Is laparoscopic appendectomy safe in pregnant women?

SAGES guidelines for the use of laparoscopy during pregnancy

BACKGROUND

When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD).

METHODS

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient.

RESULTS

The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy.

CONCLUSIONS

Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

Ethical Principles Do Not Support Mandatory Preanesthesia Pregnancy Screening Tests: A Narrative Review

Respect for patient autonomy is a pillar of medical ethics, manifested predominantly through informed consent. Mandatory (routine) nonconsented preoperative urine pregnancy testing does not adequately respect patient autonomy, is potentially coercive, and has the potential to cause harm medically, psychologically, socially, and financially. Inaccuracies in pregnancy testing can result in false-positive and false-negative results, especially in early pregnancy. There is substantial scientific evidence that anesthesia is not harmful to the fetus, raising the question of whether pregnancy testing provides substantial benefit to the patient. Not performing a preanesthesia pregnancy test has not been associated with significant medicolegal consequences. We review the ethical implications of mandatory preanesthesia pregnancy testing in light of these facts.

Non-obstetric surgery during pregnancy and the effects on maternal and fetal outcomes: A systematic review

BACKGROUND AND OBJECTIVE

Non-obstetric surgery is fairly common in pregnant women. We performed a systematic review to update data on non-obstetric surgery in pregnant women. The aim of this review was to evaluate the effects of non-obstetric surgery during pregnancy on pregnancy, fetal and maternal outcomes.

METHODS

A systematic literature search of MEDLINE and Scopus was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search span was from January 2000 to November 2022. Thirty-six studies matched the inclusion criteria, and 24 publications were identified through reference mining; 60 studies were included in this review. Outcome measures were miscarriage, stillbirth, preterm birth, low birth weight, low Apgar score, and infant and maternal morbidity and mortality rates.

RESULTS

We obtained data for 80,205 women who underwent non-obstetric surgery and data for 16,655,486 women who did not undergo surgery during pregnancy. Prevalence of non-obstetric surgery was between 0.23% and 0.74% (median 0.37%). Appendectomy was the most common procedure with median prevalence of 0.10%. Near half (43%) of the procedures were performed during the second trimester, 32% during the first trimester, and 25% during the third trimester. Half of surgeries were scheduled, and half were emergent. Laparoscopic and open techniques were used equally for abdominal cavity. Women who underwent non-obstetric surgery during pregnancy had increased rate of stillbirth (odds ratio (OR) 2.0) and preterm birth (OR 2.1) compared to women without surgery. Surgery during pregnancy did not increase rate of miscarriage (OR 1.1), low 5 min Apgar scores (OR 1.1), the fetus being small for gestational age (OR 1.1) or congenital anomalies (OR 1.0).

CONCLUSIONS

The prevalence of non-obstetric surgery has decreased during last decades, but still two out of 1000 pregnant women have scheduled surgery during pregnancy. Surgery during pregnancy increases the risk of stillbirth, and preterm birth. For abdominal cavity surgery, both laparoscopic and open approaches are feasible.

Updated Evaluation of Laparoscopic vs. Open Appendicectomy During Pregnancy: A Systematic Review and Meta-Analysis

To explore the updated evaluation about the obstetrical and perioperative outcomes of laparoscopic appendicectomy (LA) for pregnancy appendicitis compared with open appendicectomy (OA). Two reviewers independently searched the PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science databases to screen eligible studies up to December 2020. Only clinical researches, no < 10 cases for LA and OA group were included. Twenty retrospective studies with 7,248 pregnant women, evaluating LA and OA in surgical and obstetrical outcomes, were included. The weighted mean difference (WMD) with 95% CI and odds ratio (OR) was used to compare continuous and dichotomous variables. It seems LA was connected with significantly shorter hospital time and lower wound infection [mean difference (MD), −0.57 days; 95% CI, −0.96 to −0.18; p = 0.004 and OR, 0.34; 95% CI, 0.18 to 0.62; p = 0.0005, respectively]. The incidence of fetal loss after LA was higher than OA (OR,1.93; 95% CI, 1.39–2.69; p < 0.0001). It was almost similar in the rate of preterm delivery (OR, 0.80; 95% CI, 0.48 to 1.34; p = 0.40) and other perioperative and obstetrical complications (p > 0.05). Our results indicated that the occurrence of fetal loss after LA should not be ignored. Caution, skillful operation, and thoroughly informed consent about the advantages and disadvantages of laparoscopy are necessary.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42021233150.

Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study

Background

Acute appendicitis is the most frequent non-obstetric surgical emergency during pregnancy. The benefits of laparoscopy during pregnancy are well known, but complications can occur, and these can affect both the mother and/or the foetus.We present results of laparoscopic surgical treatment of acute appendicitis in pregnant women, analysing the occurrence of adverse postoperative, obstetric and foetal outcomes and reviewing literature.

Materials and methods

Retrospective observational study on pregnant women with a preoperative diagnosis of acute appendicitis.

Results

n = 63, mean age 28.4 years, average gestational age of 17.7 weeks (3-30 weeks). 6.4 % exploratory laparoscopies, 92 % laparoscopic appendectomies and one right colectomy were performed. Conversion rate was 3.2 %. When symptoms begun within 48 hours prior to surgery, a perforated appendicitis was found in 11 %; whereas when the time from symptom onset to surgery was greater than or equal to 48 hours, it was evident in 31 % of the cases (p 0.008). The only independent variable associated with the presence of postoperative complications was symptom duration prior to surgery greater than or equal to 48 hours (OR 4.8; 95 % CI 1.1-16.2; p 0.04). Seven minor and 2 mayor postoperative complications were observed. Patients with complications spent, on average, twice as many days hospitalized (p < 0.001); and had 8 times more risk of preterm delivery (p 0.03). Obstetric complications were more frequent in pregnant women operated during the first trimester. Foetal mortality was 1.6 %.

Conclusion

Surgical morbidity of acute appendicitis in pregnant women is linked to the delay in the diagnosis and treatment of the inflammatory condition. Laparoscopic appendectomy during pregnancy is not exempt from postoperative, obstetric and foetal complications. It is necessary to standardize the definitions of "complication" in order to collate reliably the outcomes presented in the literature.

Safety of appendectomy during pregnancy in the totally laparoscopic age

Purpose

Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. In the argument of the optimal surgical approach to acute appendicitis in pregnancy, laparoscopy seems to be won with a similar complication rate and shorter postoperative recovery than open. We aimed to compare perioperative outcomes of appendectomy in pregnant and nonpregnant women in the totally laparoscopic age.

Methods

We retrospectively analyzed 556 nonincidental appendectomies performed in women (aged 18–45 years) between January 2014 and December 2018. To reduce the confounding effects, we used propensity score considering the variables age, American Society of Anesthesiologists physical status classification, and the operative finding; whether the appendicitis was simple or complicated. After propensity score matching, the outcomes of 15 pregnant women were compared with those of the 30 nonpregnant women.

Results

All the operations were performed with laparoscopy. Most of the pregnant cases were in their first and second trimester. The postoperative morbidity rate was significantly higher in the pregnant group before propensity score matching; however, the significance disappeared after matching. Operative outcomes and the parameters related to the postoperative recovery were not different between the two groups. Two patients in their first trimester decided to terminate the pregnancy after appendectomy. One patient in her second trimester experienced preterm labor which was resolved spontaneously. There was no other obstetric adverse outcome.

Conclusion

In the laparoscopy age, appendectomy during pregnancy is safe and not associated with a significantly increased risk of postoperative complication.

Laparoscopic Versus Open Appendectomy for Appendicitis in Pregnancy: Systematic Review and Meta-Analysis

OBJECTIVES

The clinical safety, efficacy and feasibility of laparoscopic appendectomy (LA) compared with open appendectomy (OA) in pregnancy are still controversial. Herein, we are aiming to compare the clinical outcomes of LA and OA in patients with acute appendicitis during their pregnancy.

MATERIALS AND METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and OA in pregnancy identifying using PubMed, Web of science, Embase, The Cochrane Library, Ovid and Scopus. Two independent reviewers extracted data on surgical complication, fetal loss, preterm delivery, hospital stay, Apgar score in both groups.

RESULTS

Twenty-seven studies with total of 6497 patients (4464 in open and 2031 in laparoscopic group) were included. LA was associated with lower rate of wound infection [odds risk (OR)=3.13, 95% confidence interval (CI): 1.77-5.56, P<0.0001] overall complications (OR=2.15, 95% CI: 1.47-3.14, P<0.0001) and shorter hospitalization (mean difference=0.72, 95% CI: 0.43-1.02, P<0.00001) compared with open group. LA was in a lower risk for 5-minute Apgar score (mean difference=0.09, 95% CI: 0.02-0.17, P=0.01) group than open group. No difference was found regarding preterm delivery between 2 groups. LA was associated with higher fetal loss (OR=0.57, 95% CI: 0.41-0.79, P=0.0007) compared with open surgery. However, laparoscopy was not associated with increased fetal loss after 2010 (OR=0.74, 95% CI: 0.44-1.24, P=0.26) compared with open group.

CONCLUSIONS

LA in pregnancy seems to be feasible with acceptable outcome, especially in patients with early and mid-trimester period, with sophisticated hands and experienced centers.

The diagnostic accuracy of ultrasound in the diagnosis of acute appendicitis in pregnancy

Objective: Clinically suspected appendicitis is the most common nonobstetric surgical problem encountered in pregnancy. The diagnosis of appendicitis is hampered by equivocal symptoms during pregnancy. Ultrasonography (US) remains, as a rule, the imaging test of choice for the diagnosis of clinically suspected appendicitis during pregnancy and other imaging tools such as computed tomography (CT) or magnetic resonance imaging (MRI) are usually avoided. We evaluated the accuracy of US in the diagnosis of appendicitis during pregnancy.Methods: The clinical and sonographic findings of all pregnant women (n = 90), who underwent appendectomy between January 2005 and December 2017 at our institution, were retrospectively reviewed, analyzed, and compared to the clinical and sonographic findings similarly obtained for a control group of nonpregnant women matched for age and date of surgery (±6 months). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonic findings were calculated and compared between groups as well as within the three pregnancy trimesters.Results: The mean age of the patients was 31.3 ± 0.4. Right lower quadrant pain was present in almost all patients (99%). The sole imaging modality used in our study cohort was US. Among nonpregnant controls, CT scan was primarily used on more occasions (53.3%) compared to US (45.6%). Nonpregnant women underwent significantly more laparoscopies compared to pregnant women (83.3 versus 45.6%, p < .001). The rate of negative appendectomy was higher in pregnant women (31.1 versus 10%, p = .002). Among pregnant women operated there was a higher rate of inconclusive or negative imaging (43.3 versus 11.1%, p < .001). The rate of perforated appendix at surgery was similar in both groups (6.7 and 4.4%, respectively, p = .75).Conclusions: Ultrasonography (US) is of mediocre accuracy for the diagnosis of acute appendicitis in pregnant patients beyond the first trimester of pregnancy. Thirty percent of pregnant women with suspected appendicitis are futilely operated. Given the low yield of US, a second-line imaging should be considered in cases of inconclusive US before surgery.

Pregnant patients requiring appendectomy: comparison between open and laparoscopic approaches in NY State

INTRODUCTION

Even though acute appendicitis is the most common general surgical condition encountered during pregnancy, the preferred approach to appendectomy in pregnant patients remains controversial. Current guidelines support laparoscopic appendectomy as the treatment of choice for pregnant women with appendicitis, regardless of trimester. However, recent published data suggests that the laparoscopic approach contributes to higher rates of fetal demise. Our study aims to compare laparoscopic and open appendectomy in pregnancy at a statewide population level.

METHODS

ICD-9 codes were used to extract 1006 pregnant patients undergoing appendectomy between 2005 and 2014 from the NY Statewide Planning and Research Cooperative System (SPARCS) database. Surgical outcomes (any complications, 30-day readmission rate, length of stay (LOS)) and obstetrical outcomes (antepartum hemorrhage, preterm delivery, cesarean section, sepsis, chorioamnionitis) were compared between open and laparoscopic appendectomy. Multivariable generalized linear regression models were used to compare different outcomes between two surgical approaches after adjusting for possible confounders.

RESULTS

The laparoscopic cohort (n = 547, 54.4%) had significantly shorter LOS than the open group (median ± IQR: 2.00 ± 2.00 days versus 3.00 ± 2.00 days, p value < 0.0001, ratio = 0.789, 95% CI 0.727-0.856). Patients with complicated appendicitis had longer LOS than those with simple appendicitis (p value < 0.0001, ratio = 1.660, 95% CI 1.501-1.835). Obstetrical outcomes (p value = 0.097, OR 1.254, 95% CI 0.961-1.638), 30-day non-delivery readmission (p value = 0.762, OR 1.117, 95% CI 0.538-2.319), and any complications (p value = 0.753, OR 0.924, 95% CI 0.564-1.517) were not statistically significant between the laparoscopic versus open appendectomy groups. Three cases of fetal demise occurred, all within the laparoscopic appendectomy group.

CONCLUSIONS

The laparoscopic approach resulted in a shorter LOS. Although fetal demise only occurred in the laparoscopic group, these results were not significant (p value = 0.255). Our large population-based study further supports current guidelines that laparoscopic appendectomy may offer benefits over open surgery for pregnant patients in any trimester due to reduced time in the hospital and fetal and maternal outcomes comparable to open appendectomy.

Laparoscopic appendectomy is safe and feasible in pregnant women during second trimester: A retrospective study in a top-level Chinese center

Acute appendicitis (AA) is the most common nonobstetric surgical emergency during pregnancy. According to the current guidelines and meta-analyses, traditional open appendectomy (OA) is still recommended for pregnant patients over laparoscopic appendectomy (LA), which might be associated with higher rates of fetal loss. Previous studies and experiences indicated that LA might be safe in the second trimester of pregnancy. The current study aimed to evaluate the safety and feasibility of LA in pregnant women during the second trimester.At our institution, a retrospective study was conducted with pregnant patients who underwent LA or OA during the second trimester between January 2016 and August 2018.A total of 48 patients were enrolled. Of them, 12 were managed with laparoscopy and 36 with the open approach. We found that the LA group had higher BMIs than the OA group (4.0 ± 4.3 vs 21.5 ± 2.9, P = .031). The financial results showed that the average daily medical costs for patients who underwent LA was higher than those who underwent OA (444 ± 107 US$ vs 340 ± 115 US$, P = .009), while the total cost of hospitalization was comparable between the 2 approaches. The perioperative and obstetric outcomes were comparable between LA and OA. In each group, only 1 patient had fetal loss. No "Yinao" was found in any of the patients in the LA group.In this study, with the proven advantages of the laparoscopic techniques, LA was found to be safe and feasible for pregnant women during the second trimester.

Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis

BACKGROUND

Recently, laparoscopic appendectomies (LAs) have been widely performed instead of open appendectomies (OAs) during pregnancy. However, concerns about the safety of LA during pregnancy remain. This systematic review and meta-analysis aimed to evaluate the current evidence relating to the safety of LA versus OA for suspected appendicitis during pregnancy.

METHODS

Comprehensive literature searches were conducted using the PubMed, EMBASE, and Cochrane Library databases to identify articles describing LA versus OA in pregnancy, without restrictions regarding the publication date. The primary endpoints were fetal loss and preterm delivery.

RESULTS

After screening 801 studies, 22 comparative cohort studies were included in the analysis, which involved 4694 women, of whom 905 underwent LAs and 3789 underwent OAs. Fetal loss was significantly higher among those who underwent LAs compared with those who underwent OAs, and the pooled odds ratio (OR) was 1.72 (95% confidence interval [CI]: 1.22-2.42) without heterogeneity. The sensitivity analysis showed that the effect size was influenced by one of the studies, because its removal resulted in there being no significant difference between LA and OA with respect to the risk of fetal loss (OR 1.163, 95% CI: 0.68-1.99; P = 0.581). A significant difference was not evident between LA and OA with respect to preterm delivery (OR 0.76, 95% CI: 0.51-1.15), a result that did not change following the sensitivity analysis. The patients who underwent LA had shorter hospital stays (mean difference - 1.01, 95% CI: -1.61--0.41) and a lower wound infection risk (OR 0.40, 95% CI: 0.21-0.76) compared with those who underwent OA.

CONCLUSION

It is not reasonable to conclude that LA in pregnant women might be associated with a greater risk of fetal loss. The difference between LA and OA with respect to preterm delivery was not significant.

Is the laparoscopic approach a safe choice for the management of acute appendicitis in pregnant women? A meta-analysis of observational studies

INTRODUCTION

Acute appendicitis is a common and serious situation during pregnancy, because of the increased risk of fetal loss and perforation in the third trimester, as well as a diagnostic difficulty. During recent years laparoscopic approach has been introduced to clinical practice with encouraging results. The purpose of this meta-analysis is to compare the surgical and obstetrical outcomes between laparoscopic and open appendectomy during pregnancy.

MATERIALS AND METHODS

MEDLINE, SCOPUS, Clinicaltrials.gov, CENTRAL and Google Scholar were searched for studies reporting on postoperative outcomes between laparoscopic and open appendectomy during pregnancy. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when high heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented.

RESULTS

Twenty-one studies that enrolled 6276 pregnant women are included in the present meta-analysis. Of these women, 1963 underwent laparoscopic appendectomy and 4313 underwent an open appendectomy. Women who underwent laparoscopic appendectomy demonstrated an increase in fetal loss risk, while neonates of women that underwent open appendectomy presented decreased Apgar score at five minutes after birth. All the rest outcomes were similar between the two groups. The time that each study took place seemed to affect the comparison of birth weight and postoperative hospital stay between the two groups.

CONCLUSION

Laparoscopic appendectomy seems to be a relatively safe therapeutic option in pregnancy when it is indicated. Thus, it should be implemented in clinical practice, always considering the experience of the surgeon in such procedures. Nevertheless, the need of new studies to enhance this statement remains crucial.

Safety of laparoscopic appendicectomy during pregnancy: a systematic review and meta-analysis

BACKGROUND

Acute appendicitis is the most common non-obstetric surgical presentation during pregnancy. There were concerns that laparoscopic appendicectomy increases the risk of foetal loss compared to an open approach. Therefore, with recent advances in perioperative care, it is likely the risk has changed. Here, we performed an updated meta-analysis assessing the safety of laparoscopic appendicectomy in pregnant women.

METHODS

A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was undertaken between 2000 and 2017 on Ovid Medline and Embase. The primary outcome measures were foetal loss and preterm delivery, whereas secondary outcome measures were operative time and hospital length of stay. A random-effect model was performed to pool odds ratio (OR) and standardized mean difference (SMD).

RESULTS

Seventeen observational studies were included, with 1886 patients in the laparoscopic and 4261 patients in the open group. Comparing laparoscopic versus open appendicectomy, there were 54 (5.96%) and 136 (3.73%) foetal losses, respectively. However, preterm delivery was much higher in the open approach (8.99%) compared to laparoscopic approach (2.84%). Pooled OR for foetal loss was 1.84 (95% confidence interval (CI) 1.31-2.58, P < 0.001), whereas OR for preterm delivery was 0.39 (95% CI 0.27-0.55, P < 0.001). There was no significant difference between both approaches for operative time (SMD -0.07; 95% CI -0.43 to 0.30, P = 0.71) or hospital length of stay (SMD -0.34; 95% CI -0.83 to 0.16, P = 0.18).

CONCLUSION

In a pooled analysis of level III evidence, laparoscopic appendicectomy posed a higher risk of foetal loss but lower risk of preterm delivery. Caution and informed consent are crucial when offering a laparoscopic approach.

Safety of Laparoscopic Surgery for Benign Diseases during Pregnancy: A Nationwide Retrospective Cohort Study

STUDY OBJECTIVE

To compare fetal, maternal, and operative outcomes of laparoscopic surgery versus laparotomy for major benign diseases including appendicitis, cholecystitis, adnexal masses, and uterine myoma during pregnancy.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

The Diagnosis Procedure Combination database, a national inpatient database for acute care inpatients in Japan.

PATIENTS

Eligible patients (n = 6018) underwent abdominal surgery (4047 laparotomy and 1971 laparoscopy patients) from July 2010 through March 2016.

INTERVENTIONS

The 2 groups were compared using propensity score matching analysis.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was fetal adverse events, including abortion or stillbirth within 7 days after surgery and premature delivery during hospitalization. Secondary outcomes were operative time, blood transfusion, and length of hospital stay after surgery. Propensity score matching created 740 pairs. Significant difference was observed in the primary outcome between propensity score-matched patients in the laparotomy versus laparoscopy group (1.8% vs .41%, respectively; risk difference, -1.4%; 95% confidence interval, -2.4 to -.30; p = .01). Compared with the laparotomy group, the laparoscopy group had a significantly lower incidence of blood transfusion (2.3% vs .41%, p = .002), shorter operative time (115 vs 95 minutes, p <.001), and shorter hospital stay (9.2 vs 5.9 days, p <.001).

CONCLUSION

Our current study using propensity score matching suggests the advantages of laparoscopic surgery for benign diseases compared with laparotomy because laparoscopic surgery had advantages in short-term fetal adverse events, incidence of blood transfusion, operative time, and hospital stay.

Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis

OBJECTIVES

Acute appendicitis is the most prevalent cause of non-obstetrical surgical disease during pregnancy. There is no consensus on the optimal surgical management of acute appendicitis in pregnancy. Our aim is to identify surgical and obstetrical outcomes of laparoscopic (LA) and open approach (OA) in pregnant patients with acute appendicitis.

STUDY DESIGN

Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases were searched for articles published up to May 2017, along with the references of all articles. Prospective and retrospective trials reporting outcomes among pregnant women undergoing laparoscopic and open appendectomy were included. Of the 493 records screened, 20 were eligible for meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Statistical meta-analysis was performed using the RevMan 5.3 software.

RESULTS

A total of 6210 pregnant women from twenty studies were included in meta-analysis. Laparoscopic appendectomy was associated with significantly lower overall complication rates and shorter hospital stays (1835 patients OR 0.48 95% CI 0.29, 0.80 p = 0.005). While the open appendectomy group showed prolongation of gestational age for term deliveries, laparoscopic appendectomy patients had higher rates of fetal loss (543 patients MD -0.46 weeks 95% CI-0.87 to -0.04, p = 0.03 and 4867 patients OR 1.82 95% CI 1.30 to 2.57, p = 0.0006, respectively).

CONCLUSIONS

Current literature remains inconclusive on the optimal approach of appendectomy in pregnant women. Further larger-volume studies are needed in order to elucidate the critical effect of laparoscopic appendectomy on fetal loss rates.

Risk Factors and Risk Stratification for Adverse Obstetrical Outcomes After Appendectomy or Cholecystectomy During Pregnancy

Importance

Identification of risk factors for adverse obstetrical outcomes after appendectomy and cholecystectomy during pregnancy is necessary for evidence-based risk reduction and adequate patient counseling.

Objectives

To identify risk factors for adverse obstetrical outcomes after appendectomy and cholecystectomy during pregnancy and stratify the risk of such outcomes.

Design, Setting, and Participants

A cohort study was conducted using the Nationwide Inpatient Sample, a nationally representative sample of patients discharged from community hospitals in the United States, from January 1, 2003, to December 31, 2012. Multivariable analysis of risk factors for adverse obstetric outcomes was performed for 19 926 women undergoing appendectomy or cholecystectomy during pregnancy and a scoring system for such risk factors was developed. Data analysis was conducted from January 1, 2015, to July 31, 2016.

Main Outcomes and Measures

A composite measure including 7 adverse obstetrical outcomes throughout pregnancy and occurring before hospital discharge.

Results

Of the 19 926 women (mean [SD] age, 26 [6] years) in the study, 1018 adverse obstetrical events were recorded in 953 pregnant women (4.8%). The 3 most frequent adverse events were preterm delivery (360 [35.4%]), preterm labor without preterm delivery (269 [26.4%]), and miscarriage (262 [25.7%]). The risk factors associated most strongly with an adverse obstetrical outcome included cervical incompetence (adjusted odds ratio, 24.29; 95% CI, 7.48-78.81), preterm labor during current pregnancy (adjusted odds ratio, 18.34; 95% CI, 4.95-67.96), vaginitis or vulvovaginitis (adjusted odds ratio, 5.17; 95% CI, 2.19-12.23), and sepsis (adjusted odds ratio, 3.39; 95% CI, 2.08-5.51). A scoring system based on statistically significant variables classified the study sample into 3 risk groups corresponding to predicted probabilities of adverse obstetrical outcomes of 2.5% (≤4 points), 8.2% (5-8 points), and 21.8% (≥9 points).

Conclusions and Relevance

Approximately 5% of women experience adverse obstetrical outcomes after appendectomy or cholecystectomy during pregnancy. The major risk factors for such outcomes are cervical incompetence, preterm labor during current pregnancy, vaginitis or vulvovaginitis, and sepsis.

Abdominal surgery in pregnancy--an interdisciplinary challenge

BACKGROUND

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

METHOD

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

RESULTS

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

CONCLUSION

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence

Surgical intervention for acute appendicitis during pregnancy carries significant risk to both mother and foetus. The safety of Laparoscopic Appendicectomy in pregnancy has been a matter of debate among clinicians. We have critically reviewed the available published evidence in regards with this debate.

CONCLUSION

There is no strong current evidence as to the preferred modality of appendicectomy; open or laparoscopic, during pregnancy from the prospect of foetal or maternal safety. However, low grade evidence shows that laparoscopic appendicectomy during pregnancy might be associated with higher rates of foetal loss.

Hemodynamic effect and safety of intermittent sequential pneumatic compression leg sleeves in patients with congestive heart failure

BACKGROUND

Pneumatic leg sleeves are widely used after prolonged operations for prevention of venous stasis. In healthy volunteers they increase cardiac function. We evaluated the hemodynamic effects and safety of intermittent sequential pneumatic compression (ISPC) leg sleeves in patients with chronic congestive heart failure (CHF).

METHODS AND RESULTS

We studied 19 patients with systolic left ventricular dysfunction and CHF. ISPC leg sleeves, each with 10 air cells, were operated by a computerized compressor, exerting 2 cycles/min. Hemodynamic and echocardiographic parameters were measured before, during, and after ISPC activation. The baseline mean left ventricular ejection fraction was 29 ± 9.2%, median 32%, range 10%-40%. Cardiac output (from 4.26 to 4.83 L/min; P = .008) and stroke volume (from 56.1 to 63.5 mL; P = .029) increased significantly after ISPC activation, without a reciprocal increase in heart rate, and declined after sleeve deactivation. Systemic vascular resistance (SVR) decreased significantly (from 1,520 to 1,216 dyne-s/cm5; P = .0005), and remained lower than the baseline level throughout the study. There was no detrimental effect on diastolic function and no adverse clinical events, despite increased pulmonary venous return.

CONCLUSIONS

ISPC leg sleeves in patients with chronic CHF do not exacerbate symptoms and transiently improve cardiac output through an increase in stroke volume and a reduction in SVR.

Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women

BACKGROUND

Despite the initial absolute or relative contraindication of laparoscopic surgery during pregnancy, in the last decade, laparoscopic appendectomy (LA) has been performed in pregnant women. But few studies compare the outcomes of LA compared with open appendectomy (OA). We investigated clinical outcomes to evaluate the safety and efficacy of LA compared with OA in pregnant women.

METHODS

We recruited consecutive pregnant patients with a diagnosis of acute appendicitis who were undergoing LA or OA between May 2007 and August 2011 into the study.

RESULTS

Sixty-one patients (22 LA and 39 OA) enrolled in our study. There were no significant differences in duration of surgery, postoperative complication rate and obstetric and fetal outcomes, including incidence of preterm labour, delivery type, gestation age at delivery, birth weight and APGAR scores between the 2 groups. However, the LA group had shorter time to first flatus (2.4 ± 0.4 d v. 4.0 ± 1.7 d, p = 0.034), earlier time to oral intake (2.3 ± 1.6 d v. 4.1 ± 1.9 d, p = 0.023) and shorter postoperative hospital stay (4.2 ± 2.9 d v. 6.9 ± 3.7 d, p = 0.043) than the OA group.

CONCLUSION

Laparoscopic appendectomy is a clinically safe and effective procedure in all trimesters of pregnancy and should be considered as a standard treatment alternative to OA. Further evaluation including prospective randomized clinical trials comparing LA with OA are needed to confirm our results.

Appendectomy during pregnancy--is pregnancy outcome depending by operation technique?

OBJECTIVE

To compare perioperative and pregnancy outcome between women undergoing laparoscopic appendectomy and those undergoing open appendectomy during pregnancy for presumed acute appendicitis.

METHODS

A retrospective cohort study of all women undergoing appendectomy during pregnancy in a tertiary referral medical center from 2000 to 2009. Outcome was compared between those undergoing laparoscopic appendectomy and those undergoing open appendectomy.

RESULTS

Overall, 83,510 deliveries occurred during the study period, 85 (0.10%) were eligible for the study group. Of these, 26 (31%) had a laparoscopic appendectomy and 59 (69%) had an open appendectomy. No significant difference was found in the general, delivery and neonatal outcome characteristics between the two groups. There was a significant difference in the mean gestational age at surgery between laparoscopic appendectomy and the open appendectomy groups (14.6 versus 19.3 weeks respectively, p = 0.009). Post-operative complications (fever >38.0 °C or the presence of uterine contractions) rate was higher in the open appendectomy compared to the laparoscopic appendectomy group (25.5% versus 3.8%, respectively, p = 0.009).

CONCLUSION

Laparoscopic appendectomy appears to be a safe procedure for presumed acute appendicitis during pregnancy with less post-operative complications as compared to open appendectomy.

Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy

BACKGROUND

Laparoscopic appendicectomy has gained wide acceptance as an alternative to open appendicectomy during pregnancy. However, data regarding the safety and optimal surgical approach to appendicitis in pregnancy are still controversial.

METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and open appendicectomy in pregnancy identified using PubMed and Scopus search engines from January 1990 to July 2011. Two reviewers independently extracted data on fetal loss, preterm delivery, wound infection, duration of operation, hospital stay, Apgar score and birth weight between laparoscopic and open appendicectomy groups.

RESULTS

Eleven studies with a total of 3415 women (599 in laparoscopic and 2816 in open group) were included in the analysis. Fetal loss was statistically significantly worse in those who underwent laparoscopy compared with open appendicectomy; the pooled relative risk (RR) was 1·91 (95 per cent confidence interval (c.i.) 1·31 to 2·77) without heterogeneity. The pooled RR for preterm labour was 1·44 (0·68 to 3·06), but this risk was not statistically significant. The mean difference in length of hospital stay was - 0·49 (-1·76 to - 0·78) days, but this was not clinically significant. No significant difference was found for wound infection, birth weight, duration of operation or Apgar score.

CONCLUSION

The available low-grade evidence suggests that laparoscopic appendicectomy in pregnant women might be associated with a greater risk of fetal loss.

Safety and Clinical Efficacy of Laparoscopic Appendectomy for Pregnant Women with Acute Appendicitis

Introduction: The aim of this study was to investigate the clinical efficacy and safety of laparoscopic appendectomy (LA) during pregnancy by comparing the operative and obstetric outcomes of patients who during pregnancy underwent LA performed by an expert gynaecologic laparoscopist (LA group) with those patients who underwent an open appendectomy (OA) by a general surgeon (OA group). Materials and Methods: In this retrospective study, we evaluated all patients consecutively who had undergone appendectomy for acute appendicitis during pregnancy from January 2000 to December 2010. Twenty-eight patients underwent OA and 15 were treated by LA. We reviewed the clinical charts and analysed the data for each patient’s age, parity, body mass index, gestational age at appendectomy, type of appendectomy, operating time, haemoglobin change, hospital stay, histopathological results, postoperative analgesics, complications, and obstetric outcomes. Results: There were no significant differences between the OA and LA groups in terms of clinical characteristics, hospital stay, haemoglobin change, return of bowel activity, complication rates, gestational age at delivery, and birth weight. However, there were significantly shorter operating time and less usage of postoperative analgesics in LA group. Conclusion: LA performed by an expert gynaecologist can be a safe and effective method for treating acute appendicitis during the first and second trimester of pregnancy. Key words: Laparoscopic appendectomy, Appendicitis, Pregnant women

Appendectomy during pregnancy: follow-up of progeny

BACKGROUND

The incidence of appendicitis in pregnant patients is 0.04% to 0.20%, making it the most common nonobstetric surgical procedure in pregnancy. This study examines whether an appendectomy during any stage of pregnancy affects future development of motor, sensory, and social skills of the progeny.

STUDY DESIGN

A prospective survey was administered to women who underwent an appendectomy during pregnancy at Mount Sinai Hospital from 2000 to 2009. The survey, which ranged from 1 to 9 years postpartum, consisted of questions about motor, sensory, and social development of their progeny, based on established pediatric milestones. Data were collected from the medical records of mother and child. Additional follow-up was gathered from outpatient and emergency room records.

RESULTS

Fifty-two pregnant patients underwent an appendectomy during our study period. All pregnancies continued to full term with the exception of one fetal death due to extreme prematurity. Twenty-nine patients completed the follow-up survey, making the yield response rate 55.8%. There were 7 (26.9%), 14 (48.3%), and 8 (27.6%) appendectomies in the first, second, and third trimesters, respectively. Mean follow-up time was 47.2 months (range 13 to 117 months) after delivery. None of the children exhibited any developmental delay by their third year of life. Timing of the surgery (trimester) had no effect on child development.

CONCLUSIONS

Appendectomy during pregnancy is not associated with developmental delays in children, regardless of which trimester the procedure was performed. All children in this study had normal motor, sensory, and social development by 3 years of age.

Laparoscopy: a safe approach to appendicitis during pregnancy

BACKGROUND

The aim of this study was to evaluate laparoscopic versus open surgery for suspected appendicitis during pregnancy.

METHODS

A hospital-based retrospective review of 65 consecutive pregnant patients who underwent surgery for suspected appendicitis from 1999 to 2008 was performed. Significance was determined by Pearson's chi(2) test, Fisher's exact test, Mann-Whitney test, and Kruskal-Wallis test.

RESULTS

Of the 65 patients, 48 cases were laparoscopic and 17 open. Use of the laparoscopic versus open approach was significantly increased in the first (100% vs. 0%, p < 0.001) and second trimesters (73% vs. 27%, p < 0.001). The open approach was used more frequently in third-trimester patients (71% vs. 29%, p = NS). Significance was demonstrated in mean length of hospital stay in the laparoscopic versus open group (3.4 vs. 4.2 days, p = 0.001). No maternal mortalities occurred. Follow-up of fetal outcome was achieved in 89% of patients. No difference was demonstrated in fetal loss (1 in laparoscopic group), APGAR score, birth weight, and preterm delivery rate by operative approach. Adverse outcome was associated with maternal temperature greater than 38 degrees C, leukocytosis greater than 16 x 10(9)/l, or more than 48 h between onset of symptoms and emergency room presentation.

CONCLUSIONS

This article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks.

Laparoscopic versus open appendicectomy in pregnancy: a systematic review

BACKGROUND

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnant women. The benefits of a laparoscopic over an open approach to appendicectomy are well established in the non-pregnant population. Data on the optimal surgical approach to acute appendicitis in pregnant women are conflicting.

METHODS

A systematic review of reported cases of laparoscopic appendicectomy (LA) in pregnancy over the period 1990 to 2007. Twenty-eight articles documenting 637 cases of LA in pregnancy were included. Data on pregnancy outcome, patient characteristics, operative technique and peri-operative complications were analysed.

RESULTS

The rate of fetal loss following LA in pregnancy approaches 6% and is significantly higher than that following open appendicectomy. Fetal loss was highest in cases of complicated appendicitis. Incidence of preterm delivery appears lower in the LA group although this complication is likely to be under-reported in a significant proportion of cases. Trimester at the time of LA does not appear to influence complication rates. The negative appendicectomy rate in this series was 27%, which is higher than in the non-pregnant population. Complication rates following LA with negative appendicitis are as high as with simple appendicitis. Rates of entry-related complications were 2.8% in the Veress needle group and 0% in the Hasson open entry group. The overall rate of conversion to laparotomy was 1%. No difference was found in the preterm delivery rate between women who received prophylactic tocolysis and those who were not tocolysed.

CONCLUSIONS

Laparoscopic appendicectomy in pregnancy is associated with a low rate of intra-operative complications in all trimesters. However, LA in pregnancy is associated with a significantly higher rate of fetal loss compared to open appendicectomy. Rates of preterm delivery appear similar or slightly better following a laparoscopic approach. Open appendicectomy would appear to be the safer option for pregnant women for whom surgical intervention is indicated.

Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss

BACKGROUND

The preoperative diagnosis of acute appendicitis is often inaccurate in pregnant women, and complicated appendicitis is associated with a high rate of fetal loss. The study objective was to evaluate rates of fetal loss and early delivery in pregnant patients undergoing appendectomy, using a large population-based database.

STUDY DESIGN

Using the California Inpatient File, we retrospectively analyzed all women undergoing appendectomy between 1995 and 2002 for pregnancy, diagnosis, operative technique, fetal loss, and early delivery during the same hospitalization as appendectomy.

RESULTS

Of 94,789 women who underwent appendectomy, 3,133 were pregnant. Complicated appendicitis was found in 30% of pregnant women and 29% of nonpregnant women (p=NS). The rate of negative appendectomy was considerably higher in pregnant compared with nonpregnant women (23% versus 18%, p < 0.05). Rates of fetal loss and early delivery were considerably higher in women with complex appendicitis (6% and 11% respectively; p < 0.05) in comparison with negative (4% and 10%) and simple (2% and 4%) appendicitis. Using multivariate logistic regression, complicated and negative appendicitis (odds ratio [OR] 2.69 and 1.88 respectively, compared with simple) remained major positive predictors of fetal loss. Also, laparoscopy was associated with a higher rate of fetal loss compared with open appendectomy (odds ratio=2.31).

CONCLUSIONS

The current approach to possible acute appendicitis in pregnant women puts 23% at risk for fetal loss, even though they have a normal appendix. These data indicate that reducing fetal loss in pregnant women suspected of having acute appendicitis will require more accurate diagnosis to avoid unnecessary operation.

Safety and efficacy of laparoscopic surgery in pregnancy: experience of a single institution

We report all the procedures performed in pregnant patients in our institute. There were 2 cases of laparoscopic mesh repair (for posterolateral diaphragmatic Bochdalek hernia and laparoscopic Heller cardiomyotomy) and 1 laparoscopic cystectomy for torsion of an ovarian cyst; 7 laparoscopic appendectomies (6 for acute appendicitis and 1 for perforated appendix); and 9 laparoscopic cholecystectomies (8 for acute cholecystitis and 1 for gallbladder empyema). All these patients were in their second trimester of pregnancy. All the laparoscopic procedures were successful: there was no mortality, morbidity, or conversions. There were no complications for either mother or child related to general anesthesia. The changes in physiology of the pregnant patient have to be adequately addressed and proper precautions taken to ensure safety. The second trimester is the ideal time to do laparoscopic surgery, though procedures have been performed in all trimesters. Our initial experience is satisfactory, although more data are essential to standardize laparoscopic procedures in pregnancy. We conclude that laparoscopic surgery is proving to be as safe as open surgery in pregnancy.

Laparoscopic appendectomy in pregnancy

BACKGROUND

Laparoscopic appendectomy (LA) is a safe, effective, and beneficial procedure for the treatment of acute appendicitis. However, limited data are available regarding the safety and feasibility of LA during pregnancy.

METHODS

Between January 2001 and August 2004, 1235 patients with clinically suspected appendicitis underwent laparoscopic surgery at our hospital. Eleven patients (0.9%) were pregnant women (mean age, 25 years; age range, 19-37 years; range of gestational age, 4-30 weeks). Clinical data collected retrospectively included demographic information; preoperative, procedural, and postoperative information; and outcome of the pregnancy.

RESULTS

All 11 pregnant women underwent laparoscopic surgery without need of conversion. Ten patients underwent LA and were found to have acute appendicitis on histologic analysis. One patient had torsion of the right fallopian tube and a healthy-looking appendix; she underwent detorsion of the fallopian tube and incidental appendectomy. Mean operative time was 50.5 minutes (range, 20-135 minutes). Length of postoperative hospital stay averaged 4.2 days (range, 1-11 days). One patient had a surgical wound infection, which was managed conservatively. Mean follow-up period was 14 months (range, 2-46 months). Seven pregnant women delivered healthy term infants, 2 had planned abortions, and 1 experienced fetal loss due to uterine infection and premature contractions 1 month after LA. Another patient had normal results at prenatal examination.

CONCLUSION

Our data support the accumulating evidence that LA is a safe and feasible procedure for the treatment of acute appendicitis in all trimesters of pregnancy. Close maternal and fetal monitoring is essential during and after the operation.

Appendectomy during Early Pregnancy: What is the Preferred Surgical Approach?

Appendectomy is the most common nongynecologic surgery performed during pregnancy. Although many surgeons offer laparoscopic appendectomy (LA) as an alternative to open appendectomy (OA) during early pregnancy, few studies have compared the effects of LA versus OA on the fetus and the outcome of the pregnancy. Twenty-eight consecutive females undergoing appendectomy for presumed appendicitis in the first two trimesters of pregnancy between January 2000 and December 2002 were identified retrospectively. Demographic information, weeks of pregnancy at operation, and surgical approach (LA or OA) were recorded. Study outcomes included operative and pregnancy-related complications, length of hospitalization, final outcome of pregnancy, and infant birth weight. Seventeen LA and 11 OA were performed. There were no significant differences in surgical or obstetrical complications, length of hospitalization, or birth weight between the two groups. Two cases of postoperative fetal demise were noted in the LA group. Although not statistically significant, the two fetal losses in the laparoscopic group are concerning. The current study did not demonstrate any advantages to the laparoscopic approach. Pending further investigation, the open approach may be preferred for appendectomy in pregnant patients during the first two trimesters of pregnancy.

Pregnancy outcome following non-obstetric surgical intervention

OBJECTIVE

To evaluate the effects of non-obstetric surgical procedures on maternal and fetal outcome.

METHODS

A systematic review of all English language literature.

RESULTS

Fifty-four papers met the inclusion criteria. The overall number of patients reported was 12,452. Reported maternal death was rare at .006%. The miscarriage rate was 5.8%; however, this number is difficult to interpret since matched controls were not available. The rate of elective termination of pregnancy following non-obstetric surgery was 1.3%. The rate of premature labor induced by non-obstetric surgical intervention was 3.5% and this was noted specifically following appendectomy versus other types of interventions (P<.001). A total of 2.5% of pregnancies resulted in fetal loss. The prematurity rate was 8.2%. The rate of major birth defects among women who underwent non-obstetric surgical intervention in the first trimester was 3.9%. Sub-analysis of papers reporting on appendectomy during pregnancy revealed a high rate (4.6%) of surgery-induced labor. Fetal loss associated with appendectomy was 2.6%; however, this rate was increased when peritonitis was present (10.9%).

CONCLUSIONS

Modern surgical and anesthesia techniques appear to diminish the rate of maternal death. Surgery in the first trimester does not appear to increase major birth defects and should not be delayed when indicated. Acute appendicitis with peritonitis is associated with higher risk to the mother and fetus.