Laparoscopic versus open approach for diffuse peritonitis from appendicitis ethiology: a subgroup analysis from the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study

[Laparoscopic surgery for advanced peritonitis]

OBJECTIVE

To determine the criteria for choosing surgical access in patients with advanced peritonitis considering its local and general manifestations.

MATERIAL AND METHODS

We analyzed treatment outcomes in 588 patients with advanced peritonitis. The most common causes of peritonitis were destructive forms of acute appendicitis (273 cases), perforated gastroduodenal ulcers (165 cases), acute cholecystitis (59 cases). To determine the criteria for choosing surgical access in advanced peritonitis, we analyzed treatment outcomes considering MPI, SPP and WSES SSS score.

RESULTS

The choice of surgical access in advanced peritonitis can only symbolically be standardized according to modern scoring systems (MPI, SPP, WSES SSS). Laparotomy is necessary for MPI score ≥30 and SPP score > 10 (WSES SSS score > 8). Regardless of MPI, SPP, WSES SSS scores, the absolute contraindications for laparoscopic surgery are dense non-removable fibrin deposits, interintestinal abscesses, purulent recesses, intra-abdominal pressure > 20 mm Hg or small intestine dilation> 3 cm, sepsis or septic shock (qSOFA score 2-3), previous open abdominal surgery, unstable hemodynamics, technical difficulties. Conversion should be used at any doubt.

CONCLUSION

Careful patient selection, surgical experience and training in laparoscopic technique are decisive factors for wider use of laparoscopic approach in patients undergoing emergency abdominal surgery.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Single incision laparoscopic appendectomy with surgical-glove port is cost-effective and reliable in complicated acute appendicitis: A casecontrol multicenter study in Colombia

Background

The single-port (SPL) and multi-port (MPL) laparoscopic approach are the gold standard of management of acute appendicitis, due to its multiple advantages over open surgery, mainly because of its direct effects on recovery, esthetics and costs of the procedure. However, in third-world countries, the laparoscopic approach is not yet fully reproducible due to the costs of the technique. The surgical-glove port single incision laparoscopic appendectomy (SGP-SILA) has been proposed as a viable option. However, it has never been studied in Colombia.

Objective

To evaluate the cost-effectiveness and reliability of SGP-SILA in the management of complicated acute appendicitis, compared to traditional MPL approach.

Materials and methods

A retrospective case control study was carried out comparing patients undergoing laparoscopic appendectomy by SGP-SILA vs. MPL, evaluating operating costs associated with intraoperative and postoperative variables in two tertiary centers in Bogota, Colombia. The data were analyzed and expressed according to their nature and distribution.

Results

116 patients were included (SGP-SILA: 62 and MPL: 54). The median surgical time for SGP-SILA was 60 min vs. 39 min for MPL. SGP-SILA was shown to cause lower frequency of surgical site infection (4 vs. 8 patients; p = 0.047). It was found a significant correlation between Grade III surgical site infection and surgery time (p = 0.047) in the MPL group; also, with hospital stay (p < 0.001). Also, a lower risk of surgical site infection was found with the SGP-SILA technique (22% vs. 31%). SGP-SILA generated a reduction in both direct and indirect operating costs of approximately 10% (616 USD vs. 683 USD).

Conclusion

SGP-SILA and MPL are feasible and comparable procedures in the resolution of complicated acute appendicitis. SGP-SILA turns out to be more cost-effective compared to MPL, due to the use of more easily accessible instruments. This may be a reproducible technique in low- and middle-income countries.

Implications of bacteriological study in complicated and uncomplicated acute appendicitis

Purpose

Bacteriological sample in the presence of intraabdominal free fluid is necessary to adapt the antibiotherapy and to prevent the development of resistance. The aim was to evaluate the differences between uncomplicated (UAA) and complicated acute appendicitis (CAA) in terms of bacterial culture results and antibiotic resistance, and to evaluate the factors linked with CAA.

Methods

We performed a single-center, retrospective observational study of all consecutive patients who presented with appendicular peritonitis and underwent emergent surgery in a tertiary referral hospital in Brussels, Belgium, between January 2013 and December 2020. The medical history, parameters at admission, bacterial culture, antibiotic resistance, and postoperative outcomes of 268 patients were analyzed. UAA was considered catarrhal or phlegmonous inflammation of the appendix. CAA was considered gangrenous or perforated appendicitis.

Results

Positive microbiological cultures were significantly higher in the CAA group (68.2% vs. 53.4%). The most frequently isolated bacteria in UAA and CAA cultures were Escherichia coli (37.9% and 48.6%). Most observed resistances were against ampicillin (28.9% and 21.7%) and amoxicillin/clavulanic acid (16.4% and 10.5%) in UAA and CAA, respectively. A higher Charlson comorbidity index, an elevated white blood cell count, an open procedure, and the need for drainage were linked to CAA. Culture results, group of bacterial isolation, and most common isolated bacteria were not related to CAA.

Conclusion

CAA presented a higher rate of positive cultures with increased identification of gram-negative bacteria. Bacterial culture from the peritoneal liquid does not reveal relevant differences in terms of antibiotic resistance.

Conventional three-port laparoscopic appendectomy versus transumbilical and suprapubic single-incision laparoscopic appendectomy using only conventional laparoscopic instruments

PURPOSE

Single-incision laparoscopic appendectomy (SILA) is usually performed using single-port instruments, which may restrict its development and application. This study explored the performance of transumbilical SILA (TSILA) and suprapubic SILA (SSILA) using only conventional laparoscopic instruments and compared them with conventional three-hole/port laparoscopic appendectomy (CLA).

METHODS

This retrospective study included 174 patients who underwent CLA, TSILA, or SSILA for acute appendicitis at our hospital between June 2019 and July 2021. Demographic data and clinical outcomes were compared among the three groups.

RESULTS

Compared with CLA, TSILA was associated with significant reductions in postoperative pain, length of hospital stay, and hospital cost, while SSILA was associated with significant reductions in length of hospital stay and hospital cost (all P < 0.05). Significantly more patients in the two SILA groups were cosmetically satisfied than those in the CLA group (all P < 0.05). However, compared with CLA, SSILA required a significantly longer operative time (65.3 ± 24.1 vs 56.5 ± 20.9, P = 0.039). Besides, compared with TSILA, SSILA showed significantly higher postoperative pain score (2 ± 2 vs 3 ± 2, P = 0.006). Mild incisional or intraabdominal infections were noticed in 2 (3.0%) patients in the CLA group, 3 (5.1%) in the TSILA group, and 3 (6.3%) in the SSILA group (P = 0.69).

CONCLUSION

SILA performed with only conventional laparoscopic instruments was associated with reduced hospital stay and cost and higher cosmetic satisfaction in comparison to CLA. However, it is technically demanding and may increase operative time.

Laparoscopic appendicectomy without the use of disposable materials - a low-cost alternative - 1,552 cases operated in 20 years

INTRODUCTION

Laparoscopic appendectomy does not have a single protocol on its technical systematization, access routes, and use of energy and staplers. The cost of disposable materials can prevent its widespread use. Alternatives to decrease cost can help disseminate the laparoscopic access to appendectomy.

OBJECTIVE

to introduce a low-cost laparoscopic appendectomy method with good aesthetic results through the location of incisions; to show its viability through its application in 1,552 cases of laparoscopic appendectomy operated between 2000 and 2019 with three portals and very low-cost regarding materials used.

METHODS

we applied three punctures - an umbilical one for the camera (5 or 10mm in diameter), a 10mm puncture in the right iliac fossa, and one 5mm puncture in the left iliac fossa. The materials used were permanent use trocars, grasping forceps, hook, scissors, and needle holder, without the need for any disposable device.

RESULTS

1.552 patients were operated between 2000 and 2019, 56.2% being female, mean age 32.66 years (9-93), average hospital stay of 1.74 days (1-10), and median of 1.2 days.

CONCLUSION

the technique we describe uses three metallic trocars and four permanent instruments, in addition to a single cotton suture. It is, therefore, a very low-cost laparoscopic procedure. Its application has shown good results and low morbidity, which may become the preferred indication for laparoscopic surgery in the treatment of acute appendicitis.

[Eritonitis outcome prediction]

The review is devoted to the most common general clinical and specific grading systems for peritonitis outcome prediction. Particular attention is paid to methodological approaches, prediction reliability, simplicity of use in clinical practice and their importance in decision-making. It is shown that none of the modern grading systems is universal and absolutely reliable. Combining several systems is quite difficult and will take additional time that is impossible for intraoperative environment. Despite various systems for peritonitis outcome prediction, none of them can completely satisfy surgeons, primarily in choice of surgical access, intervention type and option for its completion.

New System For Predicting The Outcome Of Secondary Peritonitis

Despite improvements in the methods of diagnostics, surgical interventions and intensive care, the problem of treating patients with diffuse peritonitis remains relevant. Diffuse peritonitis is a major contributor to mortality in all urgent care settings and the second leading cause of sepsis in critically ill patients. At the same time, even in developed countries, the number of patients with peritonitis does not tend to decrease, and mortality rates remain high, reaching 90-93% with the development of abdominal sepsis and toxic shock syndrome. One of the ways to reduce mortality in peritonitis is the use of objective systems for prognosis of the peritonitis outcome, allowing to compare the results of patient treatment and to choose the optimal treatment tactics for each particular patient. The objective — To develop a new system for predicting the outcome of secondary peritonitis (survival or death) focused on the criteria of abdominal sepsis and multiple organ dysfunction syndrome (associated or not associated with peritonitis), and to analyze its accuracy versus the most common comparable systems. Material and Methods — Our study was based on analyzing the treatment outcomes in 352 patients with secondary diffuse peritonitis. On admission, sepsis was diagnosed in 15 (4.3%), and toxic shock in 4 (1.1%) patients. The main causes of death were purulent intoxication and/or sepsis (51 cases or 87.9%), cancer intoxication (4 cases or 6.9%), and acute cardiac failure (3 cases or 5.2%). We analyzed the effectiveness of several systems of predicting the peritonitis outcomes: the Mannheim’s Peritoneal Index (MPI), World Society for Emergency Surgery Sepsis Severity Score (WSES SSS), Acute Physiology and Chronic Health Evaluation II (APACHE II) system, general Sequential Organ Failure Assessment Score (gSOFA), as well as the Peritonitis Prognosis System (PPS) developed by the authors. The probability of the effect of 40 clinical and laboratory parameters on the outcome of patients with secondary peritonitis was analyzed via using parametric and nonparametric methods of statistical analysis (Fisher’s test, Mann-Whitney U test, Chi-squared test with Yates’s continuity correction). The criteria were selected that had a predictive power for the lethal outcome (p <0.05), and they were included in the PPS system. To compare the predictive value of the PPS, ROC analysis was conducted with construction of receiver operating characteristic curves for each analyzed system of predicting the peritonitis outcome. The STATISTICA 8 software was used for performing the statistical analysis. Results — The following criteria were of greatest importance in predicting the lethal outcome: a patient’s age, a presence of a malignant neoplasm, a nature of the exudate, the development of sepsis (toxic shock), as well as multiple organ dysfunction not associated with the developed peritonitis. PPS exhibited the greatest accuracy in terms of predicting mortality in patients with secondary diffuse peritonitis (AUC=0.942) versus minimal in APACHE II (AUC=0.840). Conclusion — APACHE II, MPI, WSES SSS and PPS can be considered reliable in terms of mortality prognosis in peritonitis patients. PPS has the greatest accuracy of predicting the mortality in patients with secondary diffuse peritonitis (94%).