Cutting out the surgeon from appendicitis?

David Mathison, MD, MBA, takes a fresh look at how we practice pediatric emergency medicine, looking to turn PEM upside down

I remember being a medical student on general surgery and drawing the short straw, the straw that meant I had to call the attending surgeon at 1am about a patient in the ED with routine appendicitis.  The surgeon answered the phone, strung off a slew of expletives, and finished with the statement, “I’m on my way.”

A decade later, that straw changed. A non-perforated appendicitis was no longer an emergency and appendectomies could be deferred to the next day after the initiation of antibiotic therapy.1 Calling the attending surgeon meant you would hear, “ok, I’ll see the patient in the morning.”
Now, we’re seeing that paradigm shift further, questioning the role of appendectomy all together. Evidence for the outpatient antibiotic treatment of acute uncomplicated non-perforated appendicitis continues to grow. What was once the most common surgical emergency of childhood may no longer be a routine surgical disease. Multi-centered randomized studies are ongoing, but appendicitis is becoming a family-physician negotiation rather than a ticket to surgery.

Non-operative management of appendicitis is not without complication. As many as 12% of patients fail within 7 days and require appendectomy. However, few patients past the short-term period have true recurrence that requires operative management.2  While we’re searching for the NNT in pediatrics and how to correctly risk stratify the non-operative options, non-operative appendicitis is becoming an increasing reality.

An antibiotic-first approach may completely change our ED approach to the patient with new-onset RLQ pain. Is it ridiculous to treat patients with clinically diagnosed uncomplicated appendicitis using PO broad-spectrum antibiotics and defer radiologic diagnosis for outpatient care?

Twenty years ago, surgeons would say that 1 out of 4 patients taken to the OR for suspected appendicitis would have a normal appendix. An evolving safety culture and medicolegal landscape demand radiographic diagnosis before operative management. I remember only one case in the past ten years where I was able to convince a surgeon that a patient had appendicitis without radiographic diagnosis. All the stars were aligned: Adolescent male patient, classic presentation, and attending walking by the room coincidentally.

Radiologic diagnosis is important before operative care to diagnose as well as rule out other disease masking RLQ symptoms. For example, the patient with undiagnosed Crohn’s disease who has ileocolic disease may present with RLQ pain. But is radiologic diagnosis so important if we are treating with antibiotics, especially if the radiologic diagnosis carries its own risk and cost? We diagnose pneumonia with a stethoscope and don’t need an ultrasound to diagnose a classic testicular torsion. While the radiologic evaluation is important, maybe it’s no longer part of the ED evaluation?

The Children’s Hospital Association advocates for ultrasound as the preferred initial modality. However many community hospitals cannot perform this test as well as a pediatric equipped facility. This results in over-utilization of CT scans or needless transports to pediatric centers. Even facilities with excellent US diagnostic technique still have high equivocal rates resulting in secondary testing. Trends to avoid ionizing radiation favor MR as a secondary modality. MRI is often not available 24 hours a day and is difficult in patients less than 8 years who may not be able to hold still.

As we approach value-based care, we have opportunity as PEM physicians to facilitate management of many acute diseases, but this may no longer be a reflexive call to a surgeon or admission. Rather, creative approaches with initiation of antibiotic therapy and outpatient surgical care coordination are the future. For example, using POC ultrasound to rule-out abscess formation followed by care coordination to follow clinical progress, arranging further radiologic testing, and managing the length of antibiotic therapy. What better opportunity to take over the management of this “surgical” disease? Time to change our thinking on appendicitis.

Who wants to take the lead?

1. Dunlop et al, Is Nonperforated Pediatric Appendicitis Still Considered a Surgical Emergency? A Survey of Pediatric Surgeons; Acad Pediatrics (12) 2012

2. Di Saverio, et al.  The NOTA Study (Non-Operative Treatment for Acute Appendicitis)  Ann Surg 2014 Jul; 260(1)

 

David Mathison MD MBA

David Mathison MD MBA

Adjunct professor of pediatric and emergency medicine at George Washington University, Regional medical director at PM Pediatrics
David practiced in the ED at Children’s National for 10 years where he was the director of the pediatric transport team. He is the author of the blue card (ED med dosing) app on iTunes/Android and founded healthEworks LLC in 2010. He continues to contribute articles, workshops, apps, and technology to the field of pediatric emergency medicine.
David Mathison MD MBA

Latest posts by David Mathison MD MBA (see all)

David Mathison MD MBA

David practiced in the ED at Children’s National for 10 years where he was the director of the pediatric transport team. He is the author of the blue card (ED med dosing) app on iTunes/Android and founded healthEworks LLC in 2010. He continues to contribute articles, workshops, apps, and technology to the field of pediatric emergency medicine.