Meta-analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis

Patient characteristics, outcomes and costs following interhospital transfer to a tertiary facility for appendectomy versus patients who present directly

BACKGROUND

Recent healthcare policy changes have emphasized pay-for-performance. Previous studies have not examined outcome differences between primary presenting appendicitis patients and transferred patients.

METHODS

A retrospective cohort design examined appendicitis patients between March 2011 and 2013. Patients < age 18, were scheduled for an elective appendectomy, who were pregnant or had an interval appendectomy were excluded.

RESULTS

The transfer cohort (n = 59) had more comorbidities, more severe American Society of Anesthesiologists status, a higher rate of pre-operative abscess/rupture as well as higher rates of perforation, gangrene, intra-operative drain placement and open conversion versus primary presenting patients (n = 622). After statistical regression adjustment, a higher open conversion rate in the transfer cohort, OR = 3.48 (95%CI: 1.04-11.61) and higher total costs $672.47 (95%CI: $68.75-$1276.19) remained.

CONCLUSIONS

Adjustments in clinical outcome/reimbursement metrics may be needed to address the complexity of transfers and the subsequent higher in-hospital costs on tertiary facilities.

LEVEL OF EVIDENCE

IV.

Analysis of antibiotics selection in patients undergoing appendectomy in a Chinese tertiary care hospital

Background

To investigate the status of antibiotics use in acute appendicitis patients who undergo appendectomy in a Chinese tertiary care hospital.

Methods

A retrospective analysis of 93 patients who underwent appendectomy from June 1, 2011 to May 30, 2012 and had recorded use of intravenous antibiotics. We defined simple appendicitis and suppurative appendicitis as mild appendicitis. Gangrenous appendicitis and perforated appendicitis were classified as advanced appendicitis. The occurrence of advanced appendicitis, postoperative complications and length of hospital stay were the three major end points for outcomes analysis.

Results

100 % of the patients received antibiotics therapy before and after operation. 45 patients received Fluoroquinolones (48.4 %), 41 patients received Cephalosporins (44.1 %) and 7 patients received Carbapenems (7.5 %). We found no statistical difference between antibiotics selection and the occurrence of advanced appendicitis (P = 0.3337). Both the monovariate analysis and multivariate analysis showed no statistical difference between antibiotics selection and the postoperative complications (P > 0.05). The average stay of patients receiving Fluoroquinolones was 2.6 days shorter than patients who received Cephalosporins (P = 0.0085).

Conclusion

It is a lack of a standardized guideline for antibiotics selection in our hospital. All the antibiotics prescription were empirical. We tended to choose high levels of antibiotics, pay insufficient attention to the anaerobic bacteria and have a long duration of antibiotics therapy. We also found that antibiotics selection bore no relationship with the occurrence of advanced appendicitis and postoperative complications. Fluoroquinolones may lead to a shorter hospital stay, but this result may also be affected by the fewer underlying diseases and lower severity of the patients.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Two-port laparoscopic anterior resection through a self-made glove device versus conventional laparoscopic anterior resection for rectal cancer: a comparison of short-term surgical results

Background

The laparoscopic approach has become increasingly incorporated into the development of new surgical procedures. An ever-increasing number of surgeons desire methods that minimize surgical trauma and provide improved cosmetic outcomes. Since 2014, we have performed two-port laparoscopic surgery using a transumbilical multichannel glove port and a 12-mm port. The aim of this study was to compare the short-term surgical results of two-port laparoscopic anterior resection (TPLAR) with those of conventional laparoscopic anterior resection (CLAR) for rectal cancer.

Methods

Between January 2014 and May 2014, a total of 27 patients underwent TPLAR and 30 patients underwent CLAR for the treatment of rectal cancer. The short-term surgical results of these two groups of patients were analyzed retrospectively.

Results

The differences in operative time, blood loss, conversion rate, complication rate, distal resection margin, number of harvested lymph nodes, duration until ambulation, duration until first flatus, length of postoperative hospital stay, and overall hospital costs between the two groups were not significant. The median (range) length of the abdominal incisions of the TPLAR patients was shorter than the length of the CLAR patients (5.1 (4.5–16.3) cm vs 8.2 (7.0–10.0) cm, respectively; p < 0.001). The respective median (range) postoperative pain scores were lower in the TPLAR than in the CLAR patients at 24 h (4 (1–6) h vs 5 (2–8) h; p = 0.045), 48 h (3 (1–4) h vs 4 (range 1–8) h; P = 0.004) and 72 h (1 (0–3) h vs 2 (1–5) h; p = 0.010). The median overall score on the satisfaction-with-abdominal-incision questionnaire of the TPLAR patients was significantly higher (better) than the score of the CLAR patients.

Conclusions

TPLAR for rectal cancer is safe and feasible, with short-term perioperative and oncological outcomes similar to those of CLAR. TPLAR provides less postoperative pain and better cosmetic outcomes.

Laparoscopy in Duodenal Switch: Safe and Halves Length of Stay in a Nationwide Cohort from the Scandinavian Obesity Registry

BACKGROUND AND AIMS

Unsatisfactory weight loss after gastric bypass or sleeve gastrectomy in super-obese patients (body mass index > 50) is a growing concern. Biliopancreatic diversion with duodenal switch results in greater weight loss, but is technically challenging to perform, especially as a laparoscopic procedure (Lap-DS). The aim of this study was to compare perioperative outcomes of Lap-DS and the corresponding open procedure (O-DS) in Sweden.

MATERIAL AND METHODS

The data source was a nationwide cohort from the Scandinavian Obesity Surgery Registry and 317 biliopancreatic diversion with duodenal switch patients (mean body mass index = 56.7 ± 6.6 kg/m², 38.4 ± 10.2 years, and 57% females) were analyzed. Follow-up at 30 days was complete in 98% of patients.

RESULTS

The 53 Lap-DS patients were younger than the 264 patients undergoing O-DS (35.0 vs 39.1 years, p = 0.01). Operative time was 163 ± 38 min for lap-DS and 150 ± 31 min for O-DS, p = 0.01, with less bleeding in Lap-DS (94 vs 216 mL, p < 0.001). There was one conversion to open surgery. Patients undergoing Lap-DS had a shorter length of stay than O-DS, 3.3 versus 6.6 days, p = 0.02. No significant differences in overall complications within 30 days were seen (12% and 17%, respectively). Interestingly, the two leaks in Lap-DS were located at the entero-enteric anastomosis, while three out of four leaks in O-DS occurred at the top of the gastric tube.

CONCLUSION

Lap-DS can be performed by dedicated bariatric surgeons as a single-stage procedure. The use of laparoscopic approach halved the length of stay, without increasing the risk for complications significantly. Any difference in long-term weight result is pending.

Factors Associated With Small Bowel Obstruction Following Appendectomy: A Population-Based Study

Postoperative small bowel obstruction (SBO) is a common complication of appendectomy. This study aimed to assess risk factors for SBO following appendectomy.This retrospective cohort study used the 2006 to 2008 Taiwan National Health Insurance Research Database. We evaluated adult patients with acute appendicitis who underwent open (OA) or laparoscopic appendectomy (LA) between January 1, 2006 and December 31, 2008. Excluded were patients with a history of abdominal surgery and SBO before the index operation, or abdominal surgery between the appendectomy and initial diagnosis of bowel obstruction as an identifiable cause of SBO. Factors thought to influence postoperative SBO were highlighted. The OA and LA cohorts were matched by propensity score, and the hazard ratios (HRs) and 95% confidence interval (CIs) of SBO were calculated.We enrolled 11,289 patients who underwent OA, and 11,289 matched controls who underwent LA. OA patients had significant risk of adhesive SBO compared with the LA group (adjusted HR: 1.7, 95% CI: 1.11-2.63). Further analysis revealed that that female sex (adjusted HR: 1.79, 95% CI: 1.17-2.72), CCI score of 1 or ≥2 (adjusted HR: 3.16, 95% CI: 1.76-5.67; adjusted HR: 4.03, 95% CI: 1.57-10.34), complicated appendicitis (adjusted HR: 1.68, 95% CI: 1.05-2.69), treatment in district hospitals increased risk of adhesive SBO.Female sex, complicated appendicitis, more comorbidities, and treatment in district hospitals are factors associated with a risk of SBO after appendectomy. Our findings confirmed that a laparoscopic approach is better than an open approach.

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

Background

For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis.

Methods

A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.

Conclusion

The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary.

Limitations of each evolving

Evidence of surgical outcomes fluctuates over time: results from a cumulative meta-analysis of laparoscopic versus open appendectomy for acute appendicitis

Background

In surgical trials, complex variables such as equipment development and surgeons’ learning curve are involved. The evidence obtained in these trials can thus fluctuate over time. We explored the stability of the evidence obtained during surgery by conducting a cumulative meta-analysis of randomized controlled trials for open and laparoscopic appendectomy.

Methods

We conducted a cumulative meta-analysis of randomized controlled trials comparing laparoscopic appendectomy with open appendectomy for acute appendicitis, a topic with the greatest number of trials in the gastroenterological surgical field. We searched the MEDLINE (PubMed), EMBASE, and CINAHL databases up to September 2014 and reviewed the bibliographies. Outcomes were the incidence of intra-abdominal abscess, incidence of wound infection, operative time, and length of hospital stay. We used the 95 % confidence interval (95 % CI) of effect size for the significance test.

Results

Sixty-four trials were included in this analysis. Of the 51 trials addressing intra-abdominal abscesses, our cumulative meta-analysis of trials published up to and including 2001 demonstrated statistical significance in favor of open appendectomy (cumulative odds ratio [OR] 2.35, 95 % CI 1.30–4.25). The effect size in favor of open procedures began to disappear after 2001, leading to an insignificant result with an overall cumulative OR of 1.32 (95 % CI 0.84–2.10) when laparoscopic appendectomy was compared with open appendectomy.

Conclusions

The evidence regarding treatment effectiveness changed over time, after treatment effectiveness became significant in trials comparing laparoscopic and open appendectomy. Observing only the 95 % confidence interval of effect size from a meta-analysis may not provide conclusive results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-016-0453-0) contains supplementary material, which is available to authorized users.

Antimicrobial treatment after laparoscopic appendectomy for preventing a post-operative intraabdominal abscess: A Prospective Cohort Study of 1817 patients

INTRODUCTION

Post-operative antimicrobial treatment is usually administered to prevent a post-operative intraabdominal abscess (IAA) after laparoscopic appendectomy (LA). The aim of this study was to identify the role of post-operative antibiotic treatment and the optimal length for the antibiotic course to prevent post-operative IAA after LA.

METHODS

Between January 2010 and December 2013, 1817 patients who underwent three-port LA were enrolled in this study. Patients were classified into four groups according to the type of appendicitis and infectious source control. The characteristics of antimicrobial treatment and the incidence of IAA were analyzed and compared among the four groups.

RESULTS

The incidence of IAA after three-port LA was 1.5% (27/1817). The mean durations of post-operative antibiotic use were 3.1 days for the non-IAA group and 3.3 days for the IAA group, with no significant difference between the groups (p = 0.510).

DISCUSSION

The length of post-operative antibiotic treatment and antimicrobial combination therapy did not affect the development of IAA, and prolonged antibiotic treatment did not prevent IAA. However, when source control was not completely achieved, an IAA was frequently observed in the patient group that received a short course of antibiotic treatment.

CONCLUSION

The role of antibiotic treatment for preventing post-appendectomy IAA seems to be related with achieving intraperitoneal infectious source control. In the setting of incomplete source control, we recommend a 5-day course of antimicrobial combination therapy and consecutive source control such as peritoneal drainage.

Advances in laparoscopy for acute care surgery and trauma

The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers, for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a laparoscopic approach to the treatment of the most common emergency surgical conditions.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Transition towards laparoscopic appendicectomy at a UK center over a 7-year period

BACKGROUND

Acute appendicitis remains the most common indication for emergency abdominal surgery in the United Kingdom. Although laparoscopic appendicectomy has demonstrable advantages over open appendicectomy, uptake has not been universal. The aims of this study were to describe trends in laparoscopic appendicectomy in a District General Hospital in Scotland.

METHODS

Retrospective review of appendix histopathology records within NHS Fife between 2003 and 2010. Note review of cases of acute appendicitis managed with laparoscopic appendicectomy was performed. Perioperative variables in perforated and nonperforated appendicitis were compared. A multivariate logistic regression analysis to determine factors associated with developing complications was performed.

RESULTS

Between 2003 and 2010, 237 laparoscopic appendicectomies were performed. The rate of laparoscopic appendicectomy increased from 2.5% in 2003 to 78% in 2010. In 50% of cases, the trainee surgeon was the primary operator. Complications occurred in 9.6% and the mortality rate was 0.4%. No factors on multivariate logistic regression predicted development of complications.

CONCLUSIONS

We describe a change in practice towards laparoscopic appendicectomy for the treatment of acute appendicitis over a 7-year period. Furthermore, laparoscopic appendicectomy is associated with acceptable morbidity rates.

Laparoscopic management of intra-abdominal infections: Systematic review of the literature

AIM: To investigate the role of laparoscopy in diagnosis and treatment of intra abdominal infections.

METHODS: A systematic review of the literature was performed including studies where intra abdominal infections were treated laparoscopically.

RESULTS: Early laparoscopic approaches have become the standard surgical technique for treating acute cholecystitis. The laparoscopic appendectomy has been demonstrated to be superior to open surgery in acute appendicitis. In the event of diverticulitis, laparoscopic resections have proven to be safe and effective procedures for experienced laparoscopic surgeons and may be performed without adversely affecting morbidity and mortality rates. However laparoscopic resection has not been accepted by the medical community as the primary treatment of choice. In high-risk patients, laparoscopic approach may be used for exploration or peritoneal lavage and drainage. The successful laparoscopic repair of perforated peptic ulcers for experienced surgeons, is demonstrated to be safe and effective. Regarding small bowel perforations, comparative studies contrasting open and laparoscopic surgeries have not yet been conducted. Successful laparoscopic resections addressing iatrogenic colonic perforation have been reported despite a lack of literature-based evidence supporting such procedures. In post-operative infections, laparoscopic approaches may be useful in preventing diagnostic delay and controlling the source.

CONCLUSION: Laparoscopy has a good diagnostic accuracy and enables to better identify the causative pathology; laparoscopy may be recommended for the treatment of many intra-abdominal infections.

The TICAP-Study (titanium clips for appendicular stump closure): A prospective multicentre observational study on appendicular stump closure with an innovative titanium clip

Background

To evaluate the effectiveness and safety of the DS Titanium Ligation Clip for appendicular stump closure in laparoscopic appendectomy.

Methods

Overall, 502 patients undergoing laparoscopic appendectomy were recruited for this observational multicentre study in nine study centres between October 2011 and July 2013. The clip was finally applied in 390 patients. Primary outcome variables were feasibility of the clip, intra-abdominal surgical site (abscesses, stump leakages) and superficial wound infections. Patients were followed 30 days after surgery.

Results

The clip was applicable in nearly 80 % of patients. Reasons for not applying the clip were mainly an inflamed caecum or a too large diameter of the appendix base. Superficial wound infections were found in nine (2.31 %), intra-abdominal abscesses in five (1.28 %), appendicular stump leak in one (0.26 %), and other adverse events in 22 (5.64 %) patients. In total, 12 (3.08 %) patients were re-admitted to hospital for treatment. Seven re-admissions were surgery-related; ten (2.56 %) patients had to be re-operated. One patient died during the course of the study due to persisting peritonitis (mortality 0.26 %).

Conclusions

The results suggest that the DS Titanium Ligation Clip is a safe and effective option in securing the appendicular stump in laparoscopic appendectomy. The complication rates found with the use of the DS-Clip are comparable to the rates in the literature when other methods are used.

Trial Registration

NCT01734837.

Gasless transumbilical laparoscopic-assisted appendectomy as a safe and cost-effective alternative surgical procedure for mild acute appendicitis

PURPOSE

Several reports have demonstrated the effectiveness and feasibility of single incisional transumbilical laparoscopic-assisted appendectomy (TULAA). We developed a modified TULAA technique, gasless-TULAA, which involves lifting the abdominal wall with a retractor, without pneumoperitoneum or another incision.

METHODS

We assessed the surgical outcomes of 257 patients treated for appendicitis in our hospital between 2005 and 2013. In a preoperative comprehensive evaluation, appendicitis without abscess was defined as mild appendicitis (mild appendicitis group: MAG), and appendicitis with abscess was defined as severe appendicitis (severe appendicitis group: SAG). The clinical outcomes were compared with those in other published reports. The cost-effectiveness of gasless-TULAA was compared with that of conventional multiport laparoscopic appendectomy (CMLA) in our hospital.

RESULTS

In MAG (n = 228), the operation time and postoperative hospital stay were 46.9 ± 22.7 min and 2.6 ± 1.2 days, respectively. The gasless-TULAA was completed without trocars in 91.2 % of patients. The surgical outcomes of SAG were significantly worse than those of MAG (p < 0.001). The surgical cost of gasless-TULAA was significantly lower than that of CMLA (p < 0.001).

CONCLUSION

Gasless-TULAA is a cost-effective, safe, and readily available surgical technique for mild appendicitis, which can obviate the need for specialized equipment.

Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials

BACKGROUND

Several systematic reviews (SRs) of randomised controlled trials (RCTs) comparing laparoscopic versus open appendectomy have been published, but there has been no overview of SRs of these two interventions. This overview (review of review) aims to summarise the results of such SRs in order to provide the most up to date evidence, and to highlight discordant results.

METHODS

Medline, Embase, Cinahl, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects were searched for SRs published up to August 2014. Study selection and quality assessment using the AMSTAR tool were carried out independently by two reviewers. We used standardised forms to extract data that were analysed descriptively.

RESULTS

Nine SRs met the inclusion criteria. All were of moderate to high quality. The number of randomized controlled trials (RCTs) they included ranged from eight to 67. The duration of surgery pooled by eight reviews was 7.6 to 18.3 minutes shorter using the open approach. Pain scores on the first postoperative day were lower after laparoscopic appendectomy in two out of three reviews. The risk of abdominal abscesses was higher for laparoscopic surgery in half of six meta-analyses. The occurrence of wound infections pooled by all reviews was lower after laparoscopic appendectomy. One review showed no difference in mortality. The laparoscopic approach shortened hospital stay from 0.16 to 1.13 days in seven out of eight meta-analyses, though the strength of the evidence was affected by strong heterogeneity.

CONCLUSION

Laparoscopic and open appendectomy are both safe and effective procedures for the treatment of acute appendicitis. This overview shows discordant results with respect to the magnitude of the effect but not to the direction of the effect. The evidence from this overview may prove useful for the development of clinical guidelines and protocols.

The impact of disease severity, age and surgical approach on the outcome of acute appendicitis in children

PURPOSE

Although a national guideline has been implemented, the optimal approach for appendectomy in children remains subject of debate in the Netherlands. Opponents of laparoscopy raise their concerns regarding its use in complex appendicitis as it is reported to be associated with an increased incidence of intra-abdominal abscesses. The aim of this study was to evaluate the outcome of surgical approaches in both simple and complex appendicitis in paediatric patients.

METHODS

A 10-year retrospective cohort study was performed (2001-2010) in paediatric patients treated for suspected acute appendicitis. Patients were divided into either simple or complex appendicitis and into different age groups. Primary outcome parameters were complication rate (intra-abdominal abscess (IAA), superficial surgical site infection (SSI) and readmission) and hospital stay.

RESULTS

In total, 878 patients have been treated (median age 12, range 0-17 years). Two-thirds of the patients younger than 6 years had complex appendicitis, compared to one quarter in the group aged 13-18. In the complex appendicitis group, LA was associated with more IAA and early readmissions. In the simple appendicitis group, the complication rate was comparable between the two approaches. Significantly more IAAs were seen after LA in the youngest age group.

CONCLUSION

This study demonstrates the unfavourable outcome of LA in the youngest age group and in patients with complex appendicitis. Therefore, we advise to treat these patients with an open approach.

Transvaginal appendectomy: a systematic review

Background. Natural orifice transluminal endoscopic surgery (NOTES) is a new approach that allows minimal invasive surgery through the mouth, anus, or vagina. Objective. To summarize the recent clinical appraisal, feasibility, complications, and limitations of transvaginal appendectomy for humans and outline the techniques. Data Sources. PubMed/MEDLINE, Cochrane, Google-Scholar, EBSCO, clinicaltrials.gov and congress abstracts, were searched. Study Selection. All related reports were included, irrespective of age, region, race, obesity, comorbidities or history of previous surgery. No restrictions were made in terms of language, country or journal. Main Outcome Measures. Patient selection criteria, surgical techniques, and results. Results. There were total 112 transvaginal appendectomies. All the selected patients had uncomplicated appendicitis and there were no morbidly obese patients. There was no standard surgical technique for transvaginal appendectomy. Mean operating time was 53.3 minutes (25–130 minutes). Conversion and complication rates were 3.6% and 8.2%, respectively. Mean length of hospital stay was 1.9 days. Limitations. There are a limited number of comparative studies and an absence of randomized studies. Conclusions. For now, nonmorbidly obese females with noncomplicated appendicitis can be a candidate for transvaginal appendectomy. It may decrease postoperative pain and enable the return to normal life and work off time. More comparative studies including subgroups are necessary.

Single-incision laparoscopic appendectomy versus conventional 3-port laparoscopic appendectomy for appendicitis: an updated meta-analysis of randomized controlled trials

PURPOSE

To compare the efficacy and safety of single-incision laparoscopic appendectomy (SILA) and conventional 3-port laparoscopic appendectomy (3-port LA) for appendectomy.

METHODS

We searched the PubMed, Embase, Springer link, and the Cochrane library databases up to April, 2014, for relevant randomized controlled trials (RCTs). Data were pooled by weighted mean differences (WMDs) or odds ratios (ORs) with their 95% confidence intervals (CIs).

RESULTS

We found 11 RCTs, with a collective total of 731 patients treated with SILA and 725 patients treated with 3-point LA. Results indicated no significant differences between SILA and 3-port LA in primary outcomes, including wound infection, intra-abdominal abscess, postoperative ileus, and total postoperative complications, and some secondary outcomes, including postoperative pain scores and length of hospital stay. However, SILA was associated with significantly longer operative times (WMD = 6.78, 95% CI = 3.78-9.79, P < 0.00001) and higher doses of analgesia (WMD = 0.96, 95% CI = 0.45-1.47, P = 0.0002) than the 3-port LA.

CONCLUSION

Although there was no significant difference in the safety of SILA vs. that of 3-port LA, our findings do not support the application of SILA because of its significantly longer operative times and the higher doses of analgesia required compared with those for 3-point LA.

Single incision versus conventional multiport laparoscopic appendectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of single incision laparoscopic appendectomy (SILA) in comparison with conventional multiport laparoscopic appendectomy (CMLA) has not been conclusively determined.

METHODS

A systematic literature review (Medline, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trials) was performed. Meta-analyses of randomized controlled trials (RCTs) comparing SILA with CMLA were carried out by RevMan 5.0 software.

RESULTS

Eleven RCTs comparing SILA and CMLA were included. Overall, 1,216 patients were operated on: 611 cases by SILA versus 605 cases by CMLA. Compared with CMLA, SILA was associated with increased procedural difficulty, prolonged procedural duration, shorter length of hospital stay, earlier return to normal activity and better cosmesis. There were no significant differences in postoperative pain scores and complication rates between SILA and CMLA.

CONCLUSION

The current best evidence shows SILA holds the promise of improving postoperative recovery and cosmetic result with equal efficacy and safety, whereas it is associated with higher surgical difficulty with longer surgical time when compared with CMLA.

Pictorial review of normal postoperative cross-sectional imaging findings and infectious complications following laparoscopic appendectomy

Laparoscopic appendectomy is increasingly accepted as the preferred surgical treatment for acute appendicitis and represents one of the most common emergency operations performed in both adult and paediatric populations. However, in patients with perforated appendicitis laparoscopy is associated with an increased incidence of postoperative intraabdominal infections compared to open appendectomy. Nowadays urgent imaging is commonly requested by surgeons when postoperative complications are suspected. Due to the widespread use of laparoscopy, in hospitals with active surgical practices clinicians and radiologists are increasingly faced with suspected postappendectomy complications. This pictorial essay illustrates the normal cross-sectional imaging findings observed shortly after laparoscopic appendectomy and the spectrum of appearances of iatrogenic intraabdominal infections observed in adults and adolescents, aiming to provide radiologists with an increased familiarity with early postoperative imaging. Emphasis is placed on the role of multidetector CT, which according to the most recent World Society of Emergency Surgery (WSES) guidelines is the preferred and most accurate modality to promptly investigate suspected intraabdominal infections and highly helpful for correct therapeutic choice, particularly to identify those occurrences that require in-hospital treatment, drainage or surgical reintervention. In teenagers and young adults MRI represents an attractive alternative modality to detect or exclude iatrogenic abscesses without ionising radiation.

Teaching points

• Laparoscopic appendectomy is the preferred surgical treatment for uncomplicated acute appendicitis

• In perforated appendicitis laparoscopy results in increased incidence of intraabdominal infections

• Multidetector CT promptly assesses suspected iatrogenic intraabdominal infections

• Interpretation of early postoperative CT requires knowledge of normal postsurgical imaging findings

• Postsurgical infections include right-sided peritonitis, intraabdominal, pelvic or liver abscesses

Efficacy of transumbilical laparoscopic-assisted appendectomy for appendicitis: a four-year experience at a single center

PURPOSE

To compare the surgical outcomes after transumbilical laparoscopic-assisted appendectomy (TULAA) and open appendectomy (OA) at a single institution.

METHODS

We compared the surgical outcomes for 94 consecutive patients who underwent TULAA between April 2010 and March 2014 to those for 91 consecutive patients who underwent OA between April 2006 and March 2010.

RESULTS

There were no significant differences in the clinicopathological backgrounds between the two groups. Although the lengths of the operations were similar in both groups, the postoperative hospital stay was significantly shorter in the TULAA group (4.7 days vs. 5.4 days, P = 0.02). The need for abdominal drain insertion was significantly reduced in the TULAA group owing to sufficient intraperitoneal exploration (P = 0.03). The incidence of postoperative complications was also lower in the TULAA group, but the difference was not significant (8.6 % vs. 12.1 %, P = 0.31). In complicated cases, a lower incidence of surgical site infection was confirmed in the TULAA group (6.7 % vs. 20.7 %, P = 0.12).

CONCLUSION

Our results demonstrated that TULAA provided better surgical outcomes, especially a faster recovery. TULAA could be an effective procedure incorporating both open and laparoscopic techniques, and can be implemented as a standard procedure for the treatment of appendicitis, regardless of disease severity.

New strategy during complicated open appendectomy: Convert open operation to laparoscopy

AIM: To introduce a new strategy during complicated open appendectomy - converting open operation to laparoscopy.

METHODS: We retrospectively reviewed databases at two institutions between October 2010 and January 2013, identifying 826 patients who had undergone complicated appendectomy for histologically confirmed acute or chronic appendicitis. They included 214 complicated appendectomies: 155 lengthened-incision open appendectomies (LIA group) and 59 open appendectomies with conversion to laparoscopy (OACL group).

RESULTS: A total of 214 patients with complicated appendectomies were included in the study, including 155 cases of LIA and 59 cases of OACL. No major complication leading to death occurred in the study. Patient characteristics of the two groups were similar. Several parameters showed a significant difference between the two groups. For the OACL vs LIA groups they were, respectively: incision length (3.8 ± 1.4 cm vs 6.2 ± 3.5 cm, P < 0.05); time to flatus recovery (2.3 ± 0.6 d vs 4.2 ± 0.8 d, P < 0.05), drainage rate (61.0% vs 80.0%, P < 0.05); pain level (3.6 ± 1.8 vs 7.2 ± 2.4, P < 0.05); hospital stay (5.1 ± 2.7 d vs 8.7 ± 3.2 d, P < 0.05); complication rate (8.5% vs 14.7%, P < 0.05). Other factors showed no significant differences.

CONCLUSION: Lengthened-incision open appendectomy increases the incidence of complications and prolongs the hospital stay. Conversion of open to laparoscopic appendectomy is feasible and efficient in complicated cases. It decreases the rate of incisional and abdominal infections, allows faster return of bowel movements, and shortens the hospital stay.

Short-term complications and long-term morbidity of laparoscopic and open appendicectomy in a national cohort

Background

Laparoscopic appendicectomy has been proposed as the standard for surgical treatment of acute appendicitis, based on controversial evidence. This study compared outcomes after open and laparoscopic appendicectomy in a national, population-based cohort.

Methods

All patients who underwent open or intended laparoscopic appendicectomy in Sweden between 1992 and 2008 were identified from the Swedish National Patient Register. The outcomes were analysed according to intention to treat with multivariable adjustment for confounding factors and survival analytical techniques where appropriate.

Results

A total of 169 896 patients underwent open (136 754) or intended laparoscopic (33 142) appendicectomy. The rate of intended laparoscopic appendicectomy increased from 3·8 per cent (425 of 11 175) in 1992 to 32·9 per cent (3066 of 9329) in 2008. Laparoscopy was used most frequently in middle-aged patients, women and patients with no co-morbidity. The rate of conversion from laparoscopy to open appendicectomy decreased from 75·3 per cent (320 of 425) in 1992 to 19·7 per cent (603 of 3066) in 2008. Conversion was more frequent in women and those with perforated appendicitis, and the rate increased with age and increasing co-morbidity. After adjustment for co-variables, compared with open appendicectomy, laparoscopy was associated with a shorter length of hospital stay (by 0·06 days), a lower frequency of negative appendicectomy (adjusted odds ratio (OR) 0·59; P &lt; 0·001), wound infection (adjusted OR 0·54; P = 0·004) and wound rupture (adjusted OR 0·44; P = 0·010), but higher rates of intestinal injury (adjusted OR 1·32; P = 0·042), readmission (adjusted OR 1·10; P &lt; 0·001), postoperative abdominal abscess (adjusted OR 1·58; P &lt; 0·001) and urinary infection (adjusted OR 1·39; P = 0·020). Laparoscopy had a lower risk of postoperative small bowel obstruction during the first 2 years after surgery, but not thereafter.

Conclusion

The outcomes of laparoscopic and open appendicectomy showed a complex and contrasting pattern and small differences of limited clinical importance. The choice of surgical method therefore depends on the local situation, the surgeon's experience and the patient's preference.

Is laparoscopic appendectomy going to be standard procedure for acute appendicitis; a 5-year single center experience with 1,788 patients

PURPOSE

To evaluate whether laparoscopic appendectomy can be the gold standard for acute appendicitis regarding the applicability and cost effectivity.

MATERIALS AND METHODS

The study included patients who were operated by laparoscopically for acute appendicitis between January 2008 and September 2012. Patients' sex, ages, hospitalization time, the type for closure of the appendiceal stump, complication rate, surgery time and other parameters were recorded.

RESULTS

1,788 patients with acute appendicitis on laparoscopic evaluation constituted the study population. Average age of the patient group was 30.1 ± 2.3 years old. Average hospitalization time was 1.2 ± 1.1 days. Metal clips were used in 1,100 (61.5%) patients, intracorporeal knotting was performed in the remaining. Total complication rate was 3.8%.

CONCLUSION

By the using of metal clips and increased experience; laparoscopy may be gold standard for acute appendicitis.

Single-incision versus conventional laparoscopic appendectomy: a meta-analysis of randomized controlled trials

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) has gained enormous popularity worldwide. We conducted a meta-analysis to assess feasibility, safety, and benefits of SILA as compared with conventional laparoscopic appendectomy (CLA).

METHODS

A literature search in MEDLINE, EMBASE, and Cochrane Library was performed to identify eligible randomized controlled trials (RCTs). Primary outcome measures were total postoperative complications, wound infection, intra-abdominal abscess, and ileus. Secondary outcome measures were operative time, length of hospital stay, pain scores, conversion rate, reoperation rate, and time to return to normal activity.

RESULTS

Eight RCTs, totaling 1,211 patients (604 for SILA and 607 for CLA), met the inclusion criteria. The incidences of total postoperative complications, wound infection, intra-abdominal abscess, and ileus were statistically similar between the SILA and CLA groups. Compared with CLA, SILA was associated with a significantly longer operative time (weighted mean difference = 5.28 min; 95 % confidence interval = 3.61 to 6.94). Time to return to normal activity was shorter in the SILA group (by 0.69 days). Length of hospital stay, pain scores, conversion rate, and reoperation rate were similar between groups.

CONCLUSION

SILA is feasible and safe with no obvious advantages over CLA. Therefore, it may be considered as an alternative to CLA.

Laparoscopic appendectomy: State of the art. Tailored approach to the application of laparoscopic appendectomy?

Acute appendicitis is the most common surgical emergency in developed countries. The treatment of acute appendicitis is either open or laparoscopic appendectomy. The latter has gained wide acceptance in the past years, although the debate on the true merits of laparoscopic appendectomy is still on going. Some authors prefer this approach as the gold standard for all patients, but in our opinion a tailored approach is warranted for specific patient groups. In addition, a standardised guideline on the technical aspects is still lacking. In the current article, open versus laparoscopic appendectomy and several technical aspects, such as stump closure, appendix extraction and single incision are discussed laparoscopic appendectomy are being addressed. In the future perspectives we will briefly discuss the third 'newly' introduced antibiotic treatment.

Is laparoscopy a safe approach for diffuse appendicular peritonitis? Feasibility and determination of risk factors for post-operative intra-abdominal abscess

BACKGROUND

Several studies have assessed feasibility and early outcomes of the laparoscopic approach for complicated appendicitis (CA). However, these studies suffer from limitations due to the heterogeneous definitions used for CA. No studies have assessed feasibility and early post-operative outcomes of the laparoscopic approach in the specific management of diffuse appendicular peritonitis (DAP). Consequently, outcomes of the laparoscopic approach for the management of DAP are poorly documented.

METHODS

The laparoscopic approach is the first-line standardised procedure used by our team for the management of DAP. All patients (aged >16 years) who underwent laparoscopy for DAP (CA with the presence of purulent fluid with or without fibrin membranes in at least a hemi abdomen) between 2004 and 2012 were prospectively included. Post-operative outcomes were analysed according to the Clavien-Dindo classification.

RESULTS

Laparoscopy for DAP was performed for 141 patients. Mean age was 39.6 ± 20 (16-92) years. A total of 45 patients (31.9%) had pre-operative contracture. The mean pre-operative leukocyte count was 14,900 ± 4,380 mm(-3). The mean pre-operative C-reactive protein (CRP) serum concentration was 135 ± 112 (2-418) mg/dl. The conversion rate was 3.5%. The mean operative time was 80 ± 27 (20-180) min. There were no deaths. The rate of grade III morbidity was 6.5%. Ten patients (7.1%) experienced intra-abdominal abscess (IAA); seven of these cases were treated conservatively. The mean length of hospital stay was 6.9 ± 5 (2-36) days. A pre-operative leukocyte count >17,000 mm(-3), and CRP serum concentration >200 mg/dl were significant predictive factors for IAA in multivariate analyses [odds ratio (OR) 25.0, 95% confidence interval (CI) 2.4-250, p = 0.007 and OR 16.4, 95% CI 1.6-166, p = 0.02, respectively].

CONCLUSION

The laparoscopic approach for DAP is a safe and feasible procedure with a low conversion rate and an acceptable rate of IAA in view of the severity of the disease. Pre-operative leukocyte counts >17,000 mm(-3) and pre-operative CRP serum concentrations >200 mg/dl indicate a high risk of IAA.

Meta-analysis of randomized trials on single-incision laparoscopic versus conventional laparoscopic appendectomy

BACKGROUND

Single-incision laparoscopic appendectomy has emerged as a less invasive alternative to conventional laparoscopic surgery. High-quality relevant evidence is limited.

METHODS

A systematic review of electronic information sources was undertaken, with the objective of identifying randomized trials that compared single-incision with conventional laparoscopic appendectomy. Outcome measures included 30-day morbidity, abdominal abscess, wound infection, open conversion, reoperation, operative time, length of hospital stay, and postoperative pain. Fixed-effects and random-effects models were used to calculate combined overall effect sizes of pooled data. Data are presented as odds ratios or weighted mean differences with 95% confidence intervals (CIs).

RESULTS

Five randomized trials were identified, with a total of 746 patients. Thirty-day morbidity (9.6% vs 8.6%; odds ratio, 1.14; 95% CI, .69 to 1.89) and wound infection rates were similar between single-incision and conventional laparoscopy (4.0% vs 4.8%; odds ratio, .83; 95% CI, .41 to 1.68), whereas the duration of surgery was longer in the single-incision group (46.3 vs 40.7 minutes; weighted mean difference, 6.01; 95% CI, 2.26 to 9.76). Available data were not adequately robust to reach conclusions regarding the remaining outcome measures.

CONCLUSIONS

Similar postoperative morbidity and wound infection rates for single-incision and conventional laparoscopic appendectomy are supported by the current literature, but single-incision surgery requires longer operative time.

Predictive factors for failure of percutaneous drainage of postoperative abscess after abdominal surgery

BACKGROUND

The aims of this study were to assess the efficacy of percutaneous drainage of postoperative abscess after abdominal surgery and to identify factors predictive of failed drainage.

METHODS

Data from 81 patients with postoperative abdominopelvic abscesses treated with percutaneous drainage were reviewed. Percutaneous drainage failure was considered when surgery was needed to control the sepsis. Predictive variables were sought using univariate and multivariate analyses with logistic regression models.

RESULTS

Successful drainage requiring 1 (n = 46) or 2 (n = 17) procedures was observed in 63 patients (78%; 95% confidence interval, 67%-86%). Surgery was needed in 18 patients (22%; 95% confidence interval, 14%-38%). Residual collection after a first percutaneous drainage was the single predictive factor for failed drainage on univariate and multivariate analyses (P = .0275).

CONCLUSIONS

Percutaneous imaging-guided drainage is a feasible and effective method for the treatment of abdominopelvic abscess, with a success rate of 78%. Residual collection is an independent predictor of unfavorable outcome after percutaneous drainage.