Changing trends in surgery for acute appendicitis

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis

BACKGROUND

Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting.

METHODS

This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed.

RESULTS

In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2).

CONCLUSIONS

Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Neurogenic appendicopathy: A rare differential diagnosis of acute appendicitis

AIM OF THE STUDY

In histologically non-inflamed but clinically suspect appendices, changes described as neurogenic appendicopathy with fibrous or fibrolipomatous obliterations can be observed. The purpose of this study was to analyse the incidence of these entities of the appendix in a longitudinal patient cohort.

PATIENTS AND METHODS

This is a retrospective single-centre study of 457 patients undergoing laparoscopic appendectomy from 2017 to 2020 due to suspected acute appendicitis.

RESULTS

In 72 patients (15.8%) with clinically suspected acute appendicitis, the appendix showed no distinct signs of acute inflammation during the procedure. In 43 patients, histological analysis revealed neurogenic appendicopathy or fibrous and fibrolipomatous obliteration. Female gender (P=0.088), younger age (P<0.0001), longer pain duration (P<0.0001) and repetitive pain episodes were more frequent in these patients than in those with acute appendicitis. Inflammation markers were also decreased in the group of patients with neurogenic appendicopathy (leukocytes 9.8±3.5 vs. 13.0±4.5 G/L and C-reactive protein 38.7±60.7 vs. 59.4±70.5mg/L).

CONCLUSION

Neurogenic appendicopathy with fibrous/fibrolipomatous obliteration is a differential diagnosis of acute appendicitis that can only be confirmed by pathology. Female gender, young age, prolonged duration with repetitive episodes of pain, and relatively low inflammatory markers are evocative of this diagnosis.

The Impact of Biologic Therapies on Rate of Colectomy in Paediatric-onset Ulcerative Colitis - A Population-Based Cohort Study

AIM

Biologic therapies have been associated with reduced rate of colectomy in ulcerative colitis (UC) in adults, but data are limited in paediatric-onset UC. Our aim was to define the rate of colectomy in paediatric-onset UC, including post-transition into adult care, and to evaluate the impact of biologic therapies on rate of colectomy.

METHOD

All prevalent patients diagnosed with paediatric-onset UC in South-East Scotland were identified from a prospectively accrued database at our regional tertiary centre. Patients exposed to biologics or surgery were identified and further data collected from health records. Kaplan-Meier analysis was used to calculate cumulative risk of colectomy over time.

RESULTS

145 prevalent patients were identified between 2000 and 2021. Median follow-up was 7.9 years (IQR 4.1-13.1). 23 patients (16 %) underwent a colectomy. 50/145 (34 %) patients received biologic therapy, and 13/23 (57 %) patients who underwent colectomy received biologics. The cumulative risk of colectomy across the whole cohort at 1, 5, and 10 years was 3 %, 13 % and 16 %, respectively. Patients exposed to biologics had a higher colectomy rate at 5 and 10 years (22 % and 34 %). Patients in the pre-biologic era (2000-2008) had non-significantly reduced time from diagnosis to colectomy (2.4 vs 3.7 years, p = 0.204).

CONCLUSION

We have defined the 1-, 5-, and 10-year colectomy rate in a population-based cohort of Paediatric-onset UC patients. Patients who received biologic therapy had a significantly increased risk of colectomy. Increased severity of disease in these patients may account for the greater colectomy risk.

LEVEL OF EVIDENCE

Level 1.

Effect of Operative Time on Outcomes of Minimally Invasive Versus Open Pancreatoduodenectomy

OBJECTIVE

To evaluate how operative time interacts with outcomes among different approaches to pancreaticoduodenectomy (PD). Minimally invasive PDs (MIPD), which include laparoscopic (LPD) and robotic (RPD) approaches, are increasingly performed in the USA. MIPD are generally associated with longer operative times (OT) compared to open PD (OPD). Increased OT is associated with inferior outcomes for OPD; however, the effect of OT on MIPD is not well understood.

METHODS

National Surgical Quality Improvement Program (NSQIP)-targeted pancreatectomy dataset was utilized (2014-2019). Propensity score matching, logistic regression, and mixed effect modeling were performed to determine the effect of OT on outcomes following PD. OTs were stratified by quartiles for each approach, and outcomes were subsequently compared.

RESULTS

Among 23,988 PDs, 22,185 were OPD and 1803 MIPD. Increased OT was associated with greater overall morbidity in all approaches. When comparing OT quartiles, MIPD was consistently associated with improved overall morbidity compared to OPD in matched cohorts. However, for upper quartiles, prolonged OT in MIPD was associated with significantly increased reoperation rates and mortality. The effect of OT on overall morbidity and other outcomes was comparable among LPD and RPD.

CONCLUSIONS

In this study, increased OT was associated with incremental increases in overall morbidity after PD, irrespective of approach. While MIPD was associated with improved overall morbidity compared to OPD when stratified by OT quartile, higher mortality rates were observed with prolonged OT only with MIPD. Those data suggest that MIPD is a safe alternative to OPD when OT is optimized. NSQIP was used to compare the effect of operative time (OT) on outcomes following pancreaticoduodenectomy (PD), stratified by approach. Increased OT was associated with inferior outcomes following open, laparoscopic, and robotic PD. Surgeons should attempt to optimize OT, regardless of the approach to PD.

A prospective observational study of the utility of early diagnostic laparoscopy for right lower abdominal pain: a safe and effective diagnostic and therapeutic tool

BACKGROUND AND AIMS

Diagnostic laparoscopy is commonly performed for diagnosis of right lower abdominal pain and its use is increasing in the emergency setting. Some studies have reported that diagnostic laparoscopy and laparoscopic appendicectomy have advantages over conventional surgery. Many emergency surgeons now perform diagnostic laparoscopy for both clinically diagnosed appendicitis and when the diagnosis is in doubt. The aim of the present study was to assess whether the use of diagnostic laparoscopy is justified and safe for those admitted with right lower abdominal pain.

METHODS AND RESULTS

Data were collected prospectively on consecutive patients attending the acute surgical receiving unit with right iliac fossa pain or a suspected diagnosis of acute appendicitis. A total of 284 patients underwent diagnostic laparoscopy. Of them 233 (82%) had a positive finding at laparoscopy, 207 (88%) underwent appendicectomy, the majority of which were carried out laparoscopically. Surgical trainees performed the majority of operations and this did not have a negative impact on operative findings (p 0.856), operation performed (0.642), or operative duration (0.831). No intra-operative complications were sustained. Ultrasound examination was carried out in 49 patients, while CT was carried out in 24.

CONCLUSION

The results of the present study highlight the utility of early diagnostic laparoscopy as both a diagnostic and therapeutic tool in the acute setting.

Laparoscopic versus open surgery for suspected appendicitis

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.

Pediatric Appendicitis

Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.

Operative management of appendicitis

Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.

Learning curve after rapid introduction of laparoscopic appendectomy: are there any risks in surgical resident participation?

BACKGROUND

With the spread of the minimally invasive technique, laparoscopic appendectomy (LA) is performed with increasing frequency with excellent results. The method provides surgical residents with an excellent opportunity to learn basic laparoscopic skills and prepares them for more complex interventions.

METHODS

We evaluated the results of 600 laparoscopic appendectomies performed by 5 surgical residents (Group A) and 5 consultant surgeons (Group B) between 2006 and 2009. Comparing the two groups based on patient demographics, duration of surgery, operation time depending on the severity of inflammation, intraoperative blood loss, conversion rate, hospital stay in days, and postoperative complications. We also assessed the extent to which the minimum of 20 surgeries to be performed in the learning curve period as recommended by the EAES corresponds to our experience. SPPS 20 was used for the statistical analysis.

RESULTS

Six hundred laparoscopic appendectomies were performed in the study period (Group A: n = 319; Group B: n = 281). A significant difference was found between the two groups in duration of surgery during the learning curve period and when comparing the duration of LA surgeries in the learning curve period with the duration of later surgeries in both groups. The operation time in case of more severe inflammation also showed a significant difference when comparing with simple appendicitis operation time.

CONCLUSIONS

The rapid introduction of laparoscopy involves few risks, the surgery is also performed with sufficient safety by surgical residents, and it provides them with an excellent opportunity to learn the basic laparoscopy skills.

Minimally invasive surgery in gastrointestinal cancer: benefits, challenges, and solutions for underutilization

Background and Objectives:

After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused.

Methods:

We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field.

Results:

We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills.

Conclusions:

Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.

Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and laparoscopic findings

Advances in the technology and improved access to imaging modalities such as Computed Tomography and laparoscopy have changed the contemporary diagnostic and management of acute appendicitis. Complicated appendicitis (phlegmon, abscess and/ or diffuse peritonitis), is now reliably distinguished from uncomplicated cases. Therefore, a new comprehensive grading system for acute appendicitis is necessary. The goal is review and update the laparoscopic grading system of acute appendicitis and to provide a new standardized classification system to allow more uniform patient stratification. During the last World Society of Emergency Surgery Congress in Israel (July, 2015), a panel involving Acute Appendicitis Experts and the author’s discussed many current aspects about the acute appendicitis between then, it will be submitted a new comprehensive disease grading system. It was idealized based on three aspect of the disease (clinical and imaging presentation and laparoscopic findings). The new grading system may provide a standardized system to allow more uniform patient stratification for appendicitis research. In addition, may aid in determining optimal management according to grade. Lastly, what we want is to draw a multicenter observational study within the World Society of Emergency Surgery (WSES) based on this design.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

National trends in therapeutic approaches and outcomes for pediatric appendicitis: a Taiwanese nationwide cohort study

PURPOSE

To define the pattern of therapeutic approaches for pediatric appendicitis and compare their benefits in Taiwan, we analyzed a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA) to document the impact of the rise of laparoscopic treatment on outcomes.

METHODS

We identified 22,161 patients under 18 years who had been hospitalized with a diagnosis of acute appendicitis between 2007 and 2012 in the CCHIA. Statistical comparisons between the Laparoscopic appendectomy (LA) and open appendectomy (OA, control) groups were computed using a Chi squared test. The odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for intra-abdominal abscess (IAA) and postoperative bowel obstruction (PBO) were derived from multivariate logistic regression models.

RESULTS

In each respective year, the incidence of LA increased from 29.17% in 2007 to 57.4% in 2012, while that of OA decreased from 70.83% in 2007 to 42.60% in 2012; incidences of non-perforated appendicitis and perforated appendicitis with LA or OA seemed similar. The length of hospitalization between an LA and OA for non-perforated appendicitis was the same, but that with an LA was shorter for perforated appendicitis. The adjusted ORs for IAA and PBO for those patients with perforated and non-perforated appendicitis were 6.30 (95% CI = 5.09-7.78; p < 0.001) and 6.49 (95% CI = 4.45-9.48; p < 0.001); while for those cases undergoing an LA and OA, they were 0.50 (95 % CI = 0.40-0.62; p < 0.001) and 2.07 (95% CI = 1.45-2.95; p < 0.001), respectively. The ORs of IAA and PBO for those patients ≤6 and 7-12 years of age were 1.67 (95% CI = 1.23-2.25; p = 0.001) and 1.20 (95% CI = 0.97-1.49; p = 0.095), and 1.88 (95% CI = 1.08-3.24; p = 0.025) and 1.47 (95% CI = 1.01-2.14; p = 0.043), respectively, compared to those aged 13-18 years.

CONCLUSIONS

Our study demonstrated that young age and perforated appendicitis can affect postoperative IAA and PBO. LA appeared beneficial in reducing the length of hospitalization and postoperative IAA, but had an increasing risk of PBO. Although laparoscopic approach for pediatric appendectomy is increasing in our country, the different hospital levels and pediatric surgeon's laparoscopic experience must be evaluated in further study.

The feasibility of bipolar tissue sealer for appendix stump closure

BACKGROUND

Appendiceal stump closure is a highly important step in laparoscopic appendectomy, especially for post-operative complications. The aim of this study is to compare the effects of suture ligation and bipolar tissue sealer techniques on burst pressure using flesh appendectomy specimens.

MATERIAL AND METHODS

Appendectomy specimens of 32 patients with grade I-II disease were included in the study. Perforated or necrotic appendices and specimens ineligible for pressure measurement were excluded from the study. Appendiceal stumps of 16 patients in group 1 were double-ligated with 2/0 polyglactin sutures, then appendectomy was performed between these sutures. In group 2, the management of the stump was performed through single ligation with polyglactin suture, followed by appendectomy using a bipolar tissue sealing device. Burst pressures were recorded for all specimens.

RESULTS

There were no differences between groups in terms of age and sex. There was no significant difference between the two groups in terms of burst pressure (p = 0.92). Also, no significant difference was found between groups in terms of localization of the perforation (p > 0.05).

CONCLUSION

Bipolar tissue sealer achieves safe stump closure with satisfactory burst pressure values. Based on this, using bipolar tissue sealer for appendiceal stump closure in appendicitis may be safe and reliable.

Clinical NOTES appendectomy study: comparison of transvaginal NOTES appendectomy in hybrid technique with laparoscopic appendectomy

PURPOSE

The proposed advantages of NOTES are aimed to assess the comparison with standard procedures. Complications are a major focus of its evaluation. We initiated a prospective comparison between transvaginal hybrid appendectomy versus laparoscopic appendectomy.

PATIENTS AND METHODS

For each, NOTES and laparoscopic appendectomy, 10 consecutive female patients participated in the study with follow-up documentation for 35 days and after 1 year. Transvaginal appendectomy was considered a non-standard medical procedure and required individual patient's consent. Pre- and postoperative gynecological examinations were performed. Questionnaire-based evaluation included issues related to quality of life in addition to objective clinical findings. The study is approved by the ethics committee of the University of Rostock.

RESULTS

All women returned questionnaires for evaluation. Age and BMI are comparable. Overall procedure time was significantly shorter in laparoscopy. The only postoperative complication consisted of an intra-abdominal abscess after laparoscopic appendectomy. One patient of the NOTES group suffered from new abdominal pain 3 weeks postoperatively; a mini-laparoscopy showed a normal situation. Significant differences (p < 0.05) of the questionnaire-based comparison with advantages for the NOTES group were found in following items: reduced activity at day 1-14, postoperative pain at day 1, general health conditions at day 1-3 and quality of life at day 3. NOTES patients wished significantly earlier to be discharged and started significantly earlier with activities, but no differences existed after 4 weeks.

CONCLUSIONS

Transvaginal flexible appendectomy appears to be a safe procedure performed in hybrid technique. Data from the study point to shortened recovery intervals and improved quality of life.

Lessons learned with laparoscopic management of complicated grades of acute appendicitis

Background

Laparoscopy has not been consolidated as the approach of first choice in the management of complicated appendicitis. Methodological flaws and absence of disease stratification criteria have been implicated in that less evidence. The objective is to study the safe and effectiveness of laparoscopy in the management of complicated appendicitis according to laparoscopic grading system.

Method

From January 2008 to January 2011, 154 consecutive patients who underwent a laparoscopic appendectomy for complicated appendicitis were evaluated in the prospective way. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 58.3% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix and were graded as 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis) and 5 (diffuse peritonitis). The outcomes including operative time, infection complication, operative complications and conversion rate were chosen to evaluate the procedure.

Results

The grade 3A was the most frequent with 50 (32.4%) patients. The mean operative time was 69.4 ± 26.3 minutes. The grade 4A showed the highest mean operative time (80.1 ± 26.7 minutes). The wound and intra-abdominal infection rates were 2.6 and 4.6%, respectively. The base necrosis was the most important factor associated with the conversion (5.2%). The grades 4A and 5 were associated with greater possibility of intra-abdominal collection. There were no operative complications.

Conclusion

The laparoscopic management of all complicated grades of acute appendicitis is safe and effective and should be the procedure of first choice. The laparoscopic grading system allows us to assess patients in the same disease stage.

Suprapubic approach for laparoscopic appendectomy

Objective:

To evaluate the results of laparoscopic appendectomy using two suprapubic port incisions placed below the pubic hair line.

Design:

Prospective hospital based descriptive study.

Settings:

Department of surgery of a tertiary care teaching hospital located in Rohtas district of Bihar. The study was carried out over a period of 11months during November 2011 to September 2012.

Participants:

Seventy five patients with a diagnosis of acute appendicitis.

Materials and Methods:

All patients underwent laparoscopic appendectomy with three ports (one 10-mm umbilical for telescope and two 5 mm suprapubic as working ports) were included. Operative time, conversion, complications, hospital stay and cosmetic results were analyzed.

Results:

Total number of patients was 75 which included 46 (61.33%) females and 29 (38.67%) males with Mean age (±Standard deviation {SD}) at the time of the diagnosis was 30.32 (±8.86) years. Mean operative time was 27.2 (±5.85) min. One (1.33%) patient required conversion to open appendectomy. No one patient developed wound infection or any other complication. Mean hospital stay was 22.34 (±12.18) h. Almost all patients satisfied with their cosmetic results.

Conclusion:

A laparoscopic approach using two supra pubic ports yields the better cosmetic results and also improves the surgeons working position during laparoscopic appendectomy. Although, this study had shown better cosmetic result and better working position of the surgeon, however it needs further comparative study and randomized controlled trial to confirm our findings.

Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy

BACKGROUND

Identification of variation in practice is a key step towards standardization of service and determination of reliable quality markers. This study aimed to investigate variation in provision and outcome of emergency appendicectomy.

METHODS

A multicentre, trainee-led, protocol-driven, prospective observational cohort study was performed during May and June 2012. The main outcome of interest was the normal histopathology rate; secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and binary logistic regression models to identify patient- and hospital-related predictors of outcome.

RESULTS

A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was performed in 66.3 per cent of patients (range in centres performing more than 25 appendicectomies over the study period: 8.7-100 per cent). A histologically normal appendix was removed in 20.6 per cent of patients (range in centres performing more than 25 procedures: 3.3-36.8 per cent). Funnel plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates. Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of higher perforation rates.

CONCLUSION

This study reveals the extremely wide variation in practice patterns and outcomes among hospitals. Organizational factors leading to this variation have been identified and should be addressed to improve performance.

Appendicopathy--a clinical and diagnostic dilemma

PURPOSE

The term "neurogenic appendicopathy" has been used for patients operated on for acute appendicitis with their appendices lacking signs of acute inflammation. The aim of this retrospective study was to clarify the presence of potential neurogenic appendicopathies, analyzing patients' clinical symptoms and their corresponding appendiceal specimens.

METHODS

One hundred twenty-one patients were identified showing a histological diagnosis of chronic appendicitis. Eventually, 40 patients qualified for the potential diagnosis "neurogenic appendicopathy." Appendix specimens were immunohistochemically examined for the expression of S-100, vasoactive intestinal polypeptide (VIP), and substance P. Controls consisted of 110 patients with acute appendicitis and 120 patients following appendectomies operated on for other reasons.

RESULTS

Eventually, 40 of 120 patients qualified for the potential diagnosis "neurogenic appendicopathy." Compared to patients with acute appendicitis, there was only little difference in clinical symptoms. Histologically, neuromas, thought of being characteristic of neurogenic appendicopathy, were demonstrated significantly more often in the control group (p = 0.01). S-100 was significantly more expressed in the appendicopathy group (p = 0.0024), but nearly 50% of control specimens showed an intense staining, too. S-100(+) neurofibers were significantly (p = 0.00122) more often found in the mucosa of appendicopathy specimens, but this was true for only 25% of specimens. VIP was more strongly expressed in control specimens (p = 0.0211). Substance P was of no diagnostic value.

CONCLUSIONS

Our study could not confirm the neurogenic origin of appendicopathies. Yet, clinical data strongly suggest the existence of the entity "appendicopathy." Therefore, we suggest removing a macroscopically unaffected appendix in patients with appendicitis-like symptoms if, on laparoscopy, no other cause can be found.

Laparoscopy grading system of acute appendicitis: new insight for future trials

BACKGROUND

The mini-invasive techniques have revolutionized the surgery; however, the superiority of laparoscopic access for complicated appendicitis is still controversial. The most critical point has been the dismal quality of the methodology found in the series comparing laparoscopic and laparotomic procedures. The lack of stratification criteria to evaluate the inflammation in the appendix and abdomen has been pointed out by several authors.

PURPOSE

To validate the laparoscopic grading system for acute appendicitis.

METHODS

Prospective study of 186 patients with presumed acute appendicitis who underwent an appendectomy if diagnostic laparoscopy showed appendicitis or normal-looking appendix without any other intra-abdominal disease. The appendix was graded as to different levels based upon its visual appearance: grade 0 (normal looking), 1 (redness and edema), 2 (fibrin), 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis), and 5 (diffuse peritonitis). This was then compared with a histologic assessment of the removed appendix supplemented by a biochemical study of collected peritoneal fluid (gold standard) to determine the diagnostic indexes. Besides that, the κ coefficient confirmed concordance between them.

RESULTS

Laparoscopic sensitivity, specificity, and accuracy for acute appendicitis diagnosis were 100%, 63.3%, and 84.1%, respectively, and presented substantial concordance [κ=0.74 (95% confidence interval, 0.60-0.88)]. Sensitivity, specificity, and accuracy of the laparoscopic grading system were 63%, 83.3%, and 80.1%, respectively, and presented moderate concordance [κ=0.39 (95% confidence interval, 0.23-0.55)]. The biochemical-histologic grading system changed for 48 (25.8%) patients who had been previously classified by surgeons during laparoscopy. Most incorrect graduation occurred in grades 0 and 1. The presence of exudates was confirmed in all cases classified as grades 4A, 4B, and 5.

CONCLUSIONS

Laparoscopy showed good to excellent accuracy for diagnosis and grading of acute appendicitis. The better grading system allowed the evaluation of patients with acute appendicitis in the same clinical stage.

National trends in approach and outcomes with appendicitis in children

BACKGROUND/PURPOSE

Appendicitis is one of the most common surgical conditions in children. Laparoscopy has become the standard approach to appendectomy over the past decade. Some critics cite a lack of evidence documenting clear advantages to laparoscopy. To define the pattern of approach compared to outcomes in the United States, we analyzed the Pediatric Health Information System (PHIS) database to document the impact on outcomes with the rise in laparoscopy.

METHODS

After IRB approval, we queried the PHIS database for all patients over 12 years. The percentages of cases performed open (OA) and laparoscopically (LA) were established for each year. Annual complication percentages were identified for wound infection, intra-abdominal abscess, subsequent laparotomy, and obstruction. For each complication, trend comparisons between LA and OA were made with generalized linear models.

RESULTS

There were 111,194 appendectomies with a positive trend in percentage of laparoscopy from 1999 (22.2%) to 2010 (90.8%), P<0.0001. Over 12 years, there were significant differential trends between LA and OA in rates of wound infection, abscesses, bowel obstructions, and laparotomies within 30 days (P<0.0001 for each). There was no trend in wound infection rates within OA over time (P=0.31), while there was a decrease in infection rates within LA over time (P<0.0001).

CONCLUSIONS

On the basis of a national database analysis, laparoscopy has increased for appendectomy in children over the past 12 years and is associated with a significant decrease in post-operative complications.

Laparoscopic appendectomy as a teaching procedure: experiences with 1,197 patients in a community hospital

PURPOSE

Since laparoscopic procedures have become more common, resident surgeons have to learn complex laparoscopic skills at an early stage of their career. The aim of this study was to compare the short-term clinical outcome parameters of laparoscopic appendectomy (LA) performed by resident surgeons (RS) or attending surgeons (AS).

METHODS

A total of 1197 LA and 57 open appendectomies were performed in a Swiss community hospital between 1999 and 2009. RS performed 684 operations. Parameters including the duration of the operation and hospital stay, intraoperative complications, surgical reinterventions, and a 30-day morbidity and mortality were observed.

RESULTS

The mean age of the patients was 35.6 ± 18.17 years. The duration of the operation was longer (61.34 ± 25.73 min [RS] vs. 53.65 ± 29.89 [AS] min; p = 0.0001), but the hospital stay was shorter, in patients treated by RS (3.92 ± 2.61 days [RS] vs. 4.87 ± 3.23 [AS] days; p = 0.0001). The rate of intraoperative complications was not significantly different between the two groups (1.02 % [RS] vs. 0.8 % [AS]; p = 0.6). The need for surgical reintervention (0.6 % [RS] vs. 2.5 % [AS]; p = 0.005) and the 30-day morbidity were higher in patients treated by AS (3.7 % [AS] vs. 1.8 % [RS]; p = 0.04). There was no postoperative mortality.

CONCLUSIONS

Under appropriate supervision, surgical residents are able to perform LA with results comparable to those of experienced surgeons.

Increased use of laparoscopy in acute right iliac fossa pain - is it good for patients?

AIM

The use of laparoscopy, with or without appendicectomy, is becoming more common in the management of acute right iliac fossa (RIF) pain, but little is known of the 'unintended' consequences of this change. This study aimed to evaluate the impact of increased use of laparoscopy on the number and type of patients treated surgically and on the rate of negative appendicectomy.

METHOD

A prospective audit was carried out of admissions to a teaching hospital over two, 3-month periods during 2007 and 2008. The management, investigations and outcome of patients presenting with RIF pain were studied.

RESULTS

Admissions were stable over the two time-periods. There was a significant increase in the number of laparoscopic operations performed, from 22.5% (14/62) in 2007 to 85.7% (72/84) in 2008 (P < 0.0001), and the percentage of patients undergoing surgery rose from 55.4% (n = 62) in 2007 to 71.2% (n = 84) in 2008 (P < 0.01). In 2008, female patients were more likely to have surgery, an increase from 37.1% to 66.2% (P < 0.001), and were more likely to have a laparoscopic procedure, an increase from 50% to 98% (P < 0.0001). The rate of histologically confirmed appendicitis did not increase significantly (50/122 vs 57/118; P = 0.25), but the number of patients with a normal appendix either left in situ because it was macroscopically normal or found to be histologically normal following excision, increased significantly, from 9.01% in 2007 to 21.2% in 2008 (P < 0.01). The diagnostic value of pelvic ultrasound decreased from 75.6% of examinations in 2007 to 54.5% in 2008 (P = 0.039).

CONCLUSION

An increase in laparoscopic procedures has resulted in more operations in women, an associated higher negative appendicectomy rate and decreased usefulness of pelvic ultrasound. Increased use of laparoscopy needs to be balanced against the diagnostic benefits of 'negative' laparoscopy.

Comparison of intraabdominal abscess formation after laparoscopic and open appendicectomies in children

AIM

Although laparoscopic appendicectomy (LA) is an accepted alternative to the open appendicectomy (OA) approach, it has been suggested that there is a higher incidence of intraabdominal abscesses (IAAs). Our aim was to determine the incidence of IAA in 3 pediatric surgical centers routinely practicing both techniques.

METHODS

Data were collected retrospectively for pediatric patients undergoing LA or OA over an 8-year period. Analysis included IAA formation, appendicitis complexity, radiologic/histologic investigations, grade of surgeon, and wound infection.

MAIN RESULTS

A total of 1267 appendicectomies were performed (514 LAs and 753 OAs). There was no difference between the incidences of IAA (LA, 3.9% [19/491] vs OA, 3.9% [28/714]; P = 1.0). The incidence of IAA was increased in those with complicated appendicitis (34/375 [9.1%] vs 13/830 [1.6%]; P ≤ .0001). There was an increased proportion of those with complicated appendicitis in the LA group (182/491 [37.1%] vs 193/714 [27.0%]; P = .0002). Surgical trainees were more likely to be the primary surgeon in the OA group (79% vs 63%; P = .0001), although the incidence of IAA did not correlate with grade of surgeon. There was no significant difference in incidence of wound infection between groups (LA, 4.6% [8/173] vs OA, 2.5% [18/377]; P = .93).

CONCLUSION

This large retrospective study shows that the technique of appendicectomy does not appear to affect the incidence of IAAs. Patients with complicated appendicitis are more likely to develop an IAA regardless of technique.

Patient and surgeon factors are associated with the use of laparoscopy in appendicitis

AIM

The use of a minimally invasive approach to treat appendicitis has yet to be universally accepted. The objective of this study was to examine recent trends in Ireland in the surgical management of acute appendicitis.

METHOD

Data were obtained from the Irish Hospital In-Patient Enquiry system for patients discharged with a diagnosis of appendicitis between 1999 and 2007. An anonymous postal survey was sent to all general surgeons of consultant and registrar level in Ireland to assess current attitudes to the use of laparoscopic appendectomy.

RESULTS

The use of laparoscopic appendectomy increased throughout the study and was the most common approach for appendectomy in 2007. Multivariate analysis revealed age under 50 years (OR = 1.51), female sex (OR = 2.84) and residence in high-density population areas (OR = 4.15) as predictive factors for undergoing laparoscopic appendectomy in the most recent year of the study. While 97% of surgeons reported current use of laparoscopy in patients with acute right iliac fossa pain, in most cases it was selective. Surgeons in university teaching hospitals (42 of 77; 55%) were more likely to report using laparoscopic appendectomy for all cases of appendicitis than those in regional (six of 23; 26%) or general (13 of 53; 25%) hospitals (P = 0.048).

CONCLUSION

This study has demonstrated a significant increase in laparoscopic appendectomy, yet a variety of patient and surgeon factors contribute to the choice of procedure. Differences in the perception of benefit of the laparoscopic approach amongst surgeons appears to be an important factor in determining the operative approach for appendectomy.

Causes of short-term mortality after appendectomy: a population-based case-controlled study

OBJECTIVE

This case control study is a detailed analysis of the causes of death and the risk factors of short-term mortality after appendectomy.

SUMMARY BACKGROUND DATA

Although death is a rare event after appendectomy, we found a 7-fold excess mortality after appendectomy overall and a 9-fold excess mortality after negative appendectomy, compared to the background population in a previous study from Sweden, in accordance with others.

MATERIALS AND METHODS

All patients who died within 30 days after appendectomy, and controls matched to age, sex and period, were identified of 119,060 patients who were operated with appendectomy in 1987 to 1996 from the Swedish National Inpatient Registry. Causes of death and differences between the cases and controls in comorbidity and appendectomy diagnoses were analyzed on the basis of a review of hospital records. Only patients and controls with appendectomy as the only surgical intervention and without prevalent malignant diagnosis were included in the analysis to avoid bias.

RESULTS

A total of 179 patients who died within 30 days and 400 matched controls remained for the analyses. Nonproductive and negative exploration was strongly associated with mortality [odds ratio (OR), 5.11; confidence interval (CI), 2.09-12.48; P < 0.001 and OR, 2.38; CI, 1.24-4.57; P = 0.009, respectively] in contrast to perforated appendicitis (OR, 1.60; CI, 0.95-2.70; P = 0.078) after adjustment for age, sex, and comorbidity. Chronic obstructive pulmonary disease (OR, 3.31; CI, 1.05-10.45, P = 0.041), renal insufficiency (OR, 2.32; CI, 1.26-4.27; P = 0.007), and diabetes mellitus were also independent risk factors (OR, 2.39; CI, 1.12-5.12; P = 0.025). Cardiovascular or thromboembolic disease was responsible for the death in more than 50% of the cases, whereas appendicitis was responsible in only 17.9%.

CONCLUSIONS

Appendicitis is only responsible for a small portion of the deaths after appendectomy. Comorbidity and negative appendectomy are strongly associated with mortality, suggesting that comorbidity, diagnostic failure, and the anesthesiosurgical trauma may play an important role.

Improving outcomes after laparoscopic appendectomy: a population-based, 12-year trend analysis of 7446 patients

OBJECTIVE

Laparoscopic appendectomy for acute appendicitis has become increasingly used over the past decade. The objective of this trend analysis is to assess whether clinical outcomes after laparoscopic appendectomy have improved over the past 12 years.

METHODS

This analysis is based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. All patients undergoing emergency laparoscopic appendectomy for acute appendicitis from 1995 to 2006 were included. The following outcomes were assessed for each of the 12 years: conversion rates, intraoperative complications, surgical postoperative complications, general postoperative complications, rate of reoperations, and length of hospital stay. Unadjusted and risk-adjusted multivariable analyses were performed. Statistical significance was set at a level of P < 0.05. All statistical tests were 2-sided.

RESULTS

Data from 7446 patients undergoing laparoscopic appendectomy for acute appendicitis were prospectively collected. Over the period of observation, the conversion rate decreased significantly from 2.2% to 1.2% (P(trend)< 0.001), as did intraoperative complications (from 3.1% to 0.7%; P(trend)< 0.001), surgical postoperative complications (from 6.1% to 1.9%; P(trend)< 0.001), general postoperative complications (from 4.9% to 1.5%; P(trend)< 0.001), and rates of reoperations (from 3.4% to 0.7%; P(trend)< 0.001). Average postoperative length of hospital stay also significantly decreased from 4.9 to 3.5 days (P(trend)< 0.001).

CONCLUSIONS

Our investigation provides compelling evidence that intraoperative complications, surgical and general postoperative complications, conversion rates, rates of reoperations, and average length of hospital stay have significantly decreased over the past decade in patients undergoing surgery for acute appendicitis. The present trend analysis is the first one in the literature encompassing more than a decade and reporting clinical outcomes after laparoscopic appendectomy for acute appendicitis, which represents an important quality control.

Laparoscopy or not: a meta-analysis of the surgical effects of laparoscopic versus open appendicectomy

Both open appendicectomy and laparoscopic appendicectomy have their own advantages and disadvantages. The purpose of our meta-analysis is to compare the surgical effects of laparoscopic versus open appendicectomy. In our study, Medline, Embase, and the Cochrane Library were searched. Only prospective randomized controlled trials that compared the 2 methods of operation were included. Evaluation indexes in our study involved are operating time, complications, hospital stay, time to return to normal activities, time to return to normal diet, and the overall cost. Results showed that operating time of laparoscopic appendicectomy was significantly longer [weighted mean difference (WMD) 7.60; 95% confidence interval (CI) 6.03-9.17 min; P<0.00001]. Time of hospital stay (WMD -0.82; 95% CI: -0.93 to -0.70 d), time to return to normal activities (WMD -6.85; 95% CI: -7.62 to -6.09 d), and diet (WMD -0.61; 95% CI: -0.86 to -0.36 d) were significantly decreased in the laparoscopic appendicectomy group (all P<0.00001). There is no convincing difference in complications (odds ratio 0.99; 95% CI: 0.80-1.22; P=0.92) and death rates (odds ratio 0.97; 95% CI: 0.29-3.25; P=0.96). In conclusion, laparoscopic appendicectomy may have advantages over open appendicectomy in hospital stay and postoperative recovery.

Competitive edge of laparoscopic appendectomy versus open appendectomy: a subgroup comparison analysis

BACKGROUND

With the advances in laparoscopic instruments and surgical techniques, the use of laparoscopic appendectomy (LA) has been increasing rapidly in recent years. In this retrospective analysis, we aimed to determine the competitive edge of LA versus open appendectomy (OA) in different settings of disease complexity, gender, and age difference.

METHODS

A retrospective analysis of the patients diagnosed with acute appendicitis at Changhua and Chang-Bing Show-Chwan Memorial Hospitals from January 1, 2004 to December 31, 2009 was conducted. Trend and indication of OA and LA were recorded, combined with a comparison of medical costs, complication rates, wound infection rates, and hospital stays in different settings of disease complexity, gender, and age group.

RESULTS

A total of 1366 appendicitis patients were enrolled, and the rate of LA use increased rapidly, from 8.1% in 2004 to 90.3% in 2009. The increased use of LA was seen in both the uncomplicated and complicated appendicitis patients and in both gender and age groups (pediatric, adult, and elderly). Compared with OA, LA was associated with a lower complication rate (9.5% versus 5.8%; P = .013), a lower wound infection rate (8.6% versus 4.2%; P = .001), and a shorter hospital stay (4.60 ± 3.64 versus 4.06 ± 1.84 days; P = .001), but a higher mean cost (32,670 ± 28,568 versus 37,567 ± 12,064 New Taiwan dollars). In the subgroup analysis, the patients with complicated appendicitis, female patients, and pediatric and elderly patients benefited from a reduced hospital stay. LA is about 15% more expensive than OA.

CONCLUSIONS

LA is as safe and effective as OA in many settings of appendicitis and may be selectively advantageous in patients with complicated appendicitis and in elderly subgroups.

Minimally invasive surgery is underutilized for colon cancer

BACKGROUND

The Clinical Outcomes of Surgical Therapy Group (COST) trial published in 2004 demonstrated that minimally invasive surgery (MIS) for colorectal cancer provided equivalent oncologic results and better short-term outcomes when compared to open surgery. Before this, MIS comprised approximately 3% of colorectal cancer cases. We hypothesized that there would be a dramatic increase in the use of MIS for colon cancer after this publication.

METHODS

The National Inpatient Sample database was used to retrospectively review MIS and open colon resections from 2005 through 2007. ICD-9-specific procedure codes were used to identify open and MIS colon cancer resections. Statistical analyses performed included Pearson χ(2) tests and dependent t tests, and Cramer's V was used to measure the strength of association.

RESULTS

A total of 240,446 colon resections were performed between 2005 and 2007. The percentage of resections performed laparoscopically increased from 4.7% in 2005 to 6.7% in 2007 for colon cancer and remained relatively unchanged for benign disease (25.2% in 2005 vs. 27.4% in 2007, P < 0.007). Patients undergoing laparoscopic colectomy were younger, had lower comorbidity scores, had lower rates of complications (20.1 vs. 25.1%, P < 0.001), had shorter lengths of stay (7.2 vs. 9.6 days, P < 0.001), and had lower mortality (1.5 vs. 3.0%, P < 0.001). Furthermore, when evaluating adoption trends, urban teaching hospitals adopted laparoscopy more rapidly than rural nonteaching centers.

CONCLUSIONS

Adoption of MIS for the treatment of colorectal cancer has been slow. Additional studies to evaluate barriers in the adoption of MIS for colon cancer resection are warranted.

Outcomes of appendicectomy in an acute care surgery model

OBJECTIVE

To assess the outcomes of appendicectomy in an acute care surgery (ACS) model compared with a traditional on-call (Trad) model.

DESIGN

Retrospective historical control study comparing appendicectomy outcomes in the Trad period (April 2004 to March 2005) with outcomes in the ACS period (April 2006 to March 2007).

SETTING

The Prince of Wales Public Hospital, a metropolitan tertiary referral centre in Sydney.

PATIENTS

All adult patients undergoing appendicectomy during 1-year periods before and after the introduction of the ACS model.

INTERVENTION

The introduction of an ACS model for managing all emergency general surgical presentations.

MAIN OUTCOME MEASURE

Complication rate.

RESULTS

A total of 402 appendicectomies were performed, 176 during the Trad period and 226 during the ACS period. There was no perioperative mortality. The complication rate was lower in the ACS period than the Trad period (9.3% v 17.0%; P = 0.02). After the intervention, there was no significant change in the time from presentation to arrival in theatre or in length of stay, but the proportion of operations performed at night (24:00-08:00) was reduced from 26.1% to 15.0% (P = 0.006). The proportion of negative appendicectomies was reduced from 22.7% to 17.3%, but the change was not statistically significant (P = 0.08). There was no difference in perforation rate before and after the intervention (13.6% v 13.3%; P = 0.86).

CONCLUSION

The ACS model provides a safe surgical environment for patients and is associated with a reduced complication rate. Under the ACS model, there was an increase in the number of patients treated conservatively overnight, but this did not lead to an overall increase in perforation rate or length of stay.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.

SEARCH STRATEGY

We searched the Cochrane Library, MEDLINE, EMBASE, LILACS, CNKI, SciSearch, study registries, and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis.

MAIN RESULTS

We included 67 studies, of which 56 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.43; CI 0.34 to 0.54), but the incidence of intraabdominal abscesses was increased (OR 1.87; CI 1.19 to 2.93). The duration of surgery was 10 minutes (CI 6 to 15) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (CI 5 to 11 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.7 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Seven studies on children were included, but the results do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01).

AUTHORS' CONCLUSIONS

In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.

Comparison of intra-abdominal abscess formation following laparoscopic and open appendicectomy in children

BACKGROUND

Controversy exists over the association between laparoscopic (LA) and open appendicectomy (OA) and the formation of postoperative intra-abdominal abscesses (IAAs). Our aim was to compare the outcome following these two techniques in a pediatric population.

SUBJECTS AND METHODS

A retrospective data collection was carried out on all patients undergoing either an LA or OA at a single center over a 26-month period. Patients were identified from a hospital database and theater records. An intra-abdominal abscess was defined as recorded pyrexia, a raised inflammatory marker, and radiologic confirmation of an intra-abdominal collection. Other parameters studied included wound infection, appendiceal perforation, hospital stay, conversion rate, microbiology, histology, radiologic investigation, and serologic analysis. Data were analyzed from using Fisher's exact and Mann-Whitney tests, as appropriate. A P-value of <0.05 was considered significant.

RESULTS

Two hundred children were identified, with a median follow-up of 18 months. Forty patients underwent an LA and 151 an OA. Nine patients underwent interval appendicectomy and were not included in the final data. There was no difference between the two groups in terms of baseline demographics, duration of stay (P = 0.5), or wound infection (P = 1.0). The incidence of an intra-abdominal abscess was 0 of 40 (0%) in the laparoscopic group and 5 of 151 (3.3%) in the open group, although this was not statistically significant (P = 0.8). The median time to postoperative diagnosis of abscess was 9 days (range, 8-11). A consultant was present in more laparoscopic procedures than open (88 versus 24%; P = 0.0001).

CONCLUSIONS

The rate of intra-abdominal abscess formation was not significantly different following either an LA or OA, although there were no intra-abdominal abscesses observed in the laparoscopic group. Further investigation could address this finding more accurately in a randomized, controlled trial.

Prevention of infectious complications after laparoscopic appendectomy for complicated acute appendicitis--the role of routine abdominal drainage

PURPOSE

Complicated acute appendicitis is still associated with an increased morbidity. If laparoscopy has been accepted as a valid approach, some questions remain concerning intra-abdominal abscess formation. Routine prophylactic drainage of the abdomen has been proposed. However, this practice remains a matter of debate, poorly validated in the literature. With the present study, we investigated the impact of drainage in laparoscopic appendectomy for complicated appendicitis.

METHOD

This is a case match study of consecutive patients operated on by laparoscopy in a single institution. One hundred and thirty patients operated for complicated appendicitis (local peritonitis without perforation, with perforation, or with periappendicular abscess) with prophylactic intraperitoneal drainage were matched one by one to 130 patients operated without drainage. Uncomplicated appendicitis and generalized peritonitis were excluded. Primary endpoint was surgical complications and secondary endpoints were transit recovery time and length of hospital stay.

RESULTS

Patients without drain had significantly less overall complications (7.7% vs. 18.5%, p = 0.01). Moreover, the absence of drainage was of significant benefit for transit recovery time (2.5 vs. 3.5 days, p = 0.0068) and length of hospital stay (4.2 vs. 7.3 days, p < 0.0001).

CONCLUSION

No benefits were observed for prophylactic drainage of the abdominal cavity during emergency laparoscopic treatment of complicated appendicitis. For this reason, this practice may be abandoned.

Clinical suspicion of acute appendicitis - is the time ripe for more conservative treatment?

Traditionally, the diagnosis of acute appendicitis has been based mainly on a history compatible with acute appendicitis and pain at McBurney's point, and the treatment of choice in patients with right iliac fossa pain referring to acute appendicitis has been (laparoscopic) appendicectomy. In too many centers where these traditional rules are followed the accuracy of diagnosis of acute appendicitis still remains at the level of 80 to 85%. It is time to re-evaluate these general guidelines. Here, I face the issue from a few points of view the clinical value of which has not been extensively discussed in the literature but that in my opinion markedly improve the diagnostic accuracy and treatment of patients with right iliac fossa pain. Although there is a clinical suspicion of acute appendicitis, it can be excluded in adult patient, if both leucocyte count and C-reactive protein value are normal on admission to hospital and remain normal in the follow-up. In expert centers, up to 100% sensitivity and specificity have been reported for contrast-enhanced multidetector computed tomography in the diagnosis of acute appendicitis. Antibiotic treatment can be considered a safe first-line therapy in selected patients with acute appendicitis.

Laparoscopic appendectomies: experience of a surgical unit

Appendicitis is one of the most common causes of acute abdomen in adults and appendectomy is the most common emergency abdominal procedure. Laparoscopic appendectomy has gained popularity only in recent years and the optimal approach for the treatment of acute appendicitis is still under debate. This retrospective study aimed at examining the current indications for laparoscopic appendectomy. 1024 patients undergoing laparoscopic appendectomy between February 1992 and December 2007 were retrospectively reviewed. 39.9% of patients (n=408) underwent emergency surgery. In 616 cases (60.1%) conservative management was performed in vain and these patients underwent an elective operation. In the 36 patients with an intraoperative normal appendix, other pathological findings were laparoscopically detected and treated. Conversion to an open procedure was required for 13 (1.3%) cases. The mean operative time was 38 min and the average length of postoperative hospitalization was 2.5 days. The overall morbidity rate was 2.6%. Laparoscopic appendectomy should be considered a procedure of choice for the treatment of non-complicated appendicitis. We stress the possibility to laparoscopically treat even complicated appendicitis in the surgical setting with substantial experience in minimally invasive surgery.

Laparoscopic appendectomy by residents: evaluating outcomes and learning curve

BACKGROUND

Laparoscopic appendectomy is being performed increasingly, worldwide. To the resident, it provides a valuable opportunity to master basic laparoscopic skills. Studies have shown that laparoscopic appendectomy performed by residents is safe. However, to date, there is no clear evidence for the minimum number of these operations required to achieving proficiency and safety. The aim of this study is to assess the outcome of laparoscopic appendectomies performed by surgical residents and to evaluate the effect of learning curve on patient outcome.

METHODS

All patients undergoing laparoscopic appendectomies performed by six residents during the study period were reviewed. Data on patient demographics,clinical and histological diagnosis, and outcome variables including operative duration, conversion to open surgery, complications, and length of stay were analyzed. We evaluated the effect of the learning curve by dividing patients into two groups: a first group consisting of the initial 20 patients and a second group consisting of the next 20 patients operated upon independently by each resident. Variables were analyzed to determine any difference between the two groups.

RESULTS

Three hundred six patients with the clinical diagnosis of acute appendicitis underwent laparoscopic appendectomy by residents. Mean operative time was 83.8 min. Of patients, 14.6% required conversion to open surgery. Mean length of hospitalization was 2.82 days. Operative duration and complication rate were significantly reduced with increasing experience of residents. The length of hospital stay and conversion rate to open surgery remained unchanged.

CONCLUSION

Operative duration and complications can be reduced with increasing experience of a resident.

The laparoscopic approach for perforated appendicitis, including cases complicated by abscess formation

BACKGROUND

Although the laparoscopic approach for perforated appendicitis is commonly performed, there is some controversy over its use because of postoperative complications. These may be associated with various types of disease entities, from gangrenous change to diffuse peritonitis with abscess formation. The aim of the present study was to evaluate the safety and benefits of the laparoscopic approach for perforated appendicitis, including cases complicated by abscess, compared to open.

MATERIALS AND METHODS

A total of 1747 patients underwent treatment for appendicitis over a period of 3 years. The diagnosis of perforated appendicitis was made by radiology, operative finding, and pathology. Of our five attending surgeons, three performed open surgery for perforated appendicitis, while two performed laparoscopy.

RESULTS

There were 474 patients (27%) with perforated appendicitis without abscess (156 underwent laparoscopy, 318 underwent open) and 113 patients (6.4%) with perforated appendicitis and abscess (44 underwent laparoscopy, 69 underwent open). The duration for resumption of diet and hospital stay was shorter in the laparoscopy group than in the open group. There were no significant differences in postoperative complications between patients who had no abscess with laparoscopy and those with open: 5 intra-abdominal abscesses and 10 wound infections versus 11 intra-abdominal abscesses and 25 wound infections (P = 0.88, 0.12), and between patients who had abscesses with laparoscopy and those with open: 4 intra-abdominal abscesses and 3 wound infections versus 6 intra-abdominal abscesses and 6 wound infections (P = 0.94, 0.72).

CONCLUSIONS

The laparoscopic approach may be a safe, effective treatment for perforated appendicitis, even in the presence of an abscess.

The management of right iliac fossa pain - is timing everything?

BACKGROUND

Right iliac fossa (RIF) pain remains the commonest clinical dilemma encountered by general surgeons. We prospectively audited the management of acute RIF pain, examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome.

METHODS

Over a six-month period, 302 patients, median age 18 years, 59% female, were admitted with RIF pain. Symptoms, clinical findings and laboratory results were documented. Patient management, timing of radiological investigations and operations, and outcome were recorded prospectively.

RESULTS

Non-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n = 29) had a longer duration of pre-hospital symptoms (median 50h) compared to those with simple appendicitis (median 17 h) (p<0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis.

CONCLUSION

The majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity.

Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway

BACKGROUND

The utility of laparoscopic appendectomy (LA) in children remains controversial. The determination of the efficacy of LA in children is complicated by variable postoperative management, duration of antibiotics,and criteria for discharge. The aim of this study was to examine the results of a commitment to LA and the concurrent implementation of an evidence-based clinical pathway (CP) for management appendicitis in a children's hospital.

METHODS

With institutional review board approval, all children presenting with appendicitis (n = 72; age =10.6 +/- 0.1 years) were offered LA and management directed by CP. Data were accrued prospectively for 12 consecutive months (May 2006 to April 2007) and analysis performed at 15 months. Data are reported as the mean +/- standard error of the mean.

RESULTS

Children were stratified based on the operative findings: group one - acute 41; group two-suppurative=11; and group 3-gangrenous or perforated 20. Duration of hospital stay differed between the groups:group one= 26 +/- 0.3 hours; group 2 =48 +/- 3 hours; group 3= 127 +/- 6 hours (P <0.05). No patients in groups one or two suffered a complication or were readmitted following discharge. Two patients in group 3 (10%)were readmitted and treated with antibiotic therapy alone. Overall, 66% of the children with acute appendicitis(27/41) and 27% with suppurative appendicitis (3/11) were discharged within 24 hours of admission. Discharge by 24 hours in groups 1 and 2 was not influenced by age, gender, or time of operation (before or after 7 PM).

CONCLUSIONS

The commitment to LA and use of CP resulted in discharge within 24 hours in 2 of 3 of children with acute appendicitis without readmission or complications being observed. Early discharge was not influenced by age, gender, or time of admission. For advanced appendicitis, length of hospital stay, determined by clinical parameters, resulted in a low rate of complication or readmission.

A lower costly laparoscopic appendectomy: our experience of more than 2000 cases

Many authors emphasize the advantages of laparoscopic techniques in their experience, including the excellent cosmetic results, reduced postoperative pain, rapid functional recovery, lower incidence of adhesions, wound infections and believe that laparoscopic appendectomy is a reliable operation for treating acute appendicitis. Laparoscopic appendectomy has become a standard procedure in the treatment of acute appendicitis in our department since it was introduced in 2003. There are 414 patients underwent laparoscopic appendectomy and 37 patients underwent open appendectomy in our department in 2008. More than 2000 laparoscopic appendectomies were performed in our department during 2003-2009. However, open appendectomy is still the standard procedure in many Taiwan and worldwide hospitals. One of the reasons is that the operating costs incurred for laparoscopic appendectomy are higher than that of open appendectomy. We describe, herein, an access technique utilizing existing instrumentation that is reliable and easy.

[Surgical techniques of appendectomy for acute appendicitis]

Over the last 20 years, the treatment of acute appendicitis has been transformed by the development of the laparoscopic approach. And yet the net value of this approach continues to be debated. Laparoscopic appendectomy is associated with a lower complication rate and a shorter period of disability in the general population. While operative costs are higher, the global cost of laparoscopic appendectomy is lower than for open appendectomy. There is a somewhat higher rate of abdominal abscess for the laparoscopic route. Laparoscopic appendectomy shows clear advantages in obese patients and in those with gangrenous or ruptured appendicitis. The laparoscopic approach is contra-indicated during pregnancy due to a higher incidence of miscarriage. Treatment of the appendiceal stump by ligature decreases the expense associated with the use of a surgical stapler. When Meckel's diverticulum is encountered during appendectomy, it should be removed in all pediatric patients; in adults, Meckel's diverticulectomy in adults should be performed only for clear-cut pathology. Surgeons continue to innovate and refine appendectomy techniques but many questions remain to be answered.

Current practice in the United Kingdom for the use of diagnostic laparoscopy in suspected acute appendicitis

OBJECTIVE

Diagnostic laparoscopy is advocated in the management of patients with acute right iliac fossa pain. We asked consultant surgeons in the UK about their current use of this technique.

METHOD

A short anonymous questionnaire was sent to consultant surgeons from the ASGBI database. Information was sought on general surgical specialty, participation in the emergency surgical on-call rota, current practice regarding the use of diagnostic laparoscopy in patients with suspected acute appendicitis and on the management of an inflamed or noninflamed appendix. Statistical analysis was by means of chi(2) test.

RESULTS

There were 161 eligible returns from 250 questionnaires (64%) and the proportion of consultants replying from each subspecialty was similar to membership numbers of subspecialty organizations. Most consultants (68%) performed diagnostic laparoscopy in patients with suspected acute appendicitis. The majority (69%) reserved its use for women of reproductive age and 14% of respondents laparoscoped all patients with suspected appendicitis. Compared to nongastrointestinal (GI), GI surgeons were significantly more likely to perform diagnostic laparoscopy (75 vs 52%, P = 0.008). In the case of an overtly inflamed appendix, 81% of respondents would remove it laparoscopically with significantly more GI surgeons following this course than nonGI surgeons (P = 0.04).

CONCLUSION

Despite good evidence on the benefits of diagnostic laparoscopy in certain patients with suspected acute appendicitis, there is significant variation in its use. This difference appears to be based upon subspecialty and may be as a result of increasing subspecialization.