Day case appendectomy in adults: A review

Are only a few hours adequate for hospitalisation following mini-incision open appendectomy in paediatric patients?

BACKGROUND

A very short hospital length of stay following an open appendectomy in children with acute simple appendicitis has never been mentioned yet in the literature. The authors reviewed the outcome of these paediatric patients who were treated with the open technique.

MATERIALS AND METHODS

In this analytical cohort observational study, we retrospectively reviewed the medical records of the 115 consecutive patients who underwent open appendectomy from June 2017 to July 2021.

RESULTS

There were 84 patients whose appendices were inflammatory or suppurative and appendectomies were done only through McBurney's point. Of these, the average age was 9.11 ± 2.67 years. The mean length of the incision was 1.95 ± 0.48 cm. Nearly one-third (25/85) were discharged within 3 h following surgery. Of the remaining cases, nine patients were discharged within the same day. There were increased percentages of patients who were eligible for early discharge in each consecutive year.

CONCLUSION

The idea of immediate discharge within 3 h seems to be feasible for children with acute simple appendicitis who were treated with open appendectomy. We believe that the practice will be widely acknowledged and proceed to reduce the resources and the expenses in the hospital.

Outpatient management of acute uncomplicated appendicitis after laparoscopic appendectomy: a randomized controlled trial

OBJECTIVE

To confirm the safety and efficacy of outpatient management of laparoscopic appendectomy, with an enhanced recovery after surgery (ERAS) protocol, in adult patients with uncomplicated acute appendicitis. Outpatient laparoscopic appendectomy is feasible and secure in selected patients in observational studies. The benefits include reduced length of stay (LOS) and postoperative complications. This is the first randomized controlled trial of outpatient management following ERAS protocol.

METHODS

Patients admitted from the emergency department with acute appendicitis were randomized into one of two groups: standard care within the hospital (HG) or the outpatient group (OG). An ERAS protocol was followed for both groups. Patients in the HG were admitted to the surgical ward. Patients in the OG were referred to the day-surgery unit. The primary endpoint was the length of stay.

RESULTS

Ninety-seven patients were included: 49 in the OG and 48 in the HG. LOS was significantly shorter in the OG (mean 8.82 h) than in the HG (mean 43.53 h), p < 0.001. There was no difference in readmission rates (p = 0.320); we observed only one readmission in the OG. No further emergency consultations or complications were observed. The cost saving was $516.52/patient as a result of the intervention.

CONCLUSION

Outpatient management of appendectomy is safe and feasible procedure in selected patients. This approach could become the standard of care for patients with uncomplicated appendicitis, showing fewer complications, lower LOS and cost.

TRIAL REGISTRATION

Registration: www.

CLINICALTRIALS

gov (NCT05401188) Clinical Trial ID: NCT05401188.

Same-day discharge after appendectomy for acute appendicitis: a systematic review and meta-analysis

PURPOSE

Patients presenting with acute appendicitis are usually hospitalized for a few days for appendectomy and postoperative recovery. Shortening length of stay may reduce costs and improve patient satisfaction. The purpose of this study was to assess the safety of same-day discharge after appendectomy for acute appendicitis.

METHODS

A systematic review was performed according to PRISMA guidelines. A literature search of EMBASE, Ovid MEDLINE, Web of Science, Cochrane Central, and Google Scholar was conducted from inception to April 14, 2020. Two reviewers independently screened the literature and selected studies that addressed discharge on the same calendar day as the appendectomy. Risk of bias was assessed with the ROBINS-I tool. Main outcomes were hospital readmission, complications, and unplanned hospital visits in the postoperative course. A random effects model was used to pool risk ratios for the main outcomes.

RESULTS

Of the 1912 articles screened, 17 comparative studies and 8 non-comparative studies met the inclusion criteria. Most only included laparoscopic procedure for uncomplicated appendicitis. Most studies were considered at moderate or serious risk of bias. In meta-analysis, same-day discharge (vs. overnight hospitalization) was not associated with increased rates of readmission, complication, and unplanned hospital visits. Non-comparative studies demonstrated low rates of readmission, complications, and unplanned hospital visits after same-day discharge.

CONCLUSION

This study suggests that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients.

TRIAL REGISTRATION

PROSPERO registration no. CRD42018115948.

Immediate effects of urgent reorganisation of emergency department-based treatment pathway in nonperforated appendicitis: a retrospective study

BACKGROUND

Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, Southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. Postoperative treatment pathway of patients with nonperforated acute appendicitis was ordered to take place in the Emergency Department (ED). The aim of this study was to assess, whether this reorganisation was feasible and safe, i.e. did it affect the length of in-hospital stay (LOS) and the 30-day complication rate.

METHODS

This is a retrospective pre- and post-intervention analysis. After the reorganisation, most patients with nonperforated appendicitis were followed postoperatively at the 24-h observation unit of the ED instead of surgical ward. Patients operated during the first 3 months after the reorganisation were compared to those operated during the 3 months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age < 18 years and perforated disease.

RESULTS

Appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. Postoperative LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.7 h for all patients after the reorganisation compared to 24.4 h before the reorganisation (standard error 6.2 h, 95% confidence interval 2.3-15.2 h, p < 0.01). There were no more complications in the group treated postoperatively in the ED.

CONCLUSIONS

Early discharge of patients with nonperforated appendicitis after enforced urgent reorganisation of the treatment pathway in the ED observation unit is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED - instead of the surgical ward - occurred in the majority of the cases after the reorganisation. This change may spare resources as in our series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.

Ambulatory versus conventional laparoscopic appendectomy: a systematic review and meta-analysis

PURPOSE

Ambulatory laparoscopic appendectomy has gained popularity due to the improved understanding of patient selection criteria, the application of enhanced recovery pathways, and the potential for improving healthcare resource utilization. The aim of the review was to compare the morbidity and readmission rates between ambulatory and conventional laparoscopic appendectomy (LA).

METHODS

A systematic search was undertaken using PubMed, Embase, Cochrane, and Web of Science. Studies from 2014 to 2018, on adult patients undergoing ambulatory LA, were considered. Meta-analyses were conducted to pool the total number of complications and readmission events in the ambulatory and conventional groups.

RESULTS

A total of 5 studies met our inclusion criteria accounting for 7079 total of patients with acute appendicitis treated by ambulatory LA and 6370 patients treated by conventional LA. We included four observational studies (two prospective and two retrospective) and one randomized controlled trial. Length of stay was significantly lower in the ambulatory group (mean difference = - 15.63 h, 95% CI = - 21.78 to - 9.49, P = < 0.00001). The relative risk (RR) of reoperation was 0.49 (95% CI = 0.12-1.95, P = 0.31). The results demonstrated a pooled RR of overall morbidity of 0.79 (95% CI = 0.65-0.97, P = 0.02) and a pooled RR of readmission of 0.72 (95% CI = 0.59-0.88, P = 0.002), both results favoring the ambulatory LA group.

CONCLUSION

There is a lack of high-quality comparative studies making conclusive recommendations not possible at this time. Based on current data, ambulatory LA may be safe and feasible as compared with conventional LA.

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Can Outcomes of a Prospective Study Be Reproduced in Real Life?

BACKGROUND

The feasibility of day case surgery (DCS) appendectomy for uncomplicated acute appendicitis (UCAA) was evaluated by the prospective AppendAmbu (Feasibility of Outpatient Appendectomy for Acute Appendicitis) study (ClinicalTrials.gov ID NCT01839435). The aim of this study was to evaluate the real-life feasibility of DCS for UCAA.

STUDY DESIGN

This single-center, retrospective, non-interventional study was conducted after the AppendAmbu study and included UCAA only. The primary end point was DCS success rate (ie length of stay <12 hours) in the intention-to-treat population (all patients with UCAA) and in the per-protocol population (population with UCAA and no preoperative and intraoperative exclusion criteria). The secondary end points were to determine the DCS quality criteria to evaluate and compare the morbidity and mortality of DCS and conventional hospitalization for UCAA (Clavien, Comprehensive Complication Index) and to externally validate the St Antoine criteria for the selection of patients for DCS.

RESULTS

From January 2016 to September 2017, two hundred and ninety-six patients underwent operations for acute appendicitis. The proportion of patients with successful DCS management was 27% in the intention-to-treat population and 95% in the per-protocol population. The unplanned consultation rate was 15%, the unplanned hospitalization rate was 4%, and the unplanned reoperation rate was 0%. The postoperative morbidity of patients managed by DCS was not different from that of patients managed in conventional hospitalization. The DCS success rate was 0%, with a St Antoine score of 0, and 80% of patients had a St Antoine score of 5 (p < 0.0001).

CONCLUSIONS

Day case surgery constitutes progress in surgery as a result of enhanced recovery programs. It avoids unnecessary prolonged hospitalization.

Day Surgery for Acute Appendicitis in Adults: A Prospective Series of 102 Patients

AIM

To report the results of a consecutive series of day surgery appendectomy (DSA) for acute appendicitis.

METHODS

Selection criteria for DSA were as follows: body mass index<28 kg/m, white cell count <15,000/mL, C-reactive protein<30 mg/L, no radiological signs of perforation, and appendix diameter ≤10 mm. All patients with radiologically proven appendicitis and 4 or 5 criteria were proposed for DSA and prospectively included.

RESULTS

A total of 102 patients (female=39.2%) were operated between January 1, 2013 and January 5, 2015 with a median age of 29.5 years [interquartile range (IQR), 23 to 37 y]. Diagnosis was mainly supported by computed tomographic scan (75.5%). About 60 patients (59%) were reconvened on the next morning for surgery with oral antibiotics. The median operative time was 40 minutes (IQR, 30 to 52 min), and 92 (90%) patients were discharged on day 0 after a postoperative period of 5h:12min (IQR, 4h:14min to 6h:33min). The overall median hospital length of stay was 8h:04min (IQR, 6h:46min to 10h:23min). Surgical morbidity was 6.9% (n=7), with 1.9% (n=2) major complications.

CONCLUSIONS

DSA is a safe procedure for selected patients; it reduces the hospital length of stay without increasing morbidity.

Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis

BACKGROUND

In 2012, a same-day discharge protocol following appendectomy for acute appendicitis was initiated. Our objective was to determine the success of the protocol by reviewing the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) outcomes following protocol development.

METHODS

The 2015 NSQIP-P Participant Use Data File was queried to identify patients with acute appendicitis who underwent appendectomy. Outcomes were compared to institutional outcomes.

RESULTS

There were 154 institutional patients and 4973 from NSQIP-P centers. Institutional rate of outpatient management was higher compared to NSQIP-P (84% vs 48%, p<0.0001). Surgical length of stay was shorter compared to national rates (0.3±0.7 vs 1.1±1.9days, p<0.0001). There was no significant difference in the incidence of superficial (1.9% vs 1.0%, p=0.2), deep (0.6% vs 0.1%, p=0.17) or organ/space surgical site infections (1.3% vs 0.7%, p=0.31). The incidences of other complications (1.3% vs 0.6%, p=0.26) and 30-day readmissions (3.2% vs 2.6%, p=0.61) were similar.

CONCLUSION

Outpatient management following appendectomy in children is possible with low morbidity and readmission rates. Comparison with other NSQIP-Pediatric centers suggests an opportunity to generalize this practice with considerable savings to the health care system.

LEVEL OF EVIDENCE

Prognosis study, level II.