UPDATE COURSE REWIND- WHO TO SEND HOME FROM THE OR: LAPAROSCOPIC APPENDECTOMY FOR A NON-PERFORATED APPENDICITIS PART 2

GlobalCast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm Cecilia Gigena, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held this past August. In this session, the surgeons discuss in roundtable fashion who can go home from the OR on the same day of the procedure.

Today, we are talking about laparoscopic appendectomy for nonperforated appendicitis.

Here we have a 12-year-old with two days of abdominal pain and ultrasound-confirmed appendicitis. Patient underwent a straightforward appendectomy and the appendix was not perforated. You can save a lot of transfers. You get patients from all over the region, from out of state, that technically can be discharged from their EDs and followed with you in clinic. And then you can have that conversation of an interval appendectomy, which many will choose not to have.

Nonoperative management of appendicitis was popular during the acute phase of the COVID-19 pandemic. But is this still the trend? Council, every family member, so we give people the option and we explain what the data shows. So you think that's where it's going to be right now? That's like we're done with the pendulum. I think you have to be honest about the fact that there's a 30% recurrence rate and that we know that recurrence rate.

So we tend not to offer it to people with appendiculis because we know the likelihood of recurrence is much higher in those patients. Are there specific patients that are more likely to choose nonoperative management? It's variable. We'll often see with athletes maybe that are about to enter their season that they'll pick to not have the operation because they don't want to miss time.

In Los Angeles, two thirds chose nonoperative management and of those, probably more than half of those were able to send home in the ED. And then in Seattle, 95% choose surgery, if not more. Sure decision making is an important part of these outcomes, provided the patient and parents with accurate data allows them to make the best decision for management, whether it's surgical or nonoperative.

I don't want to pass over the point you made, which is that this could be used to avoid transfer. That patients that are outlying facilities, you give them antibiotics and this could be treated another time. I think that's a very important topic. If patients present to an ED and there is no surgeon who can operate, it's reasonable to treat them with antibiotics and follow up with a surgeon as an outpatient to discuss interval appendectomy.

So what did the surgeons decide for sending patients home on the same day of their procedure? A third would send them home from the PACU, a third would send them home from the floor and a third would send them home on the following day. Okay, I wonder what all that something else is. Yeah, anything to chat about what the something else is? Ours is really system related. So I think many of us send these patients home from the PACU, which we can do if they have not yet made it to the floor.

So if they've been admitted to the floor, then we're not allowed to discharge them from the PACU, in which case I would send them back to the floor and discharge them. If they have come straight from the emergency department to the OR, then we can discharge them from the PACU. So it's a system problem.

And what does the NISQIP data show? In a city out of Buffalo, New York, looking at post-aponectomy discharges from 2012 to 2015, 22 percent of acute appendicitis was discharged the same day and was not associated with increased risk of readmissions or complications. In subsequent NISQIP reviews, we have seen the needle starting to move. So in the original time period, it was 22 percent.

And then this is up to a mid 30 percent. And then you can go ahead to the most recent one covering 2017 up to 2021. We're up to 43 percent. In the final paper that was reviewed, a health care system that lacked pediatric beds implemented same day discharges for uncomplicated appendectomies. The rates went from 45.5 to 84.4 with no difference in 30 day readmission or ED visit.

So I think if you implement this and get the right players involved, you can really see a substantial increase in same day discharge.

Pediatric surgeons from around the globe discussed the safety and incidence of same day discharge for laparoscopic appendectomy in non-perforated appendicitis. Nearly a third to half of surgeons are already sending their patients home on the same day. Setting expectations with the family prior to the procedure has helped with acceptance of same day discharges. And there are very few patients who come back within 24 hours of procedure.

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