Economics of appendicitis: cost trend analysis of laparoscopic versus open appendectomy from 1998 to 2008

Aiming for minimally invasive treatment of pediatric acute appendicitis in a district hospital

Background

Appendicitis is the most common cause of acute abdomen. Although emergency surgery used to be the standard treatment for both simple and complex appendicitis, there are now options for interval surgery, laparoscopic surgery, and even non-surgical treatment. In this study, we aimed to establish better treatment strategies for pediatric acute appendicitis and to find out whether minimally invasive treatment is superior to the traditional open approach. We retrospectively reviewed the cases of acute appendicitis treated in our hospital during the period from 2013 to 2018. The patients who underwent appendectomy were divided into four groups. Group 1 underwent early appendectomy with open approach, group2 underwent interval appendectomy with open approach, group 3 underwent early appendectomy with laparoscopic approach, and group 4 underwent interval appendectomy with laparoscopic approach. In addition to the above groups, the non-surgical treatment group was also studied. Clinical presentation, laboratory findings, imaging results, operative time, morbidity, and length of hospital stay were reviewed.

Results

One hundred six children’s records were reviewed. Thirty-five of them were selected for non-surgery as they were cases with no fecal stone and first onset appendicitis, and 15 of these 35 patients (42.9%) relapsed after antibiotic treatment. As for the appendix diameter, the relapse group was significantly larger than the non-relapse group (p=0.007). In cases of surgery, group 4 had significantly less intraoperative blood loss than group 1 (p<0.001). Group 4 had significantly fewer postoperative complications than groups 1 and 2 [group 4 vs. group 1 (p=0.009), group 4 vs. group 2 (p=0.034)]. The postoperative hospital stay in groups 2 and 4 were significantly shorter than group 1 [group 1 vs. group 2 (p=0.015), group 1 vs. group 4 (p<0.001)]. On the contrary, group 1 had significantly shorter total hospital stay than groups 2 and 4 [group 1 vs. group 2 (p=0.029), group 1 vs. group 4 (p<0.001)].

Conclusion

Interval laparoscopic appendectomy and non-surgical treatment were safe and effective in children. From the viewpoint of avoiding unnecessary emergency surgery and prolonged hospitalization, we believe that interval laparoscopic appendectomy or non-surgical treatment should be performed after identifying patients who do not require surgery, paying attention to the risk factors for relapse.

Comparison of outcomes and cost-effectiveness of laparoscopic and open appendectomies in public health services

Acute appendicitis is the leading cause of abdominal emergency surgery worldwide and appendectomy continues to be the definitive treatment of choice. This cost-effectiveness analysis evaluates laparoscopic versus open appendectomies performed in public health services in the state of Bahia (Brazil). We conducted a retrospective observational study using the database from the Department of Informatics of the Unified Health System (DATASUS). Available data on appendectomies between 2008 and 2019 were included, and we evaluated the temporal trend of hospital admissions, procedure-related mortality rates, length of stay, and costs. Statistical analysis was performed using the R-software (R Foundation, v.4.0.3) and the BioEstat software (IMDS, v. 5.3), considering p<0.05 as significant. During 2008-2019, 53,024 appendectomies were performed in the public health services in Bahia, of which 94.9% were open surgeries. The open technique was associated with a higher mortality rate (4.9/1,000 procedures; p<0.05) and a higher risk of death (RR=4.5; p<0.05) compared to laparoscopy (1.1/1,000 procedures). Laparoscopic appendectomy (median of 2.7 days) had a shorter length of stay compared to laparotomy (median of 4.15 days) (p<0.05). There was no difference in the medians of costs nor hospital services, per procedure (p=0.08 and p=0.08, respectively). Laparoscopic professional median costs were higher by US$ 1.39 (p<0.05). Minimally invasive surgery for appendicitis is a safe and efficacious procedure in Brazilian public health care services, as it provides advantages over the open method (including lower procedure-related mortality rate and earlier discharges), and it did not imply higher expenses for public service budgets in the state of Bahia.

Comparison of postoperative complications between open and laparoscopic appendectomy: An umbrella review of systematic reviews and meta-analyses

BACKGROUND

Laparoscopic appendectomy (LA) has been popular for decades because of shorter hospitalization and return to routine activity. However, complications (e.g., surgical site infection [SSI] and intra-abdominal abscess [IAA]) relative to open appendectomy (OA) are still debated. We therefore conducted an umbrella review to systematically appraise meta-analyses (MAs) comparing SSI and IAA between LA and OA.

METHODS

Meta-analyses that included only randomized controlled trials were identified from MEDLINE and Scopus databases from inception until July 2018. Their findings were described, the number of overlapping studies was assessed using corrected covered area, and excess significant tests were also assessed. Finally, effect sizes of SSI and IAA were repooled.

RESULTS

Ten MAs were eligible; SSI was reported in all MAs and IAA in 8 MAs. Surgical site infection rate was 48% to 70% lower in LA than OA, but conversely, IAA rate was 1.34 to 2.20 higher in LA than OA. Overlapping included studies for SSI and IAA were 61% and 54%, respectively, indicating that less information was added across MAs. However, there was no evidence of bias from excess significant tests when pooling SSI or IAA estimates. The risk ratios (95% confidence interval) comparing LA versus OA were repooled in adults and children yielding risk ratios of 0.56 (0.47-0.67) and 0.40 (0.25-0.65) for SSI, and 1.20 (0.88-1.63) and 1.05 (0.61-1.80) for IAA.

CONCLUSION

Evidence from this umbrella review indicates that LA carries a significantly lower risk of SSI but likely a higher risk of IAA than OA.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level I.

Financial Impact of Surgical Technique in the Treatment of Acute Appendicitis in Children

Appendicitis is the most common emergent problem encountered by pediatric surgeons. Driven by improved cosmetic outcomes, many surgeons are offering pediatric patients single-incision laparoscopic appendectomy. We sought to investigate the financial impact of different surgical approaches to appendectomy. A retrospective study of patients with acute appendicitis undergoing appendectomy from February 2010 to September 2011 was conducted. Based on surgeon preference, patients underwent open appendectomy (OA), laparoscopic appendectomy (LA), or single-incision laparoscopic appendectomy (SILA). Demographic information, surgical outcomes, surgical supply costs, and total direct costs were recorded. A total of 465 patients underwent appendectomy during the study. The mean age of all patients was 11.2 years (range, 1 to 18 years). There were no conversions in the LA or SILA groups. There was a significant difference among surgical technique in regard to surgical supply costs (OA $159 vs LA $650 vs SILA $814, P < 0.01) and total direct costs (OA $2129 vs LA $2624 vs SILA $2991, P < 0.01). In our institution, both multiport laparoscopic and SILA carry higher costs when compared with OA, largely as a result of the cost of disposable instrumentation. Cost efficiency should be considered by surgeons when undertaking a minimally invasive approach to appendectomy.

Cost Saving of Short Hospitalization Nonoperative Management for Acute Uncomplicated Appendicitis

BACKGROUND

Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol.

MATERIALS AND METHODS

We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model.

RESULTS

The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving.

CONCLUSIONS

Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.

Disease burden of appendectomy for appendicitis: a population-based cohort study

Background

Few large-scale epidemiologic studies evaluate the clinical and economic burden of appendicitis. These data may impact future research and treatment strategies. In this study, the objective was to determine the burden of appendectomy for appendicitis in terms of incidence rates, length of hospital stay (LOS) and hospital costs on a national level. In addition, outcomes were compared for subgroups based on surgical treatment, age and hospital setting.

Methods

Observational retrospective population-based cohort study using the national Dutch healthcare reimbursement registry, which covers hospital registration and reimbursement for 17 million inhabitants. Patients with a diagnosis of appendicitis who underwent appendectomy between 2006 and 2016 were included. Primary outcomes were incidence rates, LOS and hospital costs.

Results

A total of 135,025 patients were included. Some 53% of patients was male, and 64% was treated in a general hospital. The overall incidence rate of appendectomy was 81 per 100,000 inhabitants and showed a significant decreasing trend across time and age. Mean ± SD LOS per patient was 3.66 ± 3.5 days. LOS showed a significant increase with age and was significantly longer for open versus minimally invasive appendectomy. Mean ± SD hospital costs per patient were €3700 ± 1284. Costs were initially lower for open compared to minimally invasive appendectomy, but were similar from 2012 onward. Compared to non-university hospitals, patients treated in university hospitals had a significantly longer LOS and higher costs.

Conclusions

Appendectomy for appendicitis represents a substantial clinical and economic burden in the Netherlands. A preference for minimally invasive technique seems justified.

Mini-Incision Open Appendectomy with Incision Skin Tissue Retractor vs. Laparoscopic Appendectomy: A Retrospective Study of the Management of Child Acute Appendicitis

Introduction

This study aims to compare the clinical effects of an incision skin tissue retractor for mini-incision open appendectomy and laparoscopic surgery for pediatric appendicitis.

Methods

From January 2014 to July 2017, a total of 248 patients were included in the present study. Laparoscopic appendectomy was performed for 108 cases (LA group), and mini-incision open appendectomy with an incision skin tissue retractor was performed for 140 cases (MOA-ISTR group). Then, medical history, age, gender, operative duration, amount of bleeding during the operation, the determination of whether or not the appendix was perforated during the operation, hospitalization days, total cost of hospitalization, and complications after the operation (incision infection or intestinal obstruction) were compared. The SPSS 20.0 software package was used for the statistical analysis.

Results

There were no statistically significant differences in history, age, gender, perioperative perforation of the appendix, postoperative hospital stay and postoperative complications (incisional infection or intestinal obstruction, P  > 0.05). However, the values for duration of surgery, intraoperative blood loss and total hospitalization expense were smaller, when compared with the LA group (P  < 0.05).

Conclusion

Mini-incision open appendectomy with an incision skin tissue retractor has similar efficacy and incision appearance when compared with laparoscopic appendectomy. Furthermore, this approach leads to shorter operation time, less intraoperative blood loss and less hospitalization time, and is more convenient, especially for perforated appendicitis. Moreover, it can be widely used for pediatric appendicitis, and is more suitable for doctors who are not skilled in basic hospitals and laparoscopy.

Cost Effectiveness of Different Methods of Appendiceal Stump Closure during Laparoscopic Appendectomy

There is no standard method for closure of an appendiceal stump during laparoscopic appendectomy. This study compares stump closure using a stapler with closure using an Endoloop ligature. The charts of all patients who underwent laparoscopic appendectomy at a single tertiary care center over a two-year period were reviewed for demographics, comobidities, operative details and costs, and outcomes. There were 325 patients who underwent a laparoscopic appendectomy. The majority, 250 (77%), underwent stump closure with a stapler. They were equivalent in demographics and postoperative complication rates. Cases using an Endoloop were slightly faster in terms of procedure time and room time, and less expensive in terms of operative supply cost. The price difference is not explained by time saved in the operating room and more likely by the equipment price.

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.

A Population-Based Cohort Study of Emergency Appendectomy Performed in England and New York State

BACKGROUND

To compare selected outcomes (30-day reoperation and total length of hospital stay) following emergency appendectomy between populations from New York State and England.

METHODS

This retrospective cohort study used demographic and in-hospital outcome data from Hospital Episode Statistics (HES) and the New York Statewide Planning and Research Cooperative System (SPARCS) administrative databases for all patients aged 18+ years undergoing appendectomy between April 2009 and March 2014. Univariate and adjusted multivariable logistic regression were used to test significant factors. A one-to-one propensity score matched dataset was created to compare odd ratios (OR) of reoperations between the two populations.

RESULTS

A total of 188,418 patient records, 121,428 (64.4%) from England and 66,990 (35.6%) from NYS, were extracted. Appendectomy was completed laparoscopically in 77.7% of patients in New York State compared to 53.6% in England (P < 0.001). The median lengths of hospital stay for patients undergoing appendectomy were 3 (interquartile range, IQR 2-4) days versus 2 (IQR 1-3) days (P < 0.001) in England and New York State, respectively. All 30-day reoperation rates were higher in England compared to New York State (1.2 vs. 0.6%, P < 0.001), representing nearly a twofold higher risk of 30-day reoperation (OR 1.88, 95% CI 1.64-2.14, P < 0.001). As the proportion of appendectomy completed laparoscopically increased, there was a reduction in the reoperation rate in England (correlation coefficient -0.170, P = 0.036).

CONCLUSIONS

Reoperations and total length of hospital stay is significantly higher following appendectomy in England compared to New York State. Increasing the numbers of appendectomy completed laparoscopically may decrease length of stay and reoperations.

Cost-effectiveness of prophylactic appendectomy: a Markov model

BACKGROUND

Appendectomy is the most common emergency surgery performed in the USA. Removal of a non-inflamed appendix during unrelated abdominal surgery (prophylactic or incidental appendectomy) can prevent the downstream risks and costs of appendicitis. It is unknown whether such a strategy could be cost saving for the health system.

METHODS

We considered hypothetical patient cohorts of varying ages from 18 to 80, undergoing elective laparoscopic abdominal and pelvic procedures. A Markov decision model using cost per life-year as the main outcome measure was constructed to simulate the trade-off between cost and risk of prophylactic appendectomy and the ongoing risk of developing appendicitis, with downstream costs and risks. Rates, probabilities, and costs of disease, treatment, and outcomes by patient age and gender were extracted from the literature. Sensitivity analyses were conducted using complications and costs of prophylactic appendectomy.

RESULTS

With our base-case assumptions, including added cost of prophylactic appendectomy of $660, we find that prophylactic removal of the appendix is cost saving for males aged 18-27 and females aged 18-28 undergoing elective surgery. The margin of cost savings depends on remaining life-years and increases exponentially with age: a 20-year-old female undergoing elective surgery could save $130 over a lifetime by undergoing prophylactic appendectomy, while a 40-year-old female would lose $130 over a lifetime. When the risk of the prophylactic appendectomy exceeds the risk of laparoscopic appendectomy for appendicitis or the cost exceeds $1080, it becomes more cost saving to forego the prophylactic procedure.

CONCLUSIONS

Prophylactic appendectomy can be cost saving for patients younger than age thirty undergoing elective laparoscopic abdominal and pelvic procedures.

Patient characteristics, outcomes and costs following interhospital transfer to a tertiary facility for appendectomy versus patients who present directly

BACKGROUND

Recent healthcare policy changes have emphasized pay-for-performance. Previous studies have not examined outcome differences between primary presenting appendicitis patients and transferred patients.

METHODS

A retrospective cohort design examined appendicitis patients between March 2011 and 2013. Patients < age 18, were scheduled for an elective appendectomy, who were pregnant or had an interval appendectomy were excluded.

RESULTS

The transfer cohort (n = 59) had more comorbidities, more severe American Society of Anesthesiologists status, a higher rate of pre-operative abscess/rupture as well as higher rates of perforation, gangrene, intra-operative drain placement and open conversion versus primary presenting patients (n = 622). After statistical regression adjustment, a higher open conversion rate in the transfer cohort, OR = 3.48 (95%CI: 1.04-11.61) and higher total costs $672.47 (95%CI: $68.75-$1276.19) remained.

CONCLUSIONS

Adjustments in clinical outcome/reimbursement metrics may be needed to address the complexity of transfers and the subsequent higher in-hospital costs on tertiary facilities.

LEVEL OF EVIDENCE

IV.

Laparoscopic Appendectomy Is Safe: Influence of Appendectomy Technique on Surgical-site Infections and Intra-abdominal Abscesses

PURPOSE

Surgical-site infections (SSIs) and intra-abdominal abscesses (IAAs) are the most frequent complications of appendectomy. The role of laparoscopy in the treatment of appendicitis remains controversial concerning the complication rate. The aim of this retrospective cohort study was to compare open and laparoscopic appendectomy for SSI and IAA.

METHODS

All patients undergoing appendectomy between January 1, 2007 and May 31, 2010 were included in the study. Perioperative data and data on postoperative complications were collected from patient files. A questionnaire was used to assess complications after discharge. Main outcome parameters were SSI and IAA. Open appendectomy (OAG) and laparoscopic appendectomy (LAG) were compared with univariate and multivariate analyses for the outcome parameters.

RESULTS

Four hundred thirty patients were included in the study. SSI (all: 10.6%, OAG: 11.7%, LAG: 7.5%, P=0.293) and IAA (all: 2.8%, OAG: 2.4%, LAG: 3.8%, P=0.506) were not significantly different between OAG and LAG. Risk factors for SSI were age (P=0.003), body mass index (P=0.017), ASA score (P=0.001), the intraoperative grade of inflammation (P=0.004), and the histologic grade of inflammation (P=0.015). The only risk factor for IAA was the intraoperative grade of inflammation (P=0.028). ASA score (odds ratio: 1.992, P=0.032) and the intraoperative grade of inflammation (odds ratio: 1.573, P=0.006) remained significant in the multivariate analysis for SSI.

CONCLUSIONS

A higher ASA score correlates with SSI. A higher grade of intraoperative inflammation correlates with SSI and IAA. Laparoscopy has no impact on SSI and IAA in appendectomy.

Laparoscopic vs mini-incision open appendectomy

AIM: To compare laparoscopic vs mini-incision open appendectomy in light of recent data at our centre.

METHODS: The data of patients who underwent appendectomy between January 2011 and June 2013 were collected. The data included patients’ demographic data, procedure time, length of hospital stay, the need for pain medicine, postoperative visual analog scale of pain, and morbidities. Pregnant women and patients with previous lower abdominal surgery were excluded. Patients with surgery converted from laparoscopic appendectomy (LA) to mini-incision open appendectomy (MOA) were excluded. Patients were divided into two groups: LA and MOA done by the same surgeon. The patients were randomized into MOA and LA groups a computer-generated number. The diagnosis of acute appendicitis was made by the surgeon with physical examination, laboratory values, and radiological tests (abdominal ultrasound or computed tomography). All operations were performed with general anaesthesia. The postoperative vision analog scale score was recorded at postoperative hours 1, 6, 12, and 24. Patients were discharged when they tolerated normal food and passed gas and were followed up every week for three weeks as outpatients.

RESULTS: Of the 243 patients, 121 (49.9%) underwent MOA, while 122 (50.1%) had laparoscopic appendectomy. There were no significant differences in operation time between the two groups (P = 0.844), whereas the visual analog scale of pain was significantly higher in the open appendectomy group at the 1^st hour (P = 0.001), 6^th hour (P = 0.001), and 12^th hour (P = 0.027). The need for analgesic medication was significantly higher in the MOA group (P = 0.001). There were no differences between the two groups in terms of morbidity rate (P = 0.599). The rate of total complications was similar between the two groups (6.5% in LA vs 7.4% in OA, P = 0.599). All wound infections were treated non-surgically. Six out of seven patients with pelvic abscess were successfully treated with percutaneous drainage; one patient required surgical drainage after a failed percutaneous drainage. There were no differences in the period of hospital stay, operation time, and postoperative complication rate between the two groups. Laparoscopic appendectomy decreases the need for analgesic medications and the visual analog scale of pain.

CONCLUSION: The laparoscopic appendectomy should be considered as a standard treatment for acute appendicitis. Mini-incision appendectomy is an alternative for a select group of patients.

Cost effectiveness of nonoperative management versus laparoscopic appendectomy for acute uncomplicated appendicitis

BACKGROUND

Appendectomy remains the gold standard in the treatment of acute, uncomplicated appendicitis in the United States. Nonetheless, there is growing evidence that nonoperative management is safe and efficacious.

METHODS

We constructed a decision tree to compare nonoperative management of appendicitis with laparoscopic appendectomy in otherwise healthy adults. Model variables were abstracted from a literature review, data from the Healthcare Cost and Utilization Project data, the Medicare Physician Fee schedule, and the American College of Surgeons Surgical Risk Calculator. Uncertainty surrounding parameters of the model was assessed via 1-way and probabilistic sensitivity analyses.

RESULTS

Operative management cost $12,213 per patient. Nonoperative management without interval appendectomy (IA) was the dominant strategy, costing $1,865 less and producing 0.03 more quality-adjusted life-years (QALYs). Nonoperative management with IA cost $4,271 more than operative management, but yielded only 0.01 additional QALY. One-way sensitivity analysis suggested operative management would become the preferred strategy if the recurrence rate was >40.5% or the total cost of appendectomy was decreased to <$5,468. Probabilistic sensitivity analysis confirmed nonoperative management without IA was the preferred strategy in 95.6% of cases.

CONCLUSION

Nonoperative management without IA is the least costly, most effective treatment for acute, uncomplicated appendicitis and warrants further evaluation in a disease thought to be definitively surgical.

Cosmetic outcomes following appendectomy in children: a comparison of surgical techniques

BACKGROUND

Although cosmetic superiority is widely stated as an advantage of single-incision laparoscopy, there are limited studies looking at cosmetic outcome. We sought to determine patients' cosmetic satisfaction after undergoing appendectomy by the single-incision laparoscopic appendectomy (SILA), multiport laparoscopic appendectomy (LA), or open appendectomy (OA) procedure.

PATIENTS AND METHODS

Five hundred eighty pediatric patients who underwent appendectomy at a single institution between February 2010 and July 2011 were identified and asked to complete the Patient Scar Assessment Scale (PSAS), a validated evaluation tool for linear scars. In addition, patients were asked the "Ultimate Question" (UQ), which correlates with a patient's overall satisfaction. Linear regression models were used to examine differences between surgical approaches with statistical significance set at P<.05. Covariates for all models included patient demographics, length of stay, and surgeon.

RESULTS

In total, 212 surveys were returned (SILA, 122; LA, 41; OA, 49) for a response rate of 37%. Regression models demonstrated significantly higher mean total PSAS scores for patients who underwent SILA and laparoscopic appendectomy (LA) appendectomy procedures compared with the open procedure (SILA, 8.70; LA, 8.86; OA, 8.01; β=-0.21, P<.05). Patients who experienced the SILA and LA procedures reported significantly higher mean UQ scores compared with OA (SILA, 9.79; LA, 9.75; OA, 9.39; β=-0.22, P<.05). SILA patients reported a 10 on the UQ significantly more often (91.1%) compared with either LA (81%) or OA (75.5%) (P<.05).

CONCLUSIONS

SILA or LA appendectomy was associated with significantly increased cosmetic satisfaction by patients and their families when compared with OA. This is the first study to show that pediatric patients value attempts to minimize scarring with laparoscopic surgery. Further studies are needed to determine if specific patient factors influence satisfaction with scars.

Laparoscopic versus open appendectomy for complicated appendicitis in high risk patients

INTRODUCTION

Laparoscopic appendectomy is widely used for the treatment of complicated appendicitis. Its use in patients with high operative risk is still on debate. The aim of the presented study was to investigate the benefits of laparoscopic appendectomy in patients with high peri- and postoperative risk factors.

METHODS

We performed a retrospective analysis of all patients who underwent appendectomy in our center between 2006 and 2013. Patients were classified according to their preoperative risk (classification of the American Society of Anesthesia--ASA score). Only patients with ASA 3 and 4 were included and were divided into two groups--open appendectomy (OA group) and laparoscopic appendectomy (LA group).

RESULTS

The operation time was slightly longer in the LA group (p = 0.05), but hospital stay was shorter (p = 0.05). Complications graded according to the Clavien Dindo classification were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA (p = 0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p = 0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p = 0.05).

CONCLUSION

Laparoscopic appendectomy can be recommended for patients with complicated appendicitis even with higher risk categories.

Management of appendiceal stump in laparoscopic appendectomy--clips or ligature: a systematic review and meta-analysis

BACKGROUND

Appendicular stump closure is a crucial step during laparoscopic appendectomy. Recently, endoclips (ECs) have been described for ligation of the appendicular stump. The objective of this review was to compare outcomes with EC versus endoligature (EL) for appendiceal stump closure during laparoscopic appendectomy.

MATERIALS AND METHODS

A literature search of Medline, Embase, Cochrane Database, and Google Scholar was performed to identify studies comparing use of EL versus EC in laparoscopic appendectomy between January 1992 and September 2013. Reviews of each study were conducted, and data were extracted. The random-effects model was used to combine data, and between-study heterogeneity was assessed.

RESULTS

Seven of the 101 identified studies met the inclusion criteria: four randomized controlled trials and three case controlled series. For the primary outcome of perioperative and postoperative complications, there was no significant difference between the EC versus EL groups. No differences were noted in length of hospital stay. However, a significant reduction in operative time was observed with EC as opposed to EL (standardized mean difference=-0.90, 95% confidence interval=-1.26 to -0.54, P=.001). Moreover, EC procedures were less expensive than EL procedures.

CONCLUSIONS

EC application in the management of appendiceal stump during laparoscopic appendectomy appears to be simple, efficacious, safe, and a cost-effective alternative.

Laparoscopic Appendectomy versus Mini-Incision Appendectomy in Patients with Lower Body Mass Index and Noncomplicated Appendicitis

Laparoscopic appendectomy has become favored over open surgical methods for its association with decreased postoperative pain, more rapid return to daily activities, and improved cosmetic results. Mini-incision appendectomy was being performed in our clinic for a long time especially in patients with noncomplicated appendicitis and in patients with appropriate body mass index. Although laparoscopy presents obvious advantages especially for obese patients and young women, with respect to the results of our study, mini-incision appendectomy seems to be an alternative for selected patient groups.

Laparoscopic appendectomy with hand-made loop

Introduction

Acute appendicitis is the most common abdominal pathology requiring emergent surgical procedure. For treatment, laparoscopic surgery is commonly performed. For appendix stump closure different procedures are used.

Aim

Evaluation of the results of patients in whom the stump of the appendix was closed with a hand-made loop during laparoscopic appendectomy (LA).

Material and methods

Patients in whom the stump of the appendix was closed with a hand-made loop during LA were included in the study. Reports of patients were collected from patient files retrospectively. Laparoscopic appendectomy was applied through 3 ports. Two loops were placed in the stump of the appendix. Loop was a modification of the Roeder loop that has been described in the literature and has been shown to be safe.

Results

Sixty-one patients were included in the study. Twenty-four of them (39%) were female, 37 of them (61%) were male. The age range is from 13 to 60 (average age is 30) years. During the postoperative period, one surgical wound infection and two intraabdominal abscesses were detected. There was no leakage from the stump of the appendix in any patients.

Conclusions

One of the most important components of cost of LA is the technique of closure of the stump. Stapler, endoloop, various clips or a hand-made loop could be used for closure. We recommend using a hand-made loop for closure as an easy, safe and cheap method.

Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital

BACKGROUND

Laparoscopic appendectomy is not yet unanimously considered the "gold standard" in the treatment of acute appendicitis because of its higher operative time, intra-abdominal abscess risk, and costs compared to open appendectomy. This study aimed to compare outcomes and cost of laparoscopic and open appendectomy in a district hospital.

METHODS

A retrospective analysis of 230 patients who underwent appendectomy at the Division of General Surgery of the Civil Hospital of Ragusa, Italy, from May 2008 to May 2012 was performed. The variables analyzed included patients data (age, gender, previous abdominal surgery, preoperative WBC count, duration of symptoms, ASA risk score), rate of uncomplicated or complicated appendicitis, operative time, postoperative complications, length of hospital stay, and total costs. The patients were divided in two groups according to the surgical approach and compared for each variable. The results were analyzed using the t Student test for quantitative variables, and the Chi-square test with Yates correction and Fisher exact test for categorical.

RESULTS

Laparoscopic appendectomy was performed in 139 patients, open appendectomy in 91. Two cases (1.4%) were converted to open procedure and included in the laparoscopic group data. Patient data and rate of complicated appendicitis were similar in the two study groups. There was no statistical difference (p = 0.476) in the mean operative time between the laparoscopic (52.2 min; range, 20-155) and open appendectomy (49.3 min; range, 20-110) groups. The overall incidence of minor and major complications was significantly lower (p = 0.006) after laparoscopic appendectomy (2.9%, 4 cases) than after open appendectomy (13.2%, 12 cases); rate of intra-abdominal abscess were similar. The length of hospital stay was significantly shorter (p = 0.001) in laparoscopic group (2.75 days; range, 1-8) than in open group (3.87 days; range, 1-19). The mean total cost was 2282 Euro in laparoscopic group and 2337 Euro in open group, with a no significant difference of 55 Euro (p = 0.812).

CONCLUSION

Laparoscopic appendectomy is associated with fewer complications, shorter hospital stay, and similar operative time, intra-abdominal abscess rate, and total costs, compared with open appendectomy. Therefore, laparoscopic appendectomy can be recommended as preferred approach in acute appendicitis.

The evolution of laparoscopy in abdominal surgery: a meta-analysis of the effect on infectious outcomes

BACKGROUND

Laparoscopic surgery has been recommended as an effective strategy because of its advantages in decreasing abdominal surgical site infections (SSIs). The aim of this study was to assess the effect of laparoscopy on superficial and organ/space SSIs compared with open surgery in hollow-viscus procedures over time.

STUDY DESIGN

Data on SSIs from randomized-controlled trials (RCTs) evaluating open versus laparoscopic abdominal surgeries were extracted from the Cochrane Database Reviews. Re-analysis of these data was performed to assess infections. Heterogeneity was also explored. A subgroup analysis was performed according to elective/emergency surgery status.

RESULTS

Data from 72 RCTs including 8218 patients were collected (4116 patients in the laparoscopic group and 4102 patients in the open group). For superficial SSI, the pooled RD was -4.4% (95% CI: -5.4% to -3.3%), which indicated a lower risk in the laparoscopic group. For organ/space SSI, the pooled RD was 0.5% (95% CI: -0.1% to 1%), which indicated similar rates between the groups. Changes in SSI frequency had occurred over time.

CONCLUSION

Laparoscopic surgery significantly decreases the risk of superficial SSI but does not affect the risk of organ/space SSI. Experience with technique improves outcomes.

Cost Comparison between Laparoscopic and Open Appendectomies in Children

OBJECTIVES

Laparoscopic appendectomy (LA) for children has become very popular and is routinely performed in most health care centres around the world. The cost of surgical procedures is always a concern for patients and health care providers. This study compares, the total cost of open appendectomy (OA) with LA in children who required an appendectomy for acute appendicitis. Suitable and safe cost-effective techniques were also explored to reduce the cost of these procedures.

METHODS

The medical records of all the children (ranging between 0 and 12 years) at Sultan Qaboos University Hospital in Oman, who required OA or LA from June 2009 to July 2011, were reviewed.

RESULTS

LA were performed in 75 patients while OA were done in 34. Patients from the OA and LA groups were age- and gender-matched. The average operative time was 76 minutes for LA and 49 minutes for OA (P <0.001) while the average hospital stay was 3.14 days for LA and 2.15 days for OA (P = 0.08). The average cost of the two procedures was Omani riyals (OMR) 534 for LA and OMR 343 for OA (P = 0.00). The complication rate following procedures was lower in the case of LA, however this was not statistically significant (LA = 8% versus OA = 11.7 %, P = 0.32).

CONCLUSION

LA are costlier procedures than OA, however they are as safe as OA, and do not increase morbidity or the duration of hospital stay.