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Lee TG, Nam S, Lee HS, Lee JH, Hong YK, Kang JG. Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Uncomplicated Acute Appendicitis. Ann Coloproctol 2020; 36:30-34. [PMID: 32146786 PMCID: PMC7069673 DOI: 10.3393/ac.2019.06.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/25/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose To compare the surgical outcomes of peritoneal irrigation versus suction alone during laparoscopic appendectomy and to identify the risk factors of surgical site infection in patients with uncomplicated acute appendicitis. Methods Data from patients with uncomplicated acute appendicitis between January 2014 and March 2016 were reviewed. We compared the irrigation and suction alone groups with regard to the following parameters: postoperative complication incidence rate, length of hospital stay, operation time, time to flatus, time to diet commencement, and duration of postoperative antibiotic. Results A total of 578 patients underwent laparoscopic appendectomy for uncomplicated acute appendicitis. Twenty-five patients were excluded from the analysis because of need for drain insertion, loss to follow-up, simultaneous surgery for another indication, presence of an appendix tumor, or pregnancy. A total of 207 patients (37.4%) had undergone irrigation, and 346 patients (62.6%) received suction alone during laparoscopic appendectomy. The preoperative fever rate was significantly higher in the irrigation group than in the suction alone group. Operative time was also significantly longer in the irrigation group than in the suction alone group (53.8 ± 18.5 minutes vs. 57.8 ± 21.4 minutes, P = 0.027). The postoperative complication rate was higher in the irrigation group than in the suction alone group (4.5% vs. 12.6%, P = 0.001). Multiple logistic regression analysis showed that irrigation and preoperative fever were risk factors for surgical site infection after laparoscopic appendectomy for uncomplicated acute appendicitis. Conclusion There is no advantage to irrigating the peritoneal cavity over suction alone during laparoscopic appendectomy for uncomplicated acute appendicitis. Irrigation may actually prolong the operative time and therefore be detrimental.
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Affiliation(s)
- Tae Gyeong Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea.,Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Soomin Nam
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hyung Soon Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jin Ho Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Young Ki Hong
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jung Gu Kang
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Laparoscopic Lavage Versus Aspiration Alone in Perforated Acute Appendicitis: A Prospective Randomized Controlled Study. Surg Laparosc Endosc Percutan Tech 2019; 30:14-17. [PMID: 31855922 DOI: 10.1097/sle.0000000000000745] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Association of postoperative organ space infection after intraoperative irrigation in appendicitis. J Trauma Acute Care Surg 2019; 84:628-635. [PMID: 29271870 DOI: 10.1097/ta.0000000000001773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The benefit of intraoperative irrigation on postoperative abscess rates compared to suction alone is unclear. The American Association for the Surgery of Trauma grading system provides distinct disease severity stratification to determine if prior analyses were biased by anatomic severity. We hypothesized that for increasing appendicitis severity, patients receiving (high, ≥2 L) intraoperative irrigation would have increased postoperative organ space infection (OSI) rate compared to (low, <2 L) irrigation. METHODS Single-institution review of adults (>18 years) undergoing appendectomy for appendicitis during 2010-2016. Demographics, operative details, irrigation volumes, duration of stay, and complications (Clavien-Dindo classification) were collected. American Association for the Surgery of Trauma grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and area under the receiver operating curve analyses were performed. RESULTS Patients (n = 1187) were identified with a mean (SD) age of 41.6 (18.4) years (45% female). Operative approach included laparoscopy (n = 1122 [94.5%]), McBurney incision (n = 10 [0.8%]), midline laparotomy (n = 16 [1.3 %]), and laparoscopy converted to laparotomy (n = 39 [3.4%)]. The mean (SD) volume of intraoperative irrigation was 410 (1200) mL. Complication rate was 26.1%. Median volume of intraoperative irrigation in patients who developed postoperative OSI was 3 [0-4] compared to 0 [0-0] in those without infection (p < 0.0001). Area under the receiver operating curve analysis determined that 2 or more liters of irrigation was associated with postoperative OSI (c statistic: 0.83, 95% confidence interval, 0.76-0.89; p < 0.001). CONCLUSION Irrigation is used for increasingly severe appendicitis with wide variation. Irrigation volumes of 2 L or greater are associated with postoperative OSI. Improving standardization of irrigation volume (<2 L) may prevent morbidity associated with this high-volume disease. LEVEL OF EVIDENCE Therapeutic, level IV.
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Akingboye AA, Davies B, Tien T. Pus Samples in Complicated Appendicitis: An Important Investigation or a Waste of Resources: A Prospective Cohort Study. Scand J Surg 2019; 108:55-60. [PMID: 29973114 DOI: 10.1177/1457496918783721] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND AIMS: Appendicitis is a common presentation to hospital with appendectomy being the treatment of choice. Pre-operative administration of broad-spectrum antibiotics is common, but obtaining intra-abdominal pus samples is not. After an initial 6-month retrospective audit and departmental teaching on the importance of intra-peritoneal pus sampling, we aimed to determine whether intra-operative pus samples changed antibiotic management. MATERIALS AND METHODS: Following the initial audit cycle, a 6-month prospective cohort study was conducted. Clinical data were collected on a predetermined proforma to assess the effectiveness of the intervention and antibiotic prescribing practice. The data collected during the whole 1-year period was analyzed. RESULTS: During the 1-year period, 440 patients were identified as undergoing a laparoscopic procedure. After exclusion, 261 patients were identified as undergoing laparoscopic appendectomies, of which 141 (54%) were classified as complicated laparoscopic appendectomies. A total of 35 out of 141 (25%) pus samples were sent of which 24 (17%) resulted in positive cultures, with only nine of these positive cultures reported prior to the patient being discharged. No patient had their antibiotic regimen changed as a result of the culture results. There were three cases of cultures resistant to local antibiotics, but without significant clinical outcome. One of these patients developed a post-operative complication, but the antibiotic regimen was changed to broad spectrum rather than a specific antibiotic based on culture sensitivity. Of the 141 patients with complicated laparoscopic appendectomies, five (3.5%) developed post-operative complications: one readmission requiring a laparoscopic washout for pelvic collection, three (2%) cases of pelvic collections managed conservatively, and one case of prolonged paralytic ileus managed non-operatively. CONCLUSION: Overall, none of the patients with positive cultures had a change in prescribed antibiotics based on culture results. Hence, the routine practice of intra-peritoneal pus sampling following complicated appendicitis remains of little clinical value.
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Affiliation(s)
- A A Akingboye
- 1 Department of General Surgery, Peterborough City Hospital, Peterborough, UK
| | - B Davies
- 1 Department of General Surgery, Peterborough City Hospital, Peterborough, UK
| | - T Tien
- 2 Department of General Surgery, Colchester Hospital University NHS Foundation Trust, Colchester, UK
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Laparoscopic Lavage Versus Suction Only in Complicated Acute Appendicitis: A Prospective Randomized Control Trial. Int Surg 2018. [DOI: 10.9738/intsurg-d-18-00025.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background:
Laparoscopic appendectomy for complicated appendicitis presents a challenge with concerns about pelvic collections. It is unclear whether lavage or if simple suctioning of pus influences complications.
Methods:
A prospective, single,-blinded, randomized control trial was conducted. Patients with suspected acute appendicitis were consented. Those found to have complicated appendicitis (perforation, localized pus, or four-quadrant pus) at laparoscopy were randomized to suction or lavage. Exclusions included conversions and drainage of abscess only. Lavage consisted of 3 liters of lavage. Intra-abdominal abscess that required reintervention (i.e., relook, percutaneous drainage) was the primary outcome. Hospital stay and return of bowel function were also recorded.
Results:
A total of 213 patients were assessed for eligibility. We excluded 157 patients, as they had simple appendicitis; 7 patients were converted to laparotomies; 5 had abscesses but the appendix was not removed. We analyzed 86 patients. The mean age was 26.6 years (14–74). We lavaged 42 (48.8%) patients and 44 (51.2%) were suctioned. Four-quadrant pus was present in 26 (30.2%) of the patients overall. Complications developed in 20 (47.5%) of the patients that were lavaged versus 12 patients (27.1%) with suction only. The difference did not reach significance due to sample size (P = 0.0739). Operative time was longer in the lavage group by 30 minutes (P = 0.086). If a complication developed, then the hospital stay was significantly prolonged 13.5 days versus 5 days (P < 0.001). The study was stopped by the internal review board due to the excess risk with lavage.
Conclusions:
This exploratory study into lavage versus suction only in complicated appendicitis revealed potential harm with lavage. The study was stopped prematurely by the internal review due to the excess risk experienced by the lavage group, thus the study did not reach statistical power. If a patient with complicated appendicitis developed any complication, hospital stay was longer.
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Sun F, Wang H, Zhang F, Zhang X, Xing Z, Zhang S, Zhang H, Wang Y. Copious Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Complicated Appendicitis in Adults. J INVEST SURG 2017; 31:342-346. [PMID: 28485994 DOI: 10.1080/08941939.2017.1319995] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Fengbo Sun
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
| | - He Wang
- Qingdao Sixth People's Hospital, Qingdao, China
| | - Fengjuan Zhang
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinming Zhang
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
| | | | - Shenglin Zhang
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
| | | | - Ye Wang
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
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Bae E, Dehal A, Franz V, Joannides M, Sakis N, Scurlock J, Nguyen P, Hussain F. Postoperative antibiotic use and the incidence of intra-abdominal abscess in the setting of suppurative appendicitis: a retrospective analysis. Am J Surg 2016; 212:1121-1125. [PMID: 27871681 DOI: 10.1016/j.amjsurg.2016.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 09/08/2016] [Accepted: 09/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. METHODS We retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. RESULTS Of 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. CONCLUSIONS The administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use.
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Affiliation(s)
- Esther Bae
- Department of General Surgery, Arrowhead Regional Medical Center/Kaiser Permanente Fontana General Surgery, 400 N Pepper Ave, Colton, CA 92324, USA.
| | - Ahmed Dehal
- John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Vanessa Franz
- Department of General Surgery, Arrowhead Regional Medical Center/Kaiser Permanente Fontana General Surgery, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Michael Joannides
- LSU Heath Sciences Center-New Orleans, General Surgery, New Orleans, LA, USA
| | - Nicholas Sakis
- Arrowhead Regional Medical Center, Department of Internal Medicine, Colton, CA, USA
| | - Joshua Scurlock
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Patrick Nguyen
- Department of General and Colorectal Surgery, Kaiser Permanente SCPMG, Fontana, CA, USA
| | - Farabi Hussain
- Arrowhead Regional Medical Center, Department of General Surgery, Colton, CA, USA
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Snow HA, Choi JM, Cheng MWH, Chan STF. Irrigation versus suction alone during laparoscopic appendectomy; A randomized controlled equivalence trial. Int J Surg 2016; 28:91-6. [PMID: 26912015 DOI: 10.1016/j.ijsu.2016.01.099] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 01/27/2016] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The objective of this study was to compare operative peritoneal irrigation versus suction alone during laparoscopic appendectomy in adult patients; our hypothesis was that the two methods are equivalent in terms of rate of post-operative intra-abdominal abscess. There has been only one prospective, randomized, superiority trial in children, that showed non-significant difference in the rate of intra-abdominal abscess comparing irrigation to suction alone during laparoscopic appendectomy for perforated appendicitis. Non-significant difference in a superiority trial does not imply equivalence. METHODS This was a single-institution, prospective, randomized controlled equivalence study based on a null-hypothesis of non-equivalence between irrigation and suction alone. Adult patients with intra-operative findings of an acutely inflamed appendix, with suppuration or perforation localized to the right iliac fossa, paracolic gutter or pelvis were randomized to irrigation or suction alone. The primary endpoint was the rate of intra-abdominal abscess. An unconditional exact test of equivalence was used to test the null-hypothesis. RESULTS Eighty-one patients were included for analysis. Two (5%) of 40 patients in the irrigation group and two (4.9%) of 41 in the suction-only group developed postoperative intra-abdominal abscess. The 95% confidence interval for the difference between the two groups was -0.1200 to 0.1244, captured within the pre-defined δ limits (-0.15, 0.15). With reference to the rate of intra-abdominal abscess, equivalence was demonstrated between irrigation and suction-only techniques. CONCLUSIONS In patients with suppurative or perforated appendicitis, the rate of intra-abdominal abscess is equivalent between groups treated with peritoneal irrigation and suction alone.
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Affiliation(s)
- Hayden A Snow
- Department of Surgery, Western Health, Victoria, Australia.
| | - Julian M Choi
- Department of Surgery, Western Health, Victoria, Australia; NorthWest Academic Centre, The University of Melbourne, Sunshine Hospital, Victoria, Australia
| | | | - Steven T F Chan
- Department of Surgery, Western Health, Victoria, Australia; NorthWest Academic Centre, The University of Melbourne, Sunshine Hospital, Victoria, Australia
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Frongia G, Mehrabi A, Ziebell L, Schenk JP, Günther P. Predicting Postoperative Complications After Pediatric Perforated Appendicitis. J INVEST SURG 2016; 29:185-94. [PMID: 26822038 DOI: 10.3109/08941939.2015.1114690] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA. MATERIAL AND METHODS The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions. RESULTS Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001). CONCLUSIONS Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.
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Affiliation(s)
- G Frongia
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
| | - A Mehrabi
- b Department of General , Visceral and Transplantation Surgery
| | - L Ziebell
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
| | - J P Schenk
- c Division of Pediatric Radiology, Department of Diagnostic and Interventional Radiology , University Hospital of Heidelberg , Heidelberg , Germany
| | - P Günther
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
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Gupta A, Habib K, Harikrishnan A, Khetan N. Laparoscopic Surgery in Luminal Gastrointestinal Emergencies-a Review of Current Status. Indian J Surg 2015; 76:436-43. [PMID: 25614718 DOI: 10.1007/s12262-014-1081-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/23/2014] [Indexed: 11/28/2022] Open
Abstract
Laparoscopy has already established itself as the preferred surgical approach in a variety of elective surgical conditions. Along with its usual advantages of less tissue trauma and faster recovery, its diagnostic as well as therapeutic role is making it an attractive option in emergency surgery. In this paper, we have reviewed the current status of laparoscopic surgery in luminal gastrointestinal emergencies. Relevant papers were selected using Medline database from 2007 to the present. These were reviewed, and outcomes were stated under the headings of appendicitis, perforated peptic ulcer, colorectal emergencies and small bowel obstruction. The laparoscopic intervention was found to be of clear benefit in most of the patients with appendicitis. Its role, however, is not absolutely clear in managing perforated peptic ulcers. Laparoscopic lavage and drainage have been recommended in diverticular perforation with limited contamination. Small case series and studies have shown benefits of laparoscopic surgery in iatrogenic colonic perforations, colonic obstruction, emergency colectomy and small bowel obstruction. Laparoscopic surgery can be recommended in appendicitis and low-risk cases of perforated peptic ulcers. Its definitive role in other conditions needs more evidence. The surgeon's experience and careful patient selection are very important to improve the outcome.
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Affiliation(s)
- Ajay Gupta
- General Surgery, Doncaster Royal Infirmary, Doncaster, South Yorkshire UK
| | - Khalid Habib
- Colorectal and Laparoscopic Surgery, Doncaster Royal Infirmary, Doncaster, South Yorkshire UK
| | - Athur Harikrishnan
- Colorectal and Laparoscopic Surgery, Doncaster Royal Infirmary, Doncaster, South Yorkshire UK
| | - Niraj Khetan
- Colorectal and Laparoscopic Surgery, Doncaster Royal Infirmary, Doncaster, South Yorkshire UK
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Mosedale T, Nepogodiev D, Fitzgerald JEF, Bhangu A. Causes and costs of a decade of litigation following emergency appendectomy in England. World J Surg 2014; 37:1851-8. [PMID: 23354921 DOI: 10.1007/s00268-013-1907-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND There has been recent interest in the delayed and nonoperative management of appendicitis. The present study assessed the causes and costs of litigation against surgeons following emergency appendectomy, with an emphasis on claims relating to preoperative management. MATERIALS AND METHODS Data were obtained from the English NHS Litigation Authority for claims relevant to appendectomy between 2002 and 2011. Two authors independently extracted data and classified it against predetermined criteria. RESULTS Successful litigation occurred in 66 % of closed cases (147/223) with a total payout of £8.1 million. There were 24 claims against organizational operating room delays (9 % of total) and 27 against delayed diagnosis (10 %), with respective success rates of 70 and 68 %. From 21 claims relating to damage to fertility, nine were due to either delayed diagnosis or organizational operating room delays. Misdiagnosis was the second most common cause for litigation (16 %), but it had the lowest likelihood of success (49 %). Faulty surgical technique was the most common reason for litigation (39 %), with a 70 % likelihood of success. Of eight claims related to fatality, one was due to unacceptable preoperative delay leading to preventable perforated appendicitis. The overall highest median payouts were for claims of damage to fertility (£52,384), operating list delays (£44,716), and delayed diagnosis (£42,292). CONCLUSIONS There were significant medicolegal risks surrounding delays related to access to operating lists and diagnosis. Whereas future evidence regarding the safety of delayed appendectomy may provide scientific defense against these claims, the present study provides evidence of the current medicolegal risk to surgeons following delayed treatment of appendicitis.
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Affiliation(s)
- Thomas Mosedale
- Central Manchester University Hospitals NHS Trust, Manchester, UK
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Jo HS, Boo YJ, Lee EH, Lee JS. Comparison of Surgical Infection and Readmission Rates after Laparoscopy in Pediatric Complicated Appendicitis. ACTA ACUST UNITED AC 2014. [DOI: 10.13029/jkaps.2014.20.2.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hey Sung Jo
- Division of Pediatric Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Yoon Jung Boo
- Division of Pediatric Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Eun Hee Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Department of Medical Statistics, Korea University College of Medicine, Seoul, Korea
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Intra-abdominal collections following laparoscopic versus open appendicectomy: an experience of 516 consecutive cases at a district general hospital. Surg Endosc 2013; 27:2351-6. [PMID: 23355169 DOI: 10.1007/s00464-012-2778-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 12/14/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective of this study is to evaluate the incidence of intra-abdominal collections (IACs) in all patients undergoing laparoscopic (LA) and open appendicectomy (OA) from April 2009 to October 2011 in a district general hospital with expertise in minimally invasive surgery (MIS). METHODS A retrospective review of all patients undergoing appendicectomy in the specified time period was carried out. IACs were identified from various in-hospital data resources. Severity of appendicitis was assessed from histology reports. RESULTS 516 patients were identified, of whom 242 (47 %) underwent OA and 274 (53 %) LA. Twenty-six (5 %) patients were found to have IACs postoperatively. Fifteen (5.5 %) IACs were identified in the laparoscopic group and 11 (4.5 %) in the open group. There was no statistically significant difference in the risk of developing IACs in open versus laparoscopic groups [odds ratio (OR) 1.22, confidence interval (CI) 0.55-2.70, P = 0.63]. Patients were twelve times more likely to develop IACs with an appendix identified as being necrotic or perforated on histology (OR 12.24, CI 5.29-28.32, P < 0.0001). There was a trend towards shorter total hospital stay in the LA (3.58 days, CI 3.0-4.1 days) compared with OA (4.31 days, CI 3.7-4.9 days, P = 0.082) group, although this was not statistically significant. CONCLUSIONS Increased rates of IAC following LA have been identified in some studies. Our series shows that, in a centre with adequate MIS experience, the IAC rate following LA is comparable to that of the open approach and should not deter surgeons with adequate support and resources.
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Vettoretto N, Montori G, Bartoli M, Giovanetti M. Lesson learned from 10 years’ experience in laparoscopic appendectomy in a community hospital. Updates Surg 2012; 64:285-8. [PMID: 22991328 DOI: 10.1007/s13304-012-0177-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 09/06/2012] [Indexed: 12/24/2022]
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Vettoretto N, Gobbi S, Corradi A, Belli F, Piccolo D, Pernazza G, Mannino L. Consensus conference on laparoscopic appendectomy: development of guidelines. Colorectal Dis 2011; 13:748-54. [PMID: 21651696 DOI: 10.1111/j.1463-1318.2011.02557.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Laparoscopic appendectomy (LA) is not yet unanimously considered the gold standard treatment for appendicitis, despite the increasing use of advanced laparoscopic operations and the high incidence of the disease. METHOD Due to the results of an audit which classified LA as widespread in Italy, a Consensus Conference was organized, in order to give evidence-based answers to the most debated problems regarding the operation. After researching the literature, a panel of 20 experts were selected and interviewed on hot topics; a subsequent discussion using the Delphi methodology was utilized in the course of the consensus conference and submitted to the evaluation of an audience of surgeons. RESULTS Checkpoint statements were formulated whenever an agreement was reached. A level of evidence was then assigned to single statements and the process revised by two external reviewers. CONCLUSION Consensus development guidelines are herein reported and regard diagnostic pathway, diagnostic laparoscopy, indications, behaviour in case of innocent appendix, technical aspects, learning curve; however, some questions remain unsolved due to the lack of evidence.
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Affiliation(s)
- N Vettoretto
- Laparoscopic Surgery Unit, M Mellini Hospital, Chiari, Italy.
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Oyetunji TA, Nwomeh BC, Ong'uti SK, Gonzalez DO, Cornwell EE, Fullum TM. Laparoscopic appendectomy in children with complicated appendicitis: ethnic disparity amid changing trend. J Surg Res 2011; 170:e99-103. [PMID: 21704334 DOI: 10.1016/j.jss.2011.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 04/20/2011] [Accepted: 05/03/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic appendectomy (LA) has gained acceptance in the treatment of uncomplicated appendicitis in the pediatric population. The role of LA versus open appendectomy (OA) in complicated (perforated) appendicitis has remained controversial. METHODS A 10-y review of the Nationwide Inpatient Sample (HCUP-NIS) and 3 y of non-overlapping data from the Kids' Inpatient Database (KID) (2000, 2003, and 2006) was performed on pediatric patients (age <18 y) with complicated appendicitis. Patients were classified based on gender, race, insurance status, and type of appendectomy performed. Multivariate regression was conducted adjusting for age, race, gender, and type of appendectomy, with mortality and length of hospital stay (LOS) as outcomes. RESULTS An estimated 72,787 patients met the inclusion criteria with a median age of 11 y. The majorities of the patients were male (59.9%), Caucasian (38.1%), and insured (89.7%). Twenty-nine percent underwent LA while 71% had OA. Proportion of LA increased from 9.9% in 1999 to 46.6% in 2007. On multivariate analysis, African-Americans were less likely to undergo LA compared with Caucasians (OR: 0.80, CI = 0.69-0.92, P = 0.002) despite an increased odds of undergoing LA over the last decade from 1998 to 2007 in the entire study population (OR 6.27, 95% CI 4.73-8.30, P = 0.000). Increasing age and gender were also associated with likelihood of receiving LA (OR: 1.08, CI = 1.06-1.10 and OR 1.25, 95% CI 1.18-1.31, P < 0.001). CONCLUSIONS LA is gradually gaining acceptance over the years as an alternative to OA for complicated appendicitis, However, minority difference still exists in choice of procedure. There is a need to further investigate this disparity as it may be related to access to skilled laparoscopic pediatric surgeons.
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Affiliation(s)
- Tolulope A Oyetunji
- Department of Surgery, Howard University College of Medicine, Washington, DC 20060, USA.
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Fike FB, Mortellaro VE, Juang D, Sharp SW, Ostlie DJ, St Peter SD. The impact of postoperative abscess formation in perforated appendicitis. J Surg Res 2011; 170:24-6. [PMID: 21550056 DOI: 10.1016/j.jss.2011.03.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 02/08/2011] [Accepted: 03/15/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Abscess after appendectomy for perforated appendicitis is the most common complication. We have completed three prospective trials and are conducting a fourth in which the included patients had either a hole in the appendix or a fecalith in the abdomen identified at the time of operation. The abscess rate in each of these trials was 20%. Multiple publications have focused on prevention and management of this postoperative complication but the total impact of an abscess on the hospital course has not been well documented. Therefore, we reviewed our experience with patients who developed a postoperative abscess to evaluate the total care received compared with those who recovered uneventfully. METHODS Data from patients with abscess who have been enrolled in our prospective trials from April 2005 to December 2009 were utilized. Patients who recovered without complications in the most recent trial served as a comparison group, as this protocol offers the minimal length of stay without a predetermined length of stay. Data comparison included patient demographics, admission lab values, hospital length of stay, and hospital charges. RESULTS There were 63 patients with a postoperative abscess and 61 patients without an abscess identified. Patients with an abscess were older (11.0 versus 9.7 y, P = 0.04) and had a higher mean body mass index (22.4 versus 19.5, P = 0.03). Total hospital length of stay was significantly longer in the abscess group (11.6 d versus 5.1 d, P ≤ 0.001). Total hospital charges doubled for patients who developed an abscess ($82,000 versus $40,000 P < 0.001). CONCLUSION A postoperative abscess after appendectomy for perforated appendicitis translates into an average of an extra week in hospital care with double the total hospital cost.
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Affiliation(s)
- Frankie B Fike
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri 64108, USA
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Moore CB, Smith RS, Herbertson R, Toevs C. Does Use of Intraoperative Irrigation with Open or Laparoscopic Appendectomy Reduce Post-Operative Intra-abdominal Abscess? Am Surg 2011. [DOI: 10.1177/000313481107700126] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
To date, no study shows a decrease in postoperative abscess with the use of irrigation during appendectomy. Postoperative abscess rate for laparoscopic and open appendectomy is 3.3 and 2.6 per cent. The purpose of this study is to determine if irrigation at appendectomy decreases the postoperative intra-abdominal abscess rate. Retrospective chart review of 176 consecutive appendectomies, open (39%) and laparoscopic (61%), at a university affiliated tertiary care facility from July 2007 to November 2008 for use of intraoperative irrigation was performed. Patients under age 18 were excluded. There were no differences between the irrigation groups in regards to age, sex, or weight. Perforation was observed in 28 per cent (50/176), of which 86 per cent (43/50) of patients received intraoperative irrigation. Eleven patients (9.6%) with irrigation developed postoperative abscess compared with two (3.3%) patients without irrigation ( P = 0.22). Our results do not show decrease in postoperative intra-abdominal abscess with use of intraoperative irrigation. Thirteen patients developed postoperative abscess: 11 with irrigation, two without irrigation. Ten of 13 patients who developed abscess were perforated; nine with irrigation and one without. These results suggest routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided.
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A brief review of laparoscopic appendectomy: the issues and the evidence. Tech Coloproctol 2010; 15:1-6. [PMID: 21086013 DOI: 10.1007/s10151-010-0656-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 10/28/2010] [Indexed: 01/09/2023]
Abstract
Laparoscopic appendectomy was first performed more than 25 years ago. We performed a systematic literature search on laparoscopic appendectomy and selected related topics. The technique should be considered the gold standard for surgical removal of the appendix in women of childbearing age (level of evidence Ia). There is minor but consistent evidence that it should also be advocated for men (level of evidence III), obese (level of evidence III), and elderly (level of evidence IIb) patients, while there is some evidence of unfavorable results on pregnant women (level of evidence IIb). Studies reporting higher incidence of intra-abdominal abscesses after laparoscopic appendectomy are difficult to interpret due to a lack of standardization of the operative technique and lack of uniformity related to the different grades of disease (ranging from uninflamed appendix to diffuse peritonitis, gangrene, or perforation of the organ). As far as surgical technique, the three-port procedure is superior to needleoscopy and single port access (level of evidence Ia). Costly high-tech instruments for dissection are mostly unnecessary (level Ib). Mechanical closure of the stump might prove safer (level Ib). The quantity of peritoneal lavage fluid is generally scanty (level III), and abdominal drains are not useful (level Ia). Fast-track protocols should be implemented (level Ic). Training and technical standardization are the key to devising future trials on this topic.
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Wang X, Zhang W, Yang X, Shao J, Zhou X, Yuan J. Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy--our experience. J Pediatr Surg 2009; 44:1924-7. [PMID: 19853748 DOI: 10.1016/j.jpedsurg.2009.03.037] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Revised: 03/17/2009] [Accepted: 03/18/2009] [Indexed: 12/19/2022]
Abstract
PURPOSE Good outcomes have been reported with laparoscopic appendectomy (LA) for uncomplicated appendicitis in children, but the use of laparoscopy for complicated appendicitis in children is more controversial. This is related to a higher incidence of postoperative abdominal and wound infections. The purpose of this trial was to retrospectively compare LA and open appendectomy (OA) for complicated appendicitis and evaluate the efficacy of LA in children with complicated appendicitis. METHODS The outcome of 128 patients with complicated appendicitis in children was retrospectively analyzed. There were 80 children in the LA group and 48 in the OA group. The appendectomies were performed by a single senior surgeon and his surgical trainees. There was no selection of cases for LA. Data collection included demographics, operative time, resumption of diet, infectious complications (wound infection and intraabdominal abscess), length of hospitalization, and duration of antibiotic use. RESULTS There were no cases of LA that required conversion to OA. The operative time for LA (88.5 +/- 28.8 minutes for LA vs 71.8 +/- 30.6 minutes for OA; t = 3.10; P = .002) was longer. Patients in the LA group returned to oral intake earlier (1.8 +/- 0.6 days for LA vs 2.8 +/- 0.8 days for OA; t = -8.04; P < .01) and had a shorter length of hospital stay (6.5 +/- 2.2 days for LA vs 7.8 +/- 2.9 days for OA; t = -2.87; P = .005). The incidence of wound infection (1/80 [1.3%] for LA vs 6/48 [12.5%] for OA; P < .05) and postoperative intraabdominal abscess (2/80 [2.5%] for LA vs 7/48 [14.6%] for OA; P < .05) in LA group was lower. No significant difference was found in the duration of antibiotic administration between the 2 groups (5.8 +/- 1.8 days for LA vs 6.3 +/- 2.3 days for OA; t = -1.37; P = .174). No mortality was observed in either group. CONCLUSIONS The minimally invasive laparoscopic technique is feasible, safe, and efficacious for children with complicated appendicitis. Laparoscopic appendectomy should be the initial procedure of choice for most cases of complicated appendicitis in children.
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Affiliation(s)
- Xiaolin Wang
- Department of Pediatric Surgery, Tong ji Hospital, Tong ji Medical College, Hua zhong University of Science and Technology, Wuhan 430030, PR China.
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Franzon O, Piccoli MC, Neves TT, Volpato MG. Apendicite aguda: análise institucional no manejo peri-operatório. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2009. [DOI: 10.1590/s0102-67202009000200002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
RACIONAL: Apendicite aguda é a causa mais comum de abdômen agudo, responsável por elevada morbidade. Uma vez que o diagnóstico correto e precoce permanece um desafio, a compreensão de seu manejo peri-operatório é fundamental. OBJETIVO: Descrever o perfil clínico e avaliar o manejo peri-operatório de pacientes adultos submetidos à apendicectomia laparotômica. Métodos - Foram analisados prospectivamente 88 pacientes submetidos à apendicectomia no período de nove meses. Todos os pacientes foram operados por laparotomia, e o tratamento cirúrgico instituído obedeceu ao padrão convencional de ressecção cirúrgica por incisão Davis-Rockey, McBurney ou mediana infra-umbilical. Foi realizada análise descritiva das prevalências segundo idade, sexo, sintomatologia e resultados de exames de imagem. Antibioticoterapia foi realizada com ciprofloxacin + metronidazol ou ampicilina-sulbactam. Os pacientes foram acompanhados durante o período de internação quanto à ocorrência de complicações precoces e tempo de permanência hospitalar. RESULTADOS: Trinta pacientes foram submetidos à ultrassonografia (56,7% mulheres) e cinco à tomografia computadorizada - todos do sexo feminino. O leucograma diferencial foi diretamente relacionado com fases avançadas de apendicite, guardando relação com aumento do número de bastões e segmentados e queda no número de eosinófilos e linfócitos. Sessenta pacientes (67%) fizeram antibioticoterapia e 38,33% deles tiveram perfuração apendicular. Complicações ocorreram em 23,8% dos casos, sendo que 11,4% relacionadas à infecção de ferida operatória em maior proporção relacionadas às fases avançadas de apendicite. CONCLUSÃO: Quanto maior a porcentagem de formas jovens na contagem leucocitária, mais avançada está a fase do processo inflamatório apendicular. As mulheres utilizam a ultrassonografia abdominal para esclarecimento diagnóstico em maior número do que os homens. Quanto mais avançado o estágio de evolução da apendicite, maior a prevalência de complicações.
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Jun YW, Jung H, Kim SJ, Jun KH, Chin HM, Park WB. Comparison of Clinical Outcomes between Laparoscopic and Open Appendectomy: A Retrospective Analysis of 2,745 Patients. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.77.5.320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ye-Won Jun
- Department of Surgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Hun Jung
- Department of Surgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sung-Jeep Kim
- Department of Surgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Kyong Hwa Jun
- Department of Surgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Hyung Min Chin
- Department of Surgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Woo Bae Park
- Department of Surgery, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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