Obesity should not influence the management of appendicitis

The Effect of Body Mass Index on Patients' Length of Stay Post-appendectomy

BACKGROUND AND AIM

Appendicitis is defined as the appendix's inflammation, which requires an appendectomy for treatment. Obesity is one of the risk factors for post-surgical complications in appendicitis. This study aimed to explore obesity's influence on hospital length of stay among patients with appendicitis in Taif, Saudi Arabia.

METHODS

The study subjects consisted of both children and adults with appendicitis who were admitted to the hospital during 2021 and 2022. The patients were divided into three groups according to body mass index (BMI) following the WHO criteria: normal weight (BMI = 18.5-24.9 kg/m2), overweight (BMI = 25-29.9 kg/m2), and obesity (BMI ≥10 kg/m2). Data collection was conducted retrospectively by reviewing the medical records of patients diagnosed with appendicitis. The data collection included demographic characteristics of the patients, clinical presentation data, examination data, findings of the diagnostic approaches, management data, and complications after surgery (mainly intra-abdominal abscess formation). Prior to conducting the study, ethical approval was obtained from the Institutional Review Board of the Saudi Ministry of Health.

RESULTS

The study included 238 patients who were diagnosed with appendicitis with an age range from 4 to 74 years and a mean (SD) age of 20.24 years (12.69). Based on BMI categories, 174 patients (73.1%) were classified as non-obese (BMI < 25), 53 patients (22.3%) were overweight (BMI 25-29.9), and 11 patients (4.6%) were obese (BMI ≥ 30). Most patients were presented with fever (51.7%), anorexia (72.7%), and pain in the right lower quadrant (70.2%). According to blood pressure, the mean (SD) of systolic and diastolic blood pressure was 117.8 (14.14) and 71.03 (9.89), respectively. All cases underwent abdominal ultrasound; non-visualization of the appendix was the most common finding observed (80.3%). Appendicitis was managed among most patients with appendectomy (89.5%), and open appendectomy was the most frequent surgery performed (73.2%). The mean of hospital length of stay was 1.64 (0.73) days. There was no significant correlation between patients' BMI and hospital length of stay (p = 0.429). The mean hospital length of stay of females (1.76) was higher than that of males (1.53) (p = 0.003). Moreover, a statistically significant mean difference was observed in hospital length of stay between patients managed conservatively (1.96) and those who underwent operative management (1.60 days) (p < 0.001).

CONCLUSION

This study provides insights into the effect of obesity on patients with appendicitis who underwent an appendectomy in Taif, Saudi Arabia. The study found that obesity was not a risk factor for a prolonged hospital length of stay after appendectomy. Further studies with larger sample sizes are needed to explore other factors that may influence the outcomes of appendectomy in patients with appendicitis, such as the impact of obesity on long-term complications and recurrence rates.

The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review

Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of stay (LOS), surgical site infection (SSI), overall complications, adverse events, and mortality in children undergoing appendectomy for acute appendicitis. An extensive search of the literature in PubMed and Google Scholar was conducted to evaluate the outcomes of normal weight (NW), overweight (OW), and obese (OB) children who underwent appendectomy. Although no statistically significant differences were noted in perioperative outcomes and overall postoperative complications between OW/OB and NW children in the majority of the included studies, prolonged OT and LOS and SSI were found in some studies. Moreover, no differences in terms of readmissions and ED visits were recorded. We conclude that the impact of obesity on postoperative outcomes for children undergoing appendectomy for AA is unclear, and, therefore, no safe conclusions can be drawn with the currently available data. Due to the lack of high-quality studies, further research is required to optimize the surgical approach and prevent unwarranted complications.

Appendectomy Hospital Stay: No Difference in Obese Adult or Pediatric Patient Length of Stay Compared to Nonobese Patients

Background: Studies of adult and pediatric patients undergoing appendectomy have reported variable outcomes and operative metrics related to the effect of obesity. The purpose of this study was to investigate the effect of obesity in adult and pediatric patients undergoing appendectomy at our institution. Methods: This single-center retrospective study evaluated the relationship between length of hospital stay for appendectomy and body mass index (BMI). Data obtained from the electronic medical record included age, sex, weight, height, BMI, the number of hours the patient experienced symptoms prior to presentation to the emergency room, the number of hours the patient was admitted prior to surgery, the number of hours of hospital admission after surgery, perforated appendix, preoperative comorbidities, and evidence of preoperative sepsis. Results: During the 3-year study period, 118 adults and 38 children who underwent appendectomy composed the study groups. Patients were stratified by obese and nonobese, with obesity defined as BMI ≥30.0 kg/m². In adults, we found no significant difference between length of stay in obese (n=45) and nonobese (n=73) patients (79.6 ± 65.5 hours vs 101.6 ± 123.0 hours; P=0.21). In children, we found no significant difference between length of stay in obese (n=9) and nonobese (n=29) patients (92.9 ± 64.6 hours vs 109.0 ± 93.5 hours; P=0.54). Conclusion: Obesity did not affect length of stay in adults and children who underwent appendectomy in the present series.

TNM: a simple classification system for complicated intra-abdominal sepsis after acute appendicitis

BACKGROUND

Delayed diagnosis in case of acute appendicitis (AA) could lead to complicated intra-abdominal sepsis (IAS). Grading systems are not commonly employed in the clinical practice, because they are too complicated or too specific. Therefore, we suggest grading the severity of complicated IAS after AA with a simple system: TNM, an acronym borrowed by cancer staging where T indicates temperature, N neutrophils, and M multiple organ failure (MOF). This prospective observational study evaluates the predictive value of the TNM score on mortality of patients with complicated IAS after AA.

METHODS

Sixty-eight patients with complicated IAS after AA were treated. Three classes of attributes were chosen: temperature (T), neutrophils count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3) and M (M0-M2), these were grouped in stages (0-IV). Variables analyzed for their possible relation to death were age, sex, temperature, neutrophils count, preoperative organ failure, immunocompromised status, stage (0-IV). Odds ratios were calculated in a univariate and multivariate analysis.

RESULTS

TNM staging was: one patient stage 0; 16 patients at stage I; 26 patients at stage II; 16 patients at stage III; nine patients at stage IV. Death occurred in 15 patients (22%). Neutrophil count, preoperative organ failure, immunocompromised status, stages III-IV were potential predictors of postoperative death in univariate analysis; only stage IV was significant independent predictor of postoperative mortality in multivariate analysis.

CONCLUSIONS

TNM classification is very easy to use; it helps to define the mortality risk and is useful to objectively compare patients with sepsis.

Obesity and appendicitis: Laparoscopy versus open technique

Objectives

The clinical results of obese patients who have undergone open or laparoscopic appendectomy, whether one technique is superior to the other is still not clearly known.In our study, we compared the clinical results of obese patients operated with laparoscopic or open technique for acute appendicitis.

Material and Methods

We performed retrospective analyses of patients operated for acute appendicitis between the dates of July 2016 and July 2019 at Istinye University Faculty of Medicine Bahcesehir Liv Training and Research Hospital and Liv Hospital Ankara. Of the 241 patients whose height and weight information was accessible, 57 had a body mass index of 30 kg/m2 or higher. Eighteen of these patients underwent open surgery while the other 39 underwent laparoscopic surgery. The primary result criterion was complication ratio. Secondary criteria were operation time and length of hospital stay.

Results

Upon comparison of laparoscopic and open techniques in terms of intraoperative-postoperative complications (p= 0.01), operation time (p= 0.02) statistically significant differences were found between the groups. However the mean length of hospital stay (p= 0.181) was similar in both groups.

Conclusion

In obese appendicitis patients, the laparoscopic technique proved to be superior to the open technique in criteria such as perioperative-postoperative complications, operation time, and etc. Length of hospital stay was determined to be similar between the groups.

Impact of body mass index on utilization of selected hospital resources for four common surgical procedures

BACKGROUND

Evidence about the impact of obesity on surgical resource consumption in the Australian setting is equivocal. Our objectives were to quantify the prevalence of obesity in four frequently performed surgical procedures and explore the association between body mass index (BMI) and hospital resource utilization including procedural duration, length of stay (LOS) and costs.

METHODS

A retrospective cohort study of patients undergoing four surgical procedures at a tertiary referral centre in New South Wales, between 1 January 2016 and 31 December 2016, was conducted. The four surgical procedures were total hip replacement, laparoscopic appendectomy, laparoscopic cholecystectomy and hysteroscopy with dilatation and curettage. Surgical groups were stratified according to BMI category.

RESULTS

A total of 699 patients were included in the study. The prevalence of obesity was significantly higher than local and national population estimates for all procedures except appendectomy. BMI was not associated with increased hospital resource utilization (procedural, anaesthetic or intensive care stay duration) in any of the four surgical procedures examined after controlling for age, gender and complexity. For other outcomes of hospital resource utilization (LOS and cost), the relationship was inconsistent across the four procedures examined. A high BMI was positively associated with higher LOS, medical costs and allied health costs in those who underwent an appendectomy, and critical care costs in those who underwent laparoscopic cholecystectomy.

CONCLUSION

Obesity was common in patients undergoing four frequently performed surgical procedures. The relationship between BMI and hospital resource utilization appears to be complex and varies across the four procedures examined.

Laparoscopic Appendectomy: Risk Factors for Postoperative Intraabdominal Abscess

BACKGROUND

Laparoscopic appendectomy (LA) has obtained wide acceptance over the last two decades. However, some studies suggest that there is an increased rate of intraabdominal abscess (IAA) when is compared with open appendectomy. Since postoperative IAA is associated with high morbidity, identifying predictive factors of this complication may help to prevent it. The aim of this study was to identify preoperative and intraoperative risk factors for IAA after LA.

METHODS

From January 2005 to June 2015, all charts of consecutive patients underwent to LA were revised. Demographics, clinical and intraoperative variables were analyzed. Independent risk factors for postoperative IAA were determined by logistic regression analysis.

RESULTS

A total of 1300 LA were performed. The mean age was 34.7 (14-94) years. Two hundred and twenty-five patients (17.3%) had complicated appendicitis with perforation and peritonitis. The conversion rate was 2.3% (30 cases). The average hospital stay was 1.6 (0-27) days. There were 30 (2.3%) postoperative IAA. In the multivariate analysis, body mass index (BMI) >30 (p 0.01), leukocytosis >20,000/mm³ (p 0.02), perforated appendicitis (p < 0.001) and operative time >90 min (p 0.04) were associated with the development of postoperative IAA. There was no mortality in the series.

CONCLUSION

Patients with obesity, leukocytosis >20,000/mm³, perforated appendicitis and surgical time longer than 90 min have a higher chance of having a postoperative IAA. A close postoperative follow-up would be necessary in these situations in order to prevent and identify IAA after LA.

The influence of underweight and obesity on the diagnosis and treatment of appendicitis in children

PURPOSE

The impact of lower body mass index (BMI) on appendicitis has never been addressed. We investigated whether different BMIs affect the diagnosis and treatment of appendicitis in children.

METHODS

The correlation between BMI and diagnosis accuracy and treatment quality was evaluated by retrospective analysis of 457 children diagnosed with appendicitis. Based on BMI percentiles, patients were classified as either underweight (n = 36), normal weight (n = 346), overweight (n = 59), or obese (n = 16). Diagnosis accuracy was measured by negative appendectomy rate, perforation rate, and number of consultations. Treatment quality was measured by complication rate and length of hospital stay.

RESULTS

Underweight patients had the highest negative appendectomy (OR 3.00, P = 0.008) and complication (OR 2.75, P = 0.041) rate. BMI did not influence perforation rate or number of consultations. Both underweight and obese patients stayed in the hospital longer than normal weight patients (regression coefficient 2.34, P = 0.001, and regression coefficient 9.40, P < 0.001, respectively). Furthermore, in obese patients, the hospital stay after open appendectomy was prolonged compared to laparoscopic appendectomy (P < 0.001). No such differences were observed in patients with lower BMI.

CONCLUSIONS

Underweight children are misdiagnosed more often, stay in hospital longer, and experience more postoperative complications than children of normal weight. Obesity is associated with longer hospital stays. Laparoscopic appendectomy might shorten the length of hospital stays in these patients. We conclude that in addition to obesity, underweight should also be considered a risk factor for children with appendicitis.

The impact of obesity on laparoscopic appendectomy: Results from the ACS National Surgical Quality Improvement Program pediatric database

BACKGROUND

Childhood obesity is a worsening epidemic. Little is known about the impact of elevated BMI on perioperative and postoperative complications in children who undergo laparoscopic surgery. The purpose of this study was to examine the effects of obesity on surgical outcomes in children using laparoscopic appendectomy as a model for the broader field of laparoscopic surgery.

STUDY DESIGN

Using the Pediatric National Surgical Quality Improvement Program (NSQIP) data from 2012, patients aged 2-18years old with acute uncomplicated and complicated appendicitis who underwent laparoscopic appendectomy were identified. Children with a body mass index (BMI)≥95th percentile for their age and gender were considered obese. Primary outcomes, including overall morbidity and wound complications, were compared between nonobese and obese children. Multivariate regression analysis was conducted to identify the impact of obesity on outcome.

RESULTS

A total of 2812 children with acute appendicitis who underwent appendectomy were included in the analysis; 22% were obese. Obese children had longer operative times but did not suffer increased postoperative complications when controlling for confounders (OR 1.3, 95% CI: 0.83-0.072 for overall complications, OR 1.3, 95% CI: 0.84-1.95 for wound complications).

CONCLUSIONS

Obesity is not an independent risk factor for postoperative complications following laparoscopic appendectomy. Although operative times are increased in obese children, obesity does not increase the likelihood of 30-day postoperative complications.

Laparoscopic appendicectomy in obese is associated with improvements in clinical outcome: systematic review

BACKGROUND

Obese patients with general surgical emergencies provide unique challenges to the emergency surgical teams. Acute appendicitis is the most common adult acute surgical emergency encountered in practice. This systematic review evaluates the role of laparoscopic appendicectomy in obese by comparing the outcomes of laparoscopic appendicectomy in obese versus non-obese and the laparoscopic versus open appendicectomy in obese patients.

METHODS

Relevant comparative studies were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990-2013). Primary outcomes evaluated were mortality, overall morbidity and duration of surgery. Secondary outcomes evaluated were superficial (superficial wound infection) and deep surgical site infection (intra-abdominal abscesses), conversion to open surgery, and cost of the procedure.

RESULTS

Seven retrospective cohort studies and one prospective randomized controlled trial met the inclusion criteria. There was no statistically significant difference in the primary and secondary outcomes between the obese and non-obese patients undergoing laparoscopic appendicectomy. Laparoscopic appendicectomy in obese patients is associated with reduced mortality (risk ratio [RR]: 0.19 (95% CI 0.12-0.30), reduced overall morbidity (RR: 0.49 (95% CI: 0.47-0.51)), reduced superficial wound infections (RR: 0.27 (95% CI 0.21-0.35)), shorter operating times and post-operative length of hospital stay, compared to open appendicectomy. Methodological quality of the included studies is low.

CONCLUSION

Laparoscopic appendicectomy appears to be a safer alternative approach to open surgery in obese adult patents. There is no significant difference in the outcomes between the obese and non-obese patients undergoing laparoscopic appendicectomy.

Laparoscopic versus open appendectomy in obese patients: A meta-analysis of prospective and retrospective studies

BACKGROUND:

A meta-analysis of different kinds of studies was performed to assess outcomes of laparoscopic versus open appendectomy in obese patients.

MATERIALS AND METHODS:

Retrospective and prospective studies enrolling patients with a body mass index greater than 30 kg/m² were included. Primary outcomes were days of hospital stay, surgical procedure duration, and overall post-operative complication rate. Secondary outcomes were wound infection and intra-abdominal abscesses formation rate, hospital charges.

RESULTS:

Laparoscopic appendectomy showed to be significantly associated with lower wound infection (P < 0.001) and post-operative complication rate (P < 0.001). Surgical time was considered as a hallmark of technical challenge and resulted diminished in the laparoscopic group (P = 0.018). Although not clinically relevant per se, the statistically significant shorter hospital stay (P < 0.001) was probably the reason of decreased hospital charges (P < 0.001). Intra-abdominal abscesses formation rate was higher in the open appendectomy group (P = 0.058), although slightly above the statistical significance threshold.

CONCLUSION:

Laparoscopic approach seemed to show relevant advantages compared to open appendectomy, but a large prospective trial is necessary to collect high quality data and investigate long-term outcomes.

Obesity Disease and Surgery

Obesity is a medical disease that is increasing significantly nowadays. Worldwide obesity prevalence doubled since 1980. Obese patients are at great risk for complications with physical and psychological burdens, thus affecting their quality of life. Obesity is well known to have higher risk for cardiovascular diseases, diabetes mellitus, musculoskeletal diseases and shorter life expectancy. In addition, obesity has a great impact on surgical diseases, and elective surgeries in comparison to general population. There is higher risk for wound infection, longer operative time, poorer outcome, and others. The higher the BMI (body mass index), the higher the risk for these complications. This literature review illustrates the prevalence of obesity as a diseases and complications of obesity in general as well as, in a surgical point of view, general surgery perioperative risks and complications among obese patients. It will review the evidence-based updates in these headlines.

Acute appendicitis: position paper, WSES, 2013

Appendectomy is one of the most frequently performed operative procedures in general surgery departments of every size and category. Laparoscopic Appendectomy – LA - as compared to Open Appendectomy – OA - was very controversial at first but has found increasing acceptance all over the World, although the percentage of its acceptance is different in the various single National setting. Various meta-analyses and Cochrane reviews have compared LA with OA and different technical details. Furthermore, new surgical methods have recently emerged, namely, the single-port/incision laparoscopic appendectomy and NOTES technique. Their distribution among the hospitals, however, is unclear. Using laparoscopic mini-instruments with trocars of 2–3.5 mm diameter is proposed as a reliable alternative due to less postoperative pain and improved aesthetics. How to proceed in case of an inconspicuous appendix during a procedure planned as an appendectomy remains controversial despite existing study results. But the main question still is: operate or not operate an acute appendicitis, in the meaning of an attempt of a conservative antibiotic therapy. Therefore, we have done a literature survey on the performance of appendectomies and their technical details as well as the management of the intraoperative finding of an inconspicuous appendix in order to write down – under the light of the latest evidence – a position paper.

Laparoscopic vs open appendectomy in obese patients: outcomes using the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Although open and laparoscopic appendectomies are comparable operations in terms of outcomes, it is unknown whether this is true in the obese patient. Our objective was to compare short-term outcomes in obese patients after laparoscopic vs open appendectomy.

STUDY DESIGN

Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2009), 13,330 obese patients (body mass index ≥ 30) who underwent an appendectomy were identified (78% laparoscopic, 22% open). The association between surgical approach (laparoscopic vs open) and outcomes was first evaluated using multivariable logistic regression. Next, to minimize the influence of treatment selection bias, we created a 1:1 matched cohort using all 41 of the preoperative covariates in the National Surgical Quality Improvement Program database. Reanalysis was then performed with the unmatched patients excluded. Main outcomes measures included patient morbidity and mortality, operating room return, operative times, and hospital length of stay.

RESULTS

Laparoscopic appendectomy was associated with a 57% reduction in overall morbidity in all the obese patients after the multivariable risk-adjusted analysis (odds ratio = 0.43; 95% CI, 0.36-0.52; p < 0.0001), and a 53% reduction in risk in the matched cohort analysis (odds ratio = 0.47; 95% CI, 0.32-0.65; p < 0.0001). Mortality rates were the same. In the matched cohort, length of stay was 1.2 days shorter for obese patients undergoing laparoscopic appendectomy compared with open appendectomy (mean difference 1.2 days; 95% CI, 0.98-1.42).

CONCLUSIONS

In obese patients, laparoscopic appendectomy had superior clinical outcomes compared with open appendectomy after accounting for preoperative risk factors.

Obesity and the risk and outcome of infection

The interactions between obesity and infectious diseases have recently received increasing recognition as emerging data have indicated an association between obesity and poor outcome in pandemic H1N1 influenza infection. Obesity is an established risk factor for surgical-site infections, nosocomial infections, periodontitis and skin infections. Several studies indicate that acute pancreatitis is more severe in the obese. Data are controversial and limited as regards the association between obesity and the risk and outcome of community-acquired infections such as pneumonia, bacteremia and sepsis and obesity and the course of HIV infection. As the cause-effect relationship between obesity and infection remains obscure in many infectious diseases, further studies are warranted. The consequences of obesity may have substantial effects on the global burden of infectious diseases.

Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis

BACKGROUND

Laparoscopic appendicectomy (LA) in the obese population has been controversial. A recent SAGES guideline and a Cochrane Review have suggested a benefit for LA over the open approach but did not provide supporting data. This study is the first systematic review and meta-analysis to compare the LA with open surgery in the obese population to provide a quantitative estimate of the relative benefits.

METHODS

A comprehensive search of the online databases identified seven retrospective and prospective randomized studies that contained sufficient data on obese patients. Analysis was based on intention-to-treat. We calculated pooled odds ratios (ORs) and 95 % confidence intervals using a random-effects model.

RESULTS

The LA group contained more females (43 vs. 32 %, p < 0.001), had fewer perforations (18 vs. 23 %; p < 0.001), and fewer overall complications (OR: 0.49; 95 % CI: 0.37-0.63), including fewer wound infections (OR: 0.34; 95 % CI: 0.18-0.66). There was no difference in the intra-abdominal abscess rate between the groups (OR: 0.99; 95 % CI: 0.29-3.37). The LA group had a shorter length of stay (2.46 vs. 3.63 days; p < 0.001) but a longer operation time (96 vs. 78 min, p < 0.001). There was no heterogeneity between the studies.

CONCLUSIONS

This meta-analysis of the current published data establishes the laparoscopic approach to appendicectomy as the preferred technique for the obese population, delivering a 50 % reduction in morbidity, with a 66 % reduction in wound infections and a significantly shorter inpatient hospital stay without increasing the intra-abdominal abscess rate.

Obesity Does Not Impact Outcomes for Appendicitis

Obesity has long been considered a risk factor for surgery. The purpose of this study was to evaluate the impact of obesity on outcomes after appendectomy. A retrospective study was performed using discharge abstract data obtained from patients with documented body mass index (BMI) undergoing appendectomy for appendicitis (n = 2919). Complications and length of stay for different BMI categories were compared. Obese patients (BMI > 30 kg/m2) had similar rates of perforation (20%) and were as likely to undergo a laparoscopic approach (85%) as nonobese patients. On multivariable and univariate analysis, no significant differences were observed when comparing obese and nonobese patients for the outcomes of length of stay, infectious complications, and need for readmission. On multivariate analysis, laparoscopy predicted lower complication rates and decreased length of stay. In this study, obesity did not significantly impact rates of perforation, operative approach, length of stay, infectious complications, or readmission.

Laparoscopic appendectomy: new concepts

Over the last three decades more surgeons have used laparoscopic appendectomy as their surgical approach of choice in the management of patients with appendicitis. This includes special groups of patients, namely, pediatric, pregnant, and obese patients. Laparoscopy has the benefit of lower morbidity, decreased rate of wound complications, faster recovery, shorter length of hospital stay, and faster return to work over open appendectomy.

Comparison of laparoscopic versus open appendectomy for acute nonperforated and perforated appendicitis in the obese population

BACKGROUND

Use of laparoscopic appendectomy (LA) has been increasing in obese patients. We evaluated the outcomes of LA compared with open appendectomy (OA) in obese patients.

METHODS

By using the Nationwide Inpatient Sample database, clinical data of obese patients who underwent LA and OA for suspected acute appendicitis (perforated or nonperforated) from 2006 to 2008 were examined.

RESULTS

A total of 42,426 obese patients underwent an appendectomy during this period. In acute nonperforated cases, LA had a lower overall complication rate (7.17% vs 11.72%; P < .01), mortality rate (.09% vs .23%; P < .01), mean hospital charges ($25,193 vs $26,380; P = .04), and shorter mean length of stay (2.0 vs 3.1 d; P < .01) compared with OA. Similarly, in perforated cases, LA was associated with a lower overall complication rate (22.34% vs 34.65%; P < .01), mortality rate (.0% vs .50%; P < .01), mean hospital charges ($36,843 vs $43,901; P < .01), and a shorter mean length of stay (4.4 vs 6.5 d; P < .01) compared with OA.

CONCLUSIONS

LA can be performed safely with superior outcomes compared with OA in obese patients and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.

Laparoscopic versus open appendicectomy in obese patients

BACKGROUND

Although there appears to be no outright benefit of laparoscopic versus open surgery for acute appendicitis in the general population, it has been suggested that in obese patients a laparoscopic approach may offer more conclusive gains. The aim of this pooled analysis of comparative studies was to evaluate clinical outcome following laparoscopic and open appendicectomy in the obese population.

METHODS

A systematic literature search of MEDLINE, Embase, Web of Science and the Cochrane Library databases was performed. Primary outcomes were length of operation (min) and length of hospital stay (days). Secondary outcomes were presence of post-operative complications, wound and intra-abdominal complications. Weighted mean differences were calculated to assess the size of the effect of laparoscopic appendicectomy on continuous variables and Pooled odds ratio were calculated for discrete variables.

RESULTS

2309 appendicectomies were included in this analysis, 1122 laparoscopic and 1187 open appendicectomies. Analysis of primary outcome measures revealed a shorter length of post-operative stay associated with laparoscopic appendicectomy (weighted mean difference = -1.26; 95% confidence interval = -2.36 to -0.16; p = 0.02). There was no significant difference between the groups for length of operation, post-operative complications, intra-abdominal or wound complications.

CONCLUSION

The results of this pooled analysis indicate that laparoscopic appendicectomy may be beneficial in the obese population with a shorter length of hospital stay, and a similar incidence of post-operative complications.

Clinical outcomes in obese and normal-weight children undergoing ultrasound for suspected appendicitis

BACKGROUND

Obesity constitutes an independent predictor for a nondiagnostic screening ultrasound (US) in suspected appendicitis. Furthermore, the imaging route consisting of the screening US with a second US if necessary has a significantly lower diagnostic accuracy in the obese children (83%) than their lean counterparts (93%). However, the effect of this association on clinical outcomes in the obese population is unknown.

OBJECTIVES

In children presenting to the emergency department (ED) undergoing US for suspected appendicitis, the objective was to examine if there is a significant difference in the proportions of those with a "desirable outcome" in the obese group versus their normal-weight counterparts.

METHODS

This was a reanalysis of a recent prospective cohort study conducted at a tertiary care pediatric ED. A consecutive sample of 263 previously healthy children 4-17 years of age undergoing screening US for suspected appendicitis was enrolled. Study patients were divided into obese (body mass index-for-age percentiles [BMI-FAP] ≥ 85%) and normal-weight groups. The main outcome was the proportion of children with the desirable outcome in the obese and normal-weight groups. Desirable outcomes for patients with a nondiagnostic screening US were defined as either 1) nonperforated appendicitis or alternate surgical diagnosis undergoing appropriate surgical procedure within 24 hours of assessment without a computed tomography (CT) scan or 2) no appendicitis, discharged from the ED within 24 hours without a CT scan. Secondary outcomes included hospitalization, CT imaging for any reason within 30 days of initial presentation, length of hospital stay, return visits, time to and length of surgery, and complications.

RESULTS

Of the 263 patients, 76 (28.9%) were obese, and 187 had a normal weight. Ninety-nine children (37.6%) had appendicitis (obese = 24, normal-weight = 75). The desirable outcome was achieved in 46 (64.5%) of the obese patients versus 137 (73.3%) of the normal-weight children (95% confidence interval [CI] for the difference = -0.21 to 0.04). Compared to the normal-weight children, the obese children had similar hospitalization rates (44.7% vs. 45.5%), median length of hospital stay (20.5 hours vs. 23.0 hours), and return ED visit rates (11.8% vs. 9.1%). The median time to surgery (obese = 10.5 hours, normal-weight = 9.0 hours), complications (obese = 25%, normal-weight = 21.3%), perforations (obese = 33%, normal-weight = 31%), and length of surgery (obese 80 [±37] minutes, normal-weight 67 [±25] minutes) were also similar. The rate of CT within 30 days of initial presentation was higher in the obese compared to the normal-weight group (13/76 or 17.1% vs. 13/187 or 6.9%, 95% CI = 0.02 to 0.23).

CONCLUSIONS

Previously healthy obese children undergoing screening US for suspected appendicitis experienced comparable clinical outcomes to their normal-weight counterparts. However, they were three times more likely to receive a CT scan during their investigation. These results argue for continuing current practice of using the screening US in this population, followed by a CT if clinically warranted upon reexamination.

Laparoscopic versus open appendectomy for the obese patient: a subset analysis from a prospective, randomized, double-blind study

BACKGROUND

The clinical outcomes for patients randomized to either open or laparoscopic appendectomy are comparable. However, it is not known whether this is true in the subset of the adult population with higher body mass indexes (BMIs). This study aimed to compare the outcomes of open versus laparoscopic appendectomy in the obese population.

METHODS

A subgroup analysis of a randomized, prospective, double-blind study was conducted at a county academic medical center. Of the 217 randomized patients, 37 had a BMI of 30 kg/m(2) or higher. Open surgery was performed for 14 and laparoscopic surgery for 23 of these patients. The primary outcome measures were the postoperative complication rates. The secondary outcomes were operative time, length of hospital stay, time to resumption of diet, narcotic requirements, and Medical Outcomes Survey Short Form 36 (SF-36) quality-of-life data.

RESULTS

No differences in complications between the open and laparoscopic groups were found. Also, no significant differences were seen in any of the secondary outcomes except for a longer operative time among the obese patients.

CONCLUSIONS

In this study, laparoscopic appendectomy did not show a benefit over the open approach for obese patients with appendicitis.