Laparoscopic versus open appendectomy in children: a meta-analysis

Handmade Loop Versus Hem-o-Lok Clip in Closure of Appendiceal Stump During Laparoscopic Appendectomy: Limited Setting in a Peripheral University Hospital

Background: Today, laparoscopy is frequently used in abdominal emergencies such as acute appendicitis. There are several techniques used to close the appendiceal stump during laparoscopic appendectomy. We aimed to compare the use of handmade loop and Hem-o-lok used to close the appendiceal stump in public hospitals where resources are limited, in terms of surgical outcomes and cost. Methods: Between January 2020 and December 2022, patients for whom handmade loops and Hem-o-loks were used to close the appendiceal stump during laparoscopic appendectomy in our clinic were included in the study. There were a total of 638 patients (mean age: 33 ± 13.5 years, 325 females and 313 males) in the patient cohort. Demographic and clinical data, duration of surgery, complications, hospital stay, pathology reports, mortality, and cost of supplies were compared between the two groups. Results: There were 308 patients in the handmade loop group (160 females, 148 males, mean age: 33.7 years, range: 18-85 years) and 330 patients in the Hem-o-lok group (166 females, 164 males, mean age: 32.5 years, range: 18-89 years). There was no significant difference between the two groups for American Society of Anesthesiologists score, duration of symptom, hospital stay, intensive care unit stay, preoperative laboratory values, histopathological results, mortality, and morbidity (P > .05). The mean operation time was 48.76 ± 16.16 minutes in the handmade loop group and 40.53 ± 11.63 minutes in the Hem-o-lok group (p = 0.001). In terms of cost, the cost per case of Hem-o-lok group was about 25.8 times as much as the group that used sutures ($31 versus $1.2). Conclusions: Both methods can be used safely in laparoscopic appendectomy. The use of Hem-o-lok has no advantage other than shortening the operation time. However, it is costlier. Especially in peripheral hospitals where resources are limited, closing the appendiceal stump using a handmade loop is an easy, safe, and cost-effective method.

Access to Laparoscopic Pediatric Surgery: Do Ethnic and Racial Disparities Exist?

INTRODUCTION

Disparate access to laparoscopic surgery may contribute to poorer health outcomes among racial and ethnic minorities, especially among children. We investigated whether racial and ethnic disparities in laparoscopic procedures existed among four common surgical operations in the pediatric population in the United States.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatrics, we conducted a retrospective review of pediatric patients, aged less than 18 y old, undergoing appendectomy, fundoplication, cholecystectomy, and colectomy from 2012 to 2021. To compare the surgical approach (laparoscopy or open), a propensity score matching algorithm was used to compare laparoscopic and open procedures between non-Hispanic Black with non-Hispanic White children and Hispanic with non-Hispanic White children.

RESULTS

143,205, 9,907, 4,581, and 26,064 children underwent appendectomy, fundoplication, colectomy, and cholecystectomy, respectively. After propensity score matching, non-Hispanic Black children undergoing appendectomy were found to be treated laparoscopically less than non-Hispanic White children (93.5% versus 94.4%, P = 0.007). With fundoplication, Hispanic children were more likely to be treated laparoscopically than White ones (86.7% versus 80.9%, P < 0.0001). There were no statistically significant differences between Black or Hispanic children and White children in rates of laparoscopy for other procedures.

CONCLUSIONS

Though some racial and ethnic disparities exist with appendectomies and fundoplications, there is limited evidence to indicate that widespread inequities among common laparoscopic procedures exist in the pediatric population.

Laparoscopic versus open appendicectomy performed by adult general surgeons in pre-teenage years children: a single-centre experience

INTRODUCTION

The utilisation of laparoscopic appendicectomy (LA) in children remains contentious despite the well-recognised advantages of laparoscopic surgery. The purpose of this study was to compare intraoperative and postoperative outcomes in LA and open appendicectomy (OA) when performed by adult general surgeons outside specialist paediatric practice in younger children.

METHODS

A retrospective review of all patients under the age of 13 who underwent LA for suspected appendicitis over a two-year period was conducted. These were case-matched with an equivalent number of patients who underwent OA during the same period. Intraoperative and postoperative outcomes were compared.

RESULTS

Fifty-one patients underwent LA during the study period. Patient demographics were statistically equivalent with the OA cohort. A statistically significant longer median operating time (58 vs 49min) was noted in the LA group, but intraoperative outcomes were otherwise comparable. LA, when compared with OA, was associated with a significant improvement in postoperative length of stay (2 vs 3 days, p < 0.001), postoperative complication rate (0% vs 6%, p = 0.01), negative appendicectomy rate (3.9% vs 17.6%, p < 0.001) and 30-day readmission rate (0% vs 5.9%, p = 0.03). No patients in the LA group required conversion to open surgery.

CONCLUSION

LA can be safely delivered by adult general surgeons to younger paediatric populations outside the setting of paediatric specialist practice, with statistically significant improvements in postoperative outcomes noted when compared with OA. These findings are of importance in the current healthcare context where adult general surgeons continue to perform the majority of paediatric appendicectomies.

Outcomes of laparoscopic and open ventriculoperitoneal shunt placement

OBJECTIVE

Ventriculoperitoneal (VP) shunt placement requires a concurrent abdominal procedure. For peritoneal access laparoscopic or open approach may be utilized. Our aim was to compare patient/procedure characteristics and outcomes by peritoneal approach for VP shunts in children.

METHODS

NSQIP-Pediatric procedure targeted cerebral spinal fluid shunt Participant Use Data Files from 2016 to 2020 were queried. Patients were grouped into laparoscopic vs open abdominal approach. Patient demographics, procedure characteristics and 30-day outcomes were compared.

RESULTS

7742 NSQIP-Pediatric patients underwent VP shunt placement. Patients undergoing laparoscopic approach were older and required less preoperative support. Mean operative time was longer with laparoscopy (mean(SD): 74.2(48.1) vs. 64.6(39) minutes, p ​< ​0.0001) but had shorter hospital LOS. There was no difference in SSI, readmissions, or reoperation rates.

CONCLUSION

Patients undergoing laparoscopy for distal VP shunts are older with less support needs preoperatively. While laparoscopic approach had a shorter hospital LOS, there was no demonstratable difference in SSI, readmissions or reoperations between approaches. Further studies are needed to assess long-term outcomes.

Appendicitis-related acute referrals to Children's Health Ireland from Non-Specialist Paediatric Surgical Centres

BACKGROUND

Acute appendicitis is the most common surgical emergency in children. Eighty percent of paediatric appendicectomies are performed by adult general surgeons on an annual basis. The remaining 20% are performed at Children's Health Ireland (CHI) centres. Occasionally patients are transferred from Non-Specialist Paediatric Surgical Centres (NSPSC) for specialised pre-operative or post-operative care.

AIM

To assess the rates of and characterise appendicitis-related referrals to CHI at Crumlin from NSPSC.

METHODS

A retrospective review of all appendicitis-related transfers to CHI at Crumlin between January 2020 and December 2021 was performed. Data relating to indications for transfer, referring hospital level, patient demographics, management, type of surgery, length of stay (LOS), and radiological studies were collected and analysed.

RESULTS

Seventy-two patients were transferred to CHI at Crumlin over the 2-year period. A total of 60.9% were male, mean age 9 ± 4.3 years, mean LOS 6.0 ± 2.2 days (range 1-30 days). Nineteen percent were under 5 years of age. Seventy-three percent were transferred from level 4 centres. Ninety-seven percent were transferred pre-operatively, 25% of those transferred pre-operatively had imaging in CHI confirming appendicitis. Fifty-five percent (40/72) of patients had pre-operative imaging performed. A total of 37.5% (15/40) confirmed complicated appendicitis. Twenty percent (8/40) underwent both ultrasound and computerised tomography (CT) at the referring centre. A total of 2.7% (2/72) were transferred with known co-morbidities. Ninety-two percent (66/72) underwent appendicectomy. Eight percent (6/72) were managed non-operatively (NOM) - 2 failed NOM, 2 underwent interval appendicectomy. Of those managed operatively, 76% (50/66) underwent laparoscopic appendicectomy, and 24% (16/66) were performed open.

CONCLUSION

The majority of paediatric appendicectomies are performed at Non-Specialist Paediatric Surgical Centres. It is vital to maintain this working relationship so that specialist paediatric centres are available to provide care to complex paediatric patients.

Low-Impact Laparoscopy vs Conventional Laparoscopy for Appendectomy: A Prospective Randomized Trial

BACKGROUND

Low-impact laparoscopy (LIL), combining low-pressure insufflation and microlaparoscopy, is a surgical technique that is still not widely used and that has never been evaluated for the management of acute appendicitis. The aim of this study is to assess the feasibility of an LIL protocol, to compare postoperative pain, average length of stay, and in-hospital use of analgesics by patients who underwent appendectomy according to a conventional laparoscopy or an LIL protocol.

STUDY DESIGN

Patients presenting with acute uncomplicated appendicitis who were operated on between January 1, 2021, and July 10, 2022, were included in this double-blind, single-center, prospective study. They were preoperatively randomly assigned to a group undergoing conventional laparoscopy, ie with an insufflation pressure of 12 mmHg and conventional instrumentation, and an LIL group, with an insufflation pressure of 7 mmHg and microlaparoscopic instrumentation.

RESULTS

Fifty patients were included in this study, 24 in the LIL group and 26 in the conventional group. There were no statistically significant differences between the 2 patient groups, including weight and surgical history. The postoperative complication rate was comparable between the 2 groups (p = 0.81). Pain was reported as significantly lower according to the visual analog scale 2 hours after surgery among the LIL group (p = 0.019). For patients who underwent surgery according to the LIL protocol, the study confirms a statistically significant difference for theoretical and actual length of stay, ie -0.77 days and -0.59 days, respectively (p < 0.001 and p = 0.03). In-hospital use of analgesics was comparable between both groups.

CONCLUSIONS

In uncomplicated acute appendicitis, the LIL protocol could reduce postoperative pain and average length of stay compared to conventional laparoscopic appendectomy.

Nonoperative Management Versus Laparoscopic Appendectomy in Children: A Cost-Effectiveness Analysis

INTRODUCTION

Nonoperative management (NOM) of acute appendicitis in the pediatric population is highly debated with uncertain cost-effectiveness. We performed a decision tree cost-effectiveness analysis of NOM versus early laparoscopic appendectomy (LA) for acute appendicitis in children.

METHODS

We created a decision tree model for a simulated cohort of 49,000 patients, the number of uncomplicated appendectomies performed annually, comparing NOM and LA. We included postoperative complications, recurrent appendicitis, and antibiotic-related complications. We used the payer perspective with a 1-year time horizon. Model uncertainty was analyzed using a probabilistic sensitivity analysis. Event probabilities, health-state utilities, and costs were obtained from literature review, Healthcare Cost and Utilization Project, and Medicare fee schedules.

RESULTS

In the base-case analysis, NOM costs $6530/patient and LA costs $9278/patient on average at 1 y. Quality-adjusted life year (QALY) differences minimally favored NOM compared to LA with 0.997 versus 0.996 QALYs/patient. The incremental cost-effectiveness ratio for NOM over LA was $4,791,149.52/QALY. NOM was dominant in 97.4% of simulations, outperforming in cost and QALYs. A probabilistic sensitivity analysis showed NOM was 99.6% likely to be cost-effective at a willingness-to-pay threshold of $100,000/QALY.

CONCLUSIONS

Our model demonstrates that NOM is a dominant strategy to LA over a 1-year horizon. We use recent trial data demonstrating higher rates of early and late NOM failures. However, we also incorporate a shorter length of index hospitalizations with NOM, reflecting a contemporary approach to NOM and ultimately driving cost-effectiveness. Long-term follow-up data are needed in this population to assess the cost-effectiveness of NOM over longer time horizons, where healthcare utilization and recurrence rates may be higher.

Subhepatic Appendicitis Presenting With Recurrent Abdominal Pain

Gut malrotation may result in failure of descent of the cecum to the right iliac fossa, resulting in the anomaly where the cecum and appendix are situated in the subhepatic/gallbladder region. Although the true incidence of subhepatic cecum or appendix is not known, there is a handful of case reports in the literature describing the diagnosis and management of subhepatic appendicitis and associated challenges. Some case reports describe subhepatic appendicitis, where the cecum is in a normal position, but the subhepatic tip of the long appendix gets perforated or inflamed, resulting in the process being in the subhepatic region. We report a patient with subhepatic appendicitis, who had multiple episodes of abdominal pain for almost one year, treated with antibiotics, but was never diagnosed properly. The case was diagnosed by abdominal sonography and was managed successfully in our institution.

The Management of Pediatric Acute Appendicitis-Survey among Pediatric Surgeons in Romania

Background and Objectives: To assess the current practice pattern in the management of pediatric acute appendicitis in Romania. Materials and Methods: A questionnaire was emailed to all the members of the Romanian Society of Pediatric Surgery between June-July 2022. Results: 118 answers were received, 79.7% responses being from permanent staff members. In the diagnosis of appendicitis, complete blood count, C-reactive protein and abdominal ultrasound are the most commonly used diagnostic tools, while appendicitis scores are not widely used (25% of surgeons). In the case of simple appendicitis, 49.2% of surgeons prefer the conservative approach-oral/intravenous antibiotics. Those who choose the operative approach begin preoperative antibiotics in 56.7% of patients. In case of a stable patient, only 16.7% of surgeons will operate during the night. Laparoscopic approach is chosen by 51.7% of surgeons. In the case of a complicated appendicitis, 92.4% of surgeons will perform the appendectomy, prescribing preoperative antibiotics in 94% of the cases and continuing the therapy postoperatively in 98.2%. Laparoscopic approach is used by 28.8% of surgeons in case of complicated appendicitis. In presence of appendicular mass, 80% prefer a conservative approach with a delayed appendectomy within 6 months. Appendicular abscesses are managed operatively in 82.2% of the cases. The appendix is sent for histological analysis by 95.8% of surgeons. If the peritoneal cavity is contaminated, 95% of the respondents will take a sample for microbiological analysis, 71% will always place a drainage and 44% will always irrigate (71.9%-saline). Conclusions: Clearly, there seems to be a lack of consensus regarding several aspects of the management of acute appendicitis in children. In addition, minimally invasive surgery is not as widely used as reported, despite literature support.

Laparoscopic versus open repair of congenital duodenal obstruction: a systematic review and meta-analysis

PURPOSE

To assess the safety and efficacy of laparoscopic versus open repair of congenital duodenal obstruction (CDO), we conducted a systematic review and meta-analysis (CDO).

METHODS

A literature search was conducted to identify studies that compared laparoscopic surgery (LS) and open surgery (OS) for neonates with CDO. Meta-analysis was used to pool and compare variables such as operative time, time to feeding, length of hospital stay, anastomotic leak or stricture, postoperative ileus, wound infection, and overall postoperative complications.

RESULTS

Among the 1348 neonatal participants with CDO in the ten studies, 304 received LS and 1044 received OS. When compared to the OS approach, the LS approach resulted in shorter hospital stays, faster time to initial and full feeding, longer operative time, and less wound infection. However, no significant difference in secondary outcomes such as anastomotic leak or stricture, postoperative ileus, and overall postoperative complications was found between LS and OS.

CONCLUSIONS

LS is a safe, feasible and effective surgical procedure for neonatal CDO when compared to OS. Compared with OS, LS has a faster time to feeding, a shorter hospital stay, and less wound infection. Furthermore, in terms of anastomotic leak or stricture, postoperative ileus, and overall postoperative complications, LS is equivalent to OS. We conclude that LS should be considered an acceptable option for CDO.

Impact of the COVID-19 pandemic on management and outcomes of children with appendicitis: The Children with AppendicitiS during the CoronAvirus panDEmic (CASCADE) study

AIM

To report the impact of the SARS-CoV-2 pandemic on management and outcomes of paediatric appendicitis in the UK and Ireland.

METHODS

Prospective, multicentre observational cohort study at general surgical and specialist paediatric surgical centres in the United Kingdom and Ireland from 1st April to 31st July 2020. Primary outcome was treatment strategy used for acute appendicitis.

RESULTS

This study includes 2002 children treated for acute appendicitis of a median age of 10 (range 1-15) years and 605 children from a similar data set pre pandemic from 2017. In the pandemic cohort 560/2002(28%) were initially treated non operatively of whom 125/560(22%) proceeded to appendicectomy within initial hospital admission. Non operative treatment wasn't used in the pre pandemic cohort. Diagnostic imaging use was greater during the pandemic compared to pre pandemic (54vs31%; p < 0.00001) but overall use of laparoscopy was similar during both time periods (62.4vs66.6%). Hospital readmission rate was lower (8.7vs13.9%; p = 0.0002) during the pandemic than pre pandemic and Re-intervention rate was similar (2.9vs2.6%;p = 0.42). In cases treated operatively negative appendicectomy rate was lower during the pandemic than pre pandemic (4.4vs15.4%; p =0.0001), and during the pandemic was amongst the lowest ever reported in the UK.

CONCLUSION

COVID-19 has had a significant impact on the management of children with appendicitis in the UK and Ireland. The rate of imaging and the use of non operative management increased, whilst the negative appendicectomy rate reduced. Overall, patient outcomes have not been adversely impacted by change in management during the pandemic.

CONCLUSION

Level I.

TYPE OF STUDY

Prognosis study.

Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial

PURPOSE

This was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain.

METHODS

Patients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019-2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the "drain" (D) and "no drain" (ND) groups.

RESULTS

Thirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the "D" group was 18% and 35% in the "ND" group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups.

CONCLUSION

From our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications.

TRIAL REGISTRATION NUMBER

SMUREC/M/15/2019: PG.

Association between index complication and outcomes after inpatient pediatric surgery

PURPOSE

A cascade of complications is believed to be the primary mechanism underlying failure to rescue (FTR), or death of a patient after a postoperative complication. It is unknown whether specific types of index complications are associated with the incidence of secondary complications and FTR after pediatric surgery.

METHODS

National cohort study of patients within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2019). Index complications were grouped into nine categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, infectious, or minor [defined as having an associated mortality rate <1%]). The association between the type of index complication with FTR, secondary complications, reoperation, unplanned readmission, and postoperative length of stay was evaluated with multivariable logistic regression and generalized linear modeling.

RESULTS

Among 425,386 patients, 15.5% had at least one complication, 16.6% had one or more secondary complications, 13.9% reoperation, 14.5% readmission, and 2.4% FTR.  Secondary complication (10.8-59.7%) and FTR (0.3-31.1%) rates varied by type of index complication. Relative to patients who had an index minor complication, those with an index infectious complication were most likely to have secondary complication (Odds Ratio [OR] 10.3, 95% CI [9.36-11.4]). Index CV complications were most strongly associated with FTR (OR 30.7 [24.0-39.4]). Index wound complications had the greatest association with reoperation (OR 21.9 [20.5-23.4]) and readmission (OR 18.7 [17.6-19.9]). Index pulmonary complications had the strongest association with length of stay (coefficient 9.39 [8.95-9.83]).

CONCLUSIONS

Different types of index complications are associated with different perioperative outcomes. These data can help identify patients potentially at risk for suboptimal outcomes and can inform pediatric quality improvement interventions.

TYPE OF STUDY

Cohort study.

LEVEL OF EVIDENCE

Level II.

Pediatric Minimally Invasive Surgery-A Bibliometric Study on 30 Years of Research Activity

Background: Pediatric minimally invasive surgery (MIS) is a standard technique worldwide. We aimed to analyze the research activity in this field. Methods: Articles on pediatric MIS (1991−2020) were analyzed from the Web of Science™ for the total number of publications, citations, journals, and impact factors (IF). Of these, the 50 most cited publications were evaluated in detail and classified according to the level of evidence (i.e., study design) and topic (i.e., surgical procedure). Results: In total, 4464 publications and 53,111 citations from 684 journals on pediatric MIS were identified. The 50 most cited papers were published from 32 institutions in the USA/Canada (n = 28), Europe (n = 19), and Asia (n = 3) in 12 journals. Four authors (USA/Europe) contributed to 26% of the 50 most cited papers as first/senior author. Hot topics were laparoscopic pyeloplasty (n = 9), inguinal hernia repair (n = 7), appendectomy, and pyloromyotomy (n = 4 each). The majority of publications were retrospective studies (n = 33) and case reports (n = 6) (IF 5.2 ± 3.2; impact index 16.5 ± 6.4; citations 125 ± 39.4). They were cited as often as articles with high evidence levels (meta-analyses, n = 2; randomized controlled trials, n = 7; prospective studies, n = 2) (IF 12.9 ± 22.5; impact index 14.0 ± 6.5; citations 125 ± 34.7; p > 0.05). Conclusions: Publications on laparoscopic pyeloplasty, inguinal hernia repair, appendectomy, and pyloromyotomy are cited most often in pediatric MIS. However, the relevant number of studies with strong evidence for the advantages of MIS in pediatric surgery is missing.

Comparison of the Electrothermal Bipolar Sealing System (LigaSure) Versus Endoloop in Pediatric Laparoscopic Appendectomy

Background: Laparoscopic appendectomy has long been in the process of replacing open appendectomy owing to a better wound healing, better cosmetic appearance, less pain, and less postoperative adhesion. Although there are many methods for ligating the appendix stump, studies on energy-based coagulation methods have attracted great interest in recent years. In our study, we aimed to compare the use of LigaSure™ appendiceal sealing and ligation of appendiceal stump by endoloop with regard to duration of surgery, length of hospital stay, and complications in laparoscopic appendectomies. Materials and Methods: A total of 174 consecutive patients under the age of 18 who underwent laparoscopic appendectomy in our clinic between September 2016 and February 2021 were retrospectively analyzed. Patients with perforated appendicitis were excluded from the study. The patients were divided into two groups as the appendix stump was ligated with endoloop (Group 1) and sealed with LigaSure (Group 2). Demographic characteristics of the patients, duration of surgery, length of hospital stay, and complications were recorded. Results: Of the 132 patients who were included in the study, Group 1 consisted of patients using endoloop (n = 39) and Group 2 comprised patients that LigaSure was employed (n = 93). There was no significant difference between Groups 1 and 2 in terms of age and length of hospital stay (P = .126 and P = .784, respectively); however, the operation time was found to be significantly shorter in Group 2 (P < .001). Conclusion: The use of LigaSure is a safe and fast method to seal the mesoappendix and appendix stump in pediatric laparoscopic appendectomy. We think that infection complications due to stump leakage and intra-abdominal spillage will less be encountered.

Laparoscopy uptake for paediatric appendicectomy: a comparison of general surgeons versus specialist paediatric surgeons in England from 1997 to 2015

INTRODUCTION

Laparoscopy is used in as many as 95% of adult appendicectomies. There is level I evidence showing that it reduces wound infection, postoperative ileus and length of inpatient stay in children compared with the open approach. The aim of this study was to report the uptake of laparoscopy for paediatric appendicectomy in England and to determine whether this was similar for general surgeons (GS) and specialist paediatric surgeons (SPS).

METHODS

Hospital Episode Statistics data were obtained for all children aged <16 years who had an OPCS 4.6 code for emergency appendicectomy from 1997 to 2015 (18 years). Data are analysed to compare rate of laparoscopic vs open procedures for GS and SPS over time and to investigate factors associated with the use of laparoscopy.

RESULTS

There were 196,987 appendicectomies and where specialty was available, 133,709 (79%) cases were undertaken by GS and 35,141 (21%) by SPS. The rate of cases undertaken with laparoscopy for both specialties combined increased from 0.8% in 1998 to 50% in 2014 (p<0.0001). In 2014, this rate was 41% for GS compared with 71% for SPS (p<0.0001). Female gender (odds ratio (OR)=1.84, 95% confidence interval (CI) 1.80-1.90), increasing age (OR=1.18, 95% CI 1.18-1.19 per year) and treatment by SPS (OR=3.71, 95% CI 3.60-3.82) were all factors positively associated with use of laparoscopy in multivariate analysis.

CONCLUSIONS

There has been a vast increase in the proportion of appendicectomies undertaken laparoscopically in children. Despite adjusting for patient factors, laparoscopy was used significantly less by GS when compared with SPS. This difference is most apparent in younger children.

Laparoscopic versus Open Appendectomy: A Prospective Comparative Study and 4-Year Experience in a Tertiary Care Hospital

Background The aim of this study was to validate the pros of laparoscopic appendectomy (LA) over open appendectomy (OA) and to compare various primary outcome measures in the management of acute and recurrent appendicitis.

Study Design Prospective comparative study.

Place and Duration Between June 2015 and October 2019 in JJ Hospital, Mumbai.

Materials and Methods Total of 60 patients with acute and recurrent appendicitis were included in the study. Thirty patients underwent OA and 30 underwent LA. Both groups were comparable clinicopathologically and demographically. Various intraoperative and postoperative parameters were compared. Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. Mann–Whitney U test was used to compare continuous variables and chi-squared test was used to compare categorical variables. p-Value≤0.001 was considered to be statistically significant.

Results The median age of patients undergoing OA and LA was 24.9 and 25.2 years (p = 0.221), respectively. Female: male ratio in OA and LA was 1.30 and 1.14, respectively (p = 0.795). Mean operative duration in LA and OA group was 47.17 ± 14.39 minutes and 36.9 ± 12.33 minutes (p = 0.001), respectively. Mean length of postoperative stay in LA and OA group was 3.69 ± 0.71 days and 5.28 ± 0.63 days (p = 0.000), respectively. Median visual analogue scale score in LA and OA group was 3.5 and 5 (p = 0.001), respectively. Mean time to return to normal activity in LA and OA group was 8.13 ± 1.33 days and 10.10 ± 2.20 days (p = 0.000), respectively. About 6.66% patients in LA group and 13.33% in OA group had postoperative wound infection (p = 0.652). Mean scar scale scoring done on 30th postoperative day was 4.23 in LA and 8.23 in OA (p = 0.000).

Discussion and Conclusion LA is more promising than OA in the management of acute and recurrent appendicitis. LA offers lesser operative site pain in the postoperative period, shorter postoperative hospital stays, earlier recovery, and return to normal activities and cosmetically better scars on 30th day follow-up. No conversions or significant difference in wound related complications were seen in both groups. Prolonged intraoperative duration was the only drawback of LA.

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 appendectomy: A retrospective cohort study on the management of acute appendicitis (simple and complicated) in children under 13 years of age

INTRODUCTION

Acute appendicitis is the most common surgical emergency with a lifetime incidence of 7%-8%. There are two operative modalities that are currently used for the management of this condition in the paediatric population. The objective of this cohort study was to review the outcome of the management of paediatric surgical patients presenting with acute appendicitis after either an open appendectomy (OA) or laparoscopic appendectomy (LA) was performed.

METHODS

This was a 2-year retrospective study conducted from 01 January 2016 until 31 December 2017 on paediatric surgical patients < 13 years of age undergoing appendectomies. Eighty-one (n = 81) files of patients were reviewed, and data analysis was performed on two comparative groups namely the OA group and LA group, with the aid of the SAS system with statistical significance based on P < 0.05.

RESULTS

During the study period, 81 children (male: female ratio of 2:1) underwent appendectomies. Nearly 38% (n = 31) of the cases had an OA, with 62% (n = 50) of the cases having an LA. Seven (14%) LA cases were converted to OA. Simple appendicitis accounted for 16% (n = 13) of the patients, with complicated appendicitis accounting for 79% (n = 64) and other pathologies accounting for 5% (n = 4). There were no post-operative complications in the cases of simple appendicitis. Six cases (15.38%) in the LA group versus two cases (5.26%) in the OA group developed intra-abdominal collections, which was statistically significant (P = 0.018). One (2.56%) patient in the LA group versus two patients (7.89%) in the OA group developed intestinal ileus (P = 0.09). Two patients (5.13%) in the LA group versus six patients (15.79%) in the OA group developed surgical-site infection, which was statistically significant (P = 0.013). The mean days of hospital stay was 4.51 days in the LA group versus 5.34 days in the OA group, which was statistically significant (P = 0.016). There were no re-admissions or re-operations in the simple appendicitis group. In the complicated appendicitis cases, five cases (12.82%) were re-admitted in the LA group compared to five cases (13.16%) in the OA group (P = 0.943). Two (5.13%) cases had a re-operation in the LA group compared to one case (2.63%) in the OA group (P = 0.360).

CONCLUSION

Considering that there was an increased incidence of complicated cases and operations being performed by trainees, LA appears feasible at a tertiary-level hospital in a developing country, as shown in this study. Therefore, cases of simple appendicitis can be performed laparoscopically; however with regard to complicated appendicitis, there is no superiority between the two operative modalities in this study, which is consistent with international literature. However, in this study, it can be postulated that the learning curve was a major contributory factor to the increased levels of complications, as all operations were performed by trainees. Therefore, we recommend implementation of adequate simulation practices in laparoscopy in the setting of a developing country to attain the laparoscopic expertise of our international counterparts in order to improve the standard of care.

Management of Postoperative Complications Following Common Pediatric Operations

This review discusses complications unique to pediatric surgical populations. Here the authors focus primarily on five of the most common procedures performed in children: appendectomy, central venous catheterization, pyloromyotomy, gastrostomy, and inguinal/umbilical hernia repair.

Same-day discharge vs. observation after laparoscopic pediatric appendectomy: a prospective cohort study

Background

Through 2015, the practice at our university based free-standing children's hospital was to admit uncomplicated appendicitis patients for overnight observation post-operatively. Given the increasing body of evidence suggesting the safety and feasibility of same-day discharge after appendectomy for uncomplicated appendicitis, we elected to perform a prospective study evaluating the complication rates of same-day discharge compared to overnight observation at our institution, given our large volume of appendicitis.

Methods

Pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were analyzed. Data regarding demographics, admission, and discharge times and outcomes of complications, as well as readmissions, return to the emergency department, and nonscheduled clinic visits were collected and analyzing using chi-square and multivariate regression. Cost of stay data was obtained and analyzed using Mann-Whitney U test to compare non-parametric variables.

Results

Eight hundred and forty-nine laparoscopic appendectomies were performed for uncomplicated appendicitis during the study period, of which 382 resulted in same-day discharge and 467 in an admission for observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs. observation (2 vs. 6 patients; P=0.21) or in emergency department visits within 30 days (22 vs. 27 patients; P=0.98). There was no difference in the number of surgical site infections or extra clinic visits. There was a significantly lower median cost of stay for patients discharged home the same day at 29,150 dollars (25,644, 32,276, IQR) compared to a median of 34,827 dollars (31,154, 39,457, IQR) (P<0.0001).

Conclusions

Same-day discharge for laparoscopic uncomplicated appendectomy should be the new standard of care. This study found no differences in outcomes between the timing of discharge, with a significantly lower cost of stay for patients discharged home the same day.

National Trends and Disparities in the Diffusion of Laparoscopic Surgery for Children in the United States

Background: Laparoscopic surgery has become the standard of care for many surgical treatments. The diffusion of laparoscopy has been investigated for adult patient populations but is still unknown for pediatric populations. This study sought to describe national trends in diffusion of laparoscopic surgery for common pediatric conditions and identify disparities in use of laparoscopic surgery. Study Design: A retrospective analysis of serial cross-sectional data was performed using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 1997 to 2016. Pediatric patients (ages ≤18) undergoing appendectomy, cholecystectomy, fundoplication, or inguinal hernia repair were identified. The diffusion of laparoscopy for each procedure was measured using the proportion of laparoscopic surgeries over years. Results: National trends demonstrate increases in the use of laparoscopy for children over the past two decades from 13.4% to 88.7% for appendectomy, from 82.6% to 94.9% for cholecystectomy, from 7.4% to 77.4% for fundoplication, and from 1.5% to 23.5% for repair of inguinal hernia (P < .001). Disparities in diffusion of laparoscopy were found from various pediatric populations, and the disparities varied by specific procedures and years. In particular, the proportion of laparoscopic appendectomy in 1997 was 11.3% at urban teaching hospitals and was 13.9% at rural hospitals (P = .01), while the proportions in 2016 increased to 90.8% at urban teaching hospitals versus 71.3% at rural hospitals (P < .001). Conclusions: Laparoscopy has become the standard surgical care for common pediatric surgical conditions. Widening disparities in use of laparoscopic surgery for pediatric populations appear between urban teaching hospitals and rural hospitals.

Does speed matter? A look at NSQIP-P outcomes based on operative time

BACKGROUND

Appendicitis is a common pediatric surgical condition, comprising a large burden of healthcare costs. We aimed to determine if prolonged operative times were associated with increased 30-day complication rates when adjusting for pre-operative risk factors.

METHODS

Patients <18 years old, diagnosed intraoperatively with acute uncomplicated appendicitis and undergoing laparoscopic appendectomy were identified from the NSQIP-P 2012-2018 databases. The primary outcome, "infectious post-operative complications", is a composite of sepsis, deep incisional surgical site infections, wound disruptions, superficial, and organ space infections within 30-days of the operation. Secondary outcomes included return to the operating room and unplanned readmissions within 30 days. Logistic regression models were used to assess associations between operative time and each outcome. A Receiver Operating Characteristic (ROC) curve was generated from the predicted probabilities of the multivariate model for infectious post-operative complications to examine operative times.

RESULTS

Between 2012 and 2018, 27,763 pediatric patients with acute uncomplicated appendicitis underwent a laparoscopic appendectomy. Over half the population was male (61%) with a median operative time of 39 min (IQR 29-52 min). Infectious post-operative complication rate was 2.8% overall and was highest (8%) among patients with operative time ≥ 90 min (Fig. 1). Unplanned readmission occurred in 2.9% of patients, with 0.7% returning to the operating room. Each 30-min increase in operating time was associated with a 24% increase in odds of an infectious post-operative complication (OR=1.24, 95% CI=1.17-1.31) in adjusted models. Operative time thresholds predicted with ROC analysis were most meaningful in younger patients with higher ASA class and pre-operative SIRS/Sepsis/Septic shock. Longer operative times were also associated with higher odds of unplanned readmission (OR=1.11, 95% CI=1.05-1.18) and return to the operating room (OR=1.13, 95% CI=1.02-1.24) in adjusted models.

CONCLUSION

There is a risk-adjusted association between prolonged operative time and the occurrence of infectious post-operative complications. Infectious postoperative complications increase healthcare spending and are currently an area of focus in healthcare value models. Future studies should focus on addressing laparoscopic appendectomy operative times longer than 60 min, with steps such as continuation of antibiotics, shifting roles between attending and resident surgeons, and simulation training.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Laparoscopic Versus Open Appendectomy for Acute Appendicitis in Children: a Nationwide Retrospective Study on Postoperative Outcomes

PURPOSE

Our aim was to compare postoperative outcomes of laparoscopic and open appendectomies for acute appendicitis in children under the circumstance of widespread use of laparoscopic surgery.

METHOD

This study included data on laparoscopic and open appendectomies in children with acute appendicitis from the National Clinical Database, which is a Japanese nationwide surgical database, in 2015. The occurrence rates of complications within 30 days after the surgery and postoperative hospital stay were compared by univariate and multivariate analyses. p < 0.05 was considered statistically significant.

RESULTS

This study included 4489 appendectomies, of which 3166 surgeries (70.5%) were performed laparoscopically. Appendectomy was performed for complicated and uncomplicated appendicitis in 1765 (39.3%) and 2724 cases (60.7%), respectively. Postoperative complications within 30 days were observed in 246 operations (5.5%). Organ-space surgical site infection (SSI), deep wound SSIs, and superficial wound SSIs were observed in 2.3%, 1.0%, and 2.4% of operations, respectively. On multivariate analysis, the incidence of postoperative complications (odds ratio 1.21, 95% CI 0.90-1.64, p = 0.207) and the length of hospital stay (median 4 days in both groups, p = 0.835) were not significantly different between patients who underwent laparoscopic or open appendectomy. Subgroup analysis in complicated and uncomplicated appendicitis cases also demonstrated no significant differences in the incidence of postoperative complications between those who underwent laparoscopic or open appendectomy.

CONCLUSION

This study suggested that the occurrence of postoperative complication and the length of hospital stay in pediatric patients who underwent laparoscopic appendectomy are similar with those in pediatric patients who underwent open appendectomy for acute appendicitis.

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.

Thirty Years of Minimally Invasive Surgery in Children: Analysis of Meta-Analyses

INTRODUCTION

 In the last three decades, minimally invasive surgery (MIS) has been widely used in pediatric surgery. Meta-analyses (MAs) showed that studies comparing minimally invasive with the corresponding open operations are available only for selected procedures. We evaluated all available MAs comparing MIS with the corresponding open procedure in pediatric surgery.

MATERIALS AND METHODS

 A literature search was performed on all MAs listed on PubMed. All analyses published in English, comparing pediatric minimally invasive with the corresponding open procedures, were included. End points were advantages and disadvantages of MIS. Results of 43 manuscripts were included. MAs evaluating the minimally invasive with the corresponding open procedures were available for 11 visceral, 4 urologic, and 3 thoracoscopic types of procedures. Studies included 34 randomized controlled trials. In 77% of MAs, at least one advantage of MIS was identified. The most common advantages of MIS were a shorter hospital stay in 20, a shorter time to feeding in 11, and a lower complication rate in 7 MAs. In 53% of MAs, at least one disadvantage of MIS was found. The most common disadvantages were longer operation duration in 16, a higher recurrence rate of diaphragmatic hernia in 4, and gastroesophageal reflux in 2 MAs. A lower native liver survival rate after laparoscopic Kasai-portoenterostomy was reported in one MA.

CONCLUSION

 In the available MAs, the advantages of MIS seem to outnumber the disadvantages. However, for some types of procedures, MIS may have considerable disadvantages. More randomized controlled trials are required to confirm the advantage of MIS for most procedures.

Obesity and postoperative outcomes of the patients with laparoscopic adrenalectomy: a systematic review and meta-analysis

Background

Studies have suggested differences in postoperative outcomes between patients with obesity and those without following adrenalectomy, but these remained to be ascertained with synthesis of available evidence. The aim of this systematic review and meta-analysis was to investigate the association between obesity and outcomes of patients after laparoscopic adrenalectomy.

Methods

We searched EMBASE, PubMed, Global Index Medicus, and Web of Science, without language restriction, to identify cohort studies published between January 1, 2000 and November 6, 2019. We considered studies with data comparing outcomes of adults with and without obesity after laparoscopic adrenalectomy. Random-effects meta-analysis was used to pool study-specific estimates. This review was registered with PROSPERO, CRD42018117070.

Results

Five studies with data on a pooled sample of 353 patients with obesity and 828 without were included in the meta-analysis. The risk of bias was moderate to low. We found no association between obesity and the various stages of postoperative complications: Clavien-Dindo grade 1 (OR = 1.57; 95%CI = 0.55–4.48; I² = 44.6%), grade 2 (OR = 1.12; 95%CI = 0.54–2.32; I² = 0.0%), grade 3 (OR = 1.79; 95%CI = 0.58–5.47; I² = 0.0%;), grade 4 (OR = 0.43; 95%CI = 0.05–3.71; I² = 0.0%), and grade 5 (death) (OR = 0.43; 95% CI = 0.02–14.31). Furthermore, no association was found between obesity and readmission rates (OR = 0.7; 95% CI = 0.13–3.62) and conversion of laparoscopic to open surgery (OR = 0.62; 95% CI = 0.16–2.34; I² = 19.5%).

Conclusions

This study suggests that obesity is not associated with complications following laparoscopic adrenalectomy. This meta-analysis might have been underpowered to detect a true association between obesity and patient outcome after laparoscopic adrenalectomy due to the small number of included studies. Larger studies are needed to clarify the role of obesity in patients undergoing laparoscopic adrenalectomy.

Impact of fellowship training on surgical outcomes after appendectomies: a retrospective cohort study

BACKGROUND

Outcome studies have failed to show significant improvement related to formal fellowship training in different surgical specialties. We aimed to look whether laparoscopic fellowship-trained (FT) surgeons had better outcomes.

METHODS

This is an IRB approved retrospective review from a single institution (inner city hospital) on adults undergoing appendectomy from 2008 to 2017. Demographics and 30-day complications were analyzed with univariate and multivariate logistic regression analyses.

RESULTS

Total of 558 appendectomies were reviewed. 151 (27.36%) appendectomies were performed by FT surgeons (MIS/CRS), 401 (72.64%) performed by GS. No difference in age, ASA, BMI, race, gender, insurance status, smoking, diabetes mellitus (DM), or hypertension was found. Also, similar rates of non-iatrogenic perforated appendicitis were seen (16.37% GS vs 20% FT, p = 0.318). For major complications, no difference was found between GS and FT (p = 0.63). However, appendectomies performed by GS showed higher rates of post-op ileus (3.99% vs 0.66%, p = 0.04), higher conversion to open (7.55% vs 2.67%, p = 0.039), higher rates of choosing an open approach (17.46% vs 0.66%, p =  < 0.001), and longer length of stay (LOS) (median 1.9 vs 1.8 days p = 0.048). Of the 16 patients with ileus from the GS group three were open, two converted to open, and eleven laparoscopic with mean OR time of 70 min and LOS of 13.3 days. The only laparoscopic case from the FT group with ileus had a mean operative time of 56 min and LOS of 15 days. On multivariate regression analysis, only DM was found as risk factor for major complications (OR 3.01, 95% CI 1.307-6.92, p = 0.01), while laparoscopic approach was seen as protective factor against major complications (OR 0.53, 95% CI 0.29-0.97, p = 0.04).

CONCLUSION

Laparoscopic fellowship training had a positive outcome on post-op ileus and LOS after appendectomy. This seems to be related to the higher prevalence of choosing laparoscopic technique and lower rate of conversion to open.

The effect of laparoscopic and open surgery on oxidative DNA damage and IL-37 in children with acute appendicitis

BACKGROUND

Although laparoscopic appendectomy (LA) is considered to be minimally invasive compared with open appendectomy (OA), there are few studies showing this in terms of cytokines and oxidative stress markers.

AIM

LA and OA techniques have been compared in terms of different conditions such as operation time and complication rate. Here, we compared how oxidative DNA damage and some cytokines levels change in relation to LA and OA.

METHOD

This study was performed in children diagnosed with acute appendicitis in our hospital. The study was conducted on 30 children with acute appendicitis in each group. Oxidative DNA damage and malondialdehyde levels were determined by high-performance liquid chromatography, and interleukin-1β, interleukin-37, ischaemia-modified albumin and total thiol levels were determined by enzyme-linked immunosorbent assays.

RESULTS

There was a dramatic decrease in ischaemia-modified albumin (IMA) levels after LA. However, there were no statistically significant differences in pre- and postoperative IMA levels in the OA group. Oxidative DNA damage and malondialdehyde levels were low significantly according to preoperative levels after the LA and OA. Total thiol levels were high in children who underwent LA while they were low after OA. In addition, postoperative interleukin-1β levels were low in both groups. Furthermore, IL-37 levels postoperatively were low in the LA group, while there was no significant change in the OA group.

CONCLUSION

LA had a more positive effect on oxidative DNA damage, IL-1β and IL-37 than the OA. In addition, surgical stress was reduced with LA.

Pediatric appendectomy in developing countries: How does it differ from international experience?

Introduction

A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country's experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones.

Method

A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients' characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher's exact test, as for continuous, Student's t test was used or one-way ANOVA in case of more than 2 categories.

Result

Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar.

Conclusion

In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.

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.

Comparison of microscopic illumination between a three-dimensional heads-up system and eyepiece in cataract surgery

INTRODUCTION

The ability to reduce illumination levels is generally accepted as one of the main benefits of a three-dimensional heads-up system (3D system: Ngenuity®; Alcon, CA, USA). Some studies have focused on illumination reduction in vitreoretinal procedures; however, information regarding illumination reduction in cataract surgery has not been published.

PURPOSE

This study aimed to compare the illumination of the operational field with a 3D system and a standard microscope eyepiece during cataract surgery.

SUBJECT AND METHODS

We retrospectively evaluated 91 eyes of 84 consecutive patients who were undergoing cataract surgery at our hospital. We used the 3D system and the eyepiece on alternative days. We determined the minimum light intensity required for safe surgery using the foot switch of the microscope (OMS800; Topcon, Tokyo, Japan). Illuminance on the ocular surface and the minimum illuminance required for the operation were calculated from the minimum light intensity.

RESULTS

The 3D system was used in 45 eyes (3D group), and the eyepiece was used in 46 eyes (eyepiece group). The values of minimum illuminance in the 3D group were significantly lower than those in the eyepiece group (3D: 5500 ± 2000 lux, eyepiece: 11,900 ± 1800 lux; p < 0.001*). In addition, the illuminance of the operational field was reduced by 60.4% on average using the 3D system.

CONCLUSION

With real-time digital processing and automated brightness control, the 3D system reduced ocular surface illumination by 50% or more. Hence, the 3D system may contribute to reducing the risk of retinal phototoxicity and patient photophobia.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis

Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

Global incidence of surgical site infection after appendectomy: a systematic review and meta-analysis

BACKGROUND

Although surgical site infection (SSI) is one of the most studied healthcare-associated infections, the global burden of SSI after appendectomy remains unknown.

OBJECTIVE

We estimated the incidence of SSI after appendectomy at global and regional levels.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Appendectomy patients.

DATA SOURCES

EMBASE, PubMed and Web of Science were searched, with no language restrictions, to identify observational studies and clinical trials published between 1 January 2000 and 30 December 2018 and reporting on the incidence of SSI after appendectomy. A random-effect model meta-analysis served to obtain the pooled incidence of SSI after appendectomy.

RESULTS

In total, 226 studies (729 434 participants from 49 countries) were included in the meta-analysis. With regard to methodological quality, 59 (26.1%) studies had low risk of bias, 147 (65.0%) had moderate risk of bias and 20 (8.8%) had high risk of bias. We found an overall incidence of SSI of 7.0 per 100 appendectomies (95% prediction interval: 1.0-17.6), varying from 0 to 37.4 per 100 appendectomies. A subgroup analysis to identify sources of heterogeneity showed that the incidence varied from 5.8 in Europe to 12.6 per 100 appendectomies in Africa (p<0.0001). The incidence of SSI after appendectomy increased when the level of income decreased, from 6.2 in high-income countries to 11.1 per 100 appendectomies in low-income countries (p=0.015). Open appendectomy (11.0 per 100 surgical procedures) was found to have a higher incidence of SSI compared with laparoscopy (4.6 per 100 appendectomies) (p=0.0002).

CONCLUSION

This study suggests a high burden of SSI after appendectomy in some regions (especially Africa) and in low-income countries. Strategies are needed to implement and disseminate the WHO guidelines to decrease the burden of SSI after appendectomy in these regions.

PROSPERO REGISTRATION NUMBER

CRD42017075257.

Development in the surgical treatment of acute appendicitis: A single-center experience

PURPOSE

Laparoscopy has become the treatment of choice for acute appendicitis. The aim of the study was to compare open (OA) and laparoscopic (LA) approaches in all forms of acute appendicitis.

METHODOLOGY

Two hundred and ninety-two children underwent appendectomy (238 LA/54 OA). 3/238 patients required conversion. LA surgical technique has been modified by closing also the distal stump of appendix (DSC) before removing it.

RESULTS

Early experience: 130 appendectomy, 44 by OA (34%), and 86 by LA (66%). The mean operative time was similar for both techniques. Complicated appendicitis (CA) was observed in 14 patients (11%). 10 patients treated with OA (10/14 = 71%) and 4 with LA (4/14 = 29%). Complications occurred mainly in the LA group without statistical significance.

LATE EXPERIENCE

One hundred and sixty-two appendectomy, 10 OA (6.17%), and 152 LA (93.8%). Thirty-eight children (23.4%) had CA. The mean operative time was lower in LA group without reaching statistical significance. Total complication rate (CR) was 7.4%. CR in patients with DSC was null and significantly lower when compared to patients without DSC.

CONCLUSION

Our results demonstrated that nearly all cases of appendicitis may be managed by laparoscopy. Ligature of distal appendiceal stump is a trick that may significantly improve outcomes during LA appendectomy.

The use of abdominal imaging studies in children visiting emergency department was variable and unsystematic

AIM

As imaging is used for various reasons in children with acute gastrointestinal complaints, we evaluated the indications and diagnostic yield of abdominal imaging, particularly ultrasound at emergency department (ED).

METHODS

Indications and imaging reports of consecutive children who had undergone abdominal imaging in general, surgical and paediatric EDs in the Tampere University Hospital, Finland, in 2015 were collected. Symptoms, clinical findings, imaging indications and findings were categorised and further analysed.

RESULTS

Altogether 394 imaging studies, 310 ultrasounds, 72 X-rays and 12 computed tomographies (CT), for 348 children (55% boys) aged 0-16.9 years, median 7.1 years, were performed. The most common indications for ultrasound were suspected appendicitis or infection (36%) and explanation for symptoms (32%), for X-ray suspected foreign body (39%) and obstruction (39%) and for CT trauma (50%). The cause of the symptoms or a clinically significant finding was established in 23% of ultrasounds, varying from 0% to 50% depending on the indication, symptoms and age.

CONCLUSION

There was wide variation in the indications and yield of abdominal imaging. The clinical benefits, particularly those of US, were often questionable, even leading to delayed diagnosis and complications. More uniform imaging guidelines are needed in the paediatric ED.

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study

BACKGROUND/PURPOSE

Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system.

METHODS

Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression.

RESULTS

Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31-4. 02, p = 0.001; and OR 2.55, 95%CI 1.35-4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates.

CONCLUSIONS

In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada.

LEVEL OF EVIDENCE

Prognosis study, level II.

Parental satisfaction with same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis

Objectives

Recent studies suggest that same-day discharge is safe for the paediatric population after various laparoscopic procedures. Same-day discharge is increasingly common after laparoscopic surgery for uncomplicated appendicitis although it is not standard practice. This prospective study aims to assess parental satisfaction with same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis.

Methods

At our institution, 849 patients with uncomplicated acute appendicitis underwent laparoscopic appendectomy in 2016; of which, 382 were discharged on the same calendar day. Postdischarge surveys assessing parental satisfaction were administered by telephone at the 2-week follow-up.

Results

Approximately 65% of 185 total parental responses reported initial satisfaction with same-day discharge. About 30% were nervous at that time, and 5% did not feel ready to go home yet. Upon reflection, a higher proportion of parents (81.6%) felt same-day discharge was the appropriate course of action, 11.4% were unsure, and 7.0% would not do it again. Some parents cited concerns regarding pain control and incongruous expectations from conversations with staff or surgical experiences of their own.

Conclusions

The majority of parents recalled being happy at discharge, with an increase to 82% retrospectively. Only 7% of parents would not elect to go home on the same day again. Opportunities for improvement include a unified plan from all providers with expectations of same-day discharge if appendicitis is intraoperatively confirmed to be uncomplicated and better analgesic instructions at discharge.

Single-Port Needlescopic Appendectomy in Children Using a Mediflex Needle: A New Simplified Technique

Background: Laparoscopic appendectomy is among the most common surgical procedures. Needlescopic appendectomy (NA) is an acceptable, safe technique in children, but with many drawbacks such as a high conversion rate and long operative time. We present a new technique for NA in children using only a single port, Mediflex^® facial closure needle, and vascular access cannula (VAC). Patients and Methods: Single-port NA was attempted in 117 patients (51 boys, 66 girls). Under general anesthesia, a 5-mm camera port was inserted through the umbilicus. Two Mediflex needles and a 14-gauge VAC were introduced. The appendix was grasped and dissected from the surrounding tissues using Mediflex needles. In case of a mobile cecum, the appendix was pulled through the umbilical port, then an extracorporeal appendectomy was performed. In cases with a fixed cecum or severely inflamed appendix, a complete intracorporeal appendectomy was done. The suture was knotted in a sliding reef knot using a single instrument. Results: NA was completed in 117 patients (51 boys, 66 girls) with an average age of 10 years. Thirty patients underwent extracorporeal appendectomy. Eighty seven patients were treated by intracorporeal appendectomy. The mean operative time was 15 ± 3 and 25 ± 4 minutes for extracorporeal and intracorporeal appendectomy respectively. The hospital stay was 1.2 days on average (ranging 8 hours to 2 days). There was no single case of conversion. Family satisfaction was achieved in 97% of cases. Conclusion: The presented unique method for single-port NA using Mediflex^® appears to be a safe, acceptable technique for appendectomy in children that allows for excellent cosmetic results.

Current practice patterns for postoperative activity restrictions in children

BACKGROUND

Postoperative activity restrictions are designed to prevent undue stress on a recent repair and minimize the risk of surgical complication, however, there is little evidence to support certain restrictions in clinical practice. For the pediatric population, there is a paucity of formal evaluations of postoperative activity restrictions, and little is known about current practice patterns among pediatric surgeons. This study aimed to describe national practice patterns of pediatric surgeons for postoperative activity recommendations following three common general surgical procedures.

METHODS

A 7-item survey was sent to all American Pediatric Surgical Association (APSA) members regarding surgeon practice of recommended activity restrictions for school attendance, participation in playground or gym, participation in contact sports, and heavy lifting in children following 3 procedures: exploratory laparotomy, laparoscopic appendectomy, and inguinal hernia repair. Information on type and duration of clinical practice was also collected for each surgeon. Descriptive and bivariate analyses were performed.

RESULTS

The survey was completed by 293 pediatric surgeons for a response rate of 28.9%. There was wide national variability in the recommended activity restrictions for children <12 years old among pediatric surgeons. Following laparoscopic appendectomy, 30.7%, 51.9% and 47.8% of surgeons recommends restriction of gym, contact sports, and heavy lifting for 2-3 weeks respectively, but 26.7%, 19.8%, and 22.2% do not recommend any restriction whatsoever of these three activities. Following inguinal hernia repair, 31.7%, 49.1% and 44.4% of surgeons recommend restriction of gym, contact sports, and heavy lifting for 2-3 weeks, but 30.8%, 30.8%, and 29.2% do not recommend any restriction of these three activities. Only 22% of surgeons change their activity restriction recommendations for children ≥12 years old, this decision was not associated with surgeon years in practice or type of practice.

CONCLUSIONS

There is considerable variability in surgeon recommendations for activity restrictions following three general surgery procedures in children. While activity restrictions are rooted in the physiology of wound healing, there is little evidence to support the benefit of these restrictions in clinical practice. In addition, activity restriction may have unintended deleterious effects on a child's psychosocial well-being and quality of life. Further investigation should be pursued to understand the utility of activity restrictions in children and their impact on clinical outcomes and patient quality of life.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level V, expert opinion.

Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules

PURPOSE

Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test.

METHODS

A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA.

RESULTS

Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate.

CONCLUSIONS

Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.

OBJECTIVES

To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.

Outcomes and Costs of Common Surgical Procedures at Children's and Nonchildren's Hospitals

BACKGROUND

Variations in the management of pediatric patients at children's hospitals (CHs) and non-CHs (NCHs) have been well described, especially within the trauma literature. However, little is known about the outcomes and costs of common general surgical procedures at NCHs. The purpose of this study was to evaluate the effect of CH designation on the outcomes and costs of appendectomy and cholecystectomy.

METHODS

The Kids' Inpatient Database (2003-2012) was queried for patients aged under 18 y who underwent appendectomy or cholecystectomy at CHs and NCHs. Outcomes analyzed included disease severity, complications, laparoscopy, length of stay (LOS), and cost.

RESULTS

Most of appendectomies and cholecystectomies were performed at NCHs. Overall, CHs cared for younger children were more likely to be teaching hospitals, had higher costs, and longer LOS. On multivariate analysis for appendectomies, CHs were associated with higher rates of perforated appendicitis (OR = 1.53, 95% CI = 1.42-1.66, P < 0.001), less complications (OR = 0.68, 95% CI = 0.61-0.75, P < 0.001), increased laparoscopy (OR = 2.93, 95% CI = 2.36-3.64, P < 0.001), longer LOS (RR = 1.13, 95% CI = 1.09-1.17, P < 0.001), and higher costs (exponentiated log $ = 1.19, 95% CI = 1.13-1.24, P < 0.001). Multivariate analysis for cholecystectomies revealed that CHs were associated with less laparoscopy (OR = 0.58, 95% CI = 0.50-0.67, P < 0.001), longer LOS (RR = 1.26, 95% CI = 1.19-1.34, P < 0.001), and higher costs (exponentiated log $ = 1.29, 95% CI = 1.22-1.37, P < 0.001) with similar complications. Independent predictors of LOS and cost included CH designation, negative appendectomy, perforated appendicitis, complications, younger age, black patients, and public insurance.

CONCLUSIONS

Variations in surgical management, outcomes, and costs after appendectomy and cholecystectomy exist between CHs and NCHs. CHs excelled in treating complicated appendicitis. NCHs effectively performed cholecystectomies. These differences in outcomes require further investigation to identify modifiable factors to optimize care across all hospitals for these common surgical diseases.