of

neutrophils and causes subcutaneous tissue vasoconstriction and hypoxia. All these facts could

increase blood loss, the development of bruising in the wound, aspects that increase the rate

of SSI. The use of warming devices is recommended to prevent hypothermia.

4.2.2.3 Glycaemia

Postoperative hyperglycemia increases complications rate. During surgery, blood glucose

should be monitored. The maintenance of normoglycemia has a positive outcome in the

postoperative period. The goal of treatment of postoperative hyperglycemia in diabetic

patients is not formally defined, however values below 110 mg / dl or greater than 150 mg / dl

seem to be detrimental and should be avoided.

4.2.2.4 Technique

Laparoscopic vs open approach

The laparoscopic approach (LA) has gradually increased in recent years. The latest Cochrane

review published in 2010 concluded that laparoscopy offers advantages over open surgery

(OA) if the clinical circumstances, surgical team and proper equipment is available. The use of

laparoscopy is especially recommended for young women, obese and active workers.

There have also been observed advantages with the LA in elderly population. Harrel

(observational cohort) described in uncomplicated appendicitis a lower hospital stay (4.6

versus 7.3 days), less requirement of intermediate care (91 versus 79%), less complications (13

versus 22%) and lower mortality (0.4 versus 2.1%) in the laparoscopy group compared with

OA. He also described in the group of patients with perforated appendicitis treated by LA a

Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, Nyquist AC, Saiman L,

Yokoe DS, Maragakis LL, Kaye KS. Strategies to prevent surgical site infections in acute care hospitals:

2014 update. Infect Control HospEpidemiol. 2014 Jun;35(6):605-27. doi: 10.1086/676022.

Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound

infection after clean surgery: a randomised controlled trial. Lancet. 2001 Sep 15;358(9285):876-80.

Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ.Randomized clinical trial of perioperative systemic

warming in major elective abdominal surgery. Br J Surg 2007;94(4):421-6198.

Sajid MS, Shakir AJ, Khatri K, Baig MK.The role of perioperative warming in surgery: a Systematic

Review. Sao Paulo Med J 2009;127(4):231-7200.

Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected

appendicitis. Cochrane Data base Syst Rev. 2010 Oct 6;(10): CD001546. doi:

10.1002/14651858.CD001546.pub3.

Harrell AG, Lincourt AE, Novitsky YW, Rosen MJ, Kuwada TS, Kercher KW, Sing RF, Heniford BT.

Advantages of laparoscopic appendectomy in the elderly. Am Surg. 2006 Jun;72(6):474-80.

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decreased hospital stay (6.8 versus 9.0 days) a lower rate of intermediate care when discharge

home (87 versus 71% ) with equivalent rates of mortality when compared to OA.

Laparoscopic approach

The patient is placed supine on the operating table with his left arm positioned along the body.

The monitor is located on the right side of the patient.

- Placement of ports: there are several options but all of them must respect the principle of

triangulation of instruments and appendix. One method is to place a 12 mm periumbilical port

and two-port of 5 mm in left lower quadrant and suprapubic midline. For retrocecale

appendicitis better exposure is achieved by situating a 5mm trocar in the epigastric region.

- Mobilization and resection:

After identifying the appendix, adhesions if necessary are released and the structure is

continued until its insertion in the cecal base. It is then identified the appendiceal artery and

sectioned by hemoclips, coagulation or stapler (GIA). In case of using the stapler for

mesoappendix ligation, a single reload including mesoappendix and appendix must be used

whenever possible.

The method for closing and transecting the appendix stump depends on the intraoperative

findings and experience of the surgeon. The use of endoloops has demonstrated safe results

comparable to the endo-stapler in observational studies.

Evaluating the effectiveness cost, the use of endoloops or clips is recommended in single

appendicecal inflammation conditions with appendicular based less than 16 mm. If there is

inflammation of the base of the cecum it is advisable to employ endo-stapler.

- Removing the surgical specimen in bag

It is recommend to extract the surgical specimen in a plastic bag to prevent contamination of

the surgical wound trocar.

Open approach

- A curvilinear incision on McBurney point in the outer third of the line between the superior

iliac spine and the navel is recommended. Some authors recommend a transverse incision,

easily to extend. It is recommended to examine the patient after anesthetic induction and if

Galatioto C, Guadagni S, Zocco G, Mazzilo M, Bagnato C, Lippolis PV, Seccia M. Mesoappendix and appendix stump treatment in laparoscopic appendectomy: a retrospective study in 1084 patients. Ann Ital Chir. 2013 May-Jun;84(3):269-74.

Sahm M, Kube R, Schmidt S, Ritter C, Pross M, Lippert H. Current analysis of endoloops in appendiceal stump closure. SurgEndosc. 2011 Jan;25(1):124-9. doi: 10.1007/s00464-010-1144-5. Epub 2010 Jun 15.

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any palpable mass corresponded to the inflammatory process appendicular incision must be

done above that mass.

- Mobilization and resection: after dissection of the subcutaneous tissue, longitudinally

sectioned external oblique fascia and muscle fibers are splitted to expose the peritoneum,

which is elevated prior section to prevent intestinal damage. The appendix is located, the

mesoappendix dissected and sectioned after making a ligature with an absorbable suture 3/0.

The cecal appendix is cut with a scalpel and the stump tied with a 2/0 absorbable suture stump

mucosa is coagulated with electrocautery. The appendiceal stump is inverted into the cecal

base with a purse string suture.

- Closure of surgical wound is performed by planes with a continuous 2/0 absorbable suture.

Wash-saline irrigation of each plane is performed and primary closure of the wound with

subcuticular sutures or staples are recommended.

4.2.2.5 Peritoneal fluid cultures

Taking peritoneal fluid cultures systematically in each intervention is controversial. It is

advisable to take in patients in whom there is a risk of ESBL or a possibility of failure of focus

control. However, in our hospital, we propose peritoneal fluid culture to identify the

responsible local flora and arrange epidemiological study.

4.2.2.6 Re-dosing antibiotic if necessary.

Although it is unusual in this type of intervention, it is recommended to re-dose if time exceed

twice the average life of the antibiotic or excessive blood loss occurs.

4.2.2.7 Irrigation and aspiration operative field

Irrigation / aspiration of the surgical field with saline solution is recommended in both open

and laparoscopic appendectomy. Volume of irrigation will be in relation with the degree of

peritonitis.

4.2.2.8 Drains

The use of drains is not recommended because they have not shown to decrease the rate of

wound infection and intra-abdominal abscess, increasing the length of hospital stay.

Soffer D, Zait S, Klausner J, Kluger Y. Peritoneal cultures and antibiotic treatment in patients with

perforated appendicitis. Eur J Surg. 2001 Mar;167(3):214-6.

Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, Nyquist AC,

Saiman L, Yokoe DS, Maragakis LL, Kaye KS. Strategies to prevent surgical site infections in acute

care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. doi:

10.1086/676022..

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4.2.2.3 Infiltration with local anesthetic

Although the studies are very heterogeneous it is convenient to infiltrate laparoscopic ports or

external oblique fascia in order to reduce the need for postoperative analgesia.

4.2.3 POSTOPERATIVE

4.2.3.1 Oxygen therapy

It is suggested to maintain adequate oxygen saturation. Infection of surgical wound is favored

in an atmosphere with low oxygen concentrations due to decreased microvascular flow that

alters the leukocyte function. Some studies have postulated that increasing the fraction of

inspired oxygen might improve neutrophil function by decreasing the incidence of surgical

wound infection.

4.2.3.2 Postoperative antibiotic

• The use of postoperative antibiotics on uncomplicated appendicitis is NOT suitable.

Uncomplicated cases of appendicitis are considered contaminated clean-surgery when the

infection site is removed, and therefore only require prophylaxis. Prolongation of antibiotic

Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic

drainage in gastrointestinal surgery: a systematic review and meta-analyses. Ann Surg. 2004

Dec;240(6):1074-84; discussion 1084-5.

Cheng Y, Zhou S, Zhou R, Lu J, Wu S, Xiong X, Ye H, Lin Y, Wu T, Cheng N. Abdominal drainage to

prevent intra-peritoneal abscess after open appendectomy for complicated

appendicitis.Cochrane DatabaseSyst Rev. 2015 Feb 7;2:CD010168. doi:

10.1002/14651858.CD010168.pub2.

Joshi GP, Bonnet F, Kehlet H; PROSPECT collaboration.Evidence-based postoperative pain

management after laparoscopic colorectal surgery. Colorectal Dis. 2013 Feb;15(2):146-55. doi:

10.1111/j.1463-1318.2012.03062.x.

Ventham NT1, O'Neill S, Johns N, Brady RR, Fearon KC. Evaluation of novel local anesthetic

wound infiltration techniques for postoperative pain following colorectal resection surgery: a

meta-analysis. Dis Colon Rectum. 2014 Feb;57(2):237-50. doi: 10.1097/DCR.0000000000000006.

Vía Clínica de Recuperación Intensificada en Cirugía Abdominal (RICA). Grupo de Trabajo de la

Vía Clínica de Recuperación Intensificada en Cirugía Abdominal (RICA). Noviembre 2014.

Ministerio de Sanidad, Servicios Sociales e Igualdad/Instituto Aragonés de Ciencias de la Salud

Gottrup F. Oxygen in wound healing and infection. World J Surg. 2004 Mar;28(3):312-5. Epub

2004 Feb 17.

Hovaguimian F, Lysakowski C, Elia N, Tramèr MR. Effect of intraoperative high inspired oxygen

fraction on surgical site infection, postoperative nausea and vomiting, and pulmonary function:

systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2013

Aug;119(2):303-16. doi: 10.1097/ALN.0b013e31829aaff4.

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treatment has not proven useful in preventing the onset of SSI and it may instead promote the

development of resistant microorganism and adverse effects such as diarrhea by antibiotics.

• In complicated appendicitis it is appropriated to extend the empirical antibiotic treatment

administration for 5 days. The Clinical Antibiotic Treatment Guide of our Hospital (HCUZ)

recommends the following administration:

The administration can be oral when

- Clinical syndrome is controlled and tolerance is present.

- The antimicrobial must have good oral bioavailability.

4.2.3.3 Diet

In patients with uncomplicated appendicitis diet might be started 6-8 hours after surgery.

Patients with peritonitis often associate postoperative ileus. Ileus is a temporary deficiency (at

least three days) of intestinal motility characterized by abdominal distension, absent bowel

sounds, accumulation of gas and liquid in bowel and delayed expulsion of flatus and

defecation. The only drug that has proven useful in the management of this adverse event is

the Almipovan (opioid antagonist), provided they are involved in the etiopathogenesis opiates.

In these patients the start of the diet is recommended when the intestinal motility is secured.

Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of

postoperative infection after appendicectomy.Cochrane DatabaseSyst Rev. 2005 Jul

20;(3):CD001439.

Asociación Española de Cirujanos. Recomendaciones programa “Compromiso por la Calidad de

las Sociedades Científicas en España”. Ministerio de Sanidad, Servicios Sociales e Igualdad.

http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/pdf/ASOCIACION_ESP_CIRUJANOS_0

K.pdf

Coakley BA, Sussman ES, Wolfson TS, Bhagavath AS, Choi JJ, Ranasinghe NE, Lynn ET, Divino CM.

Postoperative antibiotics correlate with worse outcomes after appendectomy for nonperforated

appendicitis. J Am Coll Surg. 2011 Dec;213(6):778-83. doi: 10.1016/j.jamcollsurg.2011.08.018.

Epub 2011 Sep 29.

- Amoxicillin Clavulanate 1 g/8 h or (Cefotaxime 1 gr/8 h + metronidazole 500 mg/8 h) +/- gentamicine 5 mg/kg/day or amikacin 15 mg/kg/day

- Risk of ESBLs ESBL spp productor: severe / shock sepsis, previous use of quinolones or cephalosporins, repetive urinary tract infection, urinary catheter, diabetes mellitus: Ertapenem 1 gr/24 h ev

- Penicillin alergic: aztreonam 1 gr/ 8 h + metronidazole 500 mg/8h or tigecicline 100 mg 1 dose followed by 50 mg/12 h

http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/pdf/ASOCIACION_ESP_CIRUJANOS_0K.pdf

http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/pdf/ASOCIACION_ESP_CIRUJANOS_0K.pdf

16


4.2.3.4 Analgesia

Postsurgical analgesia intravenous regimen based on Paracetamol + NSAIDs. Promote the

employ of visual analog scale

4.2.3.5 Early mobilization

Immobilization after surgery is related to the occurrence of cardiovascular, respiratory and

thromboembolic complications and therefore prolonged hospital stay. Early mobilization has

been related with reduction of these complications and hospitalization time. Mobilization of

the patient is recommended after the first six hours postoperative.

4.2.3.6 Thromboembolic prophylaxis

The risk of postoperative deep vein thrombosis is not unifactorial. Its development is

influenced by patients intrinsic factors such as history, comorbidities etc. and others from the

surgical procedure itself. Despite many attempts to quantify this risk, there is no universal

method accepted. Caprini modified scale (Annex 4) was established by the guide ACCP11 in

2012 to build the risk of postoperative thromboembolic events.

Early mobilization is mandatory for patients with very low risk (Caprini 0). For low-risk (Caprini

1-2) mechanical prophylaxis with pneumatic compression stockings is prescribed. If the risk is

moderate (Caprini 3-4) the recommendation is based in the use of low molecular weight

heparins. When the risk is high (Caprini equal to or greater than 5) the use of low molecular

weight heparins with elastic stockings or mechanical compression is suggested.

4.2.3.7 Treatment of nausea and vomiting

Prophylaxis of nausea and vomiting during surgery should be performed after individual

evaluation with Apfel scale (Annex 5). If the patient has received prophylaxis, treatment should

begin with a different antiemetic drug from the initial one. If the patient has not required any

antiemetic drug, treatment might be started with low dose of ondansetron.

4.2.4 Discharge

Douglas Smink, David I Soybel.Management of acute appendicitis in adults. Uptodate

2015.www.uptodate.com

Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA; Collaborative LAFA Study

Group. Which fast-track elements predict early recovery after colon cancer surgery? Colorectal

Dis. 2012;14(8):1001-8.

Henriksen MG, et al., Enforced mobilization,early oral feeding, and balanced analgesia improve

convalescence after colorectal surgery. Nutrition 2002;18(2):147-52

Kazemi-Kjellberg F, Henzi I, Tramèr MR. Treatment of established postoperative nausea and

vomiting: a quantitative systematic review. BMC Anesthesiol 2001;1:2-12

http://www.uptodate.com/

17


5. CONCLUSION

For uncomplicated appendicitis it is recommended early discharge within 24 hours if no signs

of complication or no presence of comorbidities that could contraindicated it. In complicated

appendicitis discharge will vary depending on the patient's progress and the presence of

adverse events, but in all cases it should be proved the restoration of intestinal transit and the

absence of signs of complication.

Patients at discharge should be informed of the care to be followed at home and monitoring

which are having and will be needing in next days. Adequate information, favored by the

development of standardized documents, reduces the readmission rate and increases patient

satisfaction.

6. OTHER REFERENCES

1. Helmer KS1, EK Robinson, Lally KP, JC Vasquez, KL Kwong, TH Liu, DW Mercer. Standardized

patient care guidelines reduce infectious morbidity in patients appendectomy. Am J Surg. 2002

Jun; 183 (6): 608-13.

2. Genser L, Vons C. abdominal surgical emergencies Can be Treated in an ambulatory setting?

Visc J Surg. 27. October 2015 PII: S1878-7886 (15) 00122-8. doi: 10.1016 /

j.jviscsurg.2015.09.015. [Epub ahead of print]

3. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement

projects: National Initiatives to Improve outcomes for patients Having surgery. Clin Infect Dis.

2006; 43 (3): 322.

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7. ANNEXED

7.1 Alvarado Score

Symptoms Scores

Migratory/right iliac fossa pain 1

Nausea/Vomiting 1

Anorexia 1

Signs

Tenderness in right iliac fossa 2

Rebound tenderness in right iliac fossa

1

Elevated temperature 1

Laboratory findings

Leucocytosis 2

Shift to the left of neutrophils 1

Total 10 5-6: Possible 7-8: Probable >9 Very probable

7.2 APPENDICITIS INFLAMMATORY RESPONSE (AIR) SCORE

Vomiting 1

Pain in right iliac fossa 1

Rebound tenderness or muscular defense Light Medium Strong

1 2 3

Body temperature > 38,5 1

Polymorphonuclear leucocytes 70-84% > 85%

1 2

WBC count >10.0-14.9 x 109/l >15 x 109 /l

1 2

CRP concentration 10-49 g/l >50 g/l

1 2

Total score 12

19


7.3 DIAGRAM THERAPEUTIC DIAGNOSIS

20


7.4 CAPRINI SCORE MODEL

Each risk factor represent 1 point Age 41-60 Minor surgery Obesity IMC >25 Swollen legs (current) Varicose veins Sepsis (<1 month) Serious lung disease including pneumonia (< 1 month) Abnormal pulmonary function (COPD) Acute myocardial infarction Congestive heart failure (<1 month) History of inflammatory bowel disease Medical patient currently at bed rest

Each risk factor represents 1 point (only women) Oral contraceptives or hormone replacement therapy Pregnancy or postpartum (< 1 month) History of unexplained stillborn infant , recurrent spontaneous abortion (>3), premature birth with toxemia or growth-restricted infant

Each risk factor represents 2 points Age 61 -74 years Arthroscopic surgery Major surgery (>45 min) Laparoscopic surgery (>45 min) Malignancy (present or previous) Patient confined to bed (> 72 hours) Cental venous access Plaster cast (< 1 month)

Risk level Points

Very low 0

Low 1-2

Moderate 3-4

High > 4

7.5 APFEL SCORE

Risk fastor

Female gender 1

Nonsmoker 1

History of PONV or motion sickness 1

Use of opioids > 100 mcg fentanyl or equivalent

1 Low risk 0 or 1 Moderate risk 2 High 3 or 4

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