Randomized controlled trial comparing laparoscopic and open appendicectomy

Early discharge after open appendicectomy

BACKGROUND

There is increasing pressure on surgeons to minimize the time patients stay in hospital, and there is therefore a need to establish guidelines for reasonable lengths of stay for common operations. This study was conducted to test the feasibility and safety of early discharge after open appendicectomy. In addition, this study was performed to provide standards for open appendicectomy against which the results of laparoscopic appendicectomy can be compared.

METHODS

A prospective study of all patients having open appendicectomy for suspected acute appendicitis at Liverpool Hospital, Sydney during a 4 month period was undertaken. An early discharge programme was established, with the aim of discharging patients within 48 h of operation in uncomplicated cases. Discharge was allowed when the patient was eating, walking, and had passed flatus. Follow up was with the consultant surgeon at 1 week postoperatively, and with a community nurse at 2 weeks. Multivariate linear regression, using the number of postoperative hours to discharge as the outcome, was used to analyse the data for the following four factors: age, gender, incision type, and pathology.

RESULTS

One hundred and sixteen consecutive patients were enrolled in the study. The median postoperative stay for all patients was 46 h. Perforation of the appendix, use of a midline laparotomy for appendicectomy, and age significantly prolonged hospital stay, but gender had no effect. The main complication was wound infection, which was seen in 7.5% of patients. No patient had a problem directly related to early discharge. A community nurse saw 81% of patients 2 weeks after discharge. Over three-quarters of the patients seen had returned to full normal activities by 2 weeks, including work or school. Eighty-eight per cent of patients considered the timing of their discharge "good' or "excellent'.

CONCLUSIONS

Discharge at 2 days after open appendicectomy is both feasible and safe for patients having an unperforated appendix removed through a right iliac fossa incision. Passage of stool is not required prior to discharge. Early discharge is well accepted by patients and may result in financial savings for hospitals where payment is according to Diagnosis-Related Groups. On the basis of the results of the six randomized controlled trials comparing laparoscopic and conventional open appendicectomy published to date, and on the results of this study, the authors conclude that laparoscopic appendicectomy should not yet be considered the "procedure of choice', and surgeons are justified in performing appendicectomy by either method.

A clinical outcome and cost analysis of laparoscopic versus open appendectomy

BACKGROUND

Benefits of laparoscopic appendectomy are controversial, and the results of recent clinical studies have contradictory conclusions. We performed a cost analysis comparing laparoscopic and open appendectomies to assess potential efficacy of the laparoscopic approach.

METHODS

All patients operated on for suspected acute appendicitis at the University of Washington Medical Center (UWMC) from January 1, 1991 through January 1, 1995 were analyzed. Potential benefits of the laparoscopic approach were examined in five major categories: hospital length of stay, total hospital charges, operative time, operating room charges, and postoperative complications. Patients were stratified according to the presence or absence of perforation for outcome analysis.

RESULTS

There were 163 appendectomies performed in 82 men and 81 women. Twenty-seven (17%) patients had laparoscopic evaluation, of which 21 underwent attempted laparoscopic appendectomy. Among nonperforated patients, laparoscopic appendectomy did not reduce hospital stay compared with open appendectomy, but did lead to greater hospital charges ($7760 vs $5064; P < 0.001). Operating times were longer in the laparoscopic group (104 vs 74 minutes; P < 0.001) compared with open appendectomies. Operating room charges for laparoscopic appendectomies exceeded charges for the open approach ($4740 vs $1870; P < 0.001). Complication rates were similar (laparoscopic, 19% vs open, 16%; NS). The false diagnostic rate for women was four times greater than for men among patients undergoing open appendectomy (31% vs 8%; P < 0.01). Patients with perforation undergoing a midline incision had a longer hospital stay (9.5 vs 5.9; P < 0.02) than patients operated on through a right lower quadrant incision.

CONCLUSIONS

In our analysis, laparoscopic appendectomy, while safe, was more expensive and was not associated with better clinical outcome compared with open appendectomy patients.

A prospective trial of open versus laparoscopic appendicectomy

BACKGROUND

An assessment of the value of laparoscopic appendicectomy was performed.

METHODS

During 1993, all patients above the age of 13 years admitted with clinical appendicitis to Box Hill were assigned to an open or laparoscopic procedure depending on whether the surgeon on call was an 'open' or 'laparoscopic' surgeon for the purpose of the study. Ninety-two patients were entered in the study, of whom 57 were in the open group. The rate of histologically proven appendicitis was 73.9%.

RESULTS

No significant difference between the groups was found in the use of narcotic analgesia, length of stay or incidence of wound infection. However, operating time was significantly longer in the laparoscopic group.

CONCLUSIONS

Laparoscopic appendicectomy on an unselected group of patients does not confer many advantages but laparoscopy may be beneficial in certain subgroups.

Cost-effective evaluation and management of the acute abdomen

1. Managed care gate-keeper financial responsibility must be balanced with specialist diagnostic and therapeutic responsibility to maximize cost effectiveness and quality of medical service. 2. Cost in health care is closely tied to length of stay and operating room time; extremes of patient age are associated with increased costs. 3. Through years of training and subsequent experience, surgeons are best qualified to direct work-up of patients with an acute abdomen, especially when the work-up requires costly imaging (e.g., CT scan, ultrasonography, angiography). 4. Cost is increased when the surgeon is not involved early in cases of acute abdomen. 5. Surgeons must be willing to enter the evaluation phase of the patient with an acute abdomen patient early and follow during the observation period to best reduce unnecessary laboratory work or tests. 6. Health care teams willing to implement pathways and then document the effect such pathways exert will be most successful in assessing new technologies' cost effectiveness.

Laparoscopic surgery

The introduction of video assisted laparoscopic surgery in 1987 signalled the beginning of a new era in surgery, and together with interventional endoscopy and radiology has broadened the scope of minimal access therapy and improved the multidisciplinary management of complex diseases in gastroenterology. The unprecedented enthusiasm for laparoscopic surgery and the overwhelming demands for the training of qualified surgeons to acquire the laparoscopic skills resulted in a compromise of traditional graduated teaching principles in surgery. A phase of consolidation has now been entered where academic centres are in the process of evaluating the application of minimal access surgery in a controlled fashion. This review will examine the current role of laparoscopic surgery in common gastrointestinal conditions.

A comparison of laparoscopic and traditional open splenectomy in childhood

This study aimed to determine whether laparoscopic splenectomy is more advantageous than open splenectomy in pediatric patients. Data from 61 patients treated between June 1983 and September 1994 were reviewed. Length of hospitalization, hospital costs, operating time, and postoperative complications were evaluated. Forty-seven patients had open splenectomy. Nineteen of these underwent concomitant procedures. Fourteen patients had laparoscopic splenectomy, and four had concomitant cholecystectomy. The data show a trend toward a 1-day reduction in hospital stay associated with laparoscopic splenectomy (P < .02). Operating time was 83% longer for the laparoscopic approach (P < .001), and operating costs were almost $3,000 more (P < .001) than for open splenectomy. The total hospital cost also was greater for laparoscopic procedures (P < .1), primarily reflective of a more than $3,000 difference for splenectomy alone (P < .02). Two of the fourteen laparoscopic patients (14%) had complications. One patient with Evan's syndrome had pneumonia that required antibiotics. Another patient required conversion to an open procedure because of poorly controlled hemorrhage from a short gastric vessel. Twelve of the open splenectomy patients (25%) had complications: atelectasis (3), fever (4), wound infection (2), pneumonia (1), laryngospasm (1), and pancreatitis (1). The authors conclude that laparoscopic splenectomy is a safe but currently more expensive alternative to open splenectomy, primarily because of the use of disposable instruments. Benefits include a shorter hospital stay, no greater risk of postoperative complications, and subjective improvement in the cosmetic result. Disadvantages include increased operating time and cost. Evaluation of larger series will be needed to determine the significance of the difference in complication rates between the two procedures.

Probability of adverse events that have not yet occurred: a statistical reminder

The probability of adverse and undesirable events during and after operations that have not yet occurred in a finite number of patients (n) can be estimated with Hanley's simple formula, which gives the upper limit of the 95% confidence interval of the probability of such an event: upper limit of 95% confidence interval = maximum risk = 3/n (for n > 30). Doctors and surgeons should keep this simple rule in mind when complication rates of zero are reported in the literature and when they have not (yet) experienced a disastrous complication in a procedure.

The E.A.E.S. Consensus Development Conferences on laparoscopic cholecystectomy, appendectomy, and hernia repair. Consensus statements--September 1994. The Educational Committee of the European Association for Endoscopic Surgery

Under the mandate of the Educational Committee of the European Association of Endoscopic Surgery (E.A.E.S.), three consensus development conferences (CDCs) were performed in order to assess the current status of the endoscopic surgical approaches for the treatment of cholelithiasis, appendicitis, and inguinal hernia. Consensus panels for the different disease states (10-13 members each) selected by the education committee on the basis of members' clinical expertise, academic activity, community influence, and geographical location weighed the evidence on the basis of published results according to the criteria for technology assessment: feasibility, efficacy, effectiveness, economy. Draft statements were prepared, discussed by the panels, and presented at plenary sessions of the 2nd European Congress of the E.A.E.S. in Madrid September 15-17, 1994. Following discussions final consensus statements were formulated to provide specific answers for each topic to a minimum of the following questions: 1. What stage of technological development is the endoscopic surgical procedure at (in September 1994)? 2. Is endoscopic surgery safe and feasible? 3. Is it beneficial to the patients? 4. Who should undergo endoscopic surgery? 5. What are the training recommendations? Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Laparoscopic appendectomy is presently at the efficacy stage of development, because most of the data on feasibility and safety originate from centers with special interest in endoscopic surgery: it is not yet the gold standard for acute appendicitis. Endoscopic hernia repair is presently a feasible alternative for conventional hernia repair if performed by experienced endoscopic surgeons. It appears to be efficacious in the short-term. The full text of the consensus panel's statements is given in this publication.