While surgery cures an inflamed appendix, some children do well on medical management. This case-based presentation by pediatric surgeon Aaron R. Jensen, MD, MEd, MS, clarifies which patients are candidates for nonoperative plans, factors in the decision-making process, and the pluses and minuses of delaying surgery – or not doing it at all.
So I sort of look at this is sort of a sort of tell all, you know, what's the dirt on not not management of appendicitis. Kind of like those shows that we see the reality shows where they have their tell all show after the glitz and the glamour of the real show. Um I think that none of the management sounds quite attractive, but I think that there are some problems with it and I think there are some benefits that we've really learned about with our experience with this. Um So first of all I have no disclosures. I do get some money from the government to study trauma care and rural and critical access hospitals. But none of that is relevant to our lecture here today and objectives. So I think really my objective is for everybody to understand the inner workings of the surgeons mind. Try to figure out why is it that we do not management? Why is it that sometimes we do an interval appendectomy, Sometimes we don't Why is it that we operate on certain patients for other patients? We don't try to give you some guidance as to what is the decision making that we have. So that when you see your patients back in the office and they have questions about non operative management, that you might be able to help guide them if they're looking to you for additional guidance when they're following up with you. So the real goals are to describe, what are the evidence based indications for non operative management of appendicitis? So what patients are good candidates for this describe some of the evidence based indications for interval appendectomy. So an interval appendectomy is appendectomy that we do six weeks later, 6 to 8 weeks later to prevent the appendicitis from happening again. So treat them non operatively and then bring them back in 6 to 8 weeks to remove the appendix so they never get appendicitis again. So who should get that? Who shouldn't, what's the evidence behind that? And then finally talk about risk factors that are associated with high recurrence rates of non out management and how some barriers in access to care might impact who you refer for interval appendectomy and when that might actually get done. I've tried to make this interactive, I have not used the polling function with this particular app but Tabatha is going to help us out with that. So throughout the talk I'm gonna have some interactive questions. Um There's no great at the end, don't worry. Um I'm really just looking for opinions and what people have seen and what you guys, how you guys might manage some of these patients um and really to try to maintain engagement throughout the talk. So we'll start for the case. I think cases are always a good way to start. Um I called appendicitis 101 So we have a 12 year old boy who was referred to the E. D. From their primary care providers office because he's got abdominal pain. He woke up in the middle of the night with pain but it wasn't so bad. He went back to sleep but when he woke up early that morning which was actually a little earlier than this 12 year old generally wakes up. It had moved to his right lower quadrant. Now it's pretty severe. He's got nausea but no vomiting and moms out of slurpee might make him feel better. So they stopped at 7 11 and he mixed all the flavors up in a cup and drink. It didn't help his pain. He's got no fevers, no diarrhea he put before he went to bed last night, everything was normal. He really just has this pain and a little bit of nausea that's bothering you. The er was very kind and got us a white count which was 13. You can see a dilated appendix over here. Um eight non compressible. So classic ultrasound for for a simple non perforated appendicitis. It's almost as if he read the book. Perfect case of appendicitis. So here's our first polling question. Let's try this out. So what should we do for this kid who's got classic simple appendicitis. So Tabatha do you want to start the first poll? I'm not seeing the poll on my screen. There we go and see it. Okay cool so pick one. Should he have laparoscopic appendectomy or should he be treated with I. V. Antibiotics and sent home with oral antibiotics? Cool So 57% say Nah not management. Um and 43% say laparoscopic appendectomy for a simple appendicitis. I like it perfect. Um So this is great. This is a kid who had no fecal it and I actually think that's a pretty reasonable approach. So now I have to restart my slides. This is going to be interesting. So let's talk about that. So I think um here we go for a simple appendicitis. The classic example of the classic teaching and what we've done for decades is laparoscopic appendectomy. So this kid actually did get a laparoscopic appendectomy but I do think he would have been a good candidate for no not management. Um He went to the same day the O. R. Flaps topic appendectomy. Three little five millimeter incisions. Um And you can see I've drawn a little blue line where I put my incisions. I put my third incision a lot lower than is shown in this picture because it's nice to hide them all below the belt line so that you don't have any visible scars when you want to wear a midriff baring shirt. Um But he went that data to the or has appendix out about an hour. He spent our impact. You he went home, we prescribe him some oxyCODONE. He only took four pills mostly at night to take him to sleep. And most kids don't even need that. They just use Tylenol Motrin and some ice packs. And he actually returned to zoom school on post op day two and I saw him back the assumed two weeks later and he's completely cured and he has no further symptoms. So this I think is, you know, sort of the classic surgical disease were the only way that cures with stone cold steel In the 21st century modification of the old surgical adages. Well, nowadays we actually use some plastic show cars and a scope, but this kid's cured. He's not gonna have any recurrence. Mom doesn't have to worry about him getting appendicitis. Again, he didn't spend a single night in the hospital. He had an outpatient operation and he's doing well. So this is really why I went into surgery because its curative kids get better. Don't have to worry about it. It's a very, very straightforward operation with a very safe risk profile. Um, and you know, this is sort of what we've done forever, but what if we could give him some magnet in and say call me back in the morning. Um, and see how things are going and we don't have to do surgery at all. So I'm just curious for the attendees. How many who are joining us and I have seen patients back in their office that have been on actively managed for appendicitis. And we can go to poll number two, Yep. Probably can close it. I'm expecting this to be pretty high in terms of who's actually seen on up patients in their practice. 50 50. Okay, so about half of you. Um so this has become and I'll show you some data about how popular this sort of became about five years ago and it's become more and more popular. Second question is, if they do come back to see you say they come back and maybe they moved from Los Angeles uh And they're coming back to your practice and now they're completely asymptomatic. They were treated with antibiotics let's say 4-6 months ago and they have relocated to the Bay area. They were supposed to follow up with the surgeon in L. A. But they didn't. And now they're here just to establish primary care in your office. Do you think they should be referred to a surgeon if they're now currently asymptomatic in 4-6 months out foreign and local connect to me or can we just let them be and see if their symptoms come back? So let's open the polling again to have a should they see a surgeon? Should they not see a surgeon? All right. 5050. This is good. We picked a good topic tonight. That means everything is controversial and there's no clear answers. Perfect. All right. So let's talk about that. Should they see a surgeon? Should they not see a surgeon? Let me see if I can pull my slides back up and all right. So let's talk a little bit about non management where this started, where it's going. What are some of the ups and downs of it? So, it actually started with the navy? And this is the first paper that I could find written about in 1964, published in um military medicine about conservative management or antibiotics alone for sailors on submarines. So imagine you're a sailor on a submarine that gets appendicitis and they don't have an anesthesiologist. They don't really have an operating room, but they're going to take your appendix out with you awake. As you can imagine, that probably isn't going to end. Well, this has tried a few times on submarines and the outcomes were not very good. And then the Navy realized that they could just give antibiotics. And many of these sailors would just get better with antibiotics alone. Some of them wouldn't get better, but they would develop pelvic abscesses that could easily be drained trans directly. and and there's actually no pain fibers there. So it's not a very painful procedure to have a trans rectal drainage. Um And they were able to manage these kids without surfacing their subs. And several months later when they came back to port these sailors would be referred to a surgeon to have their appendix removed to have it to prevent it from happening again. So initially described a long time ago in the military And really didn't get all that popular until fast forward until 1998. So this is a plot That shows in the blue line is the traditional operative management. So this is rates of operative management of appendicitis. And you can see it however, sort of between 94 and 96% for years and years and years and down below the green. And the red lines are not management either with or without interval appendectomy. And you can see that these rates were very similar for a long period of time, and then 2014 rolls around. And we see there's a big drop off inoperative rates and you can start to see that non operative management without an interval appendectomy became much more popular. And non operative management Uh with an interval, interval appendectomy stayed pretty constant. So this really got popular uh sort of between 2010, and rates continue to rise. And and this is when we really started to understand the top management of appendicitis. So what are the upsides? What are the downsides? What are the problems? And actually the enthusiasm behind non up management Has sort of waxed and waned in the last 3-4 years and I think it's on the downturn right now, it might pick up again in the future. Um But we're learning a lot about management as we accumulate more patients. So um let's talk about why we might do not management versus operative management. So again trying to get look into the mind of the surgeon. What are we thinking about? So not management is great because you can see a patient you can give me antibiotics and treat their disease right now and if surgery is not convenient you can do an intergalactic appendectomy on an elective basis when it's much more convenient to schedule the family or for the patient or perhaps not even do surgery at all. So there's some real benefits to non up management. However with operative management you don't have to worry about recurrence, you don't have to worry about treatment failures. And these kids get better faster because it's a definitive cure. So these are the sort of core principles we think about some of the peripherals we've got to talk about. Or what about kids who end up back in the E. D. For recurrent pain? Maybe they have appendicitis or maybe they don't. But mom is really worried because they have belly pain and they had appendicitis in the past and we all know that kids get belly pain all the time. I think my five year old tells me at least once a week their tummy hurts and I usually give her some prunes and she gets better. But just imagine if that child has had a prior episode of appendicitis. And is that mom and dad really going to worry that this could be a recurrence? Are they going to bounce back to the E. D. Are they going to get more imaging? And if you're at a non pediatric center that might mean more cts. What about those little kids who don't take their medicine if you give them 10 days of oral antibiotics and they don't take all of them. Are you have more treatment failures or recurrence? Some of these kids require home I. V. Antibiotics and again that parental anxiety components. However with surgery you gotta think about operative complications and you have to think about complications of anesthesia and overall costs because surgery is expensive and is it more expensive than non up management? I think you know five years ago we didn't really know the answer to this and now we're we're starting to see some data associated with that. So things that we think about when considering on management of appendicitis And again if anybody has any questions type in the chat box, I'm happy to answer them as we go. Um We wonder you know about treatment failure, what is the treatment failure rate for the patient that's in front of us? What can we counsel the family on? How likely is this to actually work? What about recurrence? If it actually does work? What's the likelihood that it's going to come back and if we successfully treat it? What about return visits to the er how often is that going to happen? And if we do successfully treat your child then operatively are they going to need an interval appendectomy or not? What are we going to recommend? And finally this whole issue of costs keeps popping up. So let's go back to our appendicitis one on one case but I'll throw a little curve ball in. And all of these are my patients that I've taken care of real cases in real time lines. I have changed the ages and some of the values to preserve anonymity. But this is a 14 year old who came into the E. D. For abdominal pain Again. hours of pain. Low grade fever. Classic Korean. Biblical, the right lower quadrant. He's got a little bit of nausea, no vomiting. He ate lunch today. He's got a fever and no diarrhea and he put normally last night before he went to bed again. The was nice enough to get away counter an ultrasound. And we can see over here we see this little fickle if that little rocket poop in a very dilated appendix going up here that's not compressible. We don't see any associated abscess or any other signs of preparation. Looks like simple appendicitis With a fickle if White Count's 14, everything is consistent. The curve ball however Is that it's 2020. And despite reading the book for appendicitis while reading the book for appendicitis, he picked up covid so he's now in the head with classic signs and symptoms. Simple appendicitis and a positive covid test. So let's open up the polling again. Tabatha, should we operated on him, take his dependents out? We were given some set tracks on fragile in the 80 and send him home with 10 days of Augmentin. Covid positive appendicitis patient clearly has appendicitis but also has killed it. And when you ask mom, dad really has Covid. He's home with all the symptoms and yes, this kid. Well, do you really have covid or positive test? And he says, well, I can't really smell anything doc. So he has it. All right. Let's close the polling and see what we find. All right. So 43% immediate appendectomy and 57% to treat him non operative Lee, um, and send them home on oral antibiotics. Okay, cool. So I think, you know, either way again, could could go either way, I think. Um certainly with a fecal if and we'll talk more about that later that fecal, it may impact things a little bit. But for this particular case and you know, this this case happened very early in the pandemic, where we didn't really understand a whole lot about how Covid was going to be transmitted. We knew that aerosol generating procedures are very high risk and it puts our anesthesiologists at risk when they're integrating these patients for contracting Covid. We know that the gas from laparoscopy also can aerosolize bodily fluids. We didn't know if that would spread Covid. So, you know, really worrying about health care staff. Um you know, we really try not to operate on patients if they have covid tests that are positive. And also there's some adult data that suggests that if you give patients with active Covid disease, general anesthesia that their incidence of post op complications much higher. So throughout the pandemic, we've really tried to manage patients with positive covid as a non operatively um and try to get them out of the hospital. So they're not exposing our nursing staff and other patients and other physicians to the virus and allowing them to quarantine at home. So we talked to mom about non out management versus operative management. Obviously mom has questions as would be expected. Mom's first question is as well as it's really going to work. I've never heard of this before, giving antibiotics for appendicitis. My other kid had an appendectomy and he was better than three days and he's fine. Why not just do surgery? Another question is as well, if this crazy plan, you're giving me to give him antibiotics works, is the appendicitis going to come back. So fortunately there is some data gives us some rates here and this is this is the best randomized data that we have now. This is adult data. I'll show you the pediatric data on the next slide, But the pediatric data is not randomized. So this is a meta analysis of five randomized controlled trials over 1000 adults. And what they found was that 8% of these adults had treatment failure out front. So not not management failed. So they failed. Not on management had to have an early appendectomy. So 8%, that's pretty good, 92% success rate. Um and of those that were successfully managed non operatively 22% of them had recurrent appendicitis within one year. And this is among patients who did not have an interval appendectomy. So, you know, pretty high rates of treatment success, 78% of patients who got out of the hospital the first time, didn't have any recurrence at one year. So the adult data suggests that not on management for simple. The scientists seems to be a pretty reasonable approach. Now when we look at kids again, it's not randomize. This is the best data that's available. And this was actually just published last month in Jama. And this is a multi site perspective, non randomized study done with the midwest Midwest pediatric Surgery Consortium. And it's important to note that in this study, they excluded patients with the perpendicular. So if you have a fickle, if in appendix or Raqqa poop, you are not eligible for this study and we'll come back to that later because that would be a very high risk for treatment failure. So these are kids who are actually good candidates for nana management. And they had to be entered into the nana arm after the patient and the surgeon both decided that this was a good idea. So highly selected population of good candidates and within this population that was not actively managed, they did not recommend a prophylactic interval appendectomy. So they were able to look at what is the natural history of appendicitis with upfront no not management. So very well done study across 10 major children's hospitals in the Midwest, they were able to um look at 1000 kids and about a third of them were not operatively managed and they had reasonable but not great follow up data on all the kids. What they found was is that 15% of kids who were initially treated non operative, we had treatment failure and had to have an early appendectomy. So this is higher than in adults. And again, this is a more selected patient cohort because these kids were not randomized. So these are were deemed to be great candidates for not management. And the The treatment failure rate up front was a little bit higher. So 15%. Again, no fecal, it's in this so low risk patients, higher treatment failure rate in kids compared to adults. And then when we look at those kids who were successfully managed, 23% of them That went on to develop the current appendicitis within one year. So if you look total at all of the kids who are not operatively managed, 62% of them still have their appendix that one year. So that's pretty good. About two out of three kids who are not actively managed never had their appendix removed. However, about a third of them did. So if you up front where the parents and you decided operative management and your kid was better in a few days you were happy if you were one of those families who selected not management and your kid never required an operation, you were happy. So I think this is a reasonable approach. You know, you can tell the parents that there's a one third success rate at a year and a two thirds or sorry, one third treatment failure, waited a year and a two thirds success rate. And if the parents are okay with this risk profile, then I think not to mention is actually quite reasonable without recommending interval appendectomy. Again, these are kids that don't have feet cliffs. Some of the limitations of this study uh were that it was a very highly selected population. So no feckless, no abscess. And they had some size criteria and the surgeon had to agree to it. And they had a pretty large loss to follow up group, But some of their secondary metrics that they looked at, um we're despite getting 24 hours of intravenous antibiotics in the hospital. Mom and dad missed a half day less of work with non management. So mom and dad got back to work faster if their Children didn't have surgery. And if you look at miss days of school, they're pretty equivalent between the two groups. But more importantly, everybody was happy at one year with the decision that they made. So families that chose surgery up front, we're very happy that they chose surgery. Families that chose not management upfront. We're very happy that they surgery. And if you look at both groups that one year, they both had equivalent quality of life, which was very good in both groups. So I think you really have to feel out the families, you know, some families may have a close family member that's had complications of perforated appendicitis and they just don't want to take those risks with their kid and they're going to want surgery up front. There are other families that really don't want to have surgery because maybe they have a loved one who has had complications of surgery and if they can avoid surgery at all costs, they would rather do that. So I think at this point in time and kids who present with simple early appendicitis and no vehicle, if you know, you really have to have a discussion with the family and ask them what is their acceptable risk profile and what risks are more important for them to consider. And many of them may choose to proceed with um non operating management and they don't all need a laparoscopic appendectomy upfront. Or even an interval appendectomy if they don't have a fatalist. Okay so um the kid who had covid Um I saw him on Sunday gave a 24 hour dose of subtracts on financial in the E. D. He never had to be admitted to the hospital. We sent him home from the er with some Zafran and some cipparone some fragile and come back the following day on monday and then again on Tuesday via zoom. And I gotta say zoom has really revolutionized outpatient management and not how patient management of insights it really allows us to check in with the families, check in with the kids, make sure that we're not having treatment videos with the kids not in the hospital and we're not observing them. Um And I think the families are really happy with the daily check in if we're doing on our management. So this, you know, one of the benefits of the pandemic is that we've really adopted the use of zoom and telemedicine become very facile with that. Um And I think the patient satisfaction also is much better and the care is better. He was actually better by friday, no symptoms at all except whenever he took his fragile, he'd have a little bit of nausea for a few hours, but the girlfriend took care of that. Um I did recommend an interval appendectomy in this kid because he did have that fecal if and we did that six weeks later when we knew that his covid symptoms were gone and then he was no longer a risk to health care providers and no increased anesthetic risk. We did this as an operation. He came and went the same day, went home with no opiates and I saw him back two weeks later with the telemedicine follow visit and he's back to baseline and feeling great with no residual symptoms. So not management even with a fickle if can work in many cases. And this has been something that we've actually increased our experience with during the pandemic because a lot of kids are coming in with the sights and positive covid swaps and we really tried not to get those kids in the or if we can help it. So I've talked about this vehicle, it over and over and over again. And why is that important? Well, it's important because there's really two main ideologies of appendicitis and kids, about half the kids come in with a piece of poop stuck in their appendix and this obstruction aluminum is what leads to the appendicitis. The other half of the kids come in with him limp at an apathy in their appendix and you can see a cross sectional H and E stain here of have an appendix and you can see all those tiny little lymph nodes in the sub mucosa. But when kids get a viral illness, whether it be a systemic viral illness or just a little bit of gastroenteritis, those reactive lymph nodes in the appendix, they swell up and they include the loom in and they lead to appendicitis. The difference between these two ideologies of appendicitis is that those lymph nodes eventually we're going to go away, they're going to shrink back down and everything is going to be fine again as opposed to that fecal if that's stuck in the limit is probably not going anywhere and the risk of recurrent appendicitis with that fecal if is a lot higher. Um so we actually have data about this. This is the oldest paper that I saw. Um But honestly probably the best in kids because they follow up is after two years. And this comes from the University of Toronto where they had a 6% initial treatment failure of all not not actively managed kids. And 41 of their kids had a prophylactic interval appendectomy. But the other kids who didn't, 49 kids, they followed for two years and they found that they had a 72% recurrence rate of appendicitis if there was a fecal it in place. And Nicholas are pretty easy to see on ultrasound. You can see one on the ultrasound emission. You can see a giant forklift on the sexual section of a C. T. Scan. Um So if we see a fickle, if we generally do recommend prophylactic interval appendectomy or even up front if we see a fickle within their good operative candidate we recommend immediate surgery. This 23% recurrence without fickle. It is remarkably similar to that large 1000 patients observational study that I talked about a few minutes ago. So I think this data about recurrence without fickle. It is actually pretty good and recurrence is reasonably low. But if you do have that fecal if it's pretty high. If you look at the large adult studies, prospective observational studies, we know that fecal it's are associated with a 40-60% recurrence rate in adults as well. Um So these these studies have all been pretty consistent. So we spent a lot of time talking about simple appendicitis. But what about complicated appendicitis? Or a perforated appendicitis With an abscess or peritonitis? And is not operative management a good approach in these patients as well. And I think this is a totally different patient populations. Much higher risk of surgery. Much higher risk of not management. Health care costs are much higher in patients. Days are much higher. So when these kids come to the E. D. So this again is the patient I took care of. So she's 12. She had seven days of pain. Um she now presents because the last two days she's had high fevers and a lot of diarrhea. Her white count is 16. She has focal tenderness in the right lower quadrant, no diffuse peritonitis. Despite her fever she's got pretty normal vital signs and she had a sandwich on the way to the er This is her cT scan. Um She got a notion that showed appendicitis for the fluid collection. So we got a ct to better to find this. And this is a well formed rim enhancing abscess in her pelvis associated with a perforated appendix. So let's open up the polling again For this 12 year old was seven days of pain. Do we think she should have a laparoscopic appendectomy right now? Or should we give her some stuff? Tracks on a flag on the E. D. And sent her home with some oral antibiotics or perhaps admit her? Have the radiologist put a drain in this abscess. Give us some idea antibiotics and manage your non operative 12 years old. Seven days of pain looks pretty good on exam doesn't look toxic. She's focal tender high white count. She's eating all right let's close the polling see what everybody thinks. Okay so about 17% think we should operate up front. 50 33%. Want to send him from E. D. And 50% want to admit for a pre continue strain. Okay cool. So I think there's a little bit of controversy here about what we should do. Um So one thing to note here is her bowel gas pattern on the scout. Used completely normal. She's not obstructed. So her eating a sandwich was pretty legitimate. So for this particular patient we admitted her. Um and I don't think the you know the the early laparoscopic happened to me um option is the wrong thing to do. But for this particular patient with seven days of symptoms this is what we did and I'll talk a little bit about why we did that. Um So we admitted her and the radiologist put this nice cute little drain in with ultrasound guidance that grade and stayed in for a few days. Her fever's eventually resolved by hospital day four. So we're a little bit nervous about sending kids out of the E. D. With high fevers on oral antibiotics. We generally keep them in patient until the fevers go away. And when the fever curve is better we generally send them home. So Her dream came out and she went home on hospital day five the day when she was 24 hours a febrile and those are a general discharge criteria. Um she came back, I saw her back in Clinic two weeks later. Um She's back to normal completely resolved symptoms. She's eating her diarrhea is gone. No fevers, no pain no nothing. She's back to playing soccer And we have the discussion about whether or not she should have an interval appendectomy or not. And she did not have a forklift but she did have perforated appendicitis with an absence. This so I think it's reasonable to not do an interval appendectomy but she wanted her appendix out. and the reason is is because we find this with many kids with perforated appendicitis for the nap says she just spent four or five days in the hospital and she doesn't want to do that again. Um So that experience of being in the hospital tends to skew these kids more towards having an interval appendectomy. So they don't get appendicitis again because their treatment course is much more complicated than the simple appendicitis patients that we talked about before. So she had an interval appendectomy six weeks later as an outpatient never admitted to the hospital came in with the same day had surgery, went home on Tylenol and Motrin. And I saw her back actually via Zoom three weeks later and she's back to normal doing well. Um So I think this is this is a pretty typical course of patients who come in with well developed abscesses. So she was a really good candidate for non operative management because she had a well formed abscess. Her perforation was already contained by her body and she was not toxic, appearing she had very focal tenderness and she was eating, she didn't have a bowel obstruction. So patients like this tend to respond very well. The per catania strange and antibiotics and rather than doing an operation and draining all that plus into her parent me um and potentially ceding everything and giving her more abscesses, you get definitive source control up front, you get her out of the hospital and then you bring her out for bring her back for an outpatient surgery to remove your appendix six weeks later. And I think this is the ideal course for non management of complicated appendicitis. So let's talk a little bit about costs. So this is a study that I was involved with a few years ago when I was still at Children's Los Angeles. We went back and looked at all of our perp to appease over a few years. Um And this was non randomised retrospective and we use some advanced statistical techniques to control for selection bias. But what we found looking back at our operative and non operative, we managed patients was that patients who were managed non operatively generally had a longer hospitalization. They had more CT scans and it was more expensive. Um And I think you know there is some selection bias here. The kids who were sicker who had longer duration of symptoms, had more abscesses. You know had a higher frequency of being managed not operatively. But there is a lot of truth in these, especially when we look at duration of preoperative symptoms and total costs. The open circles here are those that had an operation. The square dots are those who were treated non operative lee. And you can see a lot of these squares if you got if you only had one or two days pre op of symptoms, not on management is very expensive. An operative management is much cheaper, it's around $10,000. But as we go up, the non out management or the operative management cost line is oblique and it gets very expensive when you start operating with longer days of symptoms. And that's because you get an increased incidence of postoperative abscesses that prolong the operation. You can see that the cost of non management is pretty flat depending on however many it is symptoms you have. The cost is between $15 and $20,000. And these curves they cross at seven days and between five and seven days is when a body really develops a well formed abscess. So this data suggests that cost of operative management increased with duration of symptoms. So if you have a patient with perforated appendicitis and they've only had symptoms for 34 days and operation is probably what will get them out of the hospital the fastest and is associated with much less health care. Utilization Patients who present with 5-7 or longer days of symptoms. Preoperative Lee and they have a very well formed abscess. It's actually more cost effective to treat them upfront with non up management of her, continue straight in an interval appendectomy and if you don't do that interval appendectomy it becomes much much cheaper. Um So we have adopted this at Oakland Children. So we do about 500 appendectomies a year. And kids who present with more than 5 to 7 days of symptoms in a well formed abscess. We generally are managing non operative lee kids who come in with 2 to 3 days of symptoms. We generally manage them operative because it gets them out of the hospital sooner. So let's go back to that kid that we talked about up front and perhaps he used to live in phoenix and was managed you probably due to loss of insurance, whether the medical lapses or the mom loses her job or you know, whatever reason they switch insurance and they don't have the ability to follow up with the surgeon immediately and then they just don't follow up or perhaps they've moved cities. Um So patients who are lost to follow up might end up in the primary care doctor's office and they might ask you if they need surgery because at the other the surgeon told them they probably should have an interval appendectomy, But now it's 4-6 months later and they're completely asymptomatic. I would say if they don't have a fickle, if they probably don't need an interval appendectomy, particularly if they've already been a year without symptoms, I think they have a fickle if we probably should be offering an interval appendectomy and furthermore, if they're going to be traveling exotically or outside of reliable health care, we probably should be taking the appendix out. The analogy is the submarine soldiers who are getting back on the submarine and are going to be away from a hospital anesthesiologist for awhile, probably should have an interval appendectomy before they get back on the boat. Um, So these are sort of the things that we use for guidance when we meet patients post operatively talk about interval appendectomy. Um, and these are the two greatest risk factors. But I do think that this loss of insurance issue is a big deal. So for us, if a kid has a chocolate or other high risk factors for recurrent appendicitis, we try to give them a surgery date before they leave the hospital, we get the authorizations. We do everything we can so that if they're surgery date pops up on the calendar and you know, they don't have insurance or whatever. We have. One of our social workers reach out to them to get their medical reauthorized or see what we can do to get them coverage because of the high risk of recurrence. So this is one of the things that we've really focused on having seen many of these kids get lost to follow up. So if a kid does come to your office and they don't know if they need to follow up with the surgeon or not, if they have a fecal, if certainly send them along and if you think that they're not going to have reliable access to healthcare, we probably should meet them and discuss risks and benefits of a prophylactic interval appendectomy. Um, so finally, um, this is something that was quite common a couple years ago. Um, And I think we're running low on time. So I probably won't do the polling for these. I'll just blow through these because it's more interesting to just talk about the progression. So again, these are real patients that I've seen with the ages and the other identify has changed. But this is a kid who came to eat with one day of pain white county 12 and on the ultrasound they see a five millimeter, minimally compressible appendix. And the radiologist says, we can't rule out appendicitis. He's barely tender in the railway required and he's not toxic. He's tolerating pio intake and you're not sure if it's appendicitis. So what was being advocated a few years ago was for these kids. Um But you're not sure if they have appendicitis or not just give them antibiotics, treat them non operable for appendicitis. There's no fecal it there's no high risk factors just treat them. And you know what's the harm? So you do you give me some Augmentin? And mom says he actually was better the next day. Which sounds like probably not appendicitis if you got better that quick. Um But three weeks later he comes back to the E. D. With the same symptoms. He's got one day of pain he's got fever. He's got some diarrhea zone. I'm white counts 12 and now the ultrasound can't see the appendix and he's pretty tender. So we're worried now and mom is worried that this is recurrent appendicitis because she is convinced that the first time he did have appendicitis even though we're we weren't convinced. Um So you know the question is should he just go to the or for a laugh ferocity to remove his appendix Or should he be treated non operative lee again and again Real case treated non operative lee in the E. D. Sent home with Augmentin and he got better within three days. And then mom's getting really frustrated because two months later he comes back to the er with abdominal pain and she's worried that it might be appendicitis. Again he's got one day of pain. No fever is white counts seven and the ultrasound definitively sees the normal appendix. This time he has a KGB that shows he's got constipation. And mom's worried that you know it might be appendicitis again. So I had a discussion with the mom and he says you know he doesn't have appendicitis but this is the third time in 2.5 months that I've seen you in the er for abdominal pain. And are you really worried about this appendicitis? And she said yeah every time his tummy hurts, I'm worried that he has appendix might burst. Um So I actually offered a laparoscopic appendectomy. We did it the same day he went home the same you know that evening. Uh Mom was quite grateful that she didn't have to worry about appendicitis anymore. So I do think this parental anxiety component is a big part of it and you know some parents are going to be more anxious than others and I think you just have to have a discussion with the family about how much you know anxiety are they going to have about recurring appendicitis? Because Some studies actually show the rate of return appendicitis is as low as 10-15%. Many most studies say it's closer to 20, But even if the recurrence rates only 15%,, the moms are so worried that the appendicitis is going to come back every little belly, it gets him back in the day. So, I think that is something that needs to be taken into consideration. And we just have to have an open dialogue with the patients about what are their preferences and they may choose not management upfront. But later on, then we decide that it's just something that they I want to change their mind about. Um So, in summary, I think these are the key points. Um And again, there's no test, but if there's some things to go home with. Um I think that not on management, uhm, for simple appendicitis is probably not ideal if they have a fickle if there are very large appendix, Um it's associated with anywhere from 8-15% immediately failed immediate failure rate. And there's a 20-25% recurrence if there's no fecal, if anywhere from 40 to 75% recurrence. If there is a fickle if or perforated appendicitis, we know that it's more expensive and there's more complications if we routinely use non management for complicated appendicitis. But in highly selective population of kids who have longer duration of symptoms and well formed abscesses, it's actually less expensive. And there are less complications and patient satisfaction is actually better if we do up front non management with per continuous drainage. And finally, the issue of interval appendectomy, which may be what comes up most frequently in primary care offices, should they or should they not? And I would say that if you're going to be traveling overseas and not have access to reliable health care, you probably should get an interval appendectomy. Remember the general incidence of appendicitis in the population is about 8-10% and the recurrent appendicitis rate is about 23%. So they have a two-fold higher risk of developing appendicitis while traveling than the general population. If there is a fickle if certainly should consider having an interval appendectomy and this parental anxiety issue. You know, some, some parents just want the referral to have the appendix out because they can't take, they can't take it anymore. And finally paid to have medical that has to be renewed every month, timing of referral and authorization and surgeries can be a challenge. So we often will work very closely with primary care provider offices to make sure that that medical stays active so that we can get it done. I think that's all I have for today. Um, here's a access center number if you want to send a kid are way, um, here's our team. This is all my wonderful partners.