Laparoscopic versus open appendectomy for complicated appendicitis

Traditional and laparoscopic appendectomy in adults: outcomes in English NHS hospitals between 1996 and 2006

OBJECTIVE

This study investigated length of stay, readmission rates, and postoperative mortality in adult patients undergoing traditional and laparoscopic appendectomy in England between April 1, 1996, and March 31, 2006.

METHODS

All procedures coded to the "H01-Emergency Excision of Appendix" procedure code in the Hospital Episode Statistics database were included. Multivariate analyses were used to identify independent predictors of length of hospital stay, 30-day and 365-day mortality.

RESULTS

A total of 259,735 procedures were assigned to the H01-Emergency excision of appendix OPCS-4 3-digit code procedure between 1996 and 2006. A laparoscopic technique was employed in 16,315 (6.3%). A greater proportion of deaths occurred in hospital within 30 days of "open" appendectomy surgery (0.25%) compared with procedures utilizing a laparoscopic technique (0.09%, P < 0.001). One-year mortality rates, measured over a 5-year period, were also higher after open surgery (0.64% vs. 0.29%, P < 0.001). Multiple logistic regressions demonstrated that an open operative technique, older age, male gender, and increasing comorbidity were strong independent determinants of early and 1-year postoperative mortality after emergency appendectomy. The duration of stay for patients undergoing open emergency appendectomy exceeded that for patients undergoing the laparoscopic technique (P < 0.001). Patients undergoing a laparoscopic technique were, however, more likely to be readmitted within 28 days of surgery (7.10% vs. 4.95%, P < 0.001).

CONCLUSIONS

Laparoscopic appendectomy is safe and associated with lower postoperative mortality rates than open procedures. The cost implications are uncertain as this technique is associated with shorter hospital stay but higher subsequent readmission rates.

Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese

BACKGROUND

The current study compared the outcome of morbidly obese patients undergoing laparoscopic versus open appendectomy.

METHODS

We obtained data from the University HealthSystem Consortium (UHC) database on 1,943 morbidly obese patients who underwent appendectomy for acute or perforated appendicitis between 2002 and 2007.

RESULTS

Compared to open appendectomy, laparoscopic appendectomy was associated with a shorter length of stay (3 vs 4 days) and a lower overall complication rate (9% vs 17%). Most notably, a lower rate of wound infection was noted (1% vs 3%). Within a subset analysis of morbidly obese patients who underwent appendectomy for perforated appendicitis, there was a higher overall complication rate (27% vs 18%) and cost ($16,600 vs $12,300) in the open appendectomy group.

CONCLUSION

In the morbidly obese, laparoscopic appendectomy performed for acute and perforated appendicitis is associated with a shorter length of stay and lower morbidity and costs. Laparoscopic appendectomy should be the procedure of choice for the treatment of acute appendicitis in the morbidly obese population.

Open vs laparoscopic repair of congenital duodenal obstructions: a concurrent series

OBJECTIVE

The advantages of using laparoscopy for repair of congenital duodenal obstructions (CDO) are unclear because of scant data about complications and outcomes. Nitinol U-clips (Medtronic Surgical, Minneapolis, Minn) were developed to assist in the creation of vascular anastomoses in small vessels. Because of their ability to approximate tissue tightly with little tissue damage, we have begun to use these U-clips for laparoscopic repair of CDO. In this report, we investigate the impact of laparoscopic U-clip repair of CDO compared to the traditional open repair.

METHODS

With institutional review board approval, a retrospective analysis of all patients undergoing repair of CDO from January 2003 to July 2007 was performed. During this study period, patients who underwent open repair of CDO (group 1) were compared with patients that underwent laparoscopic repair using the U-clip technique (group 2).

RESULTS

Twenty-nine patients underwent repair of CDO. Fourteen patients (11 atresia, 3 stenosis) were in group 1 and 15 patients (11 atresia, 4 stenosis) in group 2. A female sex bias existed in group 1 (female-male [9:5]) compared to group 2 (female-male [7:8]). There was no difference in birth weight, age at operation, chromosomal anomalies, or congenital heart disease between the groups. There were no duodenal anastomotic leaks in either group. Operative times were similar between groups (96 vs 126 minutes; P = .06). The length of postoperative hospitalization (20.1 vs 12.9 days; P = .01), time to initial feeding (11.3 vs 5.4 days; P = .002), and time to full oral intake (16.9 vs 9 days; P = .007) were all statistically shorter in group 2.

CONCLUSIONS

The laparoscopic approach to CDO repair using U-clips is safe and efficacious. In addition, patients undergoing laparoscopic repair of CDO had a shorter length of hospitalization and more rapid advancement to full feeding compared to babies undergoing the open approach. We feel that in the hands of experienced laparoscopic surgeons, the preferred technique for correction of CDO will become the laparoscopic U-clip repair.

Current management of appendicitis at a community center--how can we improve?

BACKGROUND

Controversies regarding the diagnosis and treatment of appendicitis remain. Practices and outcomes at a community center including imaging, timing of surgery, and surgical technique are reported.

METHODS

From January to July 2006, 134 patients undergoing appendectomy in Victoria, British Columbia, were reviewed. Accuracy of preoperative imaging, time from the emergency room to the operating room, length of stay, and early complications were analyzed. Patients with and without perforation were compared using sample t tests.

RESULTS

Preoperative computed tomography was obtained for 101 patients (75%) with a negative appendectomy rate of 3% versus 10% for patients without imaging. Imaging did not prolong the time to surgery (11.8 vs 10.9 h, P = .48). Patients with perforation stayed in the hospital significantly longer and had more complications.

CONCLUSIONS

The liberal use of computed tomography resulted in fewer negative appendectomies without a significant delay to surgery. Patients with perforation had increased complications and longer hospitalizations. Efforts should be made to identify and treat early appendicitis.