When an appendectomy is necessary, less invasive

Pediatric general surgeon on the cost-effective diagnosis, treatment of acute appendicitis

Dr. Adam Gorra discusses appendicitis cases in children

Episode Transcript

Courtney Collen (Host): Hello, welcome to our new medical series ‘Called to Care’ by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance they can use in their primary care practice and information about when it’s time to refer patients and families to more specialized care.

Joining me for six episodes, focusing on children’s care is Joseph Segeleon, MD. He’s the vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. Glad to have you here, Dr. Segeleon. Today, we’re talking about cost-effective diagnosis and management of acute appendicitis.

Dr. Segeleon, tell us why you chose this topic.

Dr. Joseph Segeleon: You know appendicitis is something that a lot of providers see and, and you hear about, and that’s, it’s not uncommon for a child to have appendicitis or to need a appendectomy. So, I thought it would be really useful to get a pediatric surgeon’s perspective of this common condition.

Courtney Collen: Let’s welcome, Dr. Adam Gorra to the conversation today.

Dr. Segeleon: Dr. Adam Gorra, welcome.

Dr. Adam Gorra: Well, thanks for having me.

Dr. Segeleon: We really are glad to have you here, and I know our providers are quite excited to listen to what you have to say. What should we start off by telling us a little bit about what is the training for a pediatric surgeon?

Dr. Gorra: As a pediatric surgeon, we have to get board certified first in  general surgery. So that is usually five years of training after medical school which covers all aspects of general surgery: pediatric and adult. And then it requires more advanced training and it fellowship in pediatric general surgery. And that covers any condition from neonatal congenital anomalies all the way up through usually 18 years of age and trauma, malignancies, cancer surgery, thoracic surgery… so, we really cover a broad spectrum of cases in ages of, of patients. I did my general surgery training in Portland, Maine at Maine Medical Center. And then I did my fellowship at Omaha Children’s Hospital in Omaha.

Dr. Segeleon: Well, great. Thank you. And, and how many pediatric surgeons do we have here at Sanford?

Dr. Gorra: We have three, three board certified pediatric surgeons in our practice here at Sanford Children’s.

Dr. Segeleon: Great. So I, you know, I think the Sioux falls market has three pediatric surgeons and the Fargo market has two, I believe. Is that correct? Great, super well, let’s go ahead and get onto our topic. You know, appendicitis is something we all learned about in medical school and, and certainly a number of our providers see children with appendicitis. Maybe you can expand it and some of the new things and the, the current perspective on the management of appendicitis in children,

Dr. Gorra: Well, appendicitis obviously is a condition that we’ve been treating for centuries. There’s been a lot of advancements in how we care for it surgically over the last 20 to 30 years with the advanced minimally-invasive techniques. And I think those techniques started in adult surgery and quickly expanded into pediatric surgery as well. So that would be the big advancement from a surgical perspective and how we manage it would be more minimally-invasive approaches. But even so, we’ve actually really kind of streamlined our medical treatment of complicated appendicitis as well, to the point where we have efficient, cost-effective techniques, management protocols to get these patients through the hospital and out of the hospital, as you know, with fewer complications. A lot of people come to us with appendicitis and they think that the, they think it’s a dire surgical emergency that child’s potentially, you know, they hear the word sepsis, and they say things like that and the child’s gonna, you know, on death’s door. In reality we’ve really become, we’ve really become adept with modern antibiotics and sort of and how we manage these patients post-operatively to the point where I always reassure the parents that every single one of these patients is gonna get better. It’s just, sometimes it takes a little longer for some than others.

Dr. Segeleon: Great. So, I think that a lot of these patients present to their outside emergency department. For our providers that are listening, what should the workup entail for the patient that you’re concerned about appendicitis?

Dr. Gorra: I think the most important thing is as always it’s a thorough physical exam and history, you can get most of the diagnosis, you can arrive at a really narrow it down pretty quickly with a really good history and physical exam. And the classic findings of right, lower quadrant, paraumbilical pain rating, eventually rating to the right lower quadrant right lower quadrant point tenderness associated with nausea, anorexia, vomiting and eventually fever. These are all sort of classic signs of appendicitis. And there aren’t a lot of things that cause us in children so if you really focus on this sort of constellation of signs and symptoms, you can narrow it down pretty quickly. And really then, then it’s just about getting some confirmatory testing. With modern imaging cat scans are extremely sensitive or modern cat scans can really pick up even the earliest appendicitis and so it is easy and tempting to just go right to a CAT-scan to sort of confirm your suspicion. But if you’re tempted to do that, you may end up getting a lot of CAT-scans in patients who don’t have appendicitis. So they may have a few of those symptoms, but not really the whole constellation that really raises your, your real raises your suspicion. You know, that, that this is appendicitis. And so you end up getting a CAT-scan you end up potentially getting cat scans on patients that don’t need it, or don’t have appendicitis. And you also may end up ordering cat scans on patients that are so obvious that they have appendicitis, that it really wasn’t a helpful test. So we’ve developed some the pediatric surgeons had sort of led the way in developing workup protocols to minimize radiation and streamline the process to really hammer in the diagnosis. Now there are going to be some patients that still end up getting cat scans because they don’t fit the classic presentation, and we do get fooled occasionally. But with the use of these protocols and these algorithms, we have been shown we’ve shown that we can really reduce radiation in children and, and long, big large-scale studies have demonstrated that radiation significantly increases the risk of long-term malignancy, specifically lymphoma. There’s some concerns about that. So whenever we can avoid radiation, we like to do that. Of course, ultrasound is a modality that is relatively low cost and zero radiation and risk risk to the patient. And that’s something we’re certainly have been emphasizing here locally and throughout the region with our referring providers.

Dr. Segeleon: Well, I’m really glad you hit on the CT and the radiation subject, because I think you see that a lot in the consumer literature and in the lay press. I think there’s a lot of parents that are, that are quite informed about that and of course in children’s hospitals, we do have the capability to limit radiation and give appropriate dose radiation based on guidelines. So, I appreciate that. And, and thank you.

You spoke a little bit about ultrasound and the role of ultrasound in the workup of appendicitis. Could you expand that a little bit? Particularly, do I sense there’s an expertise that’s required, or just expand a little bit on ultrasound with appendicitis?

Dr. Gorra: Really the, the number one thing is you need, you need access to an ultra sonographer. And many facilities have that during the day during the weekday. Many of them don’t have many facilities or in the, in the region, don’t have access to that at night or on the weekends, but when they do have access to it, it’s a, it’s an excellent first step in, in working up appendicitis. And you will be able to pick up the signs of appendicitis on ultrasound on most patients. And then there will be some patients who still require some additional imaging or further workup. Yes, it does require an ultra sonographer that can identify the appendix or the secondary signs of appendicitis within the abdomen. Studies have shown that the more they do it, the better they get at it. So, that’s why we encourage our providers that are seeing these patients in the emergency department or in urgent care centers, or even in clinics to get the ultrasounds when they suspect appendicitis, if they have access to an ultra sonographer to really get in the habit of doing it because the more they do it, the better they are, the better they will get at it. Pediatric centers do a lot more ultrasounds on children than general hospitals do and that’s been well documented in the literature well studied in the literature that children who come to pediatric centers are more likely to get ultrasounds and less likely to get ionizing radiation in their workup. And so we encourage our referring facilities to utilize that option when it’s there.

Dr. Segeleon: Well, great. Thank you. That’s, that’s very helpful. Now, before we get to, to surgical techniques or the type of surgery that you do, are there any patients where the diagnosis may not be as straightforward?

Dr. Gorra: Well, there’s certainly patients who have complicated histories. If they have prior surgical histories or other significant co-morbidities, congenital anomalies, it certainly raises, you know, increases the number of possible etiologies of their, of their symptoms. Most of the patients that come to see us don’t have a prior surgical history. We care for a lot of patients that have complicated problems, but, you know, statistically speaking, most kids out there have no surgical history. So, most of the kids are coming to care without any really a history of surgery on their abdomen or any other major medical comorbidities. But there is one subset of patients that can, that can require a little bit more thought. And those are females, especially adolescent females. The adnexal pathology that ovaries uterus specifically the ovaries and the fallopian tubes can certainly bring pathology that will mimic appendicitis. And so those, those patients tend to require a little further investigation. That may just be where if you have a 14 year-old girl with classic right, lower quadrant tenderness similar to a 14 year-old boy, you may not do any further imaging on the boy, but on the girl you, you want to rule out a benign nonsurgical GYN issue. And so you’ll confirm that with an ultrasound, probably the first step. But there are many times where boys in that adolescent age would come to see us and they’re so classic that we don’t even do any further imaging it’s the girls that typically require and that age group, especially the adolescent girls, would require probably more, more likely to require a little bit more of a workup.

Dr. Segeleon: Great, thank you. That that’s, that’s very helpful information. I know that the surgical technique alone in appendicitis has just changed dramatically and has evolved over the years from open to laparoscopy, if you would, for our listeners in, in sort of a general way, give us current state, as far as the technique, how long does a child usually stay in the hospital? When do they get back on their feet? When do they get a normal diet, those types of things, if you would please?

Dr. Gorra: Sure. It used to be patients would always get an open 30, 30, 40 years ago. Patients would always go got an open, right lower quadrant incision over McBurney’s Point and do an open appendectomy. And then with the advent of laparoscopy quickly, laparoscopic surgery became kind of the standard. Then in pediatric surgery especially, the standard is accepted within our field is a laparoscopic approach. That allows for a quicker recovery time, less pain, smaller incisions and traditionally the laparoscopy has been done through three ports. So, it’s usually one port in the umbilicus, another port typically above the super pubic area, and then third port in the left lower quadrant. And one of these ports being 12 minutes millimeters in size, and the other two being 5 millimeters in size. And that’s sort of been a standard for at least a decade or more maybe 15 years in pediatric surgery. That that’s kind of the accepted standard there. I don’t know any pediatric surgeons who are board certified now that are doing open appendectomies upfront. But recently, we’ve been able to develop techniques of single site laparoscopy, which is just through the umbilicus itself. So we put a special device through the umbilicus and we’re able to insert the laparoscope and a couple of instruments, and we’re able to retrieve appendix all through the umbilicus with an incision that’s about two centimeters in one and a half to two centimeters in length. The incision ends up kind of getting buried in the center of the umbilicus. And typically within four to six weeks, they heal with the healing. It’s difficult to tell the patient the child even had surgery. So there’s a cosmetic benefit to that, to that, but I believe there’s also a real benefit from a surgical morbidity standpoint in terms of pain control and also I’ve seen, in my practice, very few wound infections when we go directly through the center of the umbilicus. The center of the umbilicus has no fat plane so we avoid going through a fat plane. Whereas when you go through other other regions of the abdomen especially in patients who have a little bit more subcutaneous fat, there’s sort of that dead space there, then that’s an increased risk for postoperative wound infection, especially in the setting of perforated appendicitis. So, we’ve seen very few surgical site infections with single site laparoscopy. Obviously patients and family and parents love the idea of a minimally invasive approach with almost no scarring long-term. So overall patient satisfaction is excellent. Complication rate is no different and we can manage perforated appendicitis or non-preferred appendicitis equally. In terms of postoperative care, we’ve been able to fast track this to the point where for most patients with non perforated appendicitis. We’re able to get them home within 24 hours and typically I try to get them actually discharged from PACU. So as if it were a day surgery and that’s really any time of day. So if I were to do an operation at 11 o’clock at night, and it was acute appendicitis, I tell the family I’m willing to send you home from the recovery room. There’s really no real major advantage to keeping you in the hospital because we don’t give any post-operative antibiotics in that setting. And it’s mostly about pain control. With a single site these patients go home on Tylenol and ibuprofen. For patients with more complicated appendicitis with perforation or abscess, they do require a stay in the hospital typically it’s 72 hours minimum to get IV antibiotics and there’s a significant risk of postoperative abscess of about 30% in those patients with a perforation and keeping them on antibiotics for a period of time decreases that risk. We can get them home within 72 hours on oral antibiotics and most of them do well. They will develop a a postoperative abscess and the advantage of being in a facility like this is we have access to seven days a week access to interventional radiologists who are able to manage our postoperative abscesses with CT guided drainage and that allows us to take care of the inter abdominal abscess without another operation. It’s very rare that we have to take a child back to the operating room for an intro dominal abscess. Our radiologists here are excellent, they provide timely care and that’s a huge advantage to being in this facility that they can get that full spectrum of care of no matter how complicated the disease process is.

Dr. Segeleon: Well, well, thank you that well, it’s pretty amazing. So you can get operated on for appendicitis and go home essentially the same day. That’s pretty, pretty startling, and really speaks to the evolution in our, in our care, our workup or complications. I know it’s always great to get patients up on their feet and home where they can, where they can heal.

Pediatric surgery is a, is a is a valuable and incredible resource for our region but there’s only a few of you here. So give our viewers, or give our listeners a bit of an opportunity to understand when should a provider call a pediatric surgeon? So in general, what types of things should they refer for a pediatric surgery?

Dr. Gorra: We care for a broad spectrum of diseases and conditions. Like I said before, and anything from inguinal hernias in babies up through skin lesions in teenagers, chest wall, abnormalities in teenagers… there’s a huge broad range of conditions that we care for. I really think, if there’s a provider out there, whether they are a family practice doctor or a general, a general surgeon out in the community who sees a condition that they just, they don’t see on a regular basis, they haven’t seen in a long time, they feel that they probably could care for it, but they’re not necessarily exposed to this on a, on a routine basis, we’re happy to take the phone calls. First of all, we’re happy to take the phone calls and guide you through what would be best for the patient. But we’re also always willing to willing to see those patients because we, there’s three of us here. We’re on call 24 hours. There’s always one of us here on call 24 hours a day and we have access to all our sub-specialists here. And so really, if there’s ever a doubt in your mind about, about what’s going on, we’re happy to see the patient. Including working a patient up for something as simple as appendicitis before you order that cat scan, or before you make that transfer call you know, that the decision to transfer the patient, we always happy to, to kind of walk you through that on the phone and make sure that we’re able to deliver that care, even if it’s sort of remote guidance. If we’re able to deliver that care that we would provide here locally, and if they need to come here and we’re always happy to have them.

Dr. Segeleon: Well, thank you. That’s very helpful. And I know that here at the children’s hospital, we benefit as well from having pediatric anesthesia who works with you and can help in that recovery. And so those are very beneficial. Thank you for all you do. The pediatric surgeons are also extraordinarily involved with pediatric trauma and with safety across the state, and really a valuable resource that our colleagues benefit from, but also, and more importantly, our patients and families benefit from. So thank you so much.

Host: Dr. Segeleon, thank you. Dr. Gorra, thank you for your expertise and for all that you do here at Sanford.

Dr. Gorra: Thanks for having me.

Host: Our Called to Care podcast series focusing on children continues right here with our Sanford Health experts. Thanks for being here. We’ll see you soon.

Posted In Children's, Physicians and APPs

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