Laparoscopic versus open appendectomy for complicated appendicitis

Clips closure versus endoloop ligation in laparoscopic appendectomy: a systematic review and meta-analysis of comparative studies

Introduction

Appendiceal stump closure (ASC) is a key step in performing laparoscopic appendicectomy. Currently, there is no gold standard method to achieve this goal. The ideal method should be safe, easily available, and have a short learning curve. Out of all those appendiceal stump closure methods, the use of hem-o-Lok demonstrates its feasibility in replacing the traditionally used endoloop. In this systematic review and meta-analysis, the authors aim to review the currently available evidence addressing the topic of interest.

Method

The PubMed and Embase databases were searched with the paired search terms appendicitis, clip, and endoloop by two authors separately. The quality of the randomized controlled trials was assessed with the Cochrane risk of bias tool, and the quality of the observational studies was assessed with the Newcastle-Ottawa scale. Meta-analysis was conducted with Cochrane Review Manager version 5.4.

Result

Eighteen studies were included for quantitative analysis. The appendiceal stump closure time was shortened by 2 min 7 s using a hem-o-lok with 95% CI 1 min 48 s-2 min 26 s, p less than 0.00001. The pooled results of 6 randomized controlled trials demonstrated a statistically significant reduction in operative time of 5.15 min from adopting the hem-o-lok approach (p=0.001, 95% CI -2.05 to -8.24 min). Both endoloop and hem-o-lok demonstrated a comparable postoperative hospital stay and infective complication profile.

Conclusion

The application of Hem-o-Lok demonstrates a comparable to endoloop ligation in terms of operative time and a potential benefit on the complication. When considering financial and technical aspects, it serves as an alternative to endoloop.

LAPAROSCOPIC APPENDICECTOMY: RISK FACTORS FOR CONVERSION TO LAPAROTOMY

BACKGROUND

Laparoscopic appendectomy is the gold standard surgical procedure currently performed for acute appendicitis. The conversion rate is one of the main factors used to measure laparoscopic competence, being important to avoid wasting time in a laparoscopic procedure and proceed directly to open surgery.

AIMS

To identify the main preoperative parameters associated with a higher risk of conversion in order to determine the surgical method indicated for each patient.

METHODS

Retrospective study of patients admitted with acute appendicitis who underwent laparoscopic appendectomy. A total of 725 patients were included, of which 121 (16.7%) were converted to laparotomy.

RESULTS

The significant factors that predicted conversion, identified by univariate and multivariate analysis, were: the presence of comorbidities (OR 3.1; 95%CI; p<0.029), appendicular perforation (OR 5.1; 95%CI; p<0.003), retrocecal appendix (OR 5.0; 95%CI; p<0.004), gangrenous appendix, presence of appendicular abscess (OR 3.6; 95%CI; p<0.023) and the presence of difficult dissection (OR 9.2; 95%CI; p<0.008).

CONCLUSIONS

Laparoscopic appendectomy is a safe procedure to treat acute appendicitis. It is a minimally invasive surgery and has many advantages. Preoperatively, it is possible to identify predictive factors for conversion to laparotomy, and the ability to identify these reasons can aid surgeons in selecting patients who would benefit from a primary open appendectomy.

Laparoscopic appendectomy: Effectiveness in children with generalized and advanced generalized peritonitis cases

Laparoscopic appendectomy is one of the most common surgical procedures in treating pediatric appendicitis. This study aimed to investigate the efficacy of laparoscopic surgery in cases complicated with advanced generalized peritonitis in the pediatric population. The study retrospectively reviewed 55 cases of children who underwent laparoscopic appendectomies. The cases were classified as uncomplicated, complicated, or advanced generalized peritonitis. Laboratory results, diagnostic algorithms, surgical techniques, and complications were investigated. Twenty-four of the cases were boys and 31 were girls. Mean age was 11.3 ± 3 years. Twenty of the cases (36%) were uncomplicated and 35 (64%) were complicated. Nine of the complicated cases presented advanced generalized peritonitis and were additionally classified as "another special group". Mean leukocyte count and C-reactive protein levels were measured respectively as 22.49 ± 12 x 10⁹ /L and 120.5 ± 99 mg/L in complicated cases and as 17.06 ± 10 x 10⁹ and 52.37 ± 69 mg/L in uncomplicated cases. All advanced generalized peritonitis cases had presented to the hospital with intestinal obstruction and had diffuse abdominal rigidity on physical exam. None of the cases had any complications in the intraoperative or early postoperative period. Infection complications (namely, intra-abdominal abscesses and surgical site infections) were observed in four cases (7%) in the postoperative period. Mean length of hospital stay was 5.62 ± 2.6 days and 3.95 ± 1 days in complicated and uncomplicated cases, respectively. Mean length of stay in advanced generalized peritonitis cases was 8.33 ± 2 days. It was observed that laparoscopic appendectomy might be the first choice of treatment option in cases complicated with advanced generalized peritonitis.

Delayed Presentation and Referral Time from General Practitioners Contribute to Increased Complicated Appendicitis during the Initial COVID-19 Pandemic Period in Japan

Objectives

This study aims to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the situation of acute appendicitis (AA) with respect to patients' and general practitioners' behaviors in a general community hospital in Japan.

Methods

The surgical outcomes and periods from symptom onset to medical presentation besides practitioners' referral time for consecutive AA patients were compared between the control (January 2016 to March 2020) and COVID-19 periods (April 2020 to April 2021).

Results

Eighty-three patients who underwent emergency surgery for AA were reviewed. Complicated appendicitis significantly increased in the COVID-19 period (63.6% vs. 31.2%, P = 0.023). In the COVID-19 period, the time from symptom onset to the medical presentation (2.2 vs. 0.9 days, P < 0.001) was significantly longer than in the control period. Among the patients who first presented to a general practitioner, the referral time from the practitioner to our hospital was significantly longer in the COVID-19 period (1.6 vs. 0.7 days, P = 0.017). Furthermore, among patients with a fever of higher than 38°C at medical presentation, the time from symptom onset to medical presentation was significantly longer in the COVID-19 period (3.0 vs. 0.7 days, P = 0.015). There was no difference in severe postoperative complications.

Conclusions

Hesitation to seek surgical treatment for AA was seen in both the patients and practitioners in the COVID-19 period. The delay in surgical treatment presumably led to the increase in severe AA. In a pandemic era, timely care for emergent conditions is a crucial challenge.

Multiple regression model to analyze the total LOS for patients undergoing laparoscopic appendectomy

Background

The rapid growth in the complexity of services and stringent quality requirements present a challenge to all healthcare facilities, especially from an economic perspective. The goal is to implement different strategies that allows to enhance and obtain health processes closer to standards. The Length Of Stay (LOS) is a very useful parameter for the management of services within the hospital and is an index evaluated for the management of costs. In fact, a patient's LOS can be affected by a number of factors, including their particular condition, medical history, or medical needs. To reduce and better manage the LOS it is necessary to be able to predict this value.

Methods

In this study, a predictive model was built for the total LOS of patients undergoing laparoscopic appendectomy, one of the most common emergency procedures. Demographic and clinical data of the 357 patients admitted at “San Giovanni di Dio e Ruggi d’Aragona” University Hospital of Salerno (Italy) had used as independent variable of the multiple linear regression model.

Results

The obtained model had an R² value of 0.570 and, among the independent variables, the significant variables that most influence the total LOS were Age, Pre-operative LOS, Presence of Complication and Complicated diagnosis.

Conclusion

This work designed an effective and automated strategy for improving the prediction of LOS, that can be useful for enhancing the preoperative pathways. In this way it is possible to characterize the demand and to be able to estimate a priori the occupation of the beds and other related hospital resources.

Mastering the learning curve significantly reduces operative time for laparoscopic treatment of complicated appendicitis

Laparoscopic appendectomy is the preferred operative method for acute appendicitistreatment. In terms of complicated appendicitis it can be effective in hands of an experiencedlaparoscopist that overwhelmed the learning curve for the method. Aim: Тhis retrospectivestudy examines whether the operative time for laparoscopic appendectomy for complicatedappendicitis is shortened after mastering the learning curve. Material and methods: A totalnumber of 196 patients were operated for the diagnosis of acute appendicitis, of whom 77were diagnosed with complicated appendicitis. They were subsequently divided in two groups(laparoscopic and open). Operative time in both groups was measured and the conversionand postoperative complications were noted. Results: Conversion rate was 2.3%. Operativetime was shorter in the laparoscopic group (67.4 ± 22.9 vs. 77.9 ± 17.9 minutes; p = 0.033).Overall postoperative morbidity was 25.97% with wound infection present only in the opengroup (p = 0.018). Intraabdominal abscess occurred in one patient from the laparoscopicgroup (0.38%). Length of hospital stay was shorter in the laparoscopic group (4.3 ± 2.2 vs. 5.7 ± 2.1, p = 0.0052).  

Controversy in the classification of appendicitis and utilization of postoperative antibiotics

BACKGROUND

There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees.

METHODS

A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression.

RESULTS

In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice.

CONCLUSIONS

Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics.

Aspiration versus peritoneal lavage in appendicitis: a meta-analysis

BACKGROUND

Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis.

METHODS

According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate.

RESULTS

Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%).

CONCLUSIONS

This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.

Comparison of intra-abdominal abscess formation after laparoscopic and open appendectomy for complicated and uncomplicated appendicitis: a retrospective study

INTRODUCTION

Acute appendicitis (AA) is one of the most common causes of acute abdominal pain seen in emergency departments and appendectomy has been the preferred treatment of this disease for decades. Postoperative intra-abdominal abscess (PIAA) complicates 3% to 25% of appendectomies and the risk is highest following complicated appendicitis. However, the risk for intra-abdominal abscess formation after appendectomy is still a matter of debate.

AIM

To evaluate PIAA formation after open appendectomy (OA) and laparoscopic appendectomy (LA), in particular in complicated appendicitis.

MATERIAL AND METHODS

From January 2003 to December 2018, records of patients who underwent appendectomy with diagnosis of appendicitis were retrieved from a computer database for analysis.

RESULTS

During the study period, 1809 appendectomies were performed in our institution (939 LAs and 850 OAs). Twenty conversion cases were recorded. There was no difference between the incidences of PIAA (LA, 3.73% (35/939) and OA, 3.41% (29/850); p > 0.05). The incidence of PIAA in those with complicated appendicitis was: LA, 11/212 (5.19%) vs. OA 14/198 (7.07%); p > 0.05.

CONCLUSIONS

This retrospective study shows that the technique of appendectomy does not appear to affect the incidence of IAAs either in uncomplicated or in complicated appendicitis. However, laparoscopic appendectomy has the advantages of laparoscopic procedures, such as lower hospital stay and earlier return to activities, and should therefore be preferred for acute appendicitis.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials

AIMS

The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters.

RESULTS

Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD -0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD -2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection.

CONCLUSION

Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.

Risk of appendiceal neoplasm after interval appendectomy for complicated appendicitis: A systematic review and meta-analysis

BACKGROUND

Non-operative management is often the treatment of choice in cases of complicated appendicitis and routine interval appendectomy is not usually recommended. Actually, recent studies show an alarming number of appendiceal neoplasms following interval appendectomy. The aim of this study is to evaluate the prevalence of appendiceal neoplasms and their histological types after interval appendectomy for complicated appendicitis in adults.

METHODS

A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement. Studies reporting appendiceal neoplasm rates after interval appendectomy and histopathological characteristics were included. The most recent World Health Organization (WHO) classification of malignant tumours was considered. A pooled prevalence analysis for both prevalence and pathology was performed.

RESULTS

A total of eight studies was included: seven retrospective series and one randomized controlled trial. The pooled prevalence of neoplasms after interval appendectomy was 11% (95% CI 7-15; I² = 37.5%, p = 0.13). Appendiceal mucinous neoplasms occurred in 43% (95% CI 19-68), adenocarcinoma in 29% (95% CI 6-51), appendiceal neuroendocrine neoplasm in 21% (95% CI 6-36), globet cell carcinoma in 13% (95% CI -2-28), adenoma or serrated lesions in 20% (95% CI -0-41) of cases.

CONCLUSION

The risk of appendiceal neoplasm in patients treated with interval appendectomy for complicated appendicitis is 11%; mucinous neoplasm is the most common histopathological type. Further studies should investigate this association in order to clarify the biological pathway and clinical implications.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis in children: a systematic review and meta-analysis

AIM

To evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters.

RESULTS

Four RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) - 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes.

CONCLUSIONS

SPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.

Discrepancies between Intraoperative and Histological Evaluation of the Appendix in Acute Appendicitis

PURPOSE

To identify discrepancies between intraoperative and histological evaluations of the appendix in acute appendicitis and to evaluate the effect on surgical outcome.

METHODS

Data was used from our previous multicentre, prospective, cohort study of patients with suspected acute appendicitis. Appendices were scored during intraoperative and histological evaluation as uncomplicated or complicated appendicitis. Primary outcome was percentage of concordance between intraoperative and histological evaluation. Secondary outcomes were (infectious) postoperative complications, length of hospital stay, hospital re-admission and re-intervention rate, all within 30 days of surgery.

RESULTS

A total of 1850 patients were included. In 65.7% (1215/1850) of the appendices, the intraoperative evaluation was uncomplicated and in 34.3% (635/1850), complicated appendicitis. Patients with uncomplicated appendicitis had a postoperative course with significantly less postoperative complications (7.2% vs 24.3%), a shorter length of hospital stay (2 vs 5 days) and a lower re-admission (4.2% vs 9.6%) and re-intervention rate (1.1% vs 4.3%) than intraoperative complicated appendicitis (p < 0.001). In 93.5% (1136/1215) of the intraoperative uncomplicated patients and in 46.6% (296/635) of the intraoperative complicated patients, there was an agreement with pathology (Kappa 0.45). In 23.9% (81/339) of patients with intraoperative complicated and histological uncomplicated appendicitis, a postoperative complication was observed, which was similar to the postoperative complication rate of complicated appendicitis both on intraoperative and histological evaluation (24.7% (73/296)).

CONCLUSIONS

There is a moderate agreement between a surgeon and pathologist in diagnosing patients with complicated appendicitis. However, the intraoperative diagnosis of complicated appendicitis was significantly associated with postoperative complications. Routine histological evaluation should be preserved for excluding malignancies in suspect appendices.

Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults

BACKGROUND

Appendicitis-related hospitalizations linked with peritonitis or postoperative complications result in longer lengths of stay and higher costs. The aim of the present study was to assess the independent association between potential predictors and prolonged hospitalization after laparoscopic appendectomy (LA) for complicated acute appendicitis (CAA).

METHODS

A retrospective cohort study was conducted on adult patients diagnosed with CAA in which LA was attempted. The primary outcome was a prolonged length of stay (LOS) after surgery, defined as hospitalizations longer than or equal to the 75th percentile for LOS, including the day of discharge. Hierarchical regression models were run to elucidate the independent predictors for the variable of interest.

RESULTS

The present study involved 160 patients with a mean age of 50.71 years. The conversion rate was 1.9%, and the overall postoperative morbidity rate was 23.8%. The median length of stay (LOS) was 5 days (75th percentile: 7 days). Multivariate analyses included nine variables that are statistically and/or clinically relevant to assess its relationship with a prolonged LOS: three preoperative (age, sex, and comorbidity), four intraoperative (appendix gangrene, perforation, degree of peritonitis, and drain placement), and two postoperative (immediate ICU admission and complications). The development of postoperative complications (OR 6.162, 95% CI 2.451-15.493; p = 0.000) and the placement of an abdominal drain (OR 3.438, 95% CI 1.107-10.683; p = 0.033) were found to be independent predictors for prolonged LOS. For patients not presenting postoperative complications, drain placement was the only independent predictor for the outcome (OR 7.853, 95% CI 1.520-40.558; p = 0.014). Sensitivity analyses showed confirmatory results.

CONCLUSION

The intraoperative process of care has a clear impact on LOS after LA for CAA in adults; therefore, the decision of whether to drain in these situations should be made more restrictively yet with judicious caution.

Comparing the Cost and Outcomes of Laparoscopic versus Open Appendectomy for Perforated Appendicitis in Children

Although laparoscopic appendectomy (LA) is accepted treatment for perforated appendicitis (PA) in children, concerns remain whether it has equivalent outcomes with open appendectomy (OA) and increased cost. A retrospective review was conducted of patients younger than age 17 years treated for PA over a 12.5-year period at a tertiary medical center. Patient characteristics, pre-operative indices, and postoperative outcomes were analyzed for patients undergoing LA and OA. Of 289 patients meeting inclusion criteria, 86 had LA (29.8%) and 203 OA (70.2%), the two groups having equivalent patient demographics and preoperative indices. Inpatient costs were not significantly different between LA and OA. LA had a lower rate of wound infection (1.2 vs 8.9%, P = 0.017), total parenteral nutrition use (23.3 vs 50.7%, P < 0.0001), and length of stay (5.56 ± 2.38 days vs 7.25 ± 3.77 days, P = 0.0001). There was no significant difference in the rate of postoperative organ space abscess, surgical re-exploration, or rehospitalization. In children with PA, LA had fewer surgical site infections and shorter lengths of hospital stay compared with OA without an increase in inpatient costs.

Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Uncomplicated Acute Appendicitis

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.

Should All Complicated Appendicitis be Treated the Same? the Answer is No

Delayed presentation of acute appendicitis is associated with increased complications. We hypothesized that the outcomes of appendectomy in delayed presentations of acute appendicitis (>72 hours of pain) were dependent on radiologic findings rather than late presentation. We reviewed records from 2009 to 2015 and analyzed delayed presentations of acute appendicitis. We divided patients into three groups based on specific CT findings: uncomplicated appendicitis (UA), phlegmon or abscess (PA), and other perforated appendicitis (PERF, signs of perforation without abscess or phlegmon). One hundred thirty-eight patients were included in this study (58 in the UA, 67 in the PA, and 13 in the PERF groups). Overall, 78 (57%) patients underwent early appendectomy (EA) and 60 (43%) underwent initial conservative management. The incidence of adverse events was lower in EA than that in initial conservative management (17% vs 42%, P = 0.005). EA in the UA group was associated with shorter hospitalization (3.2 vs 5.6 days, P < 0.001) and less adverse events (6% vs 29%, P < 0.05). Severe adverse events (two colectomies and one fecal fistula) were observed in the PA group. In conclusion, in these late presentations of appendicitis, complicated appendicitis was common. EA was safe in selected patients, however, and associated with decreased adverse events.

Comparison of Open Appendectomy and Laparoscopic Appendectomy in Perforated Appendicitis

Introduction Laparoscopic appendectomy for nonperforated appendicitis is associated with improved outcomes. This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay. Materials and methods This study was a prospective randomized study conducted at the Department of Surgery, Holy Family Hospital, Rawalpindi, Pakistan, from January 2016 to January 2017, by randomly allotting the laparoscopic or the open appendectomy technique to 130 patients by the lottery method. Patients having a perforated appendix were included after they provided informed consent. Data were entered and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, US). Results The frequency of wound site infection was significantly higher in open appendectomy (27.69%) than in the laparoscopic approach (10.77%; p=0.01). Mean hospital stay was slightly longer in the laparoscopic approach (4.38 ± 1.09 days) than in open appendectomy (4.18 ± 0.77 days; p=0.23). Mean operating time for laparoscopic appendectomy and open appendectomy was 46.98 ± 2.99 minutes and 53.02 ± 2.88 minutes, respectively (p<0.000). Conclusion Laparoscopic appendectomy was associated with fewer surgical site infections and shorter mean operating time than an open appendectomy.

Laparoscopic versus open appendectomy for perforated appendicitis in adults: randomized clinical trial

BACKGROUND

The advantages of laparoscopic appendectomy did not meet the same acceptance in the setting of perforated appendicitis as in uncomplicated appendicitis in the general surgical community. The aim of this study was to compare the clinical outcome of laparoscopic and open appendectomy in perforating appendicitis.

METHODS

A randomized controlled study was conducted on 126 patients presenting with perforated appendicitis. Sixty patients were subjected to laparoscopic appendectomy (LA) and 66 patients underwent traditional open appendectomy (OA).

RESULTS

65 (51.6%) patients were female, and 61 (48.4%) patients were male in whom the mean age was 37.6 + 8.5 years. A significant difference was calculated in the domains of postoperative pain, less need for analgesics, hospital stay, and return to daily activities. The mean operative time was shorter in OA 94 ± 10.4 min than LA 120.6 ± 17.7 min. No statistically significant difference between both groups was detected as regard occurrence of intra-abdominal collection.

CONCLUSION

In view of its clinical outcomes, laparoscopy should be considered in the context of perforated appendicitis. The possibility of intra-abdominal collection should not be a barrier against the widespread practice of this surgical procedure amidst laparoscopic surgeons if adequate precautions are employed.

Single-Incision, Two-Port Laparoscopic Appendectomy as an Alternative to Transumbilical Single-Port Laparoscopic Appendectomy

Purpose

We designed a modified technique to perform an advanced procedure using conventional instruments and did not employ specialized single-incision laparoscopic surgery (SILS) port equipment. We compared postoperative results for transumbilical, single-port laparoscopic appendectomy (TUSPLA) and single-incision, 2-port laparoscopic appendectomy (SITPLA).

Methods

This retrospective study enrolled 77 patients who underwent TUSPLA or SITPLA to provide more minimally invasive surgery between May 2017 and April 2018. TUSPLA was performed in 39 patients and 38 underwent SITPLA. In the SITPLA group, two 5-mm trocars were inserted through the umbilicus and an extra puncture site was used for a left-handed instrument. Demographic characteristics, operative data, and postoperative outcomes were collected and compared between the groups.

Results

The mean total operative time in the SITPLA group was shorter than in the TUSPLA group (p=0.003). The mean laparoscopic instrumental time was also shorter (p<0.001) in the SITPLA. The number of postoperative analgesics in the SITPLA group was less than in the TUSPLA group (p=0.002). The length of hospital day after surgery was shorter in the SITPLA group than in the TUSPLA group (p=0.008). There were no other significant differences between the groups.

Conclusion

SITPLA had a shorter operative time, required less pain management, and had a similar cosmetic outcome when compared with TUSPLA.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Systematic Review and Meta-Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature

AIMS

To review and compare the outcomes of laparoscopic (LA) versus open appendicectomy (OA) in complicated appendicitis in adult patients, eight years after the last literature review.

METHODS

The PRISMA guidelines were adhered to. Pre-defined inclusion and exclusion criteria were used to search the PubMed, Scopus and Cochrane databases and extract relevant data. Methodological and quality assessment was undertaken with outcome meta-analysis and subgroup analyses of methodological quality, type of study and year of study. Assessment of clinical and statistical heterogeneity and publication bias was conducted.

RESULTS

Three randomised control trials (RCTs) (154LA vs 155OA) and 23 case-control trials were included (2034LA vs 2096OA). Methodological quality was low to average but with low statistical heterogeneity. Risk of publication bias was low, and meta-regression indicated shorter length of hospital stay (LOS) in more recent studies, Q = 7.1, P = 0.007. In the combined analysis LA had significantly less surgical site infections [OR = 0.30 (0.22,0.40); p < 0.00001] with reduced time to oral intake [WMD = -0.98 (-1.09,-0.86); P < 0.00001] and LOS [WMD = -3.49(-3.70,-3.29); p < 0.00001]. There was no significant difference in intra-abdominal abscess rates [OR = 1.11(0.85,1.45); p = 0.43]. Operative time was longer during LA [WMD = 10.51 (5.14,15.87); p = 0.0001] but did not reach statistical significance (p = 0.13) in the RCT subgroup analysis.

CONCLUSIONS

LA appears to have significant benefits with improved morbidity compared to OA in complicated appendicitis (level of evidence II).

Laparoscopic Appendectomy in Children With Perforated Appendicitis: A Meta-Analysis

BACKGROUND

The purpose of this meta-analysis was to compare the influence of different surgical procedures on perforated appendicitis in pediatric population.

MATERIALS AND METHODS

Studies were identified through a computerized literature search of Pubmed, Embase, Ovid, the Cochrane Colorectal Cancer Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials, the Cochrane Library database, and Web of Science. Two reviewers independently assessed the quality of each study and abstracted outcome data. Data were extracted comparing laparoscopic appendectomy (LA) and open appendectomy (OA) in pediatric population with regard to several postoperative variables. We synthesized published data using fixed-effect models, expressing results as relative risk (RR).

RESULTS

Nine eligible studies were included which came from various medical centers all over the world. Statistically significant differences between "LA" and "OA" groups were found for wound infection (RR=0.88), intra-abdominal abscess (RR=1.38), and bowel obstruction (RR=0.79).

CONCLUSIONS

Our meta-analysis found that LA is associated with lower incidence of wound infections and bowel obstruction, but the rate of intra-abdominal abscess was higher than OA.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

BACKGROUND

Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial.

OBJECTIVES

To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials.

SELECTION CRITERIA

We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities.

AUTHORS' CONCLUSIONS

It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.

Is laparoscopic appendectomy feasible for complicated appendicitis ?A systematic review and meta-analysis

BACKGROUND

laparoscopic appendectomy(LA) has proved to be a safe alternative to open appendectomy(OA) in uncomplicated appendicitis; however, the feasibility of LA for complicated appendicitis(CA) has not been conclusively determined.

OBJECTIVES

To assess the feasibility and safety of LA for CA through a systematic review and meta-analysis.

METHODS

A literature search in PubMed, Embase, Cochrane Library, and web of Science was performed for eligible studies published from the inception of the databases to January 2016. All studies comparing LA and OA for CA were reviewed. After literature selection, data extraction and quality assessment were performed by two reviewers independently, and meta-analysis was conducted using Revman software, vision 5.2.

RESULTS

Two randomized controlled trials (RCTs) and 14 retrospective cohort studies(RCSs) were finally identified. Our meta-analysis showed that LA for CA could reduce the rate of surgical site infections (SSIs) (OR = 0.28; 95% CI: 0.25 to0.31, P < 0.00001), but LA did not increase the rate of postoperative intra-abdominal abscess(IAA) (OR = 0.79; 95% CI: 0.45 to 1.34, P = 0.40). The results showed that the operating time in the LA groups was much longer than that in the OA groups (WMD = 13.78, 95% CI: 8.99 to 18.57, P < 0.00001). However, the length of hospital stays in the LA groups were significantly shorter than those in the OA groups (WMD = -2.47, 95%CI: -3.75 to -1.19, P < 0.0002), and the time until oral intake(TTOI) was much earlier in the LA groups than in the OA groups (WMD = -0.88, 95% CI: -1.20 to -0.55, P < 0.00001). No significant difference was observed in the times of postoperative analgesia between the two groups(P > 0.05).

CONCLUSION

LA was feasible and safe for complicated appendicitis, and it not only could shorten the hospital stays and the time until oral intake, but it could also reduce the risk of surgical site infection.

Conversion-to-open in laparoscopic appendectomy: A cohort analysis of risk factors and outcomes

BACKGROUND

Identifying risk factors for conversion from laparoscopic to open appendectomy could select patients who may benefit from primary open appendectomy. We aimed to develop a predictive scoring model for conversion from laparoscopic to open based on pre-operative patient characteristics.

METHODS

A retrospective review of the State Inpatient Database (2007-2011) was performed using derivation (N = 71,617) and validation (N = 143,235) cohorts of adults ≥ 18 years with acute appendicitis treated by laparoscopic-only (LA), conversion from laparoscopic to open (CA), or primary open (OA) appendectomy. Pre-operative variables independently associated with CA were identified and reported as odds ratios (OR) with 95% confidence intervals (CI). A weighted integer-based scoring model to predict CA was designed based on pre-operative variable ORs, and complications between operative subgroups were compared.

RESULTS

Independent predictors of CA in the derivation cohort were age ≥40 (OR 1.67; CI 1.55-1.80), male sex (OR 1.25; CI 1.17-1.34), black race (OR 1.46; CI 1.28-1.66), diabetes (OR 1.47; CI 1.31-1.65), obesity (OR 1.56; CI 1.40-1.74), and acute appendicitis with abscess or peritonitis (OR 7.00; CI 6.51-7.53). In the validation cohort, the CA predictive scoring model had an optimal cutoff score of 4 (range 0-9). The risk of conversion-to-open was ≤5% for a score <4, compared to 10-25% for a score ≥4. On composite outcomes analysis controlling for all pre-operative variables, CA had a higher likelihood of infectious/inflammatory (OR 1.44; CI 1.31-1.58), hematologic (OR 1.31; CI 1.17-1.46), and renal (OR 1.22; CI 1.06-1.39) complications compared to OA. Additionally, CA had a higher likelihood of infectious/inflammatory, respiratory, cardiovascular, hematologic, and renal complications compared to LA.

CONCLUSIONS

CA patients have an unfavorable complication profile compared to OA. The predictors identified in this scoring model could help select for patients who may benefit from primary open appendectomy.

Pediatric Appendicitis

Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.

Complications in common general pediatric surgery procedures

Complications related to general pediatric surgery procedures are a major concern for pediatric surgeons and their patients. Although infrequent, when they occur the consequences can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss the common complications encountered during several common pediatric general surgery procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair, laparoscopic pyloromyotomy, and laparoscopic appendectomy.

A single case of single-port access laparoscopic appendectomy during the puerperium

Laparoscopic appendectomy is now widely practiced for the treatment of acute appendicitis. As result of increased demand for minimally invasive surgery, single-incision access was introduced and is being performed in various abdominal surgeries. Conventional laparoscopic appendectomy (LA) is gradually being performed in pregnant women. A 33-year-old woman was referred to our department at 39 weeks and 1 day of gestation due to abdominal pain. She was aware of her gastroepiploic pain even after the delivery. Though it was past 2 days, she was not recovering from right lower abdominal pain, so she was transferred to the Department of Gynecology at our hospital on the same day. Although an antibiotic was administered, the right abdominal pain did not improve, and she was referred to our department from the Department of Gynecology. We performed single-port LA (SP-LA). The total operation time was 63 minutes, and the estimated blood loss was 0 mL. She was discharged with no complications on postoperative day 7. We report our initial experience with single-port LA (SP-LA) using the glove technique for treatment of acute appendicitis in a postpartum woman. SP-LA using the glove technique was performed successfully during the puerperium without prolongation of operation time. This approach is less invasive, offers a much better cosmetic result than with conventional methods, and can be performed safely and at low cost.

The evolving management of the appendix mass in the era of laparoscopy and interventional radiology

AIM

An appendix mass is the result of a walled-off perforation of the appendix which localises, resulting in a mass and it is encountered in up to 7% of patients presenting with acute appendicitis. However, its management is controversial due to the lack of high level evidence. This review article sets out a rationale diagnostic and therapeutic strategy for the appendix mass based upon up-to-date available evidence.

METHODS

A literature review of the investigation and management of appendix mass/complicated appendicitis was undertaken using PubMed, EMBASE and Google Scholar.

RESULTS/CONCLUSION

No prospective studies were identified. The great majority of recent evidence supports a conservative management approach avoiding urgent appendicectomy because of the high risk of major complications and bowel resection. Appendix abscesses over 5 cm in diameter and persistent abscesses should be drained percutaneously along with antibiotics. Appendix phlegmon should be treated with antibiotics alone. Surgery is reserved for patients who fail conservative treatment. Routine interval appendicectomy is not recommended, but should be considered in the context of persistent faecolith, ongoing right iliac fossa pain, recurrent appendicitis and appendix mass persistent beyond 2 weeks. Clinicians should be particularly wary of patients with appendix mass aged over 40 and those with features suggesting malignancy.

Operative management of appendicitis

Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.

Does Conversion Adversely Impact the Clinical Outcomes for Patients with Complicated Appendicitis?

BACKGROUND

Although the feasibility of laparoscopic appendectomy (LA) in complicated appendicitis (CA) has been demonstrated, LA is typically underused in CA due to its high conversion rate. However, little is known regarding the clinical course of conversion in CA.

MATERIALS AND METHODS

Between January 2005 and April 2012, 1699 patients older than 16 years underwent an appendectomy at our institution. Of these, 207 were confirmed to have CA, which was defined as operative findings of gangrenous or perforated appendix, with or without abscess formation. Patients were divided into the following three groups: open group (OG), laparoscopy group (LG), and converted group (CG). Perioperative outcomes were compared between the three groups.

RESULTS

Thirty-eight patients underwent open surgery. Among the 169 patients for whom laparoscopic surgery was originally attempted, 20 (11.8%) were converted. Operation time was significantly longer and estimated blood loss was higher in the CG than in the other groups. Fewer overall complications were observed and the length of hospital stay (LOH) was shorter in the LG than in the OG and CG. However, no significant differences were observed between the OG and CG regarding the overall complication rate or LOH. Operation method was the only factor associated with postoperative morbidity in multivariate analysis.

CONCLUSION

While completion by laparoscopy was associated with better outcomes than the other two procedures at all levels, open conversion did not increase the overall morbidity or LOH compared with open appendectomy. Laparoscopic approach could be a viable option even in the management of CA.

Comparison of clinical outcome of laparoscopic versus open appendectomy for complicated appendicitis

BACKGROUND

Laparoscopic appendectomy is now the treatment of choice in uncomplicated appendicitis. To date its importance in the treatment of complicated appendicitis is not clearly defined.

METHODS

From January 2005 to June 2013 a total of 1762 patients underwent appendectomy for the suspected diagnosis of appendicitis at our institution. Of these patients 1516 suffered from complicated appendicitis and were enrolled. In total 926 (61 %) underwent open appendectomy (OA) and 590 (39 %) underwent laparoscopic appendectomy (LA). The following parameters were retrospectively analyzed: age, sex, operative times, histology, length of hospital stay, 30-day morbidity focusing on occurrence of surgical site infections, intraabdominal abscess formation, postoperative ileus and appendiceal stump insufficiency, conversion rate, use of endoloops and endostapler.

RESULTS

A statistically significant difference in operative time was observed between the laparoscopic and the open group (64.5 vs. 60 min; p = 0.002). Median length of hospitalization was significantly shorter in the laparoscopic group (p < 0.000). Surgical site infections occurred exclusively after OA (38 vs. 0 patients). Intraabdominal abscess formation occurred statistically significantly more often after LA (2 vs. 10 patients; p = 0.002). There were no statistical significances concerning the occurrence of postoperative ileus (p = 0.261) or appendiceal stump insufficiencies (p = 0.076).

CONCLUSIONS

The laparoscopic approach for complicated appendicitis is a safe and feasible procedure. Surgeons should be aware of a potentially higher incidence of intraabdominal abscess formation following LA. Use of endobags , inversion of the appendiceal stump and carefully conducted local irrigation of the abdomen in a supine position may reduce the incidence of abscess formation.

Learning curve after rapid introduction of laparoscopic appendectomy: are there any risks in surgical resident participation?

BACKGROUND

With the spread of the minimally invasive technique, laparoscopic appendectomy (LA) is performed with increasing frequency with excellent results. The method provides surgical residents with an excellent opportunity to learn basic laparoscopic skills and prepares them for more complex interventions.

METHODS

We evaluated the results of 600 laparoscopic appendectomies performed by 5 surgical residents (Group A) and 5 consultant surgeons (Group B) between 2006 and 2009. Comparing the two groups based on patient demographics, duration of surgery, operation time depending on the severity of inflammation, intraoperative blood loss, conversion rate, hospital stay in days, and postoperative complications. We also assessed the extent to which the minimum of 20 surgeries to be performed in the learning curve period as recommended by the EAES corresponds to our experience. SPPS 20 was used for the statistical analysis.

RESULTS

Six hundred laparoscopic appendectomies were performed in the study period (Group A: n = 319; Group B: n = 281). A significant difference was found between the two groups in duration of surgery during the learning curve period and when comparing the duration of LA surgeries in the learning curve period with the duration of later surgeries in both groups. The operation time in case of more severe inflammation also showed a significant difference when comparing with simple appendicitis operation time.

CONCLUSIONS

The rapid introduction of laparoscopy involves few risks, the surgery is also performed with sufficient safety by surgical residents, and it provides them with an excellent opportunity to learn the basic laparoscopy skills.

Hospital preference of laparoscopic versus open appendectomy: Effects on outcomes in simple and complicated appendicitis

PURPOSE

We hypothesize that laparoscopic (LA) or open appendectomy (OA) outcomes are associated with hospital procedure preference.

METHODS

We queried Kids' Inpatient Database (1997-2009) for simple (ICD-9-CM 540.9) and complicated (540.0, 540.1) appendicitis.

RESULTS

On PS-matched analysis of simple appendicitis (91,118 LA vs. 97,496 OA), LA had increased transfusion (1.7) rates, but lower wound infection (0.6) and perforation/laceration (0.3) rates. LA had shorter length of stay (LOS; 1.7 vs. 2.1days), but higher total charges (TC; 19,501 vs. 13,089 USD) and cost (7121 vs. 5968) vs. OA. For complicated appendicitis (28,793 LA vs. 30,782 OA), LA had increased nausea/vomiting rates (1.9), but lower wound infection (0.5) and transfusion (0.6) rates. LA had shorter LOS (5.1 vs. 5.9), but higher TC (32,251 vs. 28,209). MVA demonstrated shorter LOS (0.9) for LA at laparoscopic-preferring hospitals vs. open-preferring hospitals for simple appendicitis. For complicated appendicitis, higher complication rates (1.1) were associated with OA at laparoscopic-preferring hospitals. Laparoscopic-preferring hospitals had higher TC in all categories.

CONCLUSION

Complications and resource utilization for appendicitis are associated with surgical technique and hospital procedure preference. Laparoscopic-preferring hospitals had higher complication rates with OA for complicated appendicitis and higher charges regardless of appendectomy technique or appendicitis type.

LEVEL OF EVIDENCE

2c, Outcomes Research.

Risk factors for the development of complicated appendicitis in adults

OBJECTIVE

To investigate the patient's history and physical examination information to find out risk factors associated with complicated appendicitis.

MATERIAL AND METHODS

Two hundred patients who were admitted with complicated appendicitis (including abscess, phlegmon, and generalized peritonitis) were retrieved from our database. Two hundred patients with non-complicated acute appendicitis were randomly selected from the same period. These two groups were compared in terms of demographic characteristics, past medical history, and presenting symptoms. We made a multivariate analysis model using binary logistic regression and backward stepwise elimination.

RESULTS

Based on multivariate analysis, risk factors for complicated appendicitis included presenting with epigastric pain (OR=3.44), diarrhea (OR=23.4) or malaise (OR=49.7), history of RLQ pain within the past 6 months (OR=4.93), older age (OR=1.04), being married (OR=2.52), lack of anorexia (OR=4.63) and longer interval between onset of symptoms and admission (OR=1.46). Conversely, higher (academic) education was associated with decreased odds for complicated appendicitis (OR=0.26).

CONCLUSION

Our findings suggest that a surgeon's clinical assessment is more reliable to make a judgment. "Bedside evaluation" is a useful, cheap, quick and readily available method for identifying those at risk for developing complicated acute appendicitis.

Laparoscopic Surgery or Conservative Treatment for Appendiceal Abscess in Adults? A Randomized Controlled Trial

OBJECTIVE

We hypothesized that immediate laparoscopic surgery for appendiceal abscess would result in faster recovery than conservative treatment.

BACKGROUND

On the basis of the retrospective studies, conservative management of appendiceal abscess is recommended as a first line treatment, but some controversy exists.

METHODS

Sixty adult patients diagnosed with appendiceal abscess were randomly assigned to either laparoscopic surgery (n = 30) or conservative treatment (n = 30). Hospital stay, recurrences, additional interventions, and complications within 60 days from randomization were recorded.

RESULTS

There was no difference in hospital stay: 4 days (interquartile range: 3-5 days) in the laparoscopy group versus 5 days (3-8) in the conservative group, P = 0.105. Patients in the laparoscopy group had 10% risk for bowel resection and 13% risk for incomplete appendectomy. There were significantly fewer patients with unplanned readmissions in the laparoscopy group: 1 (3%) versus 8 (27%), P = 0.026. Additional interventions were required in 2 (7%) patients in the laparoscopy group (percutaneous drainage) and in 9 (30%) patients in the conservative group (surgery), P = 0.042. Recurrent abscesses and failure to respond to conservative treatment were the main reasons for additional interventions. Open surgery was required in 3 (10%) patients in the laparoscopy group and in 4 (13%) patients in the conservative group. Postoperative complications occurred in 3 patients in laparoscopic group versus 2 patients in the conservative group. The rate of uneventful recovery was 90% in the laparoscopy group versus 50% in the conservative group, P = 0.002.

CONCLUSIONS

Laparoscopic surgery in experienced hands is safe and feasible first-line treatment for appendiceal abscess. It is associated with fewer readmissions and fewer additional interventions than conservative treatment with comparable hospital stay.

Early outcome of the Korean Diagnosis-Related Groups payment system for appendectomy

Purpose

The implementation of the Korean diagnosis-related groups (DRG) payment system has been recently introduced in selected several diseases including appendectomy in Korea. Here, we report the early outcomes with regard to clinical aspects and medical costs of the Korean DRG system for appendectomies in Seoul Metropolitan Government - Seoul National University Boramae Medical Center throughout comparing before and after introduction of DRG system.

Methods

The DRG system was applied since January 2013 at our institute. After the DRG system, we strategically designed and applied our algorithm for the treatment of probable appendicitis. We reviewed the patients who were treated with a procedure of appendectomy for probable appendicitis between July 2012 and June 2013, divided two groups based on before and after the application of DRG system, and compared clinical outcomes and medical costs.

Results

Total 416 patients were included (204 patients vs. 212 patients in the group before vs. after DRG). Shorter hospital stays (2.98 ± 1.77 days vs. 3.82 ± 1.84 days, P < 0.001) were found in the group after DRG. Otherwise, there were no significant differences in the perioperative outcomes and medical costs including costs for first hospitalization and operation, costs for follow-up after discharge, frequency of visits of out-patient's clinic or Emergency Department or rehospitalization.

Conclusion

In the Korean DRG system for appendectomy, there were no significant differences in perioperative outcomes and medical costs, except shorter hospital stay. Further studies should be continued to evaluate the current Korean DRG system for appendectomy and further modifications and supplementations are needed in the future.

Early experience with laparoscopic surgery in children in Ile-Ife, Nigeria

BACKGROUND

Laparoscopy is not yet routinely employed in many Paediatric Surgical Units in Nigeria despite the advantages it offers. This study describes the preliminary experience with laparoscopic procedures in a single centre.

PATIENTS AND METHODS

A retrospective analysis of all children who had laparoscopic surgery between January 2009 and December 2013 at the Paediatric Surgical Unit of Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife was carried out. Their sociodemographic, preoperative and intraoperative data along with postoperative records were subjected to descriptive analysis.

RESULTS

Eleven (44%) diagnostic and 14 (56%) therapeutic procedures were performed on 25 children whose age ranged from 5 months to 15 years (Median: 84 months, Mean: 103 ± 64.1 months), including eight (32%) females and 17 (68%) males. Indications included acute appendicitis in 12 (48%), intra-abdominal masses in six (24%), three (12%) disorders of sexual differentiation, two (8%) ventriculoperitoneal shunt malfunctions and impalpable undescended testes in two (8%) children. The procedures lasted 15-90 minutes (Mean = 54 (±21.6) minutes). Conversion rate was 17% for two patients who had ruptured retrocaecal appendices. No intra operative complications were recorded while three (12%) patients had superficial port site infections post-operatively. All diagnostic (11) and two therapeutic procedures were done as day case surgery. The mean duration of hospital stay was 3.1 (±3.3) days for those who had appendectomies.

CONCLUSION

Laparoscopic surgery in children is safe and feasible in our hospital. We advocate increased use of laparoscopy in paediatric surgical practice in Nigeria and similar developing settings.