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.
e sort of look at this is sort of 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 glam of the real show. E think that not happening? 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 eso. First of all, I have no disclosures. I do get some money from the government toe study, trauma care in 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 dio not management? Why is it that sometimes we do an interval appendectomy? Sometimes we don't. Why is it that you know we operate on certain patients, but other patients we don't try to give you some guidance extreme sort of. What is the decision making that we have, so that when you see your patients back in the office and they have questions about on a bit of 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. Eso The rial goals are to describe what is 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 a appendectomy that we do six weeks later, 6 to 8 weeks later to prevent the appendicitis from happening again. So treat them, not operatively, and then bring them back in 68 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 not not management and how some barriers and access to care might impact who you refer. Interval Appendectomy on Gwen 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 gonna help us out with that. So throughout the talk, I'm gonna have some interactive questions. There's no great at the end. Don't worry. I'm really just looking for opinions on 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 with the case. I think cases are always a good way to start. Um, e called appendicitis one on one. So we have a 12 year old boy who is 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 is actually a little earlier than this 12 year old generally wakes up, it had moved his right lower quadrant. Now it's pretty severe. He's got nausea, vomiting, and Mom thought a 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 on a little bit of nausea that's bothering you. The ER was very kind and got us a white count. With 13, you can see a dilated appendix over here. Um, eight millimeters 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. I see it. Okay, cool. So pick one. Should he have laproscopic conduct me? Or should he be treated with I v antibiotics and sent home with aural antibiotics? Cool. So 57% say non op management. Um, and 43% say laparoscopic appendectomy for a simple appendicitis. I like it. Perfect s Oh, this is great. This is a kid who had no fecal if 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 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 not management. Um, he went to the same day. The war, flash traffic, 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 wanna wear a midriff baring shirt. Um, but he went that data to the had his appendix. Patrick, about an hour. He spent our impact. You He went home. We prescribed him some oxycodone. He only took four pills, mostly at night, to take him to sleep on. Most kids don't even need that. They just use Tylenol Motrin and some ice packs, and he actually reserved Return to Zoom School on post day, too. And I saw him back via Zoom 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 to cures with stone cold steel in the 21st century. Modification of the old surgical adages. Well, nowadays we actually use some plastic troll cars and a scope, but this kid's cured. He's not gonna have any recurrent. Mom doesn't have to worry about him getting appendicitis again. He didn't spend a single night in the hospital. He had now patient operation on. 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 mag mitten and say, Call me back in the morning on and see how things were going, and we don't have to do surgery at all? so I'm just curious for the attendees. Um, how many who are joining us tonight? I have seen patients back in their office that have been on operatively managed for appendicitis. And we can go to pull 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 U. S. 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 move 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 to 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 on. 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 to 6 months out foreign and will prop conduct 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, 50 50. This is good. We picked a good topic tonight. That means everything is controversial and there's no clear answers. Perfect. Alright, 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 it 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 your 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, Azi, you can imagine that probably isn't gonna end well. This'll 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 rectally. 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, thes sailors would be referred to a surgeon to have their appendix removed to have it, uh, 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, Ah, 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 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 not upper management with an interval interval. Appendectomy stayed pretty constant. So this really got popular, uh, sort of between 2010 2014 and rates continue to rise. And and this is when we really started to understand that, not management of appendicitis. So what are the upsides? One of the downsides, one of the problems and actually the enthusiasm behind non op management. It's sort of waxed and waned in the last 3 to 4 years, and I think it's on the downturn right now. It might pick up again in the future, 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 Thio get look into the mind of the surgeon. What are we thinking about? So not a management is great because you can see a patient. You could give him antibiotics and, you know, 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 op 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 that 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's 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 there tummy hurts and I usually give us, um, prunes, and she gets better. But just imagine, if you know, that child has had a prior episode of appendicitis and you know, is that mom and Dad really gonna worry that this could be a recurrence? Are they gonna bounce back to the E D? Are they going to get more imaging? And if you had 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 Orlando biotics and they don't take all of them are you have more treatment failures or recurrence. Some of these kids require home i p 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 op 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, associate it with that. So things that we think about when considering non op 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 gonna come back? And if we successfully treat it, What about return visits to the ER? How often is that gonna happen? And if we do successfully treat your child on 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 it. So let's go back to our appendicitis. One on one case. But I'll throw a little curveball in on all of these air 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. 24 hours of pain, low grade fever, classic period. Biblical, the right lower quadrant He's got a little bit of nausea, no vomiting. He ate lunch today. He's got a fever or no diarrhea. And he put normally last night before we went to bed again, the E D. Was nice enough to get away. Counter an ultrasound and we can see over here we've seen this little fecal. If that little rock a poop in a very dilated appendix going up here, that's not not compressible. We don't see any associated abscess or any other signs of preparation. Looks like simple appendicitis with a pickle. If White counts 14, everything is consistent. The curveball, however, is that it's 2020 and despite reading the book for appendicitis while reading the book for appendicitis, he picked up co vid. So he's now in the with classic signs and symptoms of simple appendicitis and a Positive Cove. It test. So let's open up the polling again. Tabatha, should we operating on him? Take his appendix out. We're getting some subtracts on flag on the 80 and sent him home with 10 days of Augmentin Cove in positive appendicitis. Patient clearly has appendicitis, but also has coded. And when you ask, Mom, Dad really has to know that he's home with all the symptoms. And yes, this kid Well, do you really have covered 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 him home on oral antibiotics. Okay, cool. So I think you know either way again, Could could go either way, I think. Certainly with a fecal if and we'll talk more about that later. That fecal if 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 cold it was gonna 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 cope it. We know that the gas from laparoscopy also can Aris allies on bodily fluids. We didn't know if that would spread covitz. So, you know, really worrying about health care staff way. We really try not to operate on patients if they have covert tests that are positive. And also there's some adult data that suggests that if you give patients with active covert 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 covert as a non operatively on 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 management versus operative management. Obviously, Mom has questions, as would be expected. Mom's first question is as well as it's really gonna work. I've never heard of this before giving antibiotics for appendicitis, you know, My other kid had an appendectomy and he was better than three days, and he's fine. Why not just surgery? And another question is as well if this crazy plan you're giving me to give him antibiotics works, is the appendicitis gonna come back? So, fortunately, there is some data gives us, um, 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 anonymized. 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 management had to have an early appendectomy, so 8%. That's pretty good. 92% success rate. Andi. Of those that were successfully managed, not 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. Eso the adult data suggests that not not 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 on. This was actually just published last month in JAMA, and this is a multi site prospective non randomized study done with the Midwest Midwest Pediatric Surgery Consortium. And it's important to note that in this study, the excluded patients with a perpendicular it's so so if you have a fecal, if your appendix or a rock a 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 were kids who were actually good candidates for Nana banishment, 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 Thio look 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 that that 15% of kids who were initially treated, not operative. We had treatment failure and had to have an early happened back to me. So this is higher than in adults. And again, this is a more selected patient cohort because these kids were not randomized, so these air were deemed to be great. Candidates were not not management, and the the treatment failure rate upfront was a little bit higher. So 15% again, no fecal. It's in this so low risk patients, higher treatment, failure rate and kids compared to adults. And then when we look at those kids who were successfully managed, 23% of them that went on to develop a 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 were not overly managed never had their appendix removed. However, about a third of them did so If you upfront where the parents and you decided operative management in your kid was better in a few days, you are happy if you were one of those families who selected, not management and your kid never required a operation. You were happy. So, you know, 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 sorry, one third treatment failure rated a year and a two thirds success rate. And if the parents air okay with this risk profile, then I think not on management 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 where that it was a very highly selected population. So no fecal isno abscess and they had some size criteria and the surgeon had to agree to it, and they had a pretty large loss to follow a 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 op management, so Mom and Dad got back to work faster if their Children didn't have surgery. And if you look at this 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 outfront. We're very happy that they chose surgery families that chose not not management upfront. We're very happy that they surgery. And if you look at both groups at 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, Ah, 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 gonna want surgery up front. There are other families that really don't wanna 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, you know, acceptable risk profile and what risks are more important for them to consider, And many of them may choose to proceed with, um, not operate management. And they don't all need a laparoscopic appendectomy upfront or even an interval appendectomy if they don't have a fecal with King. So, um, the kid who had co vid um, I saw him on Sunday, given 24 notes of self tracks on Fragile 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. Come back the following day on Monday and then again on Tuesday via Zoom. And I gotta say, Zoom has really revolutionized outpatient management. I'm not outpatient, not management of appendicitis. It really allows us toe 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. Andi think the families were really happy with the daily check in if we're doing on that management. So this, you know, one of the benefits of the pandemic is is that we've really adopted the use of Zoom and telemedicine and become very facile with that on. But I think the patient satisfaction also is much better and the care is better. Hey 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. I did recommended Interval Appendectomy and this kid because he did have that fecal with. And we did that six weeks later when we knew that his covert symptoms were gone and then he was no longer a risk to health care providers and no increased aesthetic risk. We did this as an opposition. He came and went the same day, went home with no opiates on. I saw him back two weeks later with the telemedicine follow visit. He's back to baseline and feeling great with no residual symptoms. Eso not management even with a fecal, 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 were coming in with scientists and positive covert swaps. We really tried not to get those kids in the or if we can help it. So I've talked about this vehicle with over and over and over again. And why is that important? Well, it's important because there's there's really too many ideologies of appendicitis and kids. About half the kids come in with a piece of poop stuck in their appendix, and this obstructs the aluminum is what leads to the appendicitis. The other half of the kids come in with some limp at an apathy in their appendix, and you can see a cross sectional H and E staying here of having 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 Lumen 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's gonna be fine again, as opposed to that fecal. If that's stuck in, the Lumen is probably not going anywhere. And there's a recurrent appendicitis with that fecal, if is a lot higher. Eso we actually have data about this. This is the oldest paper that I saw. But honestly, they probably the best in kids because they have 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 up, not operatively 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. If in place, and Nicholas are pretty easy to see an ultrasound, you could see one on this ultrasound image, and you could see a giant fecal with on the central section of a CT scan. Um, so if we see a fecal, if we generally do recommend prophylactic, interval, appendectomy or even upfront, if we see a fecal within their good operative candidate, we recommend immediate surgery. This 23% recurrence without fecal if is remarkably similar to that large 1000 patient observational studies that I talked about a few minutes ago, so I think this data about recurrence without fecal it is actually pretty good, and recurrence is reasonably low. But if you do have that fecal have, it's pretty high. If you look in the large adult studies prospective observational studies, we know that fecal a store associate with 40 to 60% recurrence rate in adults as well. Eso 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 paran itis? And is not operative management a good approaching these patients as well? And I think this is a totally different patient populations, much higher risks of surgery, much higher risks of non op 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. 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 of 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 C T to better to find this. And this is a well formed rim enhancing abscess in her pelvis associated with a perforated appendix. So, Tabatha, let's open up the polling again for this 12 year old with seven days of pain. Do we think she should have a laparoscopic appendectomy right now? Or should we give her some staff tracks on a flash 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? You have some idea antibiotics and manager 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 out front 50. 33% want to send home from Eddie and 50% want to admit for percolating strain. Okay, cool. So I think there's a little bit of controversy here about what we should do. Eso 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 was pretty legitimate. So for this particular patient, we admitted her. Um and I don't think the, you know, the early laps Coptic happened that 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. Eso we admitted her and the radiologist put this nice cute little drain in with ultrasound guidance that great and stayed in for a few days for fevers eventually resolved by hospital before. So we're a little bit nervous about sending kids out of the E. D. With high fevers on aural antibiotics. We generally keep them in patient until the fevers go away. And when they're fever, curve is better. We generally send them home, So her drain came out. She went home on hospital Day five, the day when she was 24 hours a febrile and those air a general discharge criteria. Andi, 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 fecal if. But she did have perforated appendicitis with them status. So I think it's reasonable to not doing Interval Appendectomy. But she wanted her appendix out. And the reason is is because it and I we find this with many kids with perforated appendicitis for the Knapp 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 and went same day, had surgery, went home on Tylenol and Motrin. And I saw her back actually be a 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 perky, teeny strange and antibiotics. And you know, rather than doing an operation and draining all that plus into her parent knee, um, and potentially ceding everything and giving your more abscesses. You get definitive source control upfront. 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 on. I think this is the idea, of course, for not not 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 perfect Happy's over a few years on bond. This was not randomized retrospective, and we used advanced statistical techniques, toe sort of 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, not 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 on operatively. But there is a lot of truth in these, especially when we look a duration of preoperative symptoms and total costs. The open circles here are those that had an operation, the square dots or those who were treated non operatively, 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's very expensive and operative management is much cheaper. It's around $10,000. But as we go out, the non op 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 op management is pretty flat, depending on how, however many it is symptoms you have. The cost is between 15 and $20,000 and these curves they cross it seven days and between five and seven days is when a body really develops a well formed abscess. So this data suggests that, you know, cost of operative management increased with duration of symptoms. So if you have a patient with perforated appendicitis and they have 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 healthcare utilization. Patients who present with 5 to 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 up front with non op management bucatini straining an interval appendectomy. And if you don't do that interval appendectomy, it becomes much, much cheaper. Eso we have adopted this at Oakland Children's. 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 operatives because it gets them out of the hospital sooner. So let's go back to that kid that we talked about upfront and perhaps he, you know, used to live in Phoenix and was management you probably due to a loss of insurance, whether the medical lapses or the mom loses your job. 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 move cities. Um, so patients who are lost to follow up might end up in the Primary care Doctors office, and they might ask you if they need surgery because at the other, you know, the surgeon told them they probably should have an interval appendectomy, but now it's 4 to 6 months later, and they're completely asymptomatic. I would say if they don't have a fecal, if they probably don't need an interval appendectomy, particularly if they've already been a year without symptoms, I think they have a fecal. If we probably should be offering an interval appendectomy, and furthermore, if they're gonna be traveling exotically or outside of reliable health care, we probably should be taking the appendix out. You know, the analogy is the submarine soldiers who are getting back on the submarine and we're going to be away from a hospital in the Physiologist for well, probably should have an interval appendectomy before they get back on the boat. Um, so these air sort of the things that we use for guidance when we meet patients post operatively talk about interval appendectomy on These are the two greatest risk factors. But I do think that this loss of insurance issue is a big deal. Eso for us. If a kid has a fecal it 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 their 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 t to get their medical reauthorized or see what we can do to get them coverage because of the high risk of recurrence. Eso 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 with surgeon or not, if they have a fecal, if certainly send them along on If you think that they're not gonna have reliable access to health care, we probably should meet them and discuss risks and benefits of a prophylactic inter black conducting me. 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 its's more interesting to just talk about the progression. So again, these aerial patients that I've seen with the ages and other identify has changed. But this is a kid who came to the E. D with one day of pain. White counted 12, and on the ultrasound they see a five millimeter minimally compressible appendix on. The radiologist says. We can't rule out appendicitis. He's barely tender in the rail 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 that you're not sure if they have appendicitis or not. Just give them antibiotics. Treat him non operable. For appendicitis. There's no fecal. If there's no high risk factors, just treat him and you know what's the harm. So you dio you give 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. So I'm White Count's 12, and now the ultrasound can't see the appendix. Andi, he's pretty tender. So we're worried now. And Mom is worried that this is recurrent appendicitis because she's 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? Where 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 is getting really frustrated because two months later he comes back to the E. D with abdominal pain, and she's worried that it might be appendicitis again. He's got one day of pain, no fever, his white Count seven and the ultrasound definitively season normal appendix this time and has a KGB that shows he's got constipation, and Mom's worried that it, you know, 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 timing hurts, I'm worried that he has appendix might burst eso I actually offered a laparoscopic appendectomy. We did it the same day he went home the same. You know, that evening on Mom was 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. Or they're gonna have about recurring appendicitis because, you know, some studies actually show the rate of return. Appendicitis is as low as 10 to 15%. Many most studies say it's closer to 20. But even if the recurrence rates on Lee 15% the moms air so worried that the appendicitis is going to come back. Every little belly, it gets him back in the 80. So I think that is something that needs to be taken into consideration. And, you know, we just have to have an open dialogue with the patients about, you know, what are their preferences. And they may choose, not management out front. But later on, they may decide that it's just, you know, something that they I want to change their mind about, Um, so in some Marine, I think these are the key points, Um, and again, there's no test. But if there's some things to go home with, I think that not not management for simple appendicitis is probably not ideal if they have a fecal. If there are very large appendix, um, it's associated with anywhere from 8 to 15% immediately fail immediate failure rate. And there's a 20 to 25% recurrence if there's no fecal if anywhere, from 40 to 75% recurrence if there is a fecal. If for perforated appendicitis, we know that it's more expensive, and there's more complications if we routinely use non op management for complicated appendicitis. But in highly selected 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 upfront non op management with Per continues drainage. And finally, the issue of Interval Appendectomy, which may be what comes up most frequently in primary care offices. Should there 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 incidents of appendicitis in the population is about 8 to 10% and the recurrent appendicitis rate is about 23%. So they have a, you know, twofold, higher risk of developing appendicitis while traveling than the general population. If there's a fecal, if certainly should consider having a new interval appendectomy and this parental anxiety issue. You know, some some parents just want the referral. They have the appendix out because they can't take. They can't take it anymore and finally fades. Have medical that has to be renewed every month. Um, timing of referral on authorization and surgeries can be a challenge. Eso 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 our way. Um, here's our team. This is all my wonderful partners.