Laparoscopic Versus Open Appendectomy for Acute Appendicitis in Children: a Nationwide Retrospective Study on Postoperative Outcomes

Laparoscopic versus open appendicectomy performed by adult general surgeons in pre-teenage years children: a single-centre experience

INTRODUCTION

The utilisation of laparoscopic appendicectomy (LA) in children remains contentious despite the well-recognised advantages of laparoscopic surgery. The purpose of this study was to compare intraoperative and postoperative outcomes in LA and open appendicectomy (OA) when performed by adult general surgeons outside specialist paediatric practice in younger children.

METHODS

A retrospective review of all patients under the age of 13 who underwent LA for suspected appendicitis over a two-year period was conducted. These were case-matched with an equivalent number of patients who underwent OA during the same period. Intraoperative and postoperative outcomes were compared.

RESULTS

Fifty-one patients underwent LA during the study period. Patient demographics were statistically equivalent with the OA cohort. A statistically significant longer median operating time (58 vs 49min) was noted in the LA group, but intraoperative outcomes were otherwise comparable. LA, when compared with OA, was associated with a significant improvement in postoperative length of stay (2 vs 3 days, p < 0.001), postoperative complication rate (0% vs 6%, p = 0.01), negative appendicectomy rate (3.9% vs 17.6%, p < 0.001) and 30-day readmission rate (0% vs 5.9%, p = 0.03). No patients in the LA group required conversion to open surgery.

CONCLUSION

LA can be safely delivered by adult general surgeons to younger paediatric populations outside the setting of paediatric specialist practice, with statistically significant improvements in postoperative outcomes noted when compared with OA. These findings are of importance in the current healthcare context where adult general surgeons continue to perform the majority of paediatric appendicectomies.

Complication analysis in acute appendicitis, results from an international multicenter study

PURPOSE

Acute appendicitis (AA) is frequent, its diagnosis is challenging, and the surgical intervention is not risk free. An accurate diagnosis will reduce unnecessary surgeries and associated risks. This study aimed to analyze the rate of appendectomies' postoperative complications.

METHODS

Multicenter, prospective, observational study conducted at three large hospitals (Pisa University Hospital, Italy; Henri Mondor University Hospital, Paris, France; and Valencia University Hospital, Spain).

RESULTS

A total of 3070 patients with a median age of 28 years (IQR 20-43) were enrolled. 1403 (45.7%) were females. Eight hundred ninety patients (29%) did not undergo preoperative imaging. Ultrasound and CT scans were performed in 1465 (47.7%) and 715 (23.3%) patients. Patients requiring CT scan were older [median 38 (IQR 26-53) vs. no imaging median 24 (IQR 16-35), Ultrasound median 28 (IQR 20-41); p < 0.0001]. Laparoscopic appendectomy was performed in 58.6%. Complications developed in 1279 (41.7%) patients: Clavien-Dindo grades I-II in 1126 (33.9%); Clavien-Dindo grades III-IV in 146 (5.2%). Overall mortality was 0.2%. Following resection of a normal appendix, 15% experienced major complications (Clavien-Dindo grades IIIb and above). Multivariable analysis revealed that age, Charlson comorbidity index, histopathology, and Alvarado score over 7 were associated with a higher risk of Clavien-Dindo complication grades IIIa and higher.

CONCLUSION

Appendectomy may be associated with serious postoperative complications. Complications were associated with older age, Charlson comorbidity index, histopathology, and high Alvarado scores. The definition of accurate diagnostic and therapeutic pathways may improve results. The association between clinical scores and radiology is recommended.

The Outcome of Laparoscopic Versus Open Appendectomy in Childhood

BACKGROUND

Appendectomy in children is performed either lapa - roscopically (LA) or by open surgery (OA). We studied whether, and how, the outcome is affected by the technique used and by the intraoperative conversion of LA to OA.

METHODS

We analyzed routine data from children and adolescents in three age groups (1-5 years, 6-12 years, and 13-17 years) who were insured by the AOK statutory health insurance carrier in Germany and who underwent appendectomy in the period 2017-2019. General surgical complications and reoperations within 90 days were assessed with relevant indicators. Associations between the surgical technique and these indicators were studied with logistic regression.

RESULTS

Of the 21 541 patients included in the study, general surgical complications were observed in 2.1% and reoperations in 1.8% overall. Broken down by age group, the corresponding figures were 5.4% and 4.4% (age 1 to 5), 2.5% and 1.8% (age 6 to 12), and 1.5% and 1.6% (age 13 to 17). The main risk factors for complications and reoperations were acute complicated appendicitis and conversion from LA to OA. Regression analysis revealed similar outcomes with OA compared to LA in the 1-to-5 age group, (odds ratios and 95% confidence intervals: 1.1 [0.6; 2.1] for general surgical complications and 1.5 [0.8; 2.7] for reoperations), but worse outcomes with OA in the other two age groups (age 6 to 12: 1.9 [1.2; 2.9] and 2.1 [1.5; 2.9]; age 13 to 17: 1.7 [1.0; 2.9] and 2.2 [1.4; 3.6]). When conversions were assigned to the LA group, the odds ratio (OA compared to LA) for reoperation across all age groups was 3.5 [2.8; 4.4] in patients with acute uncomplicated appendicitis and 4.2 [3.4; 5.3] in patients with complicated appendicitis. Complicated appendicitis also increased the rate of general surgical complications and the length of stay in hospital.

CONCLUSION

Among children in the two older age groups, LA was followed by fewer general surgical complications and reoperations than OA. These differences were less pronounced when conversions were counted as belonging to the LA group. Children aged 1-5 appear to benefit the least from the lapa - roscopic technique.

Clinical course in children with equivocal appendicitis on computed tomography: a retrospective cohort study

Purpose

Appendectomy is one of the most common surgeries in children. Although various radiological examinations are performed, they do not always reveal a definitive diagnosis of appendicitis. This study aimed to investigate the clinical course of equivocal appendicitis, identify the factors associated with appendectomy, and suggest appropriate management for these patients.

Methods

Patients younger than 19 years who visited Seoul National University Bundang Hospital with a differential diagnosis of appendicitis from January 2013 to December 2017 were included. All participants conducted 'appendiceal CT' with a scoring scale of 1-5. The higher the score, the higher the likelihood of a radiologic diagnosis of appendicitis. We defined the appendicitis CT score of 2-4 as equivocal appendicitis (n = 143). Medical records were reviewed retrospectively for demographics, further examination as abdominal ultrasonography, and appendectomy status (yes or no). The mean follow-up period was 15.6 ± 71 days.

Results

Equivocal appendicitis accounted for 16.7%. Additional ultrasonography test was performed in 24.5% (35 of 143). In total, 34 patients (23.8%) underwent appendectomy. Among the patients with appendiceal CT scores 2, 3, and 4, 4.9%, 50.0%, and 87.5% underwent appendectomy, respectively. Higher WBC count, higher appendicitis CT score, and readmission were significantly associated with appendectomy in patients with equivocal appendicitis.

Conclusion

Higher appendicitis CT score and WBC level were positively associated with appendectomy. Careful observation can be a treatment option in appendicitis CT score 2 or 3 groups. Appendectomy is the first-line treatment for patients with appendicitis score 4. Additional ultrasonography test is advisable to determine treatment modality for equivocal appendicitis.

Clinical outcomes of locking polymeric clip for laparoscopic appendectomy in patients with appendicitis: a retrospective comparison with loop ligature

Purpose

This study aimed to compare the clinical outcomes of laparoscopic appendectomy (LA) according to the method of appendiceal stump closure.

Methods

Patients who underwent LA for appendicitis between 2010 and 2020 were retrospectively reviewed. Patients were classified into locking polymeric clip (LPC) and loop ligature (LL) groups. Clinical outcomes were compared between the groups.

Results

LPC and LL were used in 188 (56.6%) and 144 patients (43.4%), respectively for appendiceal stump closure. No significant differences were observed in sex, age, comorbidities, and the severity of appendicitis between the groups. The median operative time was shorter in the LPC group than in the LL group (64.5 minutes vs. 71.5 minutes, P=0.027). The median hospital stay was longer in the LL group than in the LPC group (4 days vs. 3 days, P=0.020). Postoperative incidences of intraabdominal abscess and ileus were higher in the LL group than in the LPC group (4.2% vs. 1.1%, P=0.082 and 2.8% vs. 0%, P=0.035; respectively). The readmission rate was higher in the LL group than that in the LPC group (6.3% vs. 1.1%, P=0.012).

Conclusion

Using LPC for appendiceal stump closure during LA for appendicitis was associated with lower postoperative complication rate, shorter operative time, and shorter hospital stay compared to the use of LL. Operative time above 60 minutes and the use of LL were identified as independent risk factors for postoperative complications in LA. Therefore, LPC could be considered a more favorable closure method than LL during LA for appendicitis.

Hospital market competition and health technology diffusion: An empirical study of laparoscopic appendectomy in China

The evidence about the role of hospital market competition on health technology diffusion in developing countries is scarce. In this study, we examined the association between hospital market competition and the diffusion of health technologies in China's healthcare system. Laparoscopic appendectomy, a minimally invasive surgery for patients with acute appendicitis, was selected as a representative of cost-effective health technology. The inpatient discharge dataset linked to the annually hospital administrative data and to the demographic and socioeconomic data were used. A total of 261,922 patients who were diagnosed with acute appendicitis and had received either open appendectomy or laparoscopic appendectomy at 820 hospitals in Sichuan, China between 2017 and 2019 were included in our analyses. Our outcome measure was the use of laparoscopic appendectomy during hospitalization. We accounted for the endogeneity of hospital competition measures using the Herfindahl-Hirschman Index calculated by predicted patient flows. Controlling for the observable patient, hospital and region characteristics, multivariate logistic regression was performed to model the association between hospital competition and the diffusion of laparoscopic appendectomy. The rapid diffusion of laparoscopic appendectomy over the study period and the substantial variation in use across regions and hospitals were observed. The regression results showed that laparoscopic appendectomy diffused faster in the markets where hospitals faced more competition. Our findings suggest that the diffusion of laparoscopic appendectomy is not only driven by medical factors but also nonmedical factors like hospital market competition. Our study provides new evidence on the association between market structure and technology diffusion in China's hospital market and offers the implications of appropriate technologies diffusion in health for policymakers.

Use of Spinal Anesthesia in Pediatric Laparoscopic Appendectomies: Case Series

BACKGROUND

Owing to the widespread use of general anesthesia, administration of spinal anesthesia in pediatric patients is not widely practiced. Yet there is ample positive evidence demonstrating its safety, effectiveness, and success.

OBJECTIVE

The objective of this study is to compare postoperative patient comfort, length of hospital stay, and cost-effectiveness of pediatric laparoscopic appendectomies performed under spinal and general anesthesia with the usual standard-of-care procedures employed in the hospital.

METHODS

This is a case series of 77 consecutive pediatric laparoscopic appendectomies (involving 5-8-year-old children) that took place in a hospital in Chittagong, Bangladesh, in 2019. A total of 40 patients underwent spinal anesthesia and 37 patients underwent general anesthesia. Variables such as surgery and operation theater times, pain score, incidence of postsurgery vomiting, analgesic usage, discharge times, and hospital costs were recorded. Statistical analysis was used to analyze the data as a function of anesthesia type.

RESULTS

The probability of vomiting when using spinal compared to general anesthesia was lower within the first 5 hours (P<.001) and 6 hours (P=.008) postoperation. A significant difference (P<.001) was observed between the total costs of the two procedures, with spinal anesthesia being less expensive. Patients were more likely to be discharged the same day of the procedure when spinal anesthesia was used (P=.008).

CONCLUSIONS

Spinal anesthesia has many advantages compared to general anesthesia for pediatric laparoscopic appendectomies. Patient comfort is improved due to a significant decrease in vomiting. This allows for more rapid hospital discharges and substantial cost savings, without compromising the outcome of the procedure.

Appendectomy Does Not Increase the Risk of Future Emergence of Parkinson's Disease: A Meta-analysis

OBJECTIVE

To explore the impact of appendectomy history on emergence of Parkinson's disease (PD).

BACKGROUND

Although there are several studies to investigate the relationship between appendectomy history and emergence of PD, the results are still controversial.

METHODS

We performed a comprehensive electronic search of the literature (the Cochrane Library, PubMed, and the Web of Science) up to April 2020 to identify studies that had employed databases allowing comparison of emergence of PD between patients with and those without appendectomy history. To integrate the impact of appendectomy history on emergence of PD, a meta-analysis was performed using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI) for the selected studies, and heterogeneity was analyzed using I² statistics.

RESULTS

Four studies involving a total of 6 080 710 patients were included in this meta-analysis. Among 1 470 613 patients with appendectomy history, 1845 (.13%) had emergences of PD during the observation period, whereas among 4 610 097 patients without appendectomy history, 6743 (.15%) had emergences of PD during the observation period. These results revealed that patients with appendectomy history and without appendectomy had almost the same emergence of PD (RR, 1.02; 95% CI, .87-1.20; P = .83; I² = 87%).

CONCLUSION

This meta-analysis has demonstrated that there was no significant difference in emergence of PD between patients with and those without appendectomy history.

Laparoscopic Appendectomy: A Safe and Definitive Solution for Suspected Appendicitis

Introduction

Since conservative antibiotic treatment in uncomplicated appendicitis might not solve the clinical problem definitively, it has to compete with the results of today's laparoscopic appendectomy.

Methods

In a county hospital, accommodating also a pediatric department, all cases of appendectomy for suspected appendicitis over 15 years were analyzed retrospectively for the following items: beginning of symptoms, time from admission to surgery, surgical technique as "open," "laparoscopic" or "converted," if perforated at operation and histological confirmation of acute inflammation. Surgical morbidity was detected in distinct categories. To evaluate changes over time, 3 time periods of 5 years each were defined.

Results

Resulting in a total of 1,956 cases there were 731 in group I, 633 in group II and 592 in group III within the 3 time periods, respectively. The median age was 17 years. The percentage of perforations was 16.8%. Those patients had - with 47 compared to 27 h - a significantly prolonged time from the beginning of symptoms to admission (p = 0.0001). The proportion of laparoscopic surgery rose from 83.3 (group I) to 98.3% (group III; p = 0.0001). The median postoperative hospital stay diminished from 4 to 3 days in nonperforated (p = 0.0001) and from 8 to 7 days in perforated cases (p = 0.0009). Surgical morbidity was reduced from 4.1% in the first to 1.7% in the third observation period (p = 0.0144). There were no surgical site infections during the last 5 years.

Conclusions

Timely laparoscopic appendectomy in case of suspected appendicitis can be offered with an extraordinary low morbidity. Taking into account the complete solution of the otherwise pending threat, compared to conservative antibiotic treatment, it is safe and definitive.

Outcomes after appendectomy in children with acute appendicitis treated at a tertiary paediatric centre: results from a retrospective cohort study

PURPOSE

In general, an appendectomy is presumed to have a limited burden of disease. However, in current literature, reported complication rates vary. This study aims to provide additional insights in the incidence of post-appendectomy complications in children with acute appendicitis.

METHODS

This retrospective cohort study included children (0-17 years old) that underwent appendectomy at our tertiary referral centre for suspected acute appendicitis (January 2011-December 2018). Children referred to our centre, and those that underwent non-operative treatment were excluded. Post-appendectomy complications were recorded from electronic medical charts using predefined definitions and classified as severe (Clavien-Dindo III-IV) or less severe (Clavien-Dindo I-II).

RESULTS

A total of 131 children were included. Simple and complex appendicitis was diagnosed in 66 (50%) and 60 (46%) children, respectively. A non-inflamed appendix was seen in five (4%) children. One or more complications were identified in 33 (25%) patients. Eight (12%) children with simple appendicitis developed a complication, three of these were severe. In children with complex appendicitis, 23 (38%) children developed a complication, 14 of these were severe.

CONCLUSION

This study shows a high rate of complications compared with current literature, both in children with simple and complex appendicitis. This is probably the result of our definition of complications and being a tertiary referral centre receiving more severe appendicitis cases. However, these results still show that appendectomy is not always a routine procedure with only few complications. Substantiating the need to keep optimizing treatment for children with appendicitis.