Tuesday, August 17, 2010

My Continued Anti-Percutaneous Drain Crusade in Appendicitis



A young kid comes into the ER with 36 hours of RLQ abdominal pain. The ER scans him. The scan shows an obvious 4cm abscess next to the appendix. What do you do?

RESIST THE URGE TO ORDER "CT GUIDED PERCUTANEOUS DRAINAGE".

Please. Just take the kid to the OR. Use your laparoscopic suction/irrigator to wash out the abscess. Remove the appendix. Leave a JP drain if you must. The kid goes home in 1-3 days. No more sitting in the hospital for a week with a foul smelling rubber tube hanging out his side. No more prolonged courses of expensive IV antibiotics. No more interval appendectomies. These patients don't need multi-staged management strategies with multiple invasive procedures. Just operate and be done with it.

15 comments:

Joseph Sucher, MD FACS said...

Valid argument... Especially in a child. BUT............

Maybe you have forgotten the last time that you went into an abscessed appendicitis, only to see what looks like the aftermath of an IED explosion.

Seriously, I have operated on some horrific appendiceal abscesses, and ended up needing to perform a right hemicolectomy. That is the whole point of drain with interval appendectomy. But figuring out which patient is OK to push forward with an operation and which to drain is not as simple as no abscess or abscess respectively - as you have pointed out.

JFS

Anonymous said...

I can't imagine patients or family wanting it any other way.

Sarada Kakinada said...

Not that I have seen 80 billion appys (as you have, I am sure), but I have never seen a JP drain placed for one, even if it was perforated. I'm not sure why, especially since there's not that much morbidity attached to popping one in, and there's a lot of benefit to keeping a drain ready to go should pus build up.

Boris Vinogradsky, MD, FACS said...

I wonder who, in sound mind, would do a CT-guided drainage of that abscess. Get the damn appendix out first.

Viktor said...

Great post. I absolutely agree!

Frank Drackman said...

Do those CT guided drainage things EVER work???...
I mean besides covering the Interventional Radiologist's Boat Payment..
I swear I could here the Staphylococci laughing the time I saw them try to drain an Empyema with those rediculous pigtails...
"Just put a 50 French Chest Tube in!!!!" I seathed silently.
That is big enough, isn't it?

Frank, "While it's true nothing heals like Stainless Steel, it'll hurt like S*** without a lung full of Sevoflurane" Drackman

Bongi said...

just one thing. i too have seen some pretty horrific appendixes and i just can't imagine needing to do a right hemi. so i suppose that means i agree with buckeye.

The Happy Hospitalist said...

if the patient doesn't have insurance, send them to IR for a drain

And then go out of town

Frank Drackman said...

Spoken like a True Flea.

Frank "I Hate Fleas" Drackman

Sauper said...

Amen from an old county brother. If the appendix still exists even with that abscess, wash it out and take it out. I've also not found interval appys to be that gratifying or even necessary if the exploded 'pendix is no longer visible on f/u CT if you've gone that route.

DHS said...

What do you do with the stump in an abscess like this? The caecum's probably completely inflamed... will it take an endoloop?

Anonymous said...

My 11 year son is currently suffering from this. His drain has been in for over 7 weeks now..still has appendix in. Perforated bowel as well. I'm freaking out! Do I need second opinion...when will the appendix come out! I have insurance.

SRWeaver said...

Comment from over the pond - CT guided drainage? Has it's place, but in a very few, well selected patients.
Remove the source of infection, wash out leave a drain - so what buckeye said!

Anonymous said...

Well - I left comment on Oct. 15. My son's appendix finally removed Oct. 24 (emergency) but huge abdominal abscess now formed shortly after surgery and his drain was already removed (Oct 27). New drain in front of my son's body now (placed in Nov. 6) for this new abscess (blood clot). Week 13 of appendix nightmare...(all started Sept. 8). No doubt this case will be in (Cdn) medical books. 8 sonograms+ and 2 CT scans later and numerous medications....he's 11 yrs old..

Anonymous said...

I see a lot of opinions...but there is data on this topic. There is a 3X higher rate of complications from attempted appy vs. drain and interval appy.