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Najah Q, Makhlouf HA, Abusalah MA, Aboelkhier MM, Rashed MA, Kashbour M, Awwad SA, Ali FY, Hendi NI, Diab S, Abdallh F, Abozaid AM, Alabdallat YJ. Effectiveness of different appendiceal stump closure methods in laparoscopic appendectomy a network meta-analysis. Langenbecks Arch Surg 2024; 409:270. [PMID: 39235593 DOI: 10.1007/s00423-024-03452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 08/15/2024] [Indexed: 09/06/2024]
Abstract
PURPOSE Choosing the best stump closure method for laparoscopic appendectomy has been a debated issue, especially for patients with acute appendicitis. The lack of consensus in the literature and the diverse techniques available have prompted the need for a comprehensive evaluation to guide surgeons in selecting the most optimal appendiceal stump closure method. METHODS A comprehensive search was conducted on multiple databases from inception until December 2023 to find relevant studies according to eligibility criteria. The primary outcome was the incidence of total complications. RESULTS 25 studies with a total of 3308 patients were included in this study, overall complications did not reveal a significant advantage for any intervention (RR = 0.72, 95% CI: 0.53; 1.01), Superficial and deep infection risks were similar across all methods, Operative time was significantly longer with endoloop and Intracorporeal sutures (MD = 7.07, 95% CI: 3.28; 10.85) (MD = 26.1, 95% CI: 20.9; 31.29). CONCLUSIONS There are no significant differences in overall complications among closure methods. However, Intracorporeal sutures and endoloop techniques were associated with extended operative durations.
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Affiliation(s)
- Qasi Najah
- Faculty of Medicine, Elmergib University, Al-Khums, Libya
- Medical Research Group of Libya, Negida Academy, Arlington, MA, USA
| | | | - Mariam A Abusalah
- Faculty of Medicine Al-Quds University-Al-Azhar branch, Gaza, Palestine
- Medical Research Group of Palestine, Negida Academy, Arlington, MA, USA
| | - Menna M Aboelkhier
- Faculty of Science, Cairo University, Cairo, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
| | - Mohamed Abdalla Rashed
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
| | - Muataz Kashbour
- Department of Diagnostic Radiology, National Cancer Institute, Misrata, Libya
- Medical Research Group of Libya, Negida Academy, Arlington, MA, USA
| | - Sara Adel Awwad
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
- Medical Research Group of Jordan, Negida Academy, Arlington, MA, USA
| | - Fatmaelzahraa Yasser Ali
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
| | - Nada Ibrahim Hendi
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
| | - Sherein Diab
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
| | - Fatima Abdallh
- Faculty of Medicine, Hashemite University, Zarqa City, Jordan
- Medical Research Group of Jordan, Negida Academy, Arlington, MA, USA
| | - Ahmed Mohamed Abozaid
- Faculty of Medicine, Tanta University, Tanta, Egypt
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
| | - Yasmeen Jamal Alabdallat
- Faculty of Medicine, Hashemite University, Zarqa City, Jordan
- Medical Research Group of Jordan, Negida Academy, Arlington, MA, USA
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Zhou S, Cheng Y, Cheng N, Gong J, Tu B. Early versus delayed appendicectomy for appendiceal phlegmon or abscess. Cochrane Database Syst Rev 2024; 5:CD011670. [PMID: 38695830 PMCID: PMC11064883 DOI: 10.1002/14651858.cd011670.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND This is an update of a Cochrane review first published in 2017. Acute appendicitis (inflammation of the appendix) can be simple or complicated. Appendiceal phlegmon and appendiceal abscess are examples of complicated appendicitis. Appendiceal phlegmon is a diffuse inflammation in the bottom right of the appendix, while appendiceal abscess is a discrete inflamed mass in the abdomen that contains pus. Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms (e.g. abdominal pain, loss of appetite, nausea, and vomiting) and avoid complications (e.g. peritonitis (infection of abdominal lining)). Surgery for people with appendiceal phlegmon or abscess may be early (immediately after hospital admission or within a few days of admission), or delayed (several weeks later in a subsequent hospital admission). The optimal timing of appendicectomy for appendiceal phlegmon or abscess is debated. OBJECTIVES To assess the effects of early appendicectomy compared to delayed appendicectomy on overall morbidity and mortality in people with appendiceal phlegmon or abscess. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 11 June 2023, together with reference checking to identify additional studies. SELECTION CRITERIA We included all individual and cluster-randomised controlled trials (RCTs), irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included eight RCTs that randomised 828 participants to early or delayed appendicectomy for appendiceal phlegmon (7 trials) or appendiceal abscess (1 trial). The studies were conducted in the USA, India, Nepal, and Pakistan. All RCTs were at high risk of bias because of lack of blinding and lack of published protocols. They were also unclear about methods of randomisation and length of follow-up. 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon We included seven trials involving 788 paediatric and adult participants with appendiceal phlegmon: 394 of the participants were randomised to the early appendicectomy group (open or laparoscopic appendicectomy as soon as the appendiceal mass resolved within the same admission), and 394 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed open or laparoscopic appendicectomy several weeks later). There was no mortality in either group. The evidence is very uncertain about the effect of early appendicectomy on overall morbidity (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.19 to 2.86; 3 trials, 146 participants; very low-certainty evidence), the proportion of participants who developed wound infections (RR 0.99, 95% CI 0.48 to 2.02; 7 trials, 788 participants), and the proportion of participants who developed faecal fistulas (RR 1.75, 95% CI 0.36 to 8.49; 5 trials, 388 participants). Early appendicectomy may reduce the abdominal abscess rate (RR 0.26, 95% CI 0.08 to 0.80; 4 trials, 626 participants; very low-certainty evidence), reduce the total length of hospital stay by about two days (mean difference (MD) -2.02 days, 95% CI -3.13 to -0.91; 5 trials, 680 participants), and increase the time away from normal activities by about five days (MD 5.00 days; 95% CI 1.52 to 8.48; 1 trial, 40 participants), but the evidence is very uncertain. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess We included one trial involving 40 paediatric participants with appendiceal abscess: 20 were randomised to the early appendicectomy group (emergent laparoscopic appendicectomy), and 20 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed laparoscopic appendicectomy 10 weeks later). There was no mortality in either group. The trial did not report on overall morbidity, various complications, or time away from normal activities. The evidence is very uncertain about the effect of early appendicectomy on the total length of hospital stay (MD -0.20 days, 95% CI -3.54 to 3.14; very low-certainty evidence). AUTHORS' CONCLUSIONS For the comparison of early versus delayed open or laparoscopic appendicectomy for paediatric and adult participants with appendiceal phlegmon, very low-certainty evidence suggests that early appendicectomy may reduce the abdominal abscess rate. The evidence is very uncertain whether early appendicectomy prevents overall morbidity or other complications. Early appendicectomy may reduce the total length of hospital stay and increase the time away from normal activities, but the evidence is very uncertain. For the comparison of early versus delayed laparoscopic appendicectomy for paediatric participants with appendiceal abscess, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery, and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities and length of hospital stay.
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Affiliation(s)
- Shiyi Zhou
- Department of Pharmacy, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Bing Tu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Tazeoglu D, Cem Esmer A. Is LigaSure Alone Sufficient for the Closure of the Appendix Stump? Surg Innov 2024; 31:167-172. [PMID: 38357718 DOI: 10.1177/15533506241234005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
PURPOSES Closure of the appendix stump is necessary for laparoscopic appendectomy. Problems that occur during the appendix stump closure can cause severe morbidity. Several methods of stump closure have been described. This study aimed to investigate the adequacy of LigaSure alone in closing the appendix stump. METHODS Patients who were operated on with the diagnosis of acute appendicitis between October 2021 and January 2022 were evaluated retrospectively. The patients were divided into two groups according to the closure technique of the appendix stump hemoclip(group I) and LigaSure only(group II). In addition, demographic data (age, gender), body mass index (BMI), presence of comorbid disease, perioperative appendicitis classification, operation time, postoperative hospital stay, radiological and pathological appendix size of the patients included in the study were recorded. Clavien Dindo was used for postoperative complication assessment. RESULT The study included 77 patients. 48(62.3%) of the patients were in group I, and 29(37.7%) were in group II. There was no statistical difference between the groups regarding age, gender distribution, BMI, presence of comorbid disease (P > .05). The operation time of group I was longer than group II (P < .001). There was no difference between the groups in terms of both radiological and pathological appendix size. There was no statistical difference between the groups regarding postoperative complications and severity of complications (P = .76, P = .99, respectively). CONCLUSION Appendiceal stump closure can be performed with Ligasure, but it should be noted that this procedure can be performed on selected patients, as in the study group, not on all patients.
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Affiliation(s)
- Deniz Tazeoglu
- Surgical Oncology, Republic of Turkey Ministry of Health Osmaniye State Hospital, Osmaniye, Turkey
| | - Ahmet Cem Esmer
- Department of Surgical Oncology, Antalya City Hospital, Antalya, Turkey
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Aday U, Çetin E, Kafadar MT, Oğuz A, Bahadır MV, Ülger BV, Gedik E, Girgin S, Yılmaz M. Single versus double Hem-o-lok clips to secure the apendiceal stump during laparoscopic appendectomy: a prospective randomized multicentric clinical trial. Langenbecks Arch Surg 2024; 409:89. [PMID: 38457041 PMCID: PMC10924000 DOI: 10.1007/s00423-024-03281-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/04/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE Polymeric clips (Hem-o-lok ligation system) are now widely used to securing the base of the appendix during laparoscopic appendectomy. Studies comparing the use of single or double hem-o-lok clips are limited. The aim of this study was to compare the reliability of a single hem-o-lok clips with a double hem-o-lok clips for closure of an appendiceal stump. METHODS This prospective randomized study includes patients from two centers who underwent laparoscopic appendectomy with the diagnosis of appendicitis between September 2020 and March 2023. Demographic, operative and clinical outcomes of the use of single or double hem-o-lok clips for closure of the appendiceal stump were compared. Factors affecting long postoperative hospital stay were investigated using univariate and multivariate analyzes. RESULTS One hundred forty two (48.3%) patients in the single hem-o-lok arm and 152 (51.7%) patients in the double hem-o-lok arm were included in the analysis.The shortest operative time was noted in the single hem-o-lok group (52.1 ± 19.9 versus 61.6 ± 24.9 min, p < 0.001). The median hospital stay was 1 day (range 1-10) in the single hem-o-lok group and 1 day (range 1-12) in the double hem-o-lok group, and was shorter in the single hem-o-lok arm (1.61 ± 1.56 vs 1.84 ± 1.69, p = 0.019). Based on multivariate analysis, drain placement was identified as an independent predictive factor for long hospital stay. CONCLUSIONS The use of single hem-o-lok clips for appendiceal stump closure during laparoscopic appendectomy is safe and effective. Trial registration NCT04387370 ( http://www. CLINICALTRIALS gov ).
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Affiliation(s)
- Ulaş Aday
- Department of Gastroenterologycal Surgery, Dicle University School of Medicine, 21280, Sur/Diyarbakır, Turkey.
| | - Erman Çetin
- Department of General Surgery, Batman Regional Hospital, Batman, Turkey
| | - Mehmet Tolga Kafadar
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Abdullah Oğuz
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Mehmet Veysi Bahadır
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Burak Veli Ülger
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Ercan Gedik
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Sadullah Girgin
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Mehmet Yılmaz
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
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Curwen O, Gaber M, Gerogiannis I. In Pursuit of the Most Cost-Effective Laparoscopic Appendicectomy: A Review of the Literature. Surg Innov 2023; 30:601-606. [PMID: 37080159 DOI: 10.1177/15533506231169072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
PURPOSE To review the literature and identify the most economical techniques for laparoscopic appendicectomy (LA) that do not compromise on patient care. METHODS We performed a search of the Cochrane Library, PubMed, EMBASE and Google Scholar for papers published between January 2001 and January 2021. The outcomes of the included studies were then grouped by theme of cost analysis, with the main areas of focus being the use of disposable equipment, appendiceal stump closure, and retrieval of the appendix. RESULTS After screening a total of 254 search results, 40 studies were included, representing 13 285 patient outcomes, having two main areas of focus: the use of reusable or disposable equipment and the different methods of appendiceal stump closure. Use of disposable instruments has been cost effective in LA in 2 studies. However, use of reusable trocars has reduced cost of procedure by €250 in another study. Appendiceal stump closure using ligature, endoloops or Endoclips had been cost-effective compared to Endostaplers in 25 studies. This can save up to €350. Endoscopic specimen bags are single use and represent further disposable equipment costs. The use of a sterile glove to replace this piece of kit can further provide cost benefit as shown in 2 studies. CONCLUSION Laparoscopic appendicectomy can be performed in a variety of ways with equivocal patient safety. We present the use of extracorporeal ligature of the appendiceal base, combined with the use of a surgical glove retrieval system as the most economic technique in laparoscopic appendicectomy.
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Affiliation(s)
- Oliver Curwen
- Department of General and Emergency Surgery, Kingston Hospital NHS Foundation Trust, London, UK
| | - Mohannad Gaber
- Department of General and Emergency Surgery, Kingston Hospital NHS Foundation Trust, London, UK
| | - Ioannis Gerogiannis
- Department of General and Emergency Surgery, Kingston Hospital NHS Foundation Trust, London, UK
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Sobocki J, Pędziwiatr M, Bigda J, Hołówko W, Major P, Mitura K, Myśliwiec P, Nowosad M, Obcowska-Hamerska A, Orłowski M, Proczko-Stepaniak M, Szeliga J, Wallner G, Zawadzki M. The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II. Wideochir Inne Tech Maloinwazyjne 2023; 18:379-400. [PMID: 37868279 PMCID: PMC10585467 DOI: 10.5114/wiitm.2023.127884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/27/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method. Aim The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions. Material and methods The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method. Results and conclusions There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.
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Affiliation(s)
- Jacek Sobocki
- Chair and Department of General Surgery and Clinical Nutrition, Medical Center of Postgraduate Education Warsaw, Warsaw, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Justyna Bigda
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
| | - Wacław Hołówko
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Kryspin Mitura
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland
| | - Piotr Myśliwiec
- 1 Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Małgorzata Nowosad
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Aneta Obcowska-Hamerska
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Orłowski
- Department of General and Oncological Surgery, Florian Ceynowa Specialist Hospital, Wejherowo, Poland
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
| | - Jacek Szeliga
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum of the Nicolaus Copernicus University, Torun, Poland
| | - Grzegorz Wallner
- 2 Department and Clinic of General, Gastroenterological and Cancer of the Digestive System Surgery, Medical University of Lublin, Lublin, Poland
| | - Marek Zawadzki
- Department of Oncological Surgery, Provincial Specialist Hospital, Wroclaw, Poland
| | - the Expert Group: Prof. Tomasz Banasiewicz, Prof. Andrzej Budzyński, Prof. Adam Dziki, Prof. Michał Grąt, Prof. Marek Jackowski, Prof. Wojciech Kielan, Prof. Andrzej Matyja, Prof. Krzysztof Paśnik, Prof. Piotr Richter, Prof. Antoni Szczepanik, Prof. Mirosław Szura, Prof. Wiesław Tarnowski, Prof. Krzysztof Zieniewicz
- Chair and Department of General Surgery and Clinical Nutrition, Medical Center of Postgraduate Education Warsaw, Warsaw, Poland
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland
- 1 Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
- Department of General and Oncological Surgery, Florian Ceynowa Specialist Hospital, Wejherowo, Poland
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum of the Nicolaus Copernicus University, Torun, Poland
- 2 Department and Clinic of General, Gastroenterological and Cancer of the Digestive System Surgery, Medical University of Lublin, Lublin, Poland
- Department of Oncological Surgery, Provincial Specialist Hospital, Wroclaw, Poland
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Liu J, Yuan H, Xu X, Yin L, Wang W, Fan W, Bai X, Wang P. Colonoscopic titanium clipping to Maddress appendiceal stump leakage: a case report. Front Surg 2023; 10:1171875. [PMID: 37538389 PMCID: PMC10394468 DOI: 10.3389/fsurg.2023.1171875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/05/2023] [Indexed: 08/05/2023] Open
Abstract
The incidence of appendiceal stump leakage (ASL) is extremely low and heterogeneous, which has been reported to be approximately 0.5%-1.0%. It is a catastrophic complication with high mortality rate despite its low morbidity. Once it occurs, it will put the doctor in a passive position because dealing with the leakage is much more cumbersome than appendectomy. We extensively reviewed the literature on ASL, focusing on the management and prognosis. Unsurprisingly, all of the physicians advocated extended resection, which apparently gave them sufficient confidence. However, partial cecum resection, cecostomy, or terminal ileectomy is extremely invasive and destructive. So, the patients had to experience great mental and physical trauma, longer hospital stays, higher rates of wound infection, more costs, and even a third surgery. Therefore, are there any better approaches for ASL? In this article, we report a case of ASL who successfully underwent endoscopic treatment. A 70-year-old male was admitted with gangrenous perforated appendicitis with a large iliopsoas abscess. Appendectomy, iliopsoas abscess debridement and sufficient drainage, appendicular stump repair and closure, and terminal ileostomy were performed. Three months later, the patient was readmitted and the stoma reversal was performed as scheduled. Seven days later, ASL was found when a liquid diet was applied routinely due to right lower quadrant pain and low fever. Finally, with the periappendiceal abscess completely drained, we clamped the appendiceal orifice with five titanium clips under an electronic colonoscope, which eventually sealed the leakage and avoided extended resection.
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Affiliation(s)
- Jianjun Liu
- Department of Gastrointestinal Surgery, Institute of Hepatobiliology and Pancreaticoenterology of the Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- North Sichuan Medical College, Nanchong, China
| | - Huayan Yuan
- Department of Gastrointestinal Surgery, Institute of Hepatobiliology and Pancreaticoenterology of the Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiulian Xu
- North Sichuan Medical College, Nanchong, China
| | | | - Wei Wang
- North Sichuan Medical College, Nanchong, China
| | - Wenhai Fan
- North Sichuan Medical College, Nanchong, China
| | - Xiangyu Bai
- North Sichuan Medical College, Nanchong, China
| | - Pan Wang
- Department of Gastrointestinal Surgery, Institute of Hepatobiliology and Pancreaticoenterology of the Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Masimango G, Cakwira H, Oduoye MO, Onesime J, Otobo DD, Kibukila F, Banga S, Akilimali A, Suvvari TK, Kyaruzi VM, Rehman IU, Bavurhe RF, Nyakio O. Surgical characteristics of appendectomy in the eastern region of the democratic republic of congo: a cross-sectional study. Ann Med Surg (Lond) 2023; 85:3764-3768. [PMID: 37427177 PMCID: PMC10328562 DOI: 10.1097/ms9.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Appendectomy is a surgical procedure performed on a patient with acute appendicitis and is often performed by surgery and performed in an emergency. The authors have carried out this study, which aims to describe the surgical characteristics of appendectomies. Methods This retrospective, descriptive, and documentary cross-sectional study was conducted from October 2021 to October 2022. Within this time ~591 acute abdominal surgical procedures were performed, including 196 appendectomies performed in the general surgery department. Results This study focused on 196 appendectomies performed out of a total of 591 surgeries performed, with an incidence of 34.2%. 51 cases (26%) for the age group between 15 and 20 years, 129 cases (65.8%) of women participated in the appendectomy. 133 (67.8%) acute appendicitis, 48 (24.5%) appendicular abscess and 15 (7.7%) appendicular peritonitis were indications for appendectomies. For the American Society of Anesthesiologists (ASA) score: for the ASA I, 112 (57.1%) of the patients had no conditions other than those requiring surgery (appendectomy). For the Altemeier classification, the authors recorded 133 (67.9%) own surgeries. 56 (28.6%) surgical site infections followed by 39 (19.8%) inflammation (swelling and redness), 37 (18.8%) pain, 24 (12.4%) purulent peritonitis, 21 (10, 7%) postoperative hemorrhage and 19 (9.7%) paralytic ileus and 157 (80.1%) patients benefited from medical treatment. Conclusion The low incidence of complications related to laparotomy appendectomy has been reduced to a minimum thanks to the respect of sanitary measures and the quality of the technique.
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Affiliation(s)
| | - Hugues Cakwira
- Faculty of Medicine, Official University of Bukavu
- Faculty of Medicine, Catholic University of Bukavu
| | | | - Jones Onesime
- Faculty of Medicine, Official University of Bukavu
- Faculty of Medicine, Université libre des pays des grands lacs, Goma, DR Congo
| | | | | | - Styves Banga
- Faculty of Medicine, Official University of Bukavu
| | - Aymar Akilimali
- Faculty of Medicine, La Sapientia Catholic Univversity, Goma, DR Congo
| | - Tarun K. Suvvari
- Department of Surgery, Rangaraya Medical College, Kakinada, Andhra Pradesh, India
| | - Victor M. Kyaruzi
- Department of Surgery, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
| | - Ibad ur Rehman
- Department of Surgery, Shifa International Hospital and Shifa Tameer e Millat University, Islamabad, Pakistan
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Bašković M, Zaninović L, Čizmić A, Žganjer M. Stump appendicitis in children: a systematic review. Pediatr Surg Int 2023; 39:199. [PMID: 37188869 DOI: 10.1007/s00383-023-05475-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Stump appendicitis is a rare complication after primary appendectomy and is often not considered in the differential diagnosis of patients who have undergone an appendectomy. With this systematic review, the aim was to identify all cases of stump appendicitis in children in order to gain a better insight into the risk factors, clinical presentation, diagnostics, and treatment. METHODS Scopus and PubMed databases were searched. The search combinations used the following MeSH and free text terms: [(stump) OR (residual) OR (remaining) OR (retained) OR (recurrent)] AND (append*). Neither search filters nor text analysis tools were used. To be included, the report had to contain information about a patient between the age of 0 and 18 who was treated for stump appendicitis as a result of an inadequately performed appendectomy. RESULTS Out of the 19,976 articles, 29 of them, with a total of 34 cases, met the inclusion criteria. The mean age at the time of stump appendectomy was 13.32 ± 3.57 years, while the median time between primary and stump appendectomy was 7.5 (2.3 - 24.0) months. The ratio between boys and girls was 3.2: 1. Primary appendectomy was performed laparoscopically in a greater number of cases compared to the open approach (1.5: 1), and according to the available data, no higher proportion of complicated appendicitis was recorded during a primary appendectomy. The median duration of symptoms during stump appendicitis was 2 days, and in most cases, the pain was localized. Stump appendectomy in most cases was performed with an open approach, and in relation to the type of appendicitis, most of them were complicated. The mean value of the length of the stump was 2.79 ± 1.22 cm, and the smallest recorded length was 0.6 cm. CONCLUSIONS A non-specific clinical presentation with a history of appendectomy usually makes the diagnosis of stump appendicitis challenging for uninformed physicians, and due to untimely treatment, it usually results in complicated forms of stump appendicitis. Complete appendectomy remains the gold standard in the treatment of stump appendicitis.
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Affiliation(s)
- Marko Bašković
- Department of Pediatric Surgery, Children's Hospital Zagreb, Ulica Vjekoslava Klaića 16, Zagreb, 10000, Croatia.
- School of Medicine, University of Zagreb, Šalata 3, Zagreb, 10000, Croatia.
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, Zagreb, 10000, Croatia.
| | - Luca Zaninović
- School of Medicine, University of Zagreb, Šalata 3, Zagreb, 10000, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, Zagreb, 10000, Croatia
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, Zagreb, 10000, Croatia
| | - Ante Čizmić
- Department of Pediatric Surgery, Children's Hospital Zagreb, Ulica Vjekoslava Klaića 16, Zagreb, 10000, Croatia
| | - Mirko Žganjer
- Department of Pediatric Surgery, Children's Hospital Zagreb, Ulica Vjekoslava Klaića 16, Zagreb, 10000, Croatia
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Self-Locking Polymeric Clips Are Safe for the Closure of Appendiceal Stump in Laparoscopic Appendectomy. Medicina (B Aires) 2023; 59:medicina59030533. [PMID: 36984534 PMCID: PMC10059700 DOI: 10.3390/medicina59030533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
Background: Closure of the appendix stump is critical to avoid serious postoperative complications. There are a number of options, but the best one has not been identified yet. The purpose of this study is to evaluate the outcomes of appendiceal stump closure using self-locking polymeric clips and endoloops. Methods: A retrospective analysis of the prospectively maintained database of patients with acute appendicitis was performed. Patient demographic details and surgical characteristics, including the duration of hospital stay, postoperative complications, and also the cost of the appendix stump closure, were recorded. Patients were divided into two groups according to the appendix stump closure method: the clips group if it was closed with self-locking polymeric clips and the loops group if Vicryl or PDS loops were used. Statistical analysis was performed using Pearson’s chi-squared test, Wilcoxon rank sum (Mann–Whitney U) test, and Fisher’s exact test in R statistical software package version 4.2.1. Results: 515 patients were included in the study from June 2016 to April 2021. There were no significant differences in terms of demographics (p-value in comparison of groups’ sex > 0.99, age p-value 0.16), postoperative complications (p-value > 0.99), histological findings (p-value 0.27), or length of hospital stays (p-value 0.18) between the two patient groups (clips group, N = 454 and loops group, N = 61). The price of operation while using different appendiceal stump closures is significantly different. In a laparoscopic appendectomy, one stump closure with self-locking clips costs 7.69 €, with Vicryl loops—91.35 €, with PDS loops—96.51 €, and with a stapler—514.50 €. Conclusions: Self-locking polymeric clips can be used for the safe and effective closure of an appendiceal stump. There were no significant differences in the postoperative time (30 days) or complication rates among patients in both (clips and loops) groups. Thus, this might be a technique to reduce expenses while maintaining good postoperative results after laparoscopic appendectomy.
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Energy Devices for Clipless-Sutureless Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis on Utility and Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111535. [PMID: 36363491 PMCID: PMC9694935 DOI: 10.3390/medicina58111535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
Background and Objectives: While laparoscopic appendectomy is standardized, techniques for appendiceal stump closure and mesoappendix division remain variable. Novel vessel sealing techniques are increasingly utilized ubiquitously. We sought to systematically summarize all relevant data and to define the current evidence on the safety and utility of energy devices for clipless−sutureless laparoscopic appendectomy in this systematic review and meta-analysis. Materials and Methods: This review was conducted following the PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science were systematically searched. Inclusion criteria included studies with laparoscopic appendectomy for appendicitis. The intervention included patients undergoing division of mesoappendix and/or securing of the appendicular base using diathermy (Monopolar or Bipolar or LigaSure Sealing Device) or Harmonic Scalpel (Group A) compared to patients undergoing division of mesoappendix and/or securing of the appendicular base using endoclip or Hem-o-lok or ligature (Group B). The methodological quality of the included studies was assessed using the Downs and Black scale. The outcomes of surgical site infection (SSI) or intra-abdominal collection, postoperative ileus, average operative duration, and length of hospital stay (LHS) were compared. Results: Six comparative studies were included; three were retrospective, two were prospective, and one was ambispective. Meta-analysis revealed a shorter operative duration in Group A with respect to appendicular base ligation (MD −12.34, 95% CI −16.57 to −8.11, p < 0.00001) and mesoappendix division (MD −8.06, 95% CI −14.03 to −2.09, p = 0.008). The pooled risk ratios showed no difference in SSI between groups. Additionally, no difference was observed in LHS. The risk of postoperative ileus was higher in group B regarding mesoappendix division (RR 0.56, 95% CI 0.34 to 0.93, p = 0.02), but no difference was found concerning appendicular base ligation. The included studies showed a moderate-to-high risk of bias. Conclusions: Clipless−sutureless laparoscopic appendectomy is safe and fast. Postoperative ileus seems less common with energy devices for mesoappendix division. However, the studies included have a moderate-to-high risk of bias. Further studies addressing the individual devices with surgeons of similar levels are needed.
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12
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Juan HL, Nicolas AM, Daniela CNL, Lineth ORM, María RHA, Camila RQM, Gabriela TPP, Felipe CVL, Catalina C. Use of a bipolar device (LigaSure) to seal the appendiceal stump in pediatric laparoscopic appendectomy: 10-year Latin-American experience. J Pediatr Surg 2022:S0022-3468(22)00677-7. [PMID: 36396473 DOI: 10.1016/j.jpedsurg.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/24/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Closure of the appendiceal stump is a critical step during an appendectomy. There is a lack of knowledge about the feasibility of using electrosurgical devices for the occlusion of the appendix. This study aims to determine the safety of this technique in pediatric patients. METHODS We performed a cross-sectional analytical study in patients less than 18 years of age treated at Hospital Militar Central Colombia between 2012 and 2021. Our institution's ethics committee approved the study. We analyzed the data using SPSS 22 statistical program. We present frequencies for qualitative variables and measures of central tendency or dispersion for quantitative variables depending on the distribution measured by the Kolmogorov-Smirnov test. In addition, we measured the association of nominal variables with the Chi-square test or Fisher's exact test. For numerical variables, the difference of means with the Student's t-test or the difference of medians with the Mann-Whitney U test. RESULTS We treated 209 patients. One hundred sixteen (55.5%) were boys, and the mean age was 9.7 years (SD 3.2). The median intraoperative time was 60 min, and the hospital stay was 2.8 days on average. There were no cases of stump leakage, and only two patients (1%) had an organ-space surgical site infection, which was unrelated to the closure technique. We found no association between procedural complications and appendicular status (p = 0.450). CONCLUSIONS Our research suggests that using a bipolar sealing device (Ligasure, Medtronic, USA) for appendiceal stump closure in pediatric patients undergoing laparoscopic appendectomy is feasible and should be further studied. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | | | | | - Cabrera-Vargas Luis Felipe
- Hospital Militar Central. Tv 3c # 49-02, Bogota, Colombia; Universidad Militar Nueva Granada. Transversal 3A No 49-00, Bogota, Colombia
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13
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Borkar N, Sharma C, Mohanty D, Singha SK. A Systematic Review and Meta-Analysis of Harmonic Scalpel Versus Conventional Techniques of Appendiceal Stump Closure in Laparoscopic Appendicectomy. Cureus 2022; 14:e28759. [PMID: 36159348 PMCID: PMC9498932 DOI: 10.7759/cureus.28759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/13/2022] Open
Abstract
Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining popularity over open appendicectomy in the current surgical practice. The advantages of laparoscopic appendectomy are early recovery, fewer wound complications, less pain and better cosmesis. One of the most critical steps in laparoscopic appendicectomy is a secure appendicular stump closure. Life-threatening postoperative complications are often encountered following the breakdown of appendicular stump closure. There are several methods to achieve appendicular stump closure such as intra-corporeal knotting, endoloops, external corporeal knotting and pushing knot inside, endoscopic linear cutting stapler (endo GIA), and endoclips. A meta-analysis on the technique of appendicular stump closure in laparoscopic appendicectomy failed to demonstrate the superiority of one method over the other. In the last few years, many authors have evaluated the outcome of sutureless appendicectomy performed using devices like a harmonic scalpel. This systematic review and meta-analysis is aimed to summarise the current evidence regarding the utility and safety of harmonic scalpel in sutureless appendicectomy. This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. A systematic, detailed search was carried out by the authors in the electronic database, including Medline, Embase, CENTRAL, Scopus, Google scholar and clinical trial registry. Studies were selected and compared based on outcomes such as operative time, hospital stay, postoperative paralytic ileus, wound infection, and total complications. Statistical analysis was performed using the random effect model, fixed-effect model, pooled risk ratio, pooled mean difference and I2 heterogeneity. Four comparative studies with a total of 642 patients (376 male and 266 females) were included in the analysis. There were 359 patients in the conventional technique of appendicular stump closure group and 283 patients in the harmonic scalpel for appendicular stump closure group. Pooled analysis of the outcome measure of total complications showed that the use of harmonic scalpel for closure of appendiceal stump does not result in an increased incidence of complications as compared to the conventional technology of appendiceal stump closure. Pooled analysis of the outcome measure of mean operative time revealed a statistically significant reduction in the operative time in the patients where harmonic scalpel has been used for the management of appendiceal stump as compared to conventional methods (pooled mean difference of -12.96 with 95% CI -15.42, -10.50). Appendiceal stump closure during laparoscopic appendectomy by harmonic scalpel (HS) is comparable with the conventional techniques in terms of hospital stay, wound infection, postoperative paralytic ileus, and total complications. The use of a harmonic scalpel for closure of appendicular stump is associated with a reduction of the mean operative time of laparoscopic appendicectomy.
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Affiliation(s)
- Nitinkumar Borkar
- Paediatric Surgery, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Charu Sharma
- Paediatric Surgery, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Debajyoti Mohanty
- General Surgery, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Subrata K Singha
- Anaesthesiology, All India Institute of Medical Sciences, Raipur, Raipur, IND
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Reinisch A, Liese J, Padberg W, Ulrich F. Robotic operations in urgent general surgery: a systematic review. J Robot Surg 2022; 17:275-290. [PMID: 35727485 PMCID: PMC10076409 DOI: 10.1007/s11701-022-01425-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/06/2022] [Indexed: 12/07/2022]
Abstract
Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy is widely used in urgent general surgery, the significance of robotic assistance in urgent operations is of interest. Currently, there are few data on robotic-assisted operations in urgent surgery. The aim of this study was to collect and classify the existing studies. A two-stage, PRISMA-compliant literature search of PubMed and the Cochrane Library was conducted. We analyzed all articles on robotic surgery associated with urgent general surgery resp. acute surgical diseases of the abdomen. Gynecological and urological diseases so as vascular surgery, except mesenterial ischemia, were excluded. Studies and case reports/series published between 1980 and 2021 were eligible for inclusion. In addition to a descriptive synopsis, various outcome parameters were systematically recorded. Fifty-two studies of operations for acute appendicitis and cholecystitis, hernias and acute conditions of the gastrointestinal tract were included. The level of evidence is low. Surgical robots in the narrow sense and robotic camera mounts were used. All narrow-sense robots are nonautonomous systems; in 82%, the Da Vinci® system was used. The most frequently published emergency operations were urgent cholecystectomies (30 studies, 703 patients) followed by incarcerated hernias (9 studies, 199 patients). Feasibility of robotic operations was demonstrated for all indications. Neither robotic-specific problems nor extensive complication rates were reported. Various urgent operations in general surgery can be performed robotically without increased risk. The available data do not allow a final evidence-based assessment.
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Affiliation(s)
- Alexander Reinisch
- Department of General, Visceral and Oncologic Surgery, Wetzlar Hospital and Clinics, Forsthausstr. 1, 35578, Wetzlar, Germany.
| | - Juliane Liese
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Giessen, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Giessen, Giessen, Germany
| | - Frank Ulrich
- Department of General, Visceral and Oncologic Surgery, Wetzlar Hospital and Clinics, Forsthausstr. 1, 35578, Wetzlar, Germany
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Gupta V, Chauhan SPS, Gupta M, Verma R, Singh SP, Panday A. Efficacy and Safety of LigaSure in Laparoscopic Sutureless Appendectomy. Cureus 2022; 14:e24764. [PMID: 35755548 PMCID: PMC9216166 DOI: 10.7759/cureus.24764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/05/2022] Open
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16
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Kim S, Jeon BH, Cho SS, Shin US, Moon SM. Clinical outcomes of locking polymeric clip for laparoscopic appendectomy in patients with appendicitis: a retrospective comparison with loop ligature. Ann Coloproctol 2022; 38:160-165. [PMID: 35038819 PMCID: PMC9021853 DOI: 10.3393/ac.2021.00598.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 11/06/2022] Open
Abstract
Purpose This study aimed to compare the clinical outcomes of laparoscopic appendectomy (LA) according to the method of appendiceal stump closure. Methods Patients who underwent LA for appendicitis between 2010 and 2020 were retrospectively reviewed. Patients were classified into locking polymeric clip (LPC) and loop ligature (LL) groups. Clinical outcomes were compared between the groups. Results LPC and LL were used in 188 (56.6%) and 144 patients (43.4%), respectively for appendiceal stump closure. No significant differences were observed in sex, age, comorbidities, and the severity of appendicitis between the groups. The median operative time was shorter in the LPC group than in the LL group (64.5 minutes vs. 71.5 minutes, P=0.027). The median hospital stay was longer in the LL group than in the LPC group (4 days vs. 3 days, P=0.020). Postoperative incidences of intraabdominal abscess and ileus were higher in the LL group than in the LPC group (4.2% vs. 1.1%, P=0.082 and 2.8% vs. 0%, P=0.035; respectively). The readmission rate was higher in the LL group than that in the LPC group (6.3% vs. 1.1%, P=0.012). Conclusion Using LPC for appendiceal stump closure during LA for appendicitis was associated with lower postoperative complication rate, shorter operative time, and shorter hospital stay compared to the use of LL. Operative time above 60 minutes and the use of LL were identified as independent risk factors for postoperative complications in LA. Therefore, LPC could be considered a more favorable closure method than LL during LA for appendicitis.
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Affiliation(s)
- Seokwon Kim
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Byong Ho Jeon
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sang Sik Cho
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Ui Sup Shin
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sun Mi Moon
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
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A new approach to laparoscopic appendectomy in children-clipless/sutureless Harmonic scalpel laparoscopic appendectomy. Langenbecks Arch Surg 2021; 407:779-787. [PMID: 34841456 DOI: 10.1007/s00423-021-02389-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/25/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this study was to investigate Harmonic scalpel performance in laparoscopic appendectomy for sealing the base of the appendix in children. METHODS During the study period, a total of 312 patients who underwent laparoscopic appendectomy were included in prospective bicenter clinical trial. The patients were divided in two study groups in regard to technique used for appendiceal base closure. In the first group (n = 197) the appendiceal base was secured using a polymeric clip while in the second group (n = 115) the Harmonic scalpel was used for sealing the base in a stepwise manner, without placing any clip or suture. Outcomes of treatment, including complication rates, duration of surgery and length of hospital stay were compared between the groups. RESULTS A total of 312 patients with a median age of 11 years (IQR 8, 15) were included in study. Of these, 191 were males (61.2%). Both groups were symmetric in regard to baseline characteristics of the patients. A total of 10 (5.1%) postoperative complications (postoperative abscess n = 7 and ileus n = 3) were recorded in the polymeric clip group while none of the patients from the clipless group had postoperative complications (P = 0.015). In the group who received a polymeric clip appendectomy, fever lasting 0-72 h and > 72 h was recorded in 16 (8.1%) and 12 (6.1%) children, respectively, while in the clipless group, it was observed in 2 (1.7%) and 5 (4.3%) children, respectively (P = 0.048). Significantly shorter surgical times were found in the clipless group compared to the polymeric clip group (21 min (IQR 18, 25) vs. 30 min (IQR 22, 40), P < 0.0001). Also, length of hospital stay was significantly shorter in the clipless group of the patients (2 days (IQR 2, 3) vs. 3 days (IQR 2, 4), P < 0.0001). CONCLUSION Clipless harmonic scalpel laparoscopic appendectomy is a safe and effective method in children for treatment of acute appendicitis with lesser number of complications and shorter duration of surgery compared to laparoscopic appendectomy in which the appendiceal base is secured with clip.
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Casas MA, Dreifuss NH, Schlottmann F. High-volume center analysis and systematic review of stump appendicitis: solving the pending issue. Eur J Trauma Emerg Surg 2021; 48:1663-1672. [PMID: 34085112 DOI: 10.1007/s00068-021-01707-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/17/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Stump appendicitis (SA) is a rare long-term complication after laparoscopic appendectomy (LA) that can be associated with high morbidity due to delayed diagnosis. We aimed to determine the incidence, risk factors, diagnosis, and management of SA by reviewing our large cohort of LA and performing a systematic review of the literature. METHODS We retrospectively reviewed data of all patients who developed SA after LA between 2006 and 2020. Demographics, peri-operative variables, and postoperative outcomes were analyzed. A systematic review of the PubMed/MEDLINE, Embase and GoogleScholar bibliographic databases was also performed to identify publications regarding SA following LA. RESULTS A total of 2,019 patients underwent LA; 5 (0.25%) developed SA after a median of 292 days. The most common symptom at presentation was right lower quadrant pain. Four SA (80%) occurred in patients with a history of complicated appendicitis at index operation. All patients were diagnosed with computed tomography and underwent completion stump appendectomy by laparoscopy. No postoperative complications were recorded. A total of 55 studies with 76 cases of SA after LA were identified in the systematic review. Most SA (98.7%) underwent surgery: 52% by laparoscopic approach and 36% through an open approach. Stump appendectomy was performed in 94.4% cases and an extended resection in 5.6%. CONCLUSION Although SA is a rare complication after LA, a high index of clinical suspicious and imaging studies are key for early diagnosis and treatment. A laparoscopic resection of the inflamed appendiceal stump is feasible, safe, and highly effective. A minority of patients with severe cecum compromise may need extended resections or conversion to open surgery.
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Affiliation(s)
- María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT, Buenos Aires, Argentina
| | - Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT, Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT, Buenos Aires, Argentina.
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Ihnát P, Tesař M, Tulinský L, Ihnát Rudinská L, Okantey O, Durdík Š. A randomized clinical trial of technical modifications of appendix stump closure during laparoscopic appendectomy for uncomplicated acute appendicitis. BMC Surg 2021; 21:272. [PMID: 34059039 PMCID: PMC8165989 DOI: 10.1186/s12893-021-01279-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/25/2021] [Indexed: 12/15/2022] Open
Abstract
Background Closure of the appendix stump presents the most critical part of laparoscopic appendectomy. The aim of the present study was to compare the medical outcomes and cost analysis of laparoscopic appendectomy with respect to the different methods of stump closure.
Methods This was a prospective randomized clinical trial conducted in a single institution (University Hospital Ostrava) within a 2-year study period. All included patients were randomized into one of three trial arms (endoloop, hem-o-lok clips or endostapler). Results In total, 180 patients (60 patients in each arm) were enrolled into the study. The mean length of hospital stay (3.6 ± 1.7 days) was comparable in all study arms. The shortest operative time was noted in the hem-o-lok subgroup of patients (37.9 ± 12.5 min). Superficial surgical site infection was detected in 4.4% of study patients; deep surgical site infection was noted in 1.7% of the patients. The frequency of surgical site infections was comparable in all study arms (p = 0.7173). The mean direct costs of laparoscopic appendectomy were significantly the lowest in the hem-o-lok subgroup of patients. Laparoscopic appendectomy is not a profit-making procedure in our institution (mean profit of made from the study patients was—104.3 ± 579.2 Euro). Closure of the appendix stump by means of endostapler presents the most expensive and the highest loss-incurring technique (p = 0.0072). Conclusions The present study indicates that all technical modifications of appendix stump closure are comparable with regards to postoperative complications. The stapler technique is significantly the most expensive. We concluded that hem-o-lok clips have the potential for becoming the preferred method of securing the appendix base during laparoscopic appendectomy. Trial registration NCT03750032 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Peter Ihnát
- Department of Surgery, University Hospital Ostrava, 17.listopadu 1790, Ostrava, 708 52, Czech Republic.
| | - Milan Tesař
- Department of Surgery, University Hospital Ostrava, 17.listopadu 1790, Ostrava, 708 52, Czech Republic
| | - Lubomír Tulinský
- Department of Surgery, University Hospital Ostrava, 17.listopadu 1790, Ostrava, 708 52, Czech Republic
| | - Lucia Ihnát Rudinská
- Department of Forensic Medicine, University Hospital Ostrava, 17.listopadu 1790, Ostrava, 708 52, Czech Republic.,Department of Oncosurgery, Faculty of Medicine, Commenius University Bratislava, Spitalska 24, Bratislava, 813 72, Slovakia
| | - Okaikor Okantey
- Department of Cardiovascular Surgery, University Hospital Ostrava, 17.listopadu 1790, Ostrava, 708 52, Czech Republic
| | - Štefan Durdík
- Department of Oncosurgery, Faculty of Medicine, Commenius University Bratislava, Spitalska 24, Bratislava, 813 72, Slovakia
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Endoloops in laparoscopic appendicectomy: A retrospective, cost effectiveness analysis. Ann Med Surg (Lond) 2021; 65:102364. [PMID: 34026100 PMCID: PMC8134709 DOI: 10.1016/j.amsu.2021.102364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background Over 50,000 appendicectomies are performed in the UK annually. Despite this highvolume. status, and the endoloop being commonly employed, there is a scarcity of literature studying differences in outcomes depending on numbers used.The aim of this study was to investigate whether a significant difference in complication rate exists where different numbers of endoloop ligatures have been applied to the appendiceal base during laparoscopic appendicectomy, and to analyse for potential cost saving. Methods We performed a retrospective analysis of appendicectomies at our centre in one year, providing a sample of 254 patients. Each was followed up for complications in the 30 days post discharge and graded using the Clavien-Dindo system. Our null hypothesis of no difference in complication rate was tested using Fisher's exact test. Results Of 254 patients, 59 were excluded due to open approach, non-endoloop method, or lack of available record, leaving a population of 195. The result of the two-tailed P value equalled 1.000, indicating no statistically significant difference in complication rate whether one or two endoloops were used. An endoloop costs £13.59. If the 62 cases in which 2 endoloops were used to secure the base had utilised a single endoloop, this would amount to a saving of £842.58. Conclusion Our study set out to assess whether the complication rate differs in cases where one or two endoloops have been applied. Retrospective statistical analysis found no significant difference between groups. Therefore, we recommend use of one endoloop to secure the base in laparoscopic appendicectomy.
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Oñate J, Pallares Gutiérrez CJ, Esparza G, Jimenez A, Berrio Medina I, Osorio-Pinzón J, Cataño J, Alvarez- Moreno C, Rodriguez J, Guevara F, Mercado M, Zuluaga M, Becerra JS, Alvarez M, Coronel W, Ordonez K, Villegas M. Consensus Recommendations Based on Evidence for Abdominal Sepsis in the Pediatric and Adult Population of Colombia. INFECTIO 2021. [DOI: 10.22354/in.v25i4.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Durán Muñoz-Cruzado V, Anguiano-Diaz G, Tallón Aguilar L, Tinoco González J, Sánchez Arteaga A, Aparicio Sánchez D, Pareja Ciuró F, Padillo Ruiz J. Is the use of endoloops safe and efficient for the closure of the appendicular stump in complicated and uncomplicated acute appendicitis? Langenbecks Arch Surg 2021; 406:1581-1589. [PMID: 33409584 DOI: 10.1007/s00423-020-02050-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/01/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION There is still controversy regarding the ideal technique to close the appendicular stump in laparoscopic appendectomy (LA). The objective of this study was to determine the safety and efficiency of the use of an endoloop (EL) and endostapler (ES) in complicated and uncomplicated acute appendicitis. METHODS Retrospective cohort study of patients undergoing LA from February 2013 to December 2019. Acute uncomplicated and complicated appendicitis were analysed separately, establishing two groups according to the stump closure technique: EL or ES. Seven hundred-nine patients were included (535 uncomplicated and 174 complicated). In uncomplicated appendicitis, an EL was used in 447 of the patients (83.55%) and an ES was used in 88 patients (16.45%). In complicated appendicitis, an EL was used in 85 patients (48.85%) and an ES was used in 89 patients (51.15%). An analysis of effectiveness and a cost analysis of each technique were performed. RESULTS In uncomplicated appendicitis, we found no differences with respect to global complications, although there were significant differences in the total mean hospital stay (EL group 1.55 (SD 1.48) days; ES group 2.21 (SD 1.69) days; p = 0.046). This meant a savings of 514.12€ per patient using the EL p < 0.001). In complicated appendicitis, the reoperations classified as Clavien-Dindo IIIB in the EL group (6.4%) were greater than in the ES group (0%) (p = 0.012), although the rate of postoperative abscesses (p = 0.788) and the mean volume of abscesses (p = 0.891) were similar. CONCLUSION The systematic use of an EL could reduce costs in uncomplicated appendicitis, while in complicated cases, both options are valid. Prospective studies with a greater number of patients are needed to observe differences in postoperative complications.
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Affiliation(s)
| | - Gregorio Anguiano-Diaz
- Division of General Surgery, Virgen del Rocío University Hospital, Av Manuel Siurot S/N, 41013, Seville, Spain
| | - Luis Tallón Aguilar
- Division of General Surgery, Virgen del Rocío University Hospital, Av Manuel Siurot S/N, 41013, Seville, Spain
| | - José Tinoco González
- Division of General Surgery, Virgen del Rocío University Hospital, Av Manuel Siurot S/N, 41013, Seville, Spain
| | - Alejandro Sánchez Arteaga
- Division of General Surgery, Virgen del Rocío University Hospital, Av Manuel Siurot S/N, 41013, Seville, Spain
| | - Daniel Aparicio Sánchez
- Division of General Surgery, Virgen del Rocío University Hospital, Av Manuel Siurot S/N, 41013, Seville, Spain
| | - Felipe Pareja Ciuró
- Division of General Surgery, Virgen del Rocío University Hospital, Av Manuel Siurot S/N, 41013, Seville, Spain.
| | - Javier Padillo Ruiz
- Division of General Surgery, Virgen del Rocío University Hospital, Av Manuel Siurot S/N, 41013, Seville, Spain
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What is the Operative Cost of Managing Acute Appendicitis in the NHS: The Impact of Stump Technique and Perioperative Imaging. World J Surg 2020; 44:749-754. [PMID: 31773223 DOI: 10.1007/s00268-019-05306-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute appendicitis is a common surgical emergency that is typically managed with laparoscopic appendicectomy in UK centres. A number of variables influence the cost of managing this condition. Our aim was to identify the major influencing factors in our centre by performing a cumulative cost analysis. METHODS We retrospectively analysed the costs associated with 99 cases of acute appendicitis managed with laparoscopic appendicectomy at Ninewells Hospital, Dundee, from January 2014 to February 2016. Costs were categorised according to blood tests, imaging, medications, operative costs and length of stay. RESULTS Our cohort included 66 males, 33 females and 28 paediatric cases. The total cost was £220030.52 with a mean of £2222.53 per patient. The factor with the greatest influence on overall cost was operative time (53.2%) followed by length of stay (39.2%). There was no cost difference between adults and children (p = 0.24) or males and females (p = 0.38). Mean cost in adults ≥50 years was greater than those <50 years (£2899.32 vs £2152.97, p = 0.008) and greater in those who underwent imaging as opposed to no imaging (£2789.53 vs £2010.65, p = 0.0001). For appendiceal stump technique, polymer clips were cheaper (£1844.70) than ligatures (£2380.11, p = 0.006). CONCLUSIONS Operative time (53.2%) and length of stay (39.2%) had the greatest impact on the cost in our cohort. Older patients have a greater overall cost, and this is associated with increased utilisation of imaging. Further studies assessing the safety and feasibility of methods to reduce operative time and to investigate the safety of reducing length of stay are required.
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Zhang P, Zhang Q, Zhao H, Li Y. Factors affecting the length of hospital stay after laparoscopic appendectomy: A single center study. PLoS One 2020; 15:e0243575. [PMID: 33296384 PMCID: PMC7725291 DOI: 10.1371/journal.pone.0243575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/23/2020] [Indexed: 12/26/2022] Open
Abstract
AIM This study aimed to explore factors may affect the length of hospital stay after laparoscopic appendectomy. METHODS The data of 636 patients undergoing laparoscopic appendectomy between July 2016 and July 2019 in Beijing Tsinghua Changgung Hospital were retrospectively analyzed. The patients were divided into group A (hospital stay ≤3 days, 348 patients) and group B (hospital stay >3 days, 288 patients) according to their hospital stay.Sex, age, disease onset time(time from onset to admission), nausea, vomiting, diarrhea, peritonitis, comorbidities, and history of appendicitis; preoperative body temperature (T), white blood cell (WBC) count, percentage of neutrophilic granulocytes, and preoperative C-reactive protein (CRP) level; time from diagnosis to surgery. appendix diameter, appendicolith, and ascites in ultrasound or CT; surgical time(the surgery start time was the time of skin incision, and the end time was the time the anesthesia intubation was removed), intraoperative blood loss (the volume of blood infiltrating into a gauze was calculated by weighing the gauze infiltrated with water and calculating the volume of water), intraoperative adhesions or effusions, and stump closure methods, convert to open appendectomy, appendix pathology(perforated or gangrenous appendicitis were defined as complicated appendicitis and simple or suppurative appendicitis were defined as uncomplicated appendicitis) and antibiotic treatment schemes were analyzed. RESULTS Significant differences were detected between group A and group B in age (37.10 ± 13.52y vs 42.94 ± 15.57y, P<0.01), disease onset time (21.36 ± 16.56 h vs 32.52 ± 27.99 h, P <0.01), time from diagnosis to surgery (8.63 ± 7.29 h vs 10.70 ± 8.47 h, P<0.01); surgical time(64.09 ± 17.24 min vs 86.19 ± 39.96 min, P < 0.01); peritonitis(52.9% vs 74%, P < 0.01), comorbidities (12.4% vs 20.5%, P < 0.01), appendicolith (27.6% vs 41.7%, P < 0.01), ascites before the surgery(13.8% vs 22.9%, P < 0.01), intraoperative adhesions or effusions(56% vs 80.2%, P < 0.01); preoperative temperature (37.11 ± 0.64°C vs 37.54 ± 0.90°C, P < 0.01); preoperative WBC count (13.06 ± 3.39 × 109/L vs 14.21 ± 4.54 × 109/L, P = 0.04);preoperative CRP level(18.99 ± 31.72 mg/L vs 32.46 ± 46.68 mg/L, P < 0.01); appendix diameter(10.22 ± 2.59 mm vs 11.26 ± 3.23 mm, P < 0.01); intraoperative blood loss (9.36 ± 7.29 mL vs 13.74 ± 13.49 mL, P < 0.01); using Hem-o-lok for stump closure(30.7% vs 38.5%, P = 0.04); complicated appendicitis (9.5% vs 45.8%, P < 0.01); and using ertapenem for antibiotic treatment after the surgery(4.3% vs 21.5%, P < 0.01). Multivariate analysis demonstrated that age (OR = 1.021; 95%CI = 1.007-1.036), peritonitis (OR = 1.603; 95% CI = 1.062-2.419), preoperative WBC count (OR = 1.084; 95% CI = 1.025-1.046), preoperative CRP level (OR = 1.010; 95% CI = 1.005-1.015), time from diagnosis to surgery (OR = 1.043; 95% CI = 1.015-1.072), appendicolith (OR = 1.852; 95% CI = 1.222-2.807), complicated appendicitis (OR = 3.536; 95% CI = 2.132-5.863), surgical time (OR = 1.025; 95% CI = 1.016-1.034), use of Hem-o-lok for stump closure (OR = 1.894; 95% CI = 1.257-2.852), and use of ertapenem for antibiotic treatment (OR = 3.076; 95% CI = 1.483-6.378) were the risk factors for a prolonged hospital stay. CONCLUSIONS The patient with appendicitis was older and had peritonitis, higher preoperative WBC count or CRP level, longer time from diagnosis to surgery, appendicolith, and complicated appendicitis, predicting a prolonged hospital stay. Shorter surgical time and the use of silk ligation for stump closure and cephalosporins + metronidazole for antibiotic treatment might be better choices to obtain a shorter hospital stay.
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Affiliation(s)
- Peng Zhang
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Qian Zhang
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hongwei Zhao
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuanxin Li
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- * E-mail:
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Grounds BE, Cross J. A Unique Presentation of an Ectopic Pregnancy After Appendectomy. Cureus 2020; 12:e11560. [PMID: 33364087 PMCID: PMC7749862 DOI: 10.7759/cureus.11560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ectopic pregnancies account for the majority of deaths in early pregnancy. A 27-year-old woman with unexplained infertility and a history of an appendectomy was referred to the reproductive endocrinology clinic. She was initially diagnosed with a pregnancy of unknown location and was later found to have an ectopic pregnancy. Final pathology found a surgical staple likely present from a previous appendectomy within the fallopian tube proximal to the ectopic site. The surgical staple is postulated to have entered the tube through ciliary action and caused the ectopic pregnancy. This rare case highlights physicians' need to carefully monitor and remove visible loose staples after using automated stapling devices.
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Affiliation(s)
- Benjamin E Grounds
- Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, USA
| | - Jennifer Cross
- Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, USA
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Sazhin AV, Nechay TV, Titkova SM, Petukhov VA, Tyagunov AE, Stradymov EA, Ermakov IV, Mishakina NY. [Appendectomy technique: paradigm shift or a well-forgotten old one? The role of mesoappendectomy in prevention of infectious intra-abdominal complications (announcement of RCT)]. Khirurgiia (Mosk) 2020:49-59. [PMID: 33047586 DOI: 10.17116/hirurgia202010149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the role of mesoappendixectomy in the development of intra-abdominal surgical site infection (IAB SSI) after LAE. MATERIAL AND METHODS A prospective randomized non-blind multiple-center registered (ClinicalTrials.gov NCT03754777) study has been performed for the period from 2016 to 2018. The study was devoted to effectiveness and safety of the modified enhanced recovery protocol in LAE. In the main group, this protocol (n=56) included routine mesoappendixectomy, restrictive strategy for abdominal drainage and postoperative antibiotic prevention. In the control group (n=71), mesoappendixectomy was performed only in case of necrotic changes. Both groups were comparable by demographic parameters and severity of comorbidities. RESULTS In the main group, significant decrease in the incidence of IAB SSI was found (0% versus 9.8%). Moreover, the main group was characterized by reduced length of hospital-stay (1.43±1.34 d versus 2.94±2, 43 days). CONCLUSION Mesoappendixectomy should be evaluated in further research as a potential factor in prevention of IAB SSI.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V A Petukhov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E A Stradymov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Ermakov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - N Yu Mishakina
- Pirogov Russian National Research Medical University, Moscow, Russia
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Makaram N, Knight SR, Ibrahim A, Patil P, Wilson MSJ. Closure of the appendiceal stump in laparoscopic appendectomy: A systematic review of the literature. Ann Med Surg (Lond) 2020; 57:228-235. [PMID: 32802324 PMCID: PMC7419254 DOI: 10.1016/j.amsu.2020.07.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022] Open
Abstract
Background Closure of the appendiceal stump is a key step performed during laparoscopic appendicectomy. Inadequate management of the appendiceal stump has the potential to cause significant morbidity. Several methods of stump closure have been described, however high-level evidence is limited. We performed a systematic review evaluating clinical outcomes and quality of the evidence for the methods of appendiceal stump closure. Methods A systematic literature search was performed using Medline, Embase, Cochrane Database and Google Scholar to identify studies comparing appendiceal stump closure methods in laparoscopic appendectomy for acute appendicitis from inception to October 2019. Data regarding operative duration, peri-operative complications, length of stay and costs were collated from all included studies. Results From 160 identified studies, 19 met the inclusion criteria. Endoloops and endoclips provide equivalent clinical outcomes at lower cost, while operative duration was shortest with endoclip closure. Endostapler devices have the lowest rate of peri-operative complications (3.56%), however their cost limits their regular use in many healthcare environments. Post-operative complication rate and length of stay were similar for all stump closure methods. Conclusion: Although there are no significant differences in method of stump closure in laparoscopic appendectomy, closure with endoclips provides the shortest operative duration. There is a need for robust and standardized reporting of cost data when comparing stump closure methods, together with higher level evidence in the form of multi-centre randomized controlled trials before firm conclusions can be drawn regarding the optimal method of stump closure. Currently there is no robust higher order evidence which assesses clinical outcomes, cost and time efficiency of methods of stump closure in laparoscopic appendicectomy. This is the first systematic review to investigate clinical outcomes, cost and quality of current evidence for all methods of laparoscopic appendiceal stump closure in acute appendicitis. No difference was observed in methods of stump closure in complication rate, length of stay, cost, and time efficiency. Endostaplers appear to provide most robust closure, albeit at a higher economic cost. Endoloops appear to provide efficient and successful closure, and are currently the most frequently studied method of closure.
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Affiliation(s)
- N Makaram
- Department of General Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - S R Knight
- Usher Institute, University of Edinburgh, Edinburgh, EH16 4XU, UK
| | - A Ibrahim
- Department of General Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - P Patil
- Department of General Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - M S J Wilson
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK
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Comparison of three techniques for appendiceal stump closure during laparoscopy. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.781614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Manatakis DK, Aheimastos V, Antonopoulou MI, Agalianos C, Tsiaoussis J, Xynos E. Unfinished Business: A Systematic Review of Stump Appendicitis. World J Surg 2020; 43:2756-2761. [PMID: 31375871 DOI: 10.1007/s00268-019-05101-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Stump appendicitis is defined as interval inflammation of any residual appendicular tissue, after an appendicectomy. We present a systematic review of case series and case reports on stump appendicitis, emphasising on risk factors, diagnosis and surgical management. METHODS The English literature (1945-2018) was reviewed, using PubMed, Embase and GoogleScholar, combining the terms "appendix", "appendicitis", "stump", "residual", "recurrent" and "retained". In total, 127 studies were included, describing 164 patients (males 59%, mean age 36 ± 17 years). RESULTS Index surgery was open in 59% and laparoscopic in 38%. It was described as "difficult" or "complicated" in 31%. 20% of patients reported episodes of recurrent abdominal pain during the time interval between index and stump appendicitis (range 2 weeks to 60 years, median 2 years). Right lower quadrant pain was the most frequent complain (88%), leukocytosis was found in 56%, whereas 92% of patients underwent imaging testing, which was diagnostic or highly suspicious in 67.5%. Mean delay between beginning of symptoms and surgery was 2.4 ± 2.3 days. The operative approach was open in 61% and laparoscopic in 35% of cases. The operation was characterised as "difficult" or "complicated" in 45%. In the majority (88%), a completion stump appendicectomy was performed, with 11% requiring more extensive procedures. Mean length of resected stump was 3.1 ± 1.6 cm (range 0.5-10 cm). CONCLUSIONS Stump appendicitis may occur following both open and laparoscopic approach, when the residual stump is > 0.5 cm. Its clinical significance lies in the delayed diagnosis, leading to higher incidence of complications and the need for more extensive surgery.
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Affiliation(s)
- Dimitrios K Manatakis
- Department of Surgery, Athens Naval and Veterans Hospital, 11521, Athens, Greece.
- Medical School, University of Crete, Heraklion, Crete, Greece.
| | - Vasileios Aheimastos
- Department of Surgery, Athens Naval and Veterans Hospital, 11521, Athens, Greece
| | | | - Christos Agalianos
- Department of Surgery, Athens Naval and Veterans Hospital, 11521, Athens, Greece
| | - John Tsiaoussis
- Medical School, University of Crete, Heraklion, Crete, Greece
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A systematic review on the cost evaluation of two different laparoscopic surgical techniques among 996 appendectomies from a single center. Updates Surg 2020; 72:1167-1174. [PMID: 32474801 DOI: 10.1007/s13304-020-00817-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/20/2020] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.
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Vuille-Dit-Bille RN, Staerkle RF, Derderian SC, Dewberry LC, Breitenstein S, Soll C. Appendiceal stump closure in children using polymeric clips is a reliable alternative to endoloops. MINERVA CHIR 2020; 75:274-275. [PMID: 32456398 DOI: 10.23736/s0026-4733.20.08313-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Raphael N Vuille-Dit-Bille
- Department of Visceral and Thoracic Surgery, Cantonal Hospital, Winterthur, Switzerland - .,Department of Pediatric Sugery, Children's Hospital Colorado, Aurora, CO, USA -
| | - Ralph F Staerkle
- Department of Visceral and Thoracic Surgery, Cantonal Hospital, Winterthur, Switzerland.,Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital, University Hospital Basel, Basel, Switzerland
| | - Sarkis C Derderian
- Department of Pediatric Sugery, Children's Hospital Colorado, Aurora, CO, USA
| | - Lindel C Dewberry
- Department of Pediatric Sugery, Children's Hospital Colorado, Aurora, CO, USA
| | - Stefan Breitenstein
- Department of Visceral and Thoracic Surgery, Cantonal Hospital, Winterthur, Switzerland
| | - Christopher Soll
- Department of Visceral and Thoracic Surgery, Cantonal Hospital, Winterthur, Switzerland
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Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15:27. [PMID: 32295644 PMCID: PMC7386163 DOI: 10.1186/s13017-020-00306-3] [Citation(s) in RCA: 471] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. METHODS This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. CONCLUSIONS The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
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Affiliation(s)
- Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
| | - Mauro Podda
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Belinda De Simone
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia
| | - Alice Gori
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Marja Boermeester
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Nicola De' Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Arianna Birindelli
- Department of General Surgery, Azienda Socio Sanitaria Territoriale, di Valle Camonica, Italy
| | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI, USA
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Michael Kelly
- Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | | | - Richard Justin Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil
| | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Gabriele Sganga
- Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy
| | - Adolfo Pisanu
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Andrey Litvin
- Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Fabio C Campanile
- Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Rifat Latifi
- Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Fakri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - David Costa
- Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain
| | - Sandro Rizoli
- Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | | | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - George Velmahos
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
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Guaitoli E, Gallo G, Cardone E, Conti L, Famularo S, Formisano G, Galli F, Giuliani G, Martino A, Pasculli A, Patini R, Soriero D, Pappalardo V, Casoni Pattacini G, Sparavigna M, Meniconi R, Mazzari A, Barra F, Orsenigo E, Pertile D. Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis. J INVEST SURG 2020; 34:1089-1103. [PMID: 32167385 DOI: 10.1080/08941939.2020.1740360] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.
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Affiliation(s)
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Eleonora Cardone
- Department of Surgery, Santa Maria del Popolo degli Incurabili Hospital, Napoli, Italy
| | - Luigi Conti
- Department of Surgery, G. Da Saliceto Hospital, Piacenza, Italy
| | - Simone Famularo
- Department of Medicine and Surgery University of Milan Bicocca HPB Unit, San Gerardo Hospital, Monza, Italy
| | - Giampaolo Formisano
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | | | - Giuseppe Giuliani
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Antonio Martino
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | - Romeo Patini
- Odontostomatology and Oral Surgery, Sacro Cuore Hospital, Rome, Italy
| | - Domenico Soriero
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | | | - Marco Sparavigna
- Department of General Surgery, University of Genoa, Genova, Italy
| | - Roberto Meniconi
- Department of General Surgeon and Transplantations, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Mazzari
- Mini Invasive and General Surgery, Cristo Re Hospital, Rome, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Elena Orsenigo
- Department of General and Emergency Surgery, San Raffaele Scientific Institute, Milano, Italy
| | - Davide Pertile
- Department of General Surgery, University of Genoa, Genova, Italy
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Fugazzola P, Ceresoli M, Agnoletti V, Agresta F, Amato B, Carcoforo P, Catena F, Chiara O, Chiarugi M, Cobianchi L, Coccolini F, De Troia A, Di Saverio S, Fabbri A, Feo C, Gabrielli F, Gurrado A, Guttadauro A, Leone L, Marrelli D, Petruzzelli L, Portolani N, Prete FP, Puzziello A, Sartelli M, Soliani G, Testini M, Tolone S, Tomasoni M, Tugnoli G, Viale P, Zese M, Ishay OB, Kluger Y, Kirkpatrick A, Ansaloni L. The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition). World J Emerg Surg 2020; 15:19. [PMID: 32156296 PMCID: PMC7063712 DOI: 10.1186/s13017-020-00298-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022] Open
Abstract
The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.
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Affiliation(s)
- Paola Fugazzola
- General and Emergency Surgery Department, Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy.
| | - Marco Ceresoli
- General Surgery Department, Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy
| | | | | | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Paolo Carcoforo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Osvaldo Chiara
- Emergency and Trauma Surgery, Niguarda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Lorenzo Cobianchi
- Department of General Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Coccolini
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Alessandro De Troia
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Salomone Di Saverio
- Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Carlo Feo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Francesco Gabrielli
- General Surgery Department, Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy
| | - Angela Gurrado
- Department of Biochemical Sciences and Human Oncology, University of Medical School "A. Moro" of Bari, Bari, Italy
| | - Angelo Guttadauro
- General Surgery Department, Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy
| | - Leonardo Leone
- General and Oncological Surgery, Filippo Neri Hospital, Rome, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Petruzzelli
- Department of Emergency Surgery, Città della Salute e della Scienza University Hospital, Torino, Italy
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Francesco Paolo Prete
- Endocrine, Digestive and Emergency Surgery Department, University of Medical School of Bari, Bari, Italy
| | | | | | - Giorgio Soliani
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Mario Testini
- Endocrine, Digestive and Emergency Surgery Department, University of Medical School of Bari, Bari, Italy
| | - Salvatore Tolone
- General, Mininvasive and Bariatric Surgery Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Matteo Tomasoni
- General and Emergency Surgery Department, Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy
| | - Gregorio Tugnoli
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Pierluigi Viale
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Monica Zese
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Offir Ben Ishay
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Andrew Kirkpatrick
- Departments of General Acute Care, Abdominal Wall Reconstruction and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Luca Ansaloni
- General and Emergency Surgery Department, Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy
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Kim R, Moore R, Schmidt L, Martin K, Sjoholm LO, Mason L, Beard J. Volvulus caused by a free intraperitoneal staple after laparoscopic appendectomy: A case report. Int J Surg Case Rep 2019; 65:259-261. [PMID: 31743842 PMCID: PMC6864125 DOI: 10.1016/j.ijscr.2019.10.072] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/27/2019] [Indexed: 12/22/2022] Open
Abstract
Free intraperitoneal staples are usually inert but can have complications. Early obstructive symptoms after appendectomy should warrant prompt work-up. Volvulus can occur due to free staples after laparoscopic appendectomy. Small bowel necrosis due to a free malformed staple required small bowel resection. We recommend removing free staples when seen in order to prevent complications.
Introduction Laparoscopic appendectomies are routinely performed using linear staplers. Few case reports have discussed complications from free intraperitoneal staples after appendectomy. We present the first case of a volvulus caused by a free staple that subsequently required bowel resection. Presentation of case A 27-year-old female underwent laparoscopic appendectomy for uncomplicated appendicitis. The base of the appendix was divided using a laparoscopic gastrointestinal anastomosis (GIA) stapler and the mesoappendix was divided using a LigaSure device. The patient was discharged the following day. Eight days later, the patient returned to the emergency department with severe abdominal pain, emesis, and peritoneal signs. Computed tomography (CT) showed significant pneumoperitoneum and nonspecific small bowel edema. Exploratory laparotomy was performed revealing a necrotic small bowel segment from a malformed, free staple caught on the peritoneum of the small bowel mesentery causing a closed loop obstruction. After reduction and detorsion, the small bowel segment was not viable and required resection. She was discharged on postoperative day four with no additional perioperative complications. Discussion Mechanical staplers are commonly used in laparoscopic appendectomy and free intraperitoneal staples are generally considered inert. A high index of suspicion should be maintained for the early postoperative appendectomy patient with obstructive symptoms. Conclusion Inspection of the staple line, choosing the appropriate staple size and cartridge, and removing free malformed staples if seen should be employed during appendectomy to prevent rare but devastating complications.
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Affiliation(s)
- Rachel Kim
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA.
| | - Ryan Moore
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA.
| | - Lauren Schmidt
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA.
| | - Katherine Martin
- Lewis Katz School of Medicine Physician Assistant Program, 3500 N. Broad Street, Suite 124, Philadelphia, PA 19140, USA.
| | - Lars Ola Sjoholm
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA.
| | - Leonard Mason
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA.
| | - Jessica Beard
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA.
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A comparison of non-absorbable polymeric clips and staplers for laparoscopic appendiceal stump closure: analysis of 618 adult patients. Langenbecks Arch Surg 2019; 404:711-716. [PMID: 31446471 DOI: 10.1007/s00423-019-01814-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/15/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE The aim of this long-term study was the comparison of appendiceal stump closure with polymeric clips or staplers with respect to perioperative costs and surgical outcome under routine conditions in a university centre. METHODS For this retrospective chart review, a total of 618 patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2010 and 2017 were reviewed: 410 patients in the stapler group and 208 patients in the clip group. The database contained demographic data, operation time, inflammation parameters, closure method of the stump, surgeon status, length of hospital stay, and complications as well as histology reports. The costs were also compared. RESULTS Clip application was more likely among younger patients (mean age 33.6 years vs. 41.7 years). Histopathological evidence for appendiceal pathology was found in 96.6% of patients in the clip group and 99.5% of patients in the stapler group. Laparoscopic appendectomy in the clip group was more frequently performed by resident physicians (69.2%) than in the stapler group (57.8%). The mean postoperative stay was 2.9 days in the clip group and 3.7 days in the stapler group. The use of the polymeric clip resulted in considerable cost savings (19.94€ vs. 348.70€). CONCLUSIONS The use of polymeric clips for appendiceal stump closure during appendectomy is safe and effective. The base of the appendix is amenable to clipping in 32% of appendectomies in adult patients. This study supports the use of polymeric clips over staplers to decrease cost and environmental impact.
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Tachezy M, Izbicki JR. [Evidence for standard surgical procedures: appendicitis, diverticulitis and cholecystitis]. Chirurg 2019; 90:351-356. [PMID: 30635701 DOI: 10.1007/s00104-018-0779-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute appendicitis, cholecystitis and sigmoid diverticulitis are the most common inflammatory visceral surgical emergencies. According to the principles of evidence-based medicine, treatment methods and surgical indications should be constantly questioned and validated by high-quality clinical studies. OBJECTIVE To identify and classify the current evidence on surgical treatment of acute appendicitis, cholecystitis and sigmoid diverticulitis. MATERIAL AND METHODS Targeted literature search in Medline, the Cochrane Library and study registers (clinicaltrials.gov). RESULTS AND CONCLUSION The indications for surgery are changing due to increasing numbers of high-quality clinical studies. Conservative treatment seems to be feasible in the early stages. In contrast, many surgical steps have not yet been sufficiently validated. Furthermore, there is a great need for high-quality, prospective randomized clinical trials, so that promotion of studies and the study culture in surgery should continue to be of greatest interest.
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Affiliation(s)
- M Tachezy
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - J R Izbicki
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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Development of a Two Port Laparoscopic Appendectomy Technique at a Rural Hospital. Minim Invasive Surg 2019; 2019:9761968. [PMID: 31236293 PMCID: PMC6545795 DOI: 10.1155/2019/9761968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023] Open
Abstract
Background Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options. Patients and Methods This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a “try-out” (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15). Results Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case. Discussion LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.
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Obrist NM, Tschuor C, Breitenstein S, Vuille-Dit-Bille RN, Soll C. Appendectomy in Switzerland: how is it done? Updates Surg 2019; 71:375-380. [PMID: 30982171 DOI: 10.1007/s13304-019-00654-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/02/2019] [Indexed: 12/19/2022]
Abstract
More than 10,000 appendectomies are performed every year in Switzerland. The aim of this study was to investigate the treatment strategy for appendicitis among Swiss surgeons with particular interest in laparoscopic technique, method of appendiceal stump closure, and abdominal lavage. We performed an anonymous survey among 540 members of the Swiss Surgical Society. Technical details and differences between the surgical procedures in adults and children as well as in complicated and non-complicated appendicitis were investigated. The overall response rate was 45% (n = 243). 78% of the surgeons perform laparoscopic appendectomies in children and 95% in adult patients. Only 3% use a single incision site technique. Surgeons consider pus or stool in the abdomen (94%), an abscess (86%) or perforation of the appendix (82%), but not an inflamed appendiceal base (16%) as complicated appendicitis. 41% of surgeons use endoloops, 36% a stapling device, and 20% polymeric clips in non-complicated appendicitis for appendiceal stump closure. However, 82% of the surgeons use a stapler in complicated appendicitis. Most (76%) of surgeons do not plunge the appendiceal stump. 24% of surgeons lavage the abdomen with > 1 L of fluid independent of the intraabdominal finding. Most Swiss surgeons perform multiport laparoscopic appendectomies. Endoloops and staplers are mostly used for appendiceal stump closures in uncomplicated appendicitis, and staplers in complicated appendicitis. Only a minor part of surgeons plunge the appendiceal stump or perform routine abdominal lavage.
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Affiliation(s)
- Nicolas M Obrist
- Department of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland
| | - Christoph Tschuor
- Department of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland
| | - Stefan Breitenstein
- Department of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland
| | - Raphael N Vuille-Dit-Bille
- Department of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland
| | - Christopher Soll
- Department of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland.
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The use of polymeric clips in securing the appendiceal stump during laparoscopic appendicectomy: a systematic review. Eur J Trauma Emerg Surg 2019; 45:665-670. [PMID: 30815719 DOI: 10.1007/s00068-019-01105-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/25/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE A key step during laparoscopic appendicectomy is securing the appendiceal stump. This has traditionally been achieved using vicryl endoloops, but increasing evidence suggests that the use of polymeric clips (Hem-o-lok) may be a safe and viable method. Current evidence for its clinical use in laparoscopic appendicectomy is unknown. We performed a systematic review of the literature examining the clinical outcomes of laparoscopic appendicectomy using polymeric clips compared to other methods of stump closure. METHODS A systematic literature review based on PRISMA guidelines was performed using MEDLINE, PubMed, EMBASE and Cochrane library databases between 2000 and 2017. All studies analysing appendiceal stump closure during laparoscopic appendicectomy using polymeric clips compared to other methods of stump closure were included. The methodological quality of the included studies was assessed using the Cochrane Handbook for Systematic Reviews. The review was registered with the PROSPERO register of systematic reviews. RESULTS Ten studies were included, involving 702 patients, 7 of which were prospective studies and 1 a randomised control trial. Polymeric clips were found to be the cheapest method (€20.47 average per patient) and also had the lowest rate of complications (2.7%) compared to other commonly used closure methods. Meanwhile, operative time and duration of in-patient stay were similar between groups. CONCLUSIONS Current evidence suggests that polymeric clips are an effective and cost-efficient method for stump closure in laparoscopic appendicectomy for acute appendicitis. Further high-quality evidence is required before polymeric clips can be recommended as the gold standard for appendiceal stump closure.
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Kryspin M, Wyrzykowsk D. Outcomes of Open and Laparoscopic Appendectomy With Single Endoloop Stump Closure. JSLS 2019; 22:JSLS.2018.00062. [PMID: 30607104 PMCID: PMC6305067 DOI: 10.4293/jsls.2018.00062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background and Objectives: Although laparoscopic appendectomy (LA) has been used for 35 years, the open approach (OA) is preferred worldwide. Widespread access to instrumentation in a number of centers has reduced economic and logistical obstacles. The aim of this work is to compare the results for patients with suspected appendicitis treated using an OA versus patients treated using LA. Methods: A retrospective study of all patients (N = 290) who underwent operation due to suspected appendicitis in the General Surgery Department from 2014 to 2017 was conducted. LA was performed in 91 patients, and OA was performed in 199 patients. Results: Average surgery duration was 67.8 minutes in the LA group and 62.9 minutes in the OA group (P =.082). It was necessary to perform 3 conversions (3.3%) from LA to OA. Wound infections occurred in 2.2% of patients in the LA group and in 12.6% of patients in the OA group (P = .007). A reduced duration of hospitalization was noted in the LA group (3.3 days) compared with the OA group (4.7 days) (P < .001). Conclusion: The duration of LA is not considerably longer than that of OA. LA in patients with suspected appendicitis reduces the number of operation site infections compared with OA. LA with single endoloop stump closure is a safe method and may be recommended for wider applications.
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Affiliation(s)
- Mitura Kryspin
- General Surgery Department, Siedlce Hospital, Siedlce, Poland
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Staplers vs. loop-ligature: a cost analysis from the hospital payer perspective. Surg Endosc 2019; 33:3419-3424. [PMID: 30604261 DOI: 10.1007/s00464-018-06639-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/19/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Presently, there is equipoise regarding the surgical technique used to manage the appendiceal stump during laparoscopic appendectomy. The purpose of this research was to determine whether the routine use of loop ligature, compared to stapling, is cost effective from a hospital payer perspective. METHODS A retrospective cohort study was conducted amongst patients undergoing emergency laparoscopic surgery for acute appendicitis at two major academic hospitals. In order to eliminate possible systematic bias arising from one technique being preferentially employed with more complex presentations, patients were divided into study groups based on the technique routinely employed by their surgeon, loop ligature (LLA) versus stapler (LSA). Pediatric patients and open appendectomies were excluded. Costs were determined using a previously published model derived from publicly available data from the Ontario Case Costing Initiative, in conjunction with local cost data for disposable procurement. Secondary outcomes included operating room time, length of stay, and complication rates. RESULTS Between Jan 1, 2014 and Dec 31, 2015, 567 adult patients had an emergency laparoscopic appendectomy for acute appendicitis. In comparing surgeons who routinely employed LLA to LSA, there was a significant decrease in total mean hospital cost with LLA ($1988 ± $143 vs. $2253 ± $99, p = 0.002). In addition, mean disposable cost was reduced for surgeons using LLA ($310 ± $27 vs. $668 ± $26, p < 0.001). This reduction in cost was not associated with a difference in length of stay (1.5 vs. 1.4 days, p = 0.28) or complication rates (8% vs. 10%, p = 0.43). CONCLUSIONS These findings suggest that surgeons who routinely use loop ligature to secure the appendiceal base during emergency laparoscopic appendectomy offer more cost-effective care compared to stapler users, saving their institution more than $200 per case with no clear disadvantages. A shift from routine use of staplers to loop ligature should result in significant overall cost savings to the hospital.
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Jaschinski T, Mosch CG, Eikermann M, Neugebauer EAM, Sauerland S. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2018; 11:CD001546. [PMID: 30484855 PMCID: PMC6517145 DOI: 10.1002/14651858.cd001546.pub4] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010. OBJECTIVES To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence. MAIN RESULTS We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies. AUTHORS' CONCLUSIONS Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.
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Affiliation(s)
- Thomas Jaschinski
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (Building 38)CologneGermany51109
| | - Christoph G Mosch
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (Building 38)CologneGermany51109
| | - Michaela Eikermann
- Medical advisory service of social health insurance (MDS)Department of Evidence‐based medicineTheodor‐Althoff‐Straße 47EssenNorth Rhine WestphaliaGermany51109
| | - Edmund AM Neugebauer
- Brandenburg Medical School Theodor Fontane 3Fehrbelliner Str 38NeuruppinBrandenburgGermany16816
| | - Stefan Sauerland
- Institute for Quality and Efficiency in Health Care (IQWiG)Department of Non‐Drug InterventionsIm Mediapark 8CologneGermany50670
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Wilson MSJ, Maniam P, Ibrahim A, Makaram N, Knight SR, Patil P. Polymeric clips are a quicker and cheaper alternative to endoscopic ligatures for securing the appendiceal stump during laparoscopic appendicectomy. Ann R Coll Surg Engl 2018; 100:454-458. [PMID: 29543058 PMCID: PMC6111912 DOI: 10.1308/rcsann.2018.0036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction The use of polymeric clips in securing the appendiceal stump has been increasingly reported as a viable alternative to current methods in emergency laparoscopic appendicectomy. We evaluated the operative outcomes following the use of polymeric clips versus endoscopic ligatures. The primary endpoint was operative time, with secondary outcomes including complications, inpatient stay, and cost analysis. Materials and methods Operative records were retrospectively analysed to identify patients undergoing laparoscopic appendicectomy between January 2014 and June 2015. Data collected included age, gender, body mass index, duration of surgery, length of hospital stay, antibiotic use, preoperative haematological and biochemical parameters, 30-day readmission rate and complications. Results A total of 125 patients were included within the study, with 78 within the endoloop group and 47 in the polymeric clip group. There were no differences in age, gender, body mass index, hospital stay, antibiotic use, 30-day readmission rates or postoperative complications. Operative time was significantly reduced in the polymeric clip group (59 vs. 68 minutes, P = 0.00751). The use of polymeric clips cost £21 compared with £49 for endoloops per operation, which rose to £70 if both clips and endoloops were used during the procedure. Discussion Polymeric clips are a safe, viable and economical method for securing the appendiceal stump during laparoscopic appendicectomy. The clinical significance of nine minutes of reduced operating time in the polymeric clip cohort warrants further study with an adequately powered randomised controlled trial.
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Affiliation(s)
- MSJ Wilson
- Department of General Surgery, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - P Maniam
- Ninewells Hospital and Medical School, Dundee, UK
| | - A Ibrahim
- Department of General Surgery, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - N Makaram
- Department of General Surgery, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - SR Knight
- Department of General Surgery, Monklands Hospital, Airdrie, UK
| | - P Patil
- Department of General Surgery, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
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