Open versus laparoscopic treatment for pan-peritonitis secondary to perforated appendicitis in children: a prospective analysis

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.

Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis

BACKGROUND

Laparoscopic appendectomy (LA) is the preferred approach in uncomplicated appendicitis. However, in patients with complicated appendicitis (CA), the best approach is still unclear though laparoscopy is being increasingly preferred over open appendicectomy (OA) nowadays.

AIM

To comprehensively review the current literature and compare the associations of LA and OA concerning various postoperative outcomes in order to determine the best approach for children with CA.

METHODS

The PRISMA guidelines were adhered to and an electronic database search was extensively performed. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Methodological and statistical heterogeneity, as well as publication bias of the included studies, were assessed.

RESULTS

Four randomized controlled trials (266 LA versus 354 OA) and thirty-six case-controlled trials (2580 LA versus 3043 OA) were included in the analysis. Compared to OA, LA has a shorter length of stay, a lower rate of surgical site infection as well as a significantly lower overall complication rate. The rates of intraabdominal abscess formation, post-operative fever, pneumonia and ileus are similar in the two groups. So are the rates of readmissions and reoperations. LA was also shown to have a shorter time taken to oral intake and a lesser requirement of analgesics as well as intravenous antibiotics. Operative time for OA was found to be significantly shorter than that for LA.

CONCLUSION

This meta-analysis objectively demonstrates that laparoscopy has a better overall complication profile compared to OA and should be the procedure of choice in children with complicated appendicitis.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Adhesive small bowel obstruction after appendectomy in children - Laparoscopic versus open approach

BACKGROUND

The aims of this study were to compare the incidence of small bowel obstruction (SBO) requiring laparotomy after laparoscopic appendectomy (LA) and open appendectomy (OA) in children and to identify risk factors for SBO.

METHODS

Medical records of patients who underwent appendectomy from 2000 to 2014 at our department of Pediatric Surgery were reviewed. Risk factors were analyzed using Cox proportional hazard regression.

RESULTS

Totally 619 out of 840 patients were included. OA was performed in 474 (76.6%), LA in 130 patients (21%), and 15 (2.4%) were converted from LA to OA. Age, sex and proportion of perforated appendicitis were comparable in the LA and OA groups. Median follow-up time was 11.4 years (2.6-18.4). The incidence of SBO after LA was 1.5%, after OA 1.9% and in the converted group 6.7% (p = 0.3650). There were no significant differences in the incidence of postoperative intraabdominal abscess, wound infection or length of stay between LA and OA. Perforation and postoperative intra-abdominal abscess were identified as risk factors with 9.03 (p < 0.001) and 6.98 (p = 0.004) times higher risk of SBO, respectively.

CONCLUSIONS

The risk for SBO after appendectomy in children was significantly related to perforated appendicitis and postoperative intra-abdominal abscess and not to the surgical approach.

LEVEL OF EVIDENCE

Level III.

[Laparoscopic surgery for advanced appendicular peritonitis]

OBJECTIVE

To evaluate the results of laparoscopic treatment of patients with advanced appendicular peritonitis.

MATERIAL AND METHODS

There were 271 patients with acute appendicitis complicated by peritonitis. The main group consisted of patients who underwent laparoscopic appendectomy after diagnostic laparoscopy (n=231), the control group - diagnostic laparoscopy followed by conversion to median laparotomy (n=36). Four extremely ill patients were operated through laparotomy and excluded from the further analysis.

RESULTS

Diagnostic laparoscopy was performed in 267 patients with advanced appendicular peritonitis. Laparoscopic appendectomy, debridement and abdominal drainage were performed in 231 (85.2%) patients. Mean age of patients was 44±18.5 years, duration of disease - 36.2±20.3 hours. Diffuse peritonitis was diagnosed in 219 (82%) patients, advanced peritonitis - in 48 (16.5%) cases. Incidence of conversion was 13.5%. Mortality was absent in both groups. Postoperative morbidity was significantly higher in the conversion group (72.2% vs. 29.4%, p<0.0001).

CONCLUSION

Laparoscopic interventions for common appendicular peritonitis are feasible, effective and reduce postoperative morbidity.

Prevalence of organ-space surgical site infections after appendectomy for ruptured appendix in children

Introduction: Appendicitis can be classified as non-perforated and perforated; based on such classification, the reported organ-space surgical site infection (OS-SSI) rate is 0.8% and 18%, respectively.Objective: To establish the prevalence of OS-SSI in patients with perforated appendicitis treated in a pediatric hospital in 2012.Materials and methods: Retrospective, observational and descriptive study conducted at Fundación Hospital Pediátrico La Misericordia, with a random sample of 200 patients, of which 160 met the inclusion criteria.Results: 20 patients (12.5%) presented with OS-SSI and all of them received antibiotic treatment; 70% did not require abscess drainage. Patients ≥8 years of age had 5 times more abscesses than younger ones (17.6% vs. 3.4%). OS-SSI was found in 33% of patients with free fecalith and in 50% of the patients who required postoperative management at the ICU vs. 9.5% of the patients who received management in the intermediate care unit and the inpatient hospital floors. The total rate of surgical site infection was 24.3% (11.8% superficial, 0% deep and 12.5% organ-space).Conclusions: The prevalence of OS-SSI found here is lower than what has been reported in the literature. Being 8 years or older and having free fecalith are risk factors to develop this type of infection. The higher frequency of OS-SSI in patients treated at the ICU during the post-operative period observed here suggests that this condition may be associated with septic shock.

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.

C-reactive Protein may Predict the Recurrence of Appendicitis in Children Formerly with Appendiceal Mass after Successful Non-operative Treatment

BACKGROUND

This study identified factors associated with the recurrence of appendicitis in children with appendiceal masses after successful nonsurgical treatment.

METHODS

In this retrospective study, children who were diagnosed as having appendiceal masses after undergoing conservative treatment between 2000 and 2014 were enrolled and the medical records of those who did not undergo an interval appendectomy were reviewed. The clinical features and outcomes of patients with and those without recurrent appendicitis were compared. Regression analysis was used to identify risk factors of appendicitis recurrence.

RESULTS

Seventy patients were included and successfully discharged after receiving nonsurgical treatment for appendiceal masses. Of the patients, 35 (50.0%) developed recurrent appendicitis and 85.7% (30/35) recurrences developed within 3 months. Multivariate analyses showed that patients with a higher serum C-reactive protein (CRP) level and peritonitis more frequently developed recurrence. The appendicitis recurrence rate was significantly higher in the patients with CRP levels of ≥103 mg/L with an odds ratio of 16.9 or in those with peritonitis with an odds ratio of 4.9.

CONCLUSION

Children with appendiceal masses who develop peritonitis or have CRP levels of ≥103 mg/L have a higher recurrence rate of appendicitis and should undergo an interval appendectomy.

Serum C-reactive protein concentrations in early abdominal and pulmonary sepsis

Objectives

To evaluate the C-reactive protein serum levels in patients with pulmonary and abdominal sepsis during the first five days of sepsis progression.

Methods

The present investigation was a retrospective cohort study conducted at the university hospital with 345 patients who were admitted to the intensive care unit and diagnosed with sepsis of pulmonary or abdominal origin. Serum C-reactive protein concentrations were measured by the turbidimetric immunoassay. For analysis of C-reactive protein, day 1 was defined as the day on which the patient was clinically diagnosed with sepsis.

Results

Thirty-four patients with sepsis (9.8%), 114 patients with severe sepsis (33.0%), and 197 patients with septic shock (57.2%) were evaluated. The age of the patients was 56.4±19.8 years. The serum C-reactive protein concentrations were higher on the day of sepsis diagnosis in the group with abdominal infection compared with the group with pulmonary sepsis (17.8±10.1 mg/dL versus 14.9±11.1 mg/dL, p=0.025) and remained significantly higher during the first five days of sepsis progression.

Conclusion

The serum C-reactive protein concentrations were significantly higher in the patients with abdominal sepsis compared with the patients with pulmonary sepsis during the first five days of sepsis progression.

Laparoscopic treatment of perforated appendicitis

The use of laparoscopy has been established in improving perioperative and postoperative outcomes for patients with simple appendicitis. Laparoscopic appendectomy is associated with less wound pain, less wound infection, a shorter hospital stay, and faster overall recovery when compared to the open appendectomy for uncomplicated cases. In the past two decades, the use of laparoscopy for the treatment of perforated appendicitis to take the advantages of minimally invasiveness has increased. This article reviewed the prevalence, approaches, safety disclaimers, perioperative and postoperative outcomes of the laparoscopic appendectomy in the treatment of patients with perforated appendicitis. Special issues including the conversion, interval appendectomy, laparoscopic approach for elderly or obese patient are also discussed to define the role of laparoscopic treatment for patients with perforated appendicitis.

Laparoscopic approach to appendectomy reduces the incidence of short- and long-term post-operative bowel obstruction: systematic review and pooled analysis

BACKGROUND

The aim of this meta-analysis was to determine the effect of laparoscopic appendectomy (LA) compared to open appendectomy (OA) on short-term and long-term post-operative bowel obstruction.

METHODS

Medline, Embase, trial registries, conference proceedings and reference lists were searched. Subset analysis was performed for paediatric patients, patients who presented with perforated appendicitis and studies with long-term follow-up and surveillance for bowel obstruction and with surgery for bowel obstruction.

RESULTS

Overall, 29 studies comprising 159,729 patients (60,875 LA versus 98,854 OA) were included. LA was associated with a significant reduction in the incidence of post-operative bowel obstruction in the general population (pooled odds ratio (POR) = 0.43 [95 %C.I. 0.3-0.63]). Subset analysis demonstrated that LA significantly reduced the incidence of post-operative bowel obstruction in paediatric patients (POR = 0.48 [95 %C.I. 0.3-0.78]) and patients with perforated appendicitis (POR = 0.44 [95 %C.I. 0.26-0.74]). Furthermore, LA was associated with a significantly reduced incidence of long-term bowel obstruction (POR = 0.33 [95 %C.I. 0.19-0.56]) and bowel obstruction requiring surgery (POR = 0.31 [95 %C.I. 0.2-0.48]).

DISCUSSIONS

This present meta-analysis provides evidence to clearly demonstrate the benefits of a laparoscopic approach to appendectomy as reflected by a reduction in short- and long-term adhesive bowel obstruction. Important future areas for assessment include the influence of surgical approach on long-term quality of life following appendectomy.

Pediatric appendicitis: the prevalence of systemic inflammatory response syndrome upon presentation and its association with clinical outcomes

INTRODUCTION

To our knowledge, the prevalence of Systemic Inflammatory Response Syndrome (SIRS) in pediatric patients with appendicitis has not been previously investigated. Our specific aim was to determine the prevalence of SIRS at the time of presentation of pediatric patients with appendicitis. Additionally, we sought to determine if the presence of SIRS had any value in predicting their clinical outcomes.

METHODS

This retrospective cohort study included pediatric patients (age <17 years) presenting to a single hospital and being diagnosed with appendicitis between July 1, 2011, and June 30, 2012. The primary exposure variable of interest was SIRS, dichotomously defined as positive or negative. The primary outcome of interest was the presence/development of an intraabdominal abscess. The secondary outcome of interest was length of hospital stay (LOS). Chi-squared and t-tests were used to evaluate the association between presence of SIRS and development of abscess and LOS.

RESULTS

This study consisted of 212 patients. The definition of SIRS was met in 66 patients (31.1%). Thirty of the 66 (45.6%) patients with SIRS had/developed an abscess versus 28 (19.2%) of those without SIRS (P<0.001). Patients with SIRS had a mean LOS of 4 days (+/-2.7), while those without SIRS stayed a mean of 2.5 days (+/-2.3) [p<0.0001]). Adjusting for age did not alter these associations.

CONCLUSION

Our study found a 31.1% prevalence of SIRS in pediatric patients presenting with appendicitis. Our results suggest these patients with SIRS have a significantly higher risk of having/developing an intraabdominal abscess (RR, 2.4; 95% CI: 1.6-3.6) and significantly longer LOS.

Feasibility of a laparoscopic approach for generalized peritonitis from perforated appendicitis in children

PURPOSE

This study evaluated the feasibility of a laparoscopic approach in children with generalized peritonitis secondary to perforated appendicitis.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of patients who underwent laparoscopic appendectomy with drainage for generalized peritonitis secondary to perforated appendicitis at our hospital between September 2001 and April 2012. Laparoscopic outcomes were compared with outcomes of an open method for perforated appendicitis.

RESULTS

Ninety-nine patients underwent laparoscopic appendectomy (LA) for generalized peritonitis from perforated appendicitis, and 87 patients underwent open appendectomy (OA) for perforated appendicitis. Wound infection was more common in the OA group (12.6%) than in the LA group (4.0%; p=0.032). The incidence of intestinal obstruction during long-term follow-up was significantly higher in the OA group (4.6% vs. 0.0% in the LA group; p=0.046). LA was possible in most patients for whom LA was attempted, with a conversion rate of 10.8%. Conversion to OA was affected by the preoperative duration of symptoms and the occurrence of intraoperative complications.

CONCLUSION

LA is feasible for use in children with generalized peritonitis from perforated appendicitis, with reasonable open conversion and perioperative complication rates comparable to those of the OA group.

Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children

BACKGROUND

Appendectomy is one of the most common emergency operations performed in the pediatric population. The aim of this pooled analysis is to compare the outcome from complicated appendicitis (CA) and uncomplicated appendicitis (UA) following laparoscopic appendectomy (LA) and open appendectomy (OA) in children.

METHODS

A systematic literature search was performed. Primary outcome measures were incidence of complications, intra-abdominal abscess, and wound infection. Secondary outcomes were length of operation, length of hospital stay, incidence of bowel obstruction, and readmission.

RESULTS

Seventy-three thousand one hundred fifty appendectomies for UA and 34,474 appendectomies for CA were included. For UA, the only significant difference between the groups was a reduced length of hospital stay following LA. LA in CA was associated with reduced complications (pooled odds ratio [POR] = 0.53; P < 0.05), wound infections (POR = 0.42; P < 0.05), length of hospital stay (WMD = -0.67; P < 0.05), and bowel obstruction episodes (POR = 0.8; P < 0.05), but an increased incidence of intra-abdominal abscess and length of operation.

CONCLUSION

Pooled analysis demonstrates that, in children with uncomplicated acute appendicitis, LA is associated with a reduced hospital stay but broad equivalence in postoperative morbidity when compared with the conventional approach. Although overall morbidity is reduced when the laparoscopic approach is utilized, in cases of CA, the risk of intra-abdominal abscess is increased.

Laparoscopic versus open appendicectomy in obese patients

BACKGROUND

Although there appears to be no outright benefit of laparoscopic versus open surgery for acute appendicitis in the general population, it has been suggested that in obese patients a laparoscopic approach may offer more conclusive gains. The aim of this pooled analysis of comparative studies was to evaluate clinical outcome following laparoscopic and open appendicectomy in the obese population.

METHODS

A systematic literature search of MEDLINE, Embase, Web of Science and the Cochrane Library databases was performed. Primary outcomes were length of operation (min) and length of hospital stay (days). Secondary outcomes were presence of post-operative complications, wound and intra-abdominal complications. Weighted mean differences were calculated to assess the size of the effect of laparoscopic appendicectomy on continuous variables and Pooled odds ratio were calculated for discrete variables.

RESULTS

2309 appendicectomies were included in this analysis, 1122 laparoscopic and 1187 open appendicectomies. Analysis of primary outcome measures revealed a shorter length of post-operative stay associated with laparoscopic appendicectomy (weighted mean difference = -1.26; 95% confidence interval = -2.36 to -0.16; p = 0.02). There was no significant difference between the groups for length of operation, post-operative complications, intra-abdominal or wound complications.

CONCLUSION

The results of this pooled analysis indicate that laparoscopic appendicectomy may be beneficial in the obese population with a shorter length of hospital stay, and a similar incidence of post-operative complications.

Laparoscopic appendectomy in children with complicated appendicitis: ethnic disparity amid changing trend

BACKGROUND

Laparoscopic appendectomy (LA) has gained acceptance in the treatment of uncomplicated appendicitis in the pediatric population. The role of LA versus open appendectomy (OA) in complicated (perforated) appendicitis has remained controversial.

METHODS

A 10-y review of the Nationwide Inpatient Sample (HCUP-NIS) and 3 y of non-overlapping data from the Kids' Inpatient Database (KID) (2000, 2003, and 2006) was performed on pediatric patients (age <18 y) with complicated appendicitis. Patients were classified based on gender, race, insurance status, and type of appendectomy performed. Multivariate regression was conducted adjusting for age, race, gender, and type of appendectomy, with mortality and length of hospital stay (LOS) as outcomes.

RESULTS

An estimated 72,787 patients met the inclusion criteria with a median age of 11 y. The majorities of the patients were male (59.9%), Caucasian (38.1%), and insured (89.7%). Twenty-nine percent underwent LA while 71% had OA. Proportion of LA increased from 9.9% in 1999 to 46.6% in 2007. On multivariate analysis, African-Americans were less likely to undergo LA compared with Caucasians (OR: 0.80, CI = 0.69-0.92, P = 0.002) despite an increased odds of undergoing LA over the last decade from 1998 to 2007 in the entire study population (OR 6.27, 95% CI 4.73-8.30, P = 0.000). Increasing age and gender were also associated with likelihood of receiving LA (OR: 1.08, CI = 1.06-1.10 and OR 1.25, 95% CI 1.18-1.31, P < 0.001).

CONCLUSIONS

LA is gradually gaining acceptance over the years as an alternative to OA for complicated appendicitis, However, minority difference still exists in choice of procedure. There is a need to further investigate this disparity as it may be related to access to skilled laparoscopic pediatric surgeons.