Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults

Single versus double Hem-o-lok clips to secure the apendiceal stump during laparoscopic appendectomy: a prospective randomized multicentric clinical trial

PURPOSE

Polymeric clips (Hem-o-lok ligation system) are now widely used to securing the base of the appendix during laparoscopic appendectomy. Studies comparing the use of single or double hem-o-lok clips are limited. The aim of this study was to compare the reliability of a single hem-o-lok clips with a double hem-o-lok clips for closure of an appendiceal stump.

METHODS

This prospective randomized study includes patients from two centers who underwent laparoscopic appendectomy with the diagnosis of appendicitis between September 2020 and March 2023. Demographic, operative and clinical outcomes of the use of single or double hem-o-lok clips for closure of the appendiceal stump were compared. Factors affecting long postoperative hospital stay were investigated using univariate and multivariate analyzes.

RESULTS

One hundred forty two (48.3%) patients in the single hem-o-lok arm and 152 (51.7%) patients in the double hem-o-lok arm were included in the analysis.The shortest operative time was noted in the single hem-o-lok group (52.1 ± 19.9 versus 61.6 ± 24.9 min, p < 0.001). The median hospital stay was 1 day (range 1-10) in the single hem-o-lok group and 1 day (range 1-12) in the double hem-o-lok group, and was shorter in the single hem-o-lok arm (1.61 ± 1.56 vs 1.84 ± 1.69, p = 0.019). Based on multivariate analysis, drain placement was identified as an independent predictive factor for long hospital stay.

CONCLUSIONS

The use of single hem-o-lok clips for appendiceal stump closure during laparoscopic appendectomy is safe and effective. Trial registration NCT04387370 ( http://www.

CLINICALTRIALS

gov ).

Development and Validation of a Prognostic Classification Model Predicting Postoperative Adverse Outcomes in Older Surgical Patients Using a Machine Learning Algorithm: Retrospective Observational Network Study

BACKGROUND

Older adults are at an increased risk of postoperative morbidity. Numerous risk stratification tools exist, but effort and manpower are required.

OBJECTIVE

This study aimed to develop a predictive model of postoperative adverse outcomes in older patients following general surgery with an open-source, patient-level prediction from the Observational Health Data Sciences and Informatics for internal and external validation.

METHODS

We used the Observational Medical Outcomes Partnership common data model and machine learning algorithms. The primary outcome was a composite of 90-day postoperative all-cause mortality and emergency department visits. Secondary outcomes were postoperative delirium, prolonged postoperative stay (≥75th percentile), and prolonged hospital stay (≥21 days). An 80% versus 20% split of the data from the Seoul National University Bundang Hospital (SNUBH) and Seoul National University Hospital (SNUH) common data model was used for model training and testing versus external validation. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) with a 95% CI.

RESULTS

Data from 27,197 (SNUBH) and 32,857 (SNUH) patients were analyzed. Compared to the random forest, Adaboost, and decision tree models, the least absolute shrinkage and selection operator logistic regression model showed good internal discriminative accuracy (internal AUC 0.723, 95% CI 0.701-0.744) and transportability (external AUC 0.703, 95% CI 0.692-0.714) for the primary outcome. The model also possessed good internal and external AUCs for postoperative delirium (internal AUC 0.754, 95% CI 0.713-0.794; external AUC 0.750, 95% CI 0.727-0.772), prolonged postoperative stay (internal AUC 0.813, 95% CI 0.800-0.825; external AUC 0.747, 95% CI 0.741-0.753), and prolonged hospital stay (internal AUC 0.770, 95% CI 0.749-0.792; external AUC 0.707, 95% CI 0.696-0.718). Compared with age or the Charlson comorbidity index, the model showed better prediction performance.

CONCLUSIONS

The derived model shall assist clinicians and patients in understanding the individualized risks and benefits of surgery.

Drain placement in paediatric complicated appendicitis: a systematic review and meta-analysis

Children undergoing appendicectomy for complicated appendicitis are at an increased risk of post-operative morbidity. Placement of an intra-peritoneal drain to prevent post-operative complications is controversial. We aimed to assess the efficacy of prophylactic drain placement to prevent complications in children with complicated appendicitis. A systematic review was performed in accordance with PRISMA guidelines. Cochrane, MEDLINE and Web of Science databases were searched from inception to November 2022 for studies directly comparing drain placement to no drain placement in children ≤ 18 years of age undergoing operative treatment of complicated appendicitis. A total of 5108 children with complicated appendicitis were included from 16 studies; 2231 (44%) received a drain. Placement of a drain associated with a significantly increased risk of intra-peritoneal abscess formation (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.16-2.24, p = 0.004) but there was no significant difference in wound infection rate (OR 1.46, 95% CI 0.74-2.88, p = 0.28). Length of stay was significantly longer in the drain group (mean difference 2.02 days, 95% CI 1.14-2.90, p < 0.001). Although the quality and certainty of the available evidence is low, prophylactic drain placement does not prevent intra-peritoneal abscess following appendicectomy in children with complicated appendicitis.

A novel model for predicting prolonged stay of patients with type-2 diabetes mellitus: a 13-year (2010-2022) multicenter retrospective case-control study

BACKGROUND

Length of stay (LOS) is an important metric for evaluating the management of inpatients. This study aimed to explore the factors impacting the LOS of inpatients with type-2 diabetes mellitus (T2DM) and develop a predictive model for the early identification of inpatients with prolonged LOS.

METHODS

A 13-year multicenter retrospective study was conducted on 83,776 patients with T2DM to develop and validate a clinical predictive tool for prolonged LOS. Least absolute shrinkage and selection operator regression model and multivariable logistic regression analysis were adopted to build the risk model for prolonged LOS, and a nomogram was taken to visualize the model. Furthermore, receiver operating characteristic curves, calibration curves, and decision curve analysis and clinical impact curves were used to respectively validate the discrimination, calibration, and clinical applicability of the model.

RESULTS

The result showed that age, cerebral infarction, antihypertensive drug use, antiplatelet and anticoagulant use, past surgical history, past medical history, smoking, drinking, and neutrophil percentage-to-albumin ratio were closely related to the prolonged LOS. Area under the curve values of the nomogram in the training, internal validation, external validation set 1, and external validation set 2 were 0.803 (95% CI [confidence interval] 0.799-0.808), 0.794 (95% CI 0.788-0.800), 0.754 (95% CI 0.739-0.770), and 0.743 (95% CI 0.722-0.763), respectively. The calibration curves indicated that the nomogram had a strong calibration. Besides, decision curve analysis, and clinical impact curves exhibited that the nomogram had favorable clinical practical value. Besides, an online interface ( https://cytjt007.shinyapps.io/prolonged_los/ ) was developed to provide convenient access for users.

CONCLUSION

In sum, the proposed model could predict the possible prolonged LOS of inpatients with T2DM and help the clinicians to improve efficiency in bed management.

Patient backgrounds and short‐term outcomes of complicated appendicitis differ from those of uncomplicated appendicitis

Background

Appendicitis is classified as either complicated (CA) or uncomplicated (UA). Some authors have shown that the epidemiologic trends of CA and UA may differ. The aim of this study was to clarify differences in backgrounds and surgical outcomes between CA and UA patients.

Methods

This study was a cohort study. We extracted case data from the Japanese Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. Patients were classified into three groups, depending on whether they underwent emergency appendectomy for CA (CA group), emergency appendectomy for UA (UA group), or elective appendectomy (EA group). We evaluated patient characteristics and surgical outcomes for each group.

Results

We included 89,355 adult patients in the study, comprising 29,331 CA, 48,691 UA, and 11,333 EA patients. Old age, larger body mass index, smoking, and medication with antidiabetic drugs, oral corticosteroids, oral antiplatelet drugs, and oral anticoagulant drugs were independent risk factors for CA. The percentage of CA increased with age. In‐hospital mortality (0.15%, 0.02%, and 0.00%) and 30‐d mortality (0.09%, 0.01%, and 0.00%), respectively, of CA patients were significantly higher than those of the UA and EA groups. The duration of postoperative antibiotic administration, duration of fasting, and time before removal of a prophylactic drain were significantly longer in the CA group than in the UA and EA groups.

Conclusion

Backgrounds and treatment outcomes of CA and UA patients after emergency surgery are entirely different. Thus, the treatment strategy of CA and UA patients should differ accordingly.

Efficacy of Preoperative Imaging Features and Blood Tests in Predicting the Increased Risk of Conversion in Laparoscopic Appendectomy Surgery

Background

In this study, we identified preoperative risk factors, including imaging features and blood tests, to predict conversion from laparoscopic appendectomy to open appendectomy. Thus, we aimed to prevent patients from being exposed to the risks of laparoscopy by choosing patients for whom proceeding directly to an open surgery as an initial approach was appropriate.

Patients and methods

The cohort of 632 patients who underwent laparoscopic appendectomy due to acute appendicitis in our center between January 2017 and March 2021 were analyzed, and 521 of these patients comprised the study population. Baseline characteristics, medical history, preoperative laboratory tests, imaging features, and postoperative pathologic findings of all patients according to groups who underwent laparoscopic appendectomy or conversion to open appendectomy were examined.

Results

Among 521 patients, the appendectomy procedure was completed laparoscopically in 498 (95.6%) patients, and conversion to open appendectomy was occurred in 23 (4.4%) patients. 223 (42.8%) patients were female, and 298 (57.2%) patients were male. The mean age of all patients was 35.17±12.61 years (range, 16-80 years). Preoperative ultrasonography feature associated with a higher rate of conversion was free fluid collection (p=0.001). The levels of C-reactive protein, neutrophil, and neutrophil/lymphocyte ratio on admission were found to be significantly higher in the conversion group compared to the laparoscopy group (p=0.001, p=0.027, p=0.02, respectively). 

Conclusions

Free fluid collection detected by ultrasonography, and elevation of C-reactive protein, neutrophil, and neutrophil/lymphocyte ratio may be useful in the prediction of a high risk of conversion appendectomy. Despite the unquestionable advantages of laparoscopic surgery, there are still substantial conversion rates. Within this framework, our study will help the surgeons to choose the most appropriate surgical methods for patients by evaluating them individually, and to inform them of the possibility of conversion to the open approach, and other risks before surgery. 

Factors Affecting Postoperative Length of Stay in Patients Undergoing Anterior Lumbar Interbody Fusion

BACKGROUND

With hospital leaders and policy makers increasingly seeking ways to improve resource use, there has been heightened interest in reducing hospital length of stay (LOS) and performing spine procedures on an outpatient basis. We aimed to determine which risk factors correlated with prolonged LOS after anterior lumbar interbody fusion (ALIF).

METHODS

Medical records for patients who underwent ALIF were retrospectively reviewed. Patients were divided into those who had extended (≥3 days) versus nonextended (<3 days) LOS, and patient demographics, medical comorbidities, and preoperative medications were analyzed. Univariate and multivariate regression were then used to determine preoperative risk factors for extended LOS.

RESULTS

A total of 166 patients were included (mean age, 48.7 years). Medical comorbidities included hypertension (31.9%), diabetes (8.4%), and obesity (body mass index >30 kg/m²) (48.8%). LOS was not extended in 121 patients and extended in 45. Mean LOS was 2.2 days (95% confidence interval, 1.9-2.5). On multivariate logistic analysis, age ≥65 years (P = 0.001), preoperative benzodiazepine use (P = 0.014), 12-item Short Form mental component score (P = 0.008), estimated blood loss (P = 0.015), time to mobilization (P < 0.001), and total operative time (P = 0.020) were independent predictors for extended LOS.

CONCLUSIONS

As attempts are made to perform more spine procedure in ambulatory surgical centers, strict patient selection criteria are all critical in making this possible. Our results suggest that age, preoperative benzodiazepine use, higher intraoperative blood loss, delayed mobilization, and lower 12-item Short Form mental component score were correlated with increased LOS. Therefore, inpatient ALIF may be more suitable for patients with these risk factors.

Long splenic flexure carcinoma requiring laparoscopic extended left hemicolectomy with CME and transverse-rectal anastomosis: technique for a modified partial Deloyers in 5 steps to achieve enough reach and preserving middle colic vessels

Introduction

This How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis.

Background

While laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article.

Technique and methods

Firstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient.

Results

This modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery.

Conclusions

Laparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02240-7.