1 00:00:00,000 --> 00:00:08,000 GlobalCast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. 2 00:00:13,000 --> 00:00:20,000 Hello, pediatric surgery family. I'm Cecilia Gigena, a research fellow from Cincinnati Children's Hospital Medical Center. 3 00:00:20,000 --> 00:00:25,000 Our 11th annual update course in pediatric surgery was held this past August. 4 00:00:25,000 --> 00:00:32,000 In this session, the surgeons discuss in roundtable fashion who can go home from the OR on the same day of the procedure. 5 00:00:32,000 --> 00:00:38,000 Today, we are talking about laparoscopic appendectomy for nonperforated appendicitis. 6 00:00:38,000 --> 00:00:44,000 Here we have a 12-year-old with two days of abdominal pain and ultrasound-confirmed appendicitis. 7 00:00:44,000 --> 00:00:49,000 Patient underwent a straightforward appendectomy and the appendix was not perforated. 8 00:00:49,000 --> 00:00:59,000 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. 9 00:00:59,000 --> 00:01:04,000 And then you can have that conversation of an interval appendectomy, which many will choose not to have. 10 00:01:04,000 --> 00:01:11,000 Nonoperative management of appendicitis was popular during the acute phase of the COVID-19 pandemic. But is this still the trend? 11 00:01:11,000 --> 00:01:16,000 Council, every family member, so we give people the option and we explain what the data shows. 12 00:01:16,000 --> 00:01:19,000 So you think that's where it's going to be right now? That's like we're done with the pendulum. 13 00:01:19,000 --> 00:01:24,000 I think you have to be honest about the fact that there's a 30% recurrence rate and that we know that recurrence rate. 14 00:01:24,000 --> 00:01:30,000 So we tend not to offer it to people with appendiculis because we know the likelihood of recurrence is much higher in those patients. 15 00:01:30,000 --> 00:01:35,000 Are there specific patients that are more likely to choose nonoperative management? 16 00:01:35,000 --> 00:01:43,000 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. 17 00:01:43,000 --> 00:01:51,000 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. 18 00:01:51,000 --> 00:01:55,000 And then in Seattle, 95% choose surgery, if not more. 19 00:01:55,000 --> 00:02:07,000 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. 20 00:02:07,000 --> 00:02:20,000 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. 21 00:02:20,000 --> 00:02:31,000 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. 22 00:02:31,000 --> 00:02:36,000 So what did the surgeons decide for sending patients home on the same day of their procedure? 23 00:02:36,000 --> 00:02:44,000 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. 24 00:02:44,000 --> 00:02:47,000 Okay, I wonder what all that something else is. 25 00:02:47,000 --> 00:02:50,000 Yeah, anything to chat about what the something else is? 26 00:02:50,000 --> 00:02:57,000 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. 27 00:02:57,000 --> 00:03:03,000 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. 28 00:03:03,000 --> 00:03:08,000 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. 29 00:03:08,000 --> 00:03:18,000 And what does the NISQIP data show? In a city out of Buffalo, New York, looking at post-aponectomy discharges from 2012 to 2015, 30 00:03:18,000 --> 00:03:28,000 22 percent of acute appendicitis was discharged the same day and was not associated with increased risk of readmissions or complications. 31 00:03:28,000 --> 00:03:36,000 In subsequent NISQIP reviews, we have seen the needle starting to move. So in the original time period, it was 22 percent. 32 00:03:36,000 --> 00:03:46,000 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. 33 00:03:46,000 --> 00:03:56,000 In the final paper that was reviewed, a health care system that lacked pediatric beds implemented same day discharges for uncomplicated appendectomies. 34 00:03:56,000 --> 00:04:03,000 The rates went from 45.5 to 84.4 with no difference in 30 day readmission or ED visit. 35 00:04:03,000 --> 00:04:10,000 So I think if you implement this and get the right players involved, you can really see a substantial increase in same day discharge. 36 00:04:10,000 --> 00:04:20,000 Pediatric surgeons from around the globe discussed the safety and incidence of same day discharge for laparoscopic appendectomy in non-perforated appendicitis. 37 00:04:20,000 --> 00:04:26,000 Nearly a third to half of surgeons are already sending their patients home on the same day. 38 00:04:26,000 --> 00:04:33,000 Setting expectations with the family prior to the procedure has helped with acceptance of same day discharges. 39 00:04:33,000 --> 00:04:38,000 And there are very few patients who come back within 24 hours of procedure. 40 00:04:38,000 --> 00:04:42,000 Don't forget to subscribe to the Stay Current MD YouTube channel. 41 00:04:42,000 --> 00:04:50,000 Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. 42 00:04:50,000 --> 00:05:13,000 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.