Strategien zur Vermeidung negativer Appendektomien

Same-Day Discharge after Laparoscopic Appendectomy for Simple Appendicitis in Pediatric Patients—Is It Possible?

(1) Background: One-day surgery has been widely adopted for many elective laparoscopic procedures in pediatric patients. Recently, the same protocol has been investigated for some emergency procedures, such as laparoscopic appendectomy. This study aimed to evaluate the safety and effectiveness of discharge from hospital within 24 h in pediatric patients who received laparoscopic appendectomy for uncomplicated acute appendicitis. (2) Methods: From 1 March 2021 to 1 May 2022, a total of 180 pediatric patients who were discharged from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis were included in this prospective single-center study. The primary outcome of this study was the safety of discharge from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis, as well as the parental satisfaction with this protocol. Secondary outcomes included the rate of readmission or unplanned return to the operating room, the complication rate and a cost-effectiveness analysis. For each patient, demographic data, preoperative evaluation (physical examination, laboratory data, imaging), duration of surgery, intraoperative and postoperative complications, length of hospital stay and pain levels, as well as parental satisfaction with this protocol, were recorded. (3) Results: The median age was 11 years (interquartile range (IQR) 10, 14). The majority of the patients (63.8%) were males. The median length of hospital stay after surgery was 15 h (IQR 12, 19). The highest level of satisfaction, at discharge, was recorded in most of the respondents (n = 155, 86.1%), while the remaining 25 (13.9%) expressed moderate levels of satisfaction. The median pain levels according to a visual analogue scale for all postoperative days were low (range 0–4). In four patients (2.2%), unplanned readmission before the seventh postoperative day because of postoperative intraabdominal abscess was recorded. All patients with abscess formation were treated conservatively. The majority of the parents (n = 175; 97.2%) expressed the highest level of satisfaction during the outpatient follow-up examination on the seventh postoperative day. (4) Conclusions: Same-day discharge after laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way.

[Appendix somewhat different-Excerpts from the history, controversies of the present and view to the future]

If one could talk about a superstar in abdominal surgery, the appendix would definitely be qualified for this name. Much has already been said about the vermiform appendix. The potential to talk about the appendix is, however, by no means exhausted. In this article already published articles are selected and subsumed. Less known details on the discovery and research of the appendix as well as the diagnostics of appendicitis and establishment of appendectomy are also included.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial Registration

NCT01734837.

Negative appendectomy: a 10-year review of a nationally representative sample

BACKGROUND

Appendectomy remains one of the most common emergency surgical procedures encountered throughout the United States. With improvements in diagnostic techniques, the efficiency of diagnosis has increased over the years. However, the entity of negative appendectomies still poses a dilemma because these are associated with unnecessary risks and costs to both patients and institutions. This study was conducted to show current statistics and trends in negative appendectomy rates in the United States.

METHODS

A retrospective analysis was conducted using data from the National Inpatient Sample from 1998 to 2007. Adult patients (>18 y) having undergone appendectomies were identified by the appropriate International Classification of Diseases 9th revision codes. Patients with incidental appendectomy and those with appendiceal pathologies, also identified by relevant International Classification of Diseases 9th revision codes, were excluded. The remaining patients represent those who underwent an appendectomy without appendiceal disease. The patients then were stratified according to sex, women were classified further into younger (18-45 y) and older (>45 y) based on child-bearing age. The primary diagnoses subsequently were categorized by sex to identify the most common conditions mistaken for appendiceal disease in the 2 groups.

RESULTS

Between 1998 and 2007, there were 475,651 cases of appendectomy that were isolated. Of these, 56,252 were negative appendectomies (11.83%). There was a consistent decrease in the negative appendectomy rates from 14.7% in 1998 to 8.47% in 2007. Women accounted for 71.6% of cases of negative appendectomy, and men accounted for 28.4%. The mortality rate was 1.07%, men were associated with a higher rate of mortality (1.93% vs .74%; P < .001). Ovarian cyst was the most common diagnosis mistaken for appendicitis in younger women, whereas malignant disease of the ovary was the most common condition mistaken for appendiceal disease in women ages 45 and older. The most common misdiagnosis in men was diverticulitis of the colon.

CONCLUSIONS

There has been a consistent decline in the rates of negative appendectomy. This trend may be attributed to better diagnostics. Gynecologic conditions involving the ovary are the most common to be misdiagnosed as appendiceal disease in women.

Gynecologic pathologies in our appendectomy series and literature review

PURPOSE

Appendectomy applied from the diagnosis of acute appendicitis is one the most common operations in surgery. The rates of negative appendectomy are still high. The rates of negative appendectomy in males and females differ and are higher in females. In our study, these differences, particularly in females, were studied and possible solutions were discussed.

METHODS

Between October 2002 and October 2009, among women receiving urgent appendectomies, those whose primary cause was gynecological pathology were studied retrospectively. All our women subjects were examined by preoperative gynecologists. After gynecological consultation, the patients were evaluated by a general surgeon due to lack of urgent ultrasonography, computed tomography (CT) and diagnostic laparoscopy and the patient received appendectomy due to acute appendicitis.

RESULTS

In our series of 1,969 appendectomies, the rate of female/male is 811/1,158. It was determined that the primary cause in 47 (47/811; 5.8%) women with applied appendectomy was gynecological pathology. As a gynecological pathology, it was observed that the most common cause was ovarian cyst ruptures at a rate of 72.3%. The negative appendectomy rate in males was found to be 14.94% (173/1,158), and in females it was 22.56% (183/811). The difference between them is significant (P < 0.01). Of these women, 5.8% were gynecologically-induced and 16.76% were unrelated to gynecological causes.

CONCLUSION

We believe that gynecological consultation before appendectomy in women is necessary, but not sufficient. It is also important that at least one of the facilities, such as us, CT, magnetic resonance imaging, and diagnostic laparoscopy should be available in surgical use for the diagnosis of negative appendicitis.

Is there an overlap between irritable bowel syndrome and appendicopathy syndrome? A new theory

BACKGROUND AND AIMS

The costs of irritable bowel syndrome are huge - personally, socially and financially. Yet despite numerous articles on the subject, an effective treatment seems far away. The hypothesis to be offered in this paper is: that a (laparoscopic) appendicectomy could also be useful in treating at least some of the patients with IBS. Using data I have collected from my own surgery practice over a number of years, I will demonstrate the link between the effective treatment of appendicitis by laparoscopic appendectomy and propose that this could also be a useful treatment for some cases of IBS. The study of symptoms of IBS showed that it shared several of the symptoms found in appendicopathy. The aim of this study is: (1) to confirm the cure rate of the laparoscopic appendectomy in cases of appendicopathy, (2) to determine the overlap of symptoms and (3) examine a new theory - that some cases of IBS originate in the appendix.

SUPPORTING DATA

Two succeeding series of patients sent to me for possible appendicopathy were treated with laparoscopic appendectomy if their list of symptoms suggested this was appropriate. The first series comprised 114 patients. The results prompted a second series of 126 patients. This second group was primarily set up to confirm the results obtained from the first group. In our material we found statistical evidence that both groups were comparable indeed. Both groups suffered from not only pain, but also other side effects: indigestion, problems with exercise, feelings of stress, defecation disorders, disuria and loss of energy. The favourable results of the second series were roughly the same as those of the first one. Not only were about 80% of the patients pain free after 6 months or less, but the co-morbidity was gone in about 80% of the patients as well. In the literature, there are several reports describing a favourable outcome of appendicectomy for appendicopathy. Especially positive was one of only a few randomised, double-blinded, placebo controlled, parallel group trials in the history of surgery (Roumen, cs), which proved that "persistent or recurrent lower abdominal pain can be treated by elective appendicectomy with significant pain reduction in properly selected cases". An important part of the symptoms of both syndromes do overlap: (1) pain in the abdomen, varying in strength and more pain after a large meal, (2) changing bowel habits between constipation and diarrhoea, (3) indigestion and (4) stress.

CONCLUSION

Taking into account the overlap in several symptoms between IBS and Appendicopathy there is a possibility that both syndromes originate (partly) in the appendix and therefore laparoscopy and appendicectomy may play a part in the treatment of IBS as well. Pilot studies in this direction seem to be indicated.