Appendicitis-Like Picture Induced by Foreign Body in a 2-Year-Old Boy

Background and Aim. Appendicitis is unusual in toddlers and foreign body- (FB-) induced appendicitis is rare. We present a FB-induced appendicitis in a toddler with no suggestive history of FB ingestion. Case Presentation. A 2-year-old healthy boy presented to the emergency department with irritability for 3 days duration associated with fever of 39°C, nausea, anorexia, and vomiting. There was no history of foreign body ingestion. The abdomen was distended and diffusely tender. An abdominal ultrasound (US) was suggestive of perforated appendicitis with appendicular mass formation. An abdominal X-ray showed a pin-like foreign body in the abdomen. An emergent appendectomy was performed. Intraoperatively, a sealed small cecal perforation was noticed. A 5 cm pin-like metallic foreign body was found to obstruct the appendicular lumen. The appendix was grossly normal without inflammatory changes. Conclusion. FB-induced perforations or appendicitis albeit in patients with no history of FB ingestion or infants and toddlers need a high clinical suspicion to prevent the delay in diagnosis and the subsequent complications.

Do Small Incisions Need Only Minimal Anesthesia?-Anesthetic Management in Laparoscopic and Robotic Surgery

Laparoscopic techniques have established themselves as a major part of modern surgery. Their implementation in every surgical discipline has played a vital part in the reduction of perioperative morbidity and mortality. Precise robotic surgery, as an evolution of this, is shaping the present and future operating theatre that an anesthetist is facing. While incisions get smaller and the impact on the organism seems to dwindle, challenges for anesthetists do not lessen and could even become more demanding than in open procedures. This review focuses on the pathophysiological effects of contemporary laparoscopic and robotic procedures and summarizes anesthetic challenges and strategies for perioperative management.

Laparoscopy versus open appendectomy for elderly patients, a meta-analysis and systematic review

BACKGROUND

Appendicitis in elderly patients is associated with increased risk of postoperative complications. The choice between laparoscopy and open appendectomy remains controversial in treating elderly patients with appendicitis.

METHODS

Comprehensive search of literature of MEDLINE, Embase, Cochrane Library and ClinicalTrials was done in January 2019. Studies compared laparoscopy and open appendectomy for elderly patients with appendicitis were screened and selected. Postoperative mortality, complications, wound infection, intra-abdominal abscess and operating time, length of hospital stay were extracted and analyzed. The Review Manage 5.3 was used for data analysis.

RESULTS

Twelve studies with 126,237 patients in laparoscopy group and 213,201 patients in open group. Postoperative mortality was significantly lower following laparoscopy (OR, 0.33; 95% CI, 0.28 to 0.39). Postoperative complication and wound infection were reduced following laparoscopy ((OR, 0.65 95% CI, 0.62 to 0.67; OR,0.27, 95% CI, 0.22 to 0.32). Intra-abdominal abscess was similar between LA and OA (OR,0.44;95% CI, 0.19 to 1.03). Duration of surgery was longer following laparoscopy and length of hospital stay was shorter following laparoscopy (MD, 7.25, 95% CI, 3.13 to 11.36; MD,-2.72, 95% CI,-3.31 to - 2.13).

CONCLUSIONS

Not only laparoscopy is safe and feasible, but also it is related with decreased rates of mortality, post-operative morbidity and shorter hospitalization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neutrophil to Lymphocyte Ratio on Appendectomy of Geriatric and Nongeriatric Patients

PURPOSE

Acute appendicitis is the most frequent emergency procedure that requires acute surgical intervention. The mortality risk is higher in geriatric patients. There is not a single parameter to diagnose it easily and negative appendectomy is traditionally accepted however the operation itself can cause morbidity and mortality especially in elderly patients. The neutrophil-to-lymphocyte ratio is a predictor of acute inflammation and was recently studied for the diagnosis of AA. The aim of this study is to analyze the diagnostic value of NLR on positive appendectomy rates amongst geriatric and nongeriatric patients.

MATERIALS AND METHODS

755 patients admitted to the emergency department, with abdominal pain who underwent urgent laparotomy after diagnosed as acute appendicitis. Patients' ages, genders, laboratory results, and intraoperative findings were collected. Geriatric patients were analyzed in group one, and nongeriatric patients were in group 2. Groups then sorted into subgroups by means of positive and negative appendectomies.

RESULTS

Although NLR was higher in positive appendectomy subgroup in group 1 it was not statistically significant. NLR could not independently predict positive appendectomy in geriatric patients. In group 2, male gender was significantly higher in the positive appendectomy group (p < 0.001). NLR was also significantly higher in the positive appendectomy group (p < 0.001). In group 2 NLR could independently predict positive appendectomy (p < 0.001).

CONCLUSION

NLR could not predict positive appendectomy rates in the geriatric population but could in the nongeriatric patient group. To find the optimal NLR levels, prospective randomized studies are needed.

Acute appendicitis in the elderly in the twenty-first century

BACKGROUND

The incidence of appendicitis in the elderly has risen. Older age is an independent predictor of poor surgical outcome. Herein, we present the most comprehensive single institution study to describe the natural history and outcome of appendicitis in elderly patients.

METHODS

A review of 1898 consecutive patients who underwent appendectomy between 2004 and 2007 was performed. The elderly patients were defined as older than 68 years.

RESULTS

The median age of the entire cohort was 25 years, and 55% were males. The elderly group included 68 patients (3.6%). On comparison by age, the elderly group had a significantly longer delay from symptom onset to admission (50 vs. 31 h, P = 0.01) and from admission to surgery, a longer operative time and hospital stay, and higher rates of postoperative complications and complicated appendicitis.

CONCLUSION

The current study demonstrated several unique characteristics of the elderly population with acute appendicitis, which include poor outcome and longer time intervals to diagnosis and treatment. In order to improve the poor outcome of the elderly population with appendicitis, prospective trials are necessary.

Major laparoscopic surgery under regional anesthesia: A prospective feasibility study

BACKGROUND

Laparoscopic surgeries have attained the status of a gold standard for most of the abdominal pathology; we therefore performed this study to assess feasibility and safety of major laparoscopic surgeries like laparoscopic cholecystectomy (LC) and laparoscopic assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) under regional anesthesia that is combined spinal epidural anesthesia (CSE) with normal pressure pneumoperitoneum using intrathecal fentanyl with bupivacain.

METHODS

In a zonal government hospital, 50 patients were selected prospectively for LC and LAVH/TLH, under normal pressure (12 mmHg) pneumoperitoneum and under CSE over a span of fifteen months. Injection bupivacaine (0.5%) and 20 μg of fentanyl were used for spinal anesthesia. Plain bupivacaine (0.5%) was used for epidural anesthesia.

RESULTS

We successfully performed the operations in 48 patients without major complications. CSE was converted to general anesthesia in two patients due to distressing shoulder tip pain. Age varied between 25 and 70 years. Duration of operation time (skin to skin) was between 50 and 170 min. Five patients had urinary retention and one developed localized pruritis. There was no incidence of respiratory depression, aspiration or headache.

CONCLUSION

Laparoscopic surgeries with normal pressure CO2 pneumoperitoneum are feasible and safe under CSE. Incidence of postoperative shoulder pain was minimal due to use of intrathecal fentanyl and complications were less and easily manageable.

Laparoscopic Appendectomy Trends and Outcomes in the United States: Data from the Nationwide Inpatient Sample (NIS), 2004–2011

Laparoscopic appendectomy (LA) is becoming the standard procedure of choice for appendicitis. We aimed to evaluate the frequency and trends of LA for acute appendicitis in the United States and to compare outcomes of LA with open appendectomy (OA). Using the Nationwide Inpatient Sample database, we examined patients who underwent appendectomy for acute appendicitis from 2004 to 2011. A total of 2,593,786 patients underwent appendectomy during this period. Overall, the rate of LA was 60.5 per cent (children: 58.1%; adults: 63%; elderly: 48.7%). LA rate significantly increased from 43.3 per cent in 2004 to 75 per cent in 2011. LA use increased 66 per cent in nonperforated appendicitis versus 100 per cent increase in LA use for perforated appendicitis. The LA rate increased in all age groups. The increased LA use was more significant in male patients (84%) compared with female patients (62%). The overall conversion rate of LA to OA was 6.3 per cent. Compared with OA, LA had a significantly lower complication rate, a lower mortality rate, a shorter mean hospital stay, and lower mean total hospital charges in both nonperforated and perforated appendices. LA has become an established procedure for appendectomy in nonperforated and perforated appendicitis in all rates exceeding OA. Conversion rate is relatively low (6.3%).

Acute appendicitis: position paper, WSES, 2013

Appendectomy is one of the most frequently performed operative procedures in general surgery departments of every size and category. Laparoscopic Appendectomy – LA - as compared to Open Appendectomy – OA - was very controversial at first but has found increasing acceptance all over the World, although the percentage of its acceptance is different in the various single National setting. Various meta-analyses and Cochrane reviews have compared LA with OA and different technical details. Furthermore, new surgical methods have recently emerged, namely, the single-port/incision laparoscopic appendectomy and NOTES technique. Their distribution among the hospitals, however, is unclear. Using laparoscopic mini-instruments with trocars of 2–3.5 mm diameter is proposed as a reliable alternative due to less postoperative pain and improved aesthetics. How to proceed in case of an inconspicuous appendix during a procedure planned as an appendectomy remains controversial despite existing study results. But the main question still is: operate or not operate an acute appendicitis, in the meaning of an attempt of a conservative antibiotic therapy. Therefore, we have done a literature survey on the performance of appendectomies and their technical details as well as the management of the intraoperative finding of an inconspicuous appendix in order to write down – under the light of the latest evidence – a position paper.

[Laparoscopic appendicectomy in 2013--a barely tolerated procedure turning into a gold standard operation?]

INTRODUCTION

Laparoscopic appendectomy is one of the first developed minimally invasive surgical procedures, nevertheless its judgement is contradictory up to the present day as far as its advantages and indications are concerned.

METHODS

The authors of this article give an overview and analyse the relevant literature concerning laparoscopic appendectomy and the data of patients on whom appendectomy was performed from 01/01/2005 to 30/09/2013 with laparoscopic and open technique.

RESULTS

At the Surgical Department of the Uzsoki Hospital 1214 patients had appendectomy because of acute appendicitis from 01/01/2005 to 30/09/2013. The applied surgical procedure was laparoscopy with 1065 patients (87.73%) and the open technique with 149 patients (12.27%). Since January 2006 our main principle has been that in case of appendicitis the primary technique to be applied is laparoscopic appendectomy. We were forced to conversion with 16.5% of patients and as the operational experience of the department grows, the proportion of conversions tends to decrease.

CONCLUSION

The advantages of laparoscopic appendectomy as opposed to open surgery have become obvious in the past decade, and the procedure may be recommended for all age groups. In case acute appendicitis is suspected the primary procedure to be applied in our department is the laparoscopic operation, the results of which are at least as good as that of open appendectomy. The routine application of laparoscopic appendectomy provides an excellent basis for the acquisition of advanced laparoscopic surgery thus appendectomy will not lose its training character due to the laparoscopic approach.

Comparison of clinical outcomes of open, laparoscopic and single port appendicectomies

INTRODUCTION

Appendicectomy is the most common surgical procedure performed in general surgery. This study aimed to compare the outcomes of open appendicectomy (OA), laparoscopic appendicectomy (LA) and single port laparoscopic appendicectomy (SPLA).

METHODS

Fifty consecutive patients with suspected acute appendicitis were studied (OA: n=20, LA: n=20, SPLA: n=10). Clinical outcomes were compared between the three groups in terms of operative time, blood loss, postoperative complications, length of hospital stay and cost.

RESULTS

Patient demographics were similar among groups (p>0.05). SPLA was characterised by longer operative time (88.1 minutes vs 35.6 minutes in OA and 33.4 minutes in LA) and higher costs (12.84 thousand Chinese yuan [RMB] vs 8.41 thousand RMB in LA and 4.99 thousand RMB in OA). OA was characterised by more blood loss (9.8ml vs 7.5ml in SPLA and 6.8ml in LA), longer hospital stay (7.5 days vs 3.5 days in LA and 3.4 days in SPLA) and lower costs. The total number of complications was higher for OA (n=2) than for LA and SPLA (n=0) although this was not statistically significant.

CONCLUSIONS

Where feasible, LA should be undertaken as the initial treatment of choice for most cases of suspected appendicitis.

Regional anesthesia for laparoscopic surgery: a narrative review

Laparoscopic surgery has advanced remarkably in recent years, resulting in reduced morbidity and shorter hospital stay compared with open surgery. Despite challenges from the expanding array of laparoscopic procedures performed with the use of pneumoperitoneum on increasingly sick patients, anesthesia has remained largely unchanged. At present, most laparoscopic operations are usually performed under general anesthesia, except for patients deemed "too sick" for general anesthesia. Recently, however, several large, retrospective studies questioned the widely held belief that general anesthesia is the best anesthetic method for laparoscopic surgery and suggested that regional anesthesia could also be a reasonable choice in certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery. Because most available data come from large, retrospective studies, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia are needed to evaluate the true value of regional anesthesia in laparoscopic surgery.

Thirty-day outcomes of laparoscopic versus open appendectomy in elderly using ACS/NSQIP database

BACKGROUND

Although laparoscopic appendectomy is becoming the procedure of choice over open appendectomy in the treatment of appendicitis, its role in the elderly has not been widely studied. The objective of this study was to compare the 30-day outcomes after laparoscopic versus open for appendicitis in the elderly patients.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP) databases for years 2005-2009, 3,674 patients (age >65 years) who underwent an appendectomy for appendicitis were identified. Seventy-two percent of the procedures were performed laparoscopically. In addition to aggregate cohort analysis, propensity score 1:1 matching was used to minimize the treatment selection bias. The association between surgical approach and morbidity, mortality, and length of stay (LOS) were analyzed.

RESULTS

In the aggregate cohort analysis, patients who underwent an open appendectomy had a higher rate of minor morbidity (9.3% vs. 4.5%; p < 0.001), overall morbidity (13.4% vs. 8.2%, p < 0.001), and mortality (2% vs. 0.9%, p = 0.003). However, in the matched cohort analysis, open appendectomy was only associated with a higher rate of minor morbidity (9.3% vs. 5.7%; p = 0.002) and overall morbidity (13.4% vs. 10.1%; p = 0.02) but similar mortality rates (2% vs. 1.5%; p = 0.313). In matched cohort analysis, open appendectomy also was associated with a higher rate of superficial surgical site infection (SSI) (3.8% vs. 1.4%; p < 0.001) and a lower rate of organ/space SSI (1.3% vs. 2.9%; p = 0.009). Laparoscopic appendectomy was associated with a shorter LOS in both aggregate and matched cohorts compared with open appendectomy (p < 0.001).

CONCLUSIONS

Within ACS NSQIP hospitals, elderly patients benefited from a laparoscopic approach to appendicitis with regards to a shorter LOS and a lower minor and overall morbidity. Laparoscopic appendectomy was associated with lower superficial SSI and higher organ/space SSI rates.

Does laparoscopic appendectomy impart an advantage over open appendectomy in elderly patients?

BACKGROUND

The use of laparoscopy in the elderly has been increasing in recent years. The data comparing laparoscopic (LA) with open appendectomy (OA) in elderly patients are minimal. We evaluated outcomes of LA versus OA in perforated and nonperforated appendicitis in elderly patients (aged ≥ 65 years).

METHODS

Using the Nationwide Inpatient Sample database, clinical data of elderly patients who underwent LA and OA for suspected acute appendicitis were evaluated from 2006 to 2008.

RESULTS

A total of 65,464 elderly patients underwent urgent appendectomy during this period. The rate of perforated appendicitis was twice as high in elderly patients (50 vs. 25%, p < 0.01) and rate of LA in elderly patients was lower (52 vs. 63%, p < 0.01) compared with patients younger than aged 65 years. Utilization of LA increased 24% from 46.5% in 2006 to 57.8% in 2008 (p < 0.01). In elderly patients with acute nonperforated appendicitis, LA had lower overall complication rate (15.82 vs. 23.49%, p < 0.01), in-hospital mortality (0.39 vs. 1.31%, p < 0.01), hospital charges ($30,414 vs. $34,095, p < 0.01), and mean length of stay (3.0 vs. 4.8 days, p < 0.01) compared with OA. Additionally, in perforated appendicitis in elderly patients, LA was associated with lower overall complication rate (36.27 vs. 46.92%, p < 0.01), in-hospital mortality (1.4 vs. 2.63%, p < 0.01), mean hospital charges ($43,339 vs. $57,943, p < 0.01), and shorter mean LOS (5.8 vs. 8.7 days, p < 0.01).

CONCLUSIONS

Laparoscopic appendectomy can be performed safely with significant advantages compared with open appendectomy in the elderly and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.

Laparoscopic appendectomy for complicated acute appendicitis does not result in increased surgical complications

BACKGROUND/OBJECTIVES

Septic postoperative complications are debated in patients with complicated acute appendicitis treated with laparoscopic appendectomy (LA). The aim of this study was to investigate the results of LA in both complicated and uncomplicated cases of acute appendicitis.

METHODS

From January to December 2009, 94 patients with acute appendicitis underwent LA by the same surgeon using the three-port technique. Data were accumulated and compared between complicated and uncomplicated acute appendicitis.

RESULTS

Of the 94 patients (45 women and 49 men), 19 had complicated and 75 uncomplicated acute appendicitis. The group with complicated acute appendicitis, as compared to the uncomplicated group, was significantly older (55.7 ± 20.5 years vs. 41.0 ± 18.0 years), and had a significantly increased operation time (117.6 ± 45.5 minutes vs. 78.2 ± 39.4 minutes), longer length of hospital stay (9.0 ± 3.3 days vs. 5.2 ± 6.0 days) and higher conversion rate (21.1% vs. 2.7%). No increase in surgical complications was noted in patients with complicated acute appendicitis, as compared to those with uncomplicated acute appendicitis.

CONCLUSION

This study demonstrated no increase in surgical complications after LA in patients with complicated acute appendicitis when compared with those who had uncomplicated disease. Therefore, LA may be considered the first-choice treatment option for both uncomplicated and complicated acute appendicitis.

Diabetes Mellitus and Cerebrovascular Disease as Independent Determinants for Increased Hospital Costs and Length of Stay in Open Appendectomy in Comparison with Laparoscopic Appendectomy: A Nationwide Cohort Study

Comorbidity has been proven to increase hospital costs and length of hospital stays in patients receiving appendectomy for the treatment of acute appendicitis. However, the specific comorbidities that independently influence discrepancy of hospital costs and length of stay between open appendectomy and laparoscopic appendectomy still need to be elucidated. Using multi-variate linear analysis, administrative claims data were obtained from Taiwan's National Health Institute Research Database to compare differences of hospitalization costs and length of stay between open appendectomy and laparoscopic appendectomy categorized by various comorbidities defined in Charlson comorbidity score. Of 103,653 patients, 81,479 open appendectomies and 22,174 laparoscopic appendectomies were performed for the treatment of acute appendicitis in Taiwan between 2004 and 2008. In multilinear regression models, the adjusted costs and length of stay for open appendectomy in patients with cerebrovascular diseases or diabetes mellitus were significantly higher than that for laparoscopic appendectomy. To reduce costs and length of stay, patients with cerebrovascular diseases or diabetes mellitus should be particularly recommended to receive laparoscopic approach rather than an open approach for the treatment of acute appendicitis.

MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome

Elderly adults are at increased risk for complications related to both delayed diagnosis of appendicitis and to unnecessary appendectomy. We assessed the diagnostic performance of computed tomography (CT) in a consecutive elderly cohort with clinically suspected appendicitis. CT findings and clinical outcomes were analyzed for 262 consecutive adult patients age 65 and older (mean 75.6 ± 7.5 years; range 65-94; M/F 111:151) referred for clinically suspected appendicitis at a single medical center between January 2000 and December 2009. The overall prevalence of proven acute appendicitis in this elderly cohort with clinically suspected appendicitis was 16.8% (44/262). CT sensitivity, specificity, PPV, and NPV for acute appendicitis were 100% (44/44), 99.1% (216/218), 95.7% (44/46), and 100.0% (216/216), respectively. The negative appendectomy rate was 2.3% (1/43). The perforation rate was 40.9% (18/44). There were no false-negative and two false-positive CT interpretations. All patients with appendicitis suspected on CT were hospitalized (44/44), with an average stay of 5.7 ± 3.2 days, and 93.5% (43/46) underwent appendectomy. Overall surgical complication rate was 34.9% (15/43). Compared with younger adults over the same period, elderly patients had higher rates of perforation and surgical complications, and longer hospital stays (p < 0.003). CT is highly accurate for the evaluation of clinically suspected appendicitis in elderly patients. Prompt diagnosis is important given the higher rates perforation and surgical complications relative to younger adults.

Laparoscopic appendectomy for acute appendicitis is more favorable for patients with comorbidities, the elderly, and those with complicated appendicitis: a nationwide population-based study

BACKGROUND

Laparoscopic appendectomy (LA) is not routinely performed for appendicitis because the costs associated with that procedure are higher than those for open appendectomy (OA). However, few studies have investigated the economic influence of LA and OA on specific subpopulations including the elderly, patients with comorbidities, and patients with complicated appendicitis. This population-based study was designed to investigate determinants of costs and hospital length of stay (LOS) for patients undergoing appendectomy. Furthermore, the differences in costs and LOS were compared between LA and OA for various subpopulations.

METHODS

Inpatients who underwent LA or OA for appendicitis during the period 2001-2008 were identified from claims data obtained from Taiwan's National Health Insurance program. Costs and LOS were evaluated by multiple linear regression models for various subpopulations stratified according to age, number of comorbidities, and severity of appendicitis.

RESULTS

Between 2001 and 2008, 22,252 patients (13.3%) underwent LA and 14,4438 (86.7%) had OA. Age, comorbidity, and severity of appendicitis were determinants of costs and LOS for both LA and OA. Although the costs and LOS for appendectomy increased with age and number of comorbidities, a sharper increase was noted for OA patients. Laparoscopic appendectomy mildly decreased LOS at the expense of significantly higher costs for young patients, those without comorbidities, and patients with uncomplicated appendicitis. In contrast, compared with OA, LA was associated with comparable costs and reduced LOS for the elderly, patients with comorbidities, and those with complicated appendicitis. In addition, hospital mortality and readmission rates for postoperative complications did not differ significantly between LA and OA.

CONCLUSION

Considering costs and LOS, patients older than 65 years, patients with comorbidities, and patients with complicated appendicitis benefit more from the laparoscopic approach for the treatment of appendicitis.

Laparoscopic appendectomy is safe and efficacious for the elderly: an analysis using the National Surgical Quality Improvement Project database

BACKGROUND

Despite increasing use of laparoscopic appendectomy, data demonstrating outcomes of this technique exclusively among the elderly population are scarce. This study aimed to compare 30-day postoperative morbidity and length of hospital stay among elderly patients after appendectomy.

METHODS

Appendicitis patients older than 65 years were extracted from the National Surgical Quality Improvement Project (NSQIP) database. Demographics and rates of complications for patients undergoing open and laparoscopic appendectomies were compared. Uni- and multivariate analyses adjusted for differences between groups compared the end points of major and minor complications as well as the days of hospital stay after initial surgery.

RESULTS

A total of 3,335 patients underwent appendectomy, with 2,235 patients (67%) receiving a laparoscopic procedure. The open appendectomy patients were significantly older and more likely to have various preoperative comorbidities (p<0.05). No difference in median operative time between the two techniques was found. Both required 51 min (p=0.11). The open cases had higher rates of both major and minor postoperative complications than the laparoscopic cases (p<0.0001), both overall and before discharge. Multivariate analysis showed no association between operative approach and major complications, and a reduced risk of minor complications with laparoscopy. Length of surgical stay was longer for the open group than for the laparoscopically treated group (median, 4 days vs 2 days; p<0.05). After adjustment, laparoscopy still was significantly associated with a shorter hospital stay than open appendectomy (p<0.0001).

CONCLUSIONS

Laparoscopic appendectomy is a safe procedure for elderly patients. During the 30-day postoperative period, no correlation with major complications was found, and the findings showed a beneficial association with regard to minor complications. After adjustment for perioperative factors, laparoscopy is associated with a shorter hospital stay than open appendectomy.

Competitive edge of laparoscopic appendectomy versus open appendectomy: a subgroup comparison analysis

BACKGROUND

With the advances in laparoscopic instruments and surgical techniques, the use of laparoscopic appendectomy (LA) has been increasing rapidly in recent years. In this retrospective analysis, we aimed to determine the competitive edge of LA versus open appendectomy (OA) in different settings of disease complexity, gender, and age difference.

METHODS

A retrospective analysis of the patients diagnosed with acute appendicitis at Changhua and Chang-Bing Show-Chwan Memorial Hospitals from January 1, 2004 to December 31, 2009 was conducted. Trend and indication of OA and LA were recorded, combined with a comparison of medical costs, complication rates, wound infection rates, and hospital stays in different settings of disease complexity, gender, and age group.

RESULTS

A total of 1366 appendicitis patients were enrolled, and the rate of LA use increased rapidly, from 8.1% in 2004 to 90.3% in 2009. The increased use of LA was seen in both the uncomplicated and complicated appendicitis patients and in both gender and age groups (pediatric, adult, and elderly). Compared with OA, LA was associated with a lower complication rate (9.5% versus 5.8%; P = .013), a lower wound infection rate (8.6% versus 4.2%; P = .001), and a shorter hospital stay (4.60 ± 3.64 versus 4.06 ± 1.84 days; P = .001), but a higher mean cost (32,670 ± 28,568 versus 37,567 ± 12,064 New Taiwan dollars). In the subgroup analysis, the patients with complicated appendicitis, female patients, and pediatric and elderly patients benefited from a reduced hospital stay. LA is about 15% more expensive than OA.

CONCLUSIONS

LA is as safe and effective as OA in many settings of appendicitis and may be selectively advantageous in patients with complicated appendicitis and in elderly subgroups.

Prevention of infectious complications after laparoscopic appendectomy for complicated acute appendicitis--the role of routine abdominal drainage

PURPOSE

Complicated acute appendicitis is still associated with an increased morbidity. If laparoscopy has been accepted as a valid approach, some questions remain concerning intra-abdominal abscess formation. Routine prophylactic drainage of the abdomen has been proposed. However, this practice remains a matter of debate, poorly validated in the literature. With the present study, we investigated the impact of drainage in laparoscopic appendectomy for complicated appendicitis.

METHOD

This is a case match study of consecutive patients operated on by laparoscopy in a single institution. One hundred and thirty patients operated for complicated appendicitis (local peritonitis without perforation, with perforation, or with periappendicular abscess) with prophylactic intraperitoneal drainage were matched one by one to 130 patients operated without drainage. Uncomplicated appendicitis and generalized peritonitis were excluded. Primary endpoint was surgical complications and secondary endpoints were transit recovery time and length of hospital stay.

RESULTS

Patients without drain had significantly less overall complications (7.7% vs. 18.5%, p = 0.01). Moreover, the absence of drainage was of significant benefit for transit recovery time (2.5 vs. 3.5 days, p = 0.0068) and length of hospital stay (4.2 vs. 7.3 days, p < 0.0001).

CONCLUSION

No benefits were observed for prophylactic drainage of the abdominal cavity during emergency laparoscopic treatment of complicated appendicitis. For this reason, this practice may be abandoned.

[Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy]

BACKGROUND

The diagnosis of acute appendicitis in the elderly bears many pitfalls due to a broad range of differential diagnoses and uncommon clinical presentation. This may result in late detection of appendicitis leading to poor outcome. The aim of this study was to examine the characteristics of appendicitis in elderly patients in order to facilitate early diagnosis.

MATERIALS AND METHODS

All patients who underwent appendectomy in our institution were prospectively recorded over a 30 month period. Data on patient's age (>60 years versus < or =60 years), clinical findings, the inflammatory parameters leucocytes and C-reactive protein (CRP) and histological-findings (perforated versus non-perforated) were collected. Statistical analysis was carried out by ROC analysis, chi(2) and t-tests.

RESULTS

In the examination period 403 patients underwent appendectomy and 11.2% (n=45) were older than 60 years. These patients were characterized by significantly more frequent perforations compared to those patients < or =60 years (35.6% versus 7.0%, p< or =0.05), peritonitis (42.2% versus 9.5%, p< or =0.05), conversion to open surgery (23% versus 5%, p< or =0.005), longer postoperative hospital stay (9.2 days versus 4.3 days, p< or =0.05) and a higher complication rate (28.9% versus 3.6%, p< or =0.005). CRP values in patients >60 years were on average 123.2 mg/l and significantly higher than in patients < or =60 years (35.5 mg/l, p< or =0.005). The ROC analysis resulted in a CRP cut-off value of 101.9 mg/l for patients >60 years for the existence of a perforation with a specificity of 72.4% and a sensitivity of 81.3% (AUC 0.811).

CONCLUSIONS

The CRP value showed a strong correlation with respect to the grade of inflammation and perforation. In conclusion, elderly patients with symptoms of appendicitis and a CRP value higher than 102 mg/l should undergo early diagnostic laparoscopy.

The effects of laparoscopic surgery and nosocomial infections on the cost of care: evidence from three common surgical procedures

OBJECTIVE

To examine the cost of care for laparoscopic versus open surgery and the added cost of nosocomial infections for three common surgical procedures: cholecystectomy, hysterectomy, and appendectomy.

METHODS

The Cardinal Health database repository was utilized to extract reimbursement data for laparoscopic and open cholecystectomy, hysterectomy, and appendectomy surgical procedures. Utilizing a 22-hospital sample and a Health Insurance Portability and Accountability Act compliant clinical data extraction technique, the Cardinal Health database repository produced a Nosocomial Infection Marker to identify and track nosocomial infection rates for these procedures. ICD-9 codes were utilized to identify 10,731 patients who had undergone these procedures between September 2004 and December 2006. Multivariable linear regression models were estimated to isolate the effects of laparoscopic versus open surgery and nosocomial infections on the cost of care.

RESULTS

Laparoscopic surgery significantly reduces the overall cost of care for cholecystectomies, hysterectomies, and appendectomies. Controlling for the cost of nosocomial infection, incremental cost savings from laparoscopic versus open surgery for all three procedures average $1608. Cholecystectomy has the largest savings ($3299), followed by hysterectomy ($1385) and appendectomy ($1032). These cost savings in part reflect that patients undergoing laparoscopic procedures have shorter lengths of stay. In contrast, nosocomial infection increases costs substantially for each surgery type, raising costs for cholecystectomy by $4794, hysterectomy by $4528, and appendectomy by $6108.

CONCLUSION

The cost of care for laparoscopic surgery is lower than open surgery for cholecystectomy, hysterectomy, and appendectomy. This conclusion is based on actual hospital reimbursement data.

[Laparoscopic or open appendectomy?]

Despite the fact that laparoscopic appendectomy was one of the first performed minimally invasive surgical procedures, the benefits and indications of its use are still controversial.

METHODS

Data of patients with the diagnosis of appendicitis operated either with laparoscopic (LA) or open (OA) appendectomy were collected and analyzed.

PATIENTS

This study involved 273 consecutive patients who had undergone appendectomy with the diagnosis of acute appendicitis at the Uzsoki Teaching Hospital, Department of Surgery between January 2005 and December 2007. 185 patients (68%) operated with the laparoscopic, 88 (32%) with the open technique, in the third year 89% of the cases underwent laparoscopic appendectomy.

RESULTS

The conversion rate was 27%, the reason of the conversion was the progression of the disease in 35 patients (70%) and technical in 15 cases (30%). The wound infection rate was 8% in the LA and 18% in the OA group ( p = 0.022). No significant difference was found in the reoperation rate and in the hospital readmission rate between the two groups. There was one insufficiency which was treated with conservative therapy. The hospital stay was significantly lower in the laparoscopic group ( p = 0.031).

CONCLUSIONS

This study demonstrated that laparoscopic appendectomy has significant advantages over open appendectomy. In our practice, laparoscopic appendectomy is the first choice of procedure in acute appendicitis.

Laparoscopic appendectomy in a district hospital: does the technique influence the outcome?

BACKGROUND

Laparoscopic appendicectomy (LA) has proved to be a safe, effective procedure for appendicitis. However, its application in the current surgical practice is still far less than the laparoscopic cholecystectomy. Therefore, its role as a gold standard operation for acute appendicitis (AA) is less well established.

METHODS

Between September 1999 and January 2007, a series of 200 patients (112 female, 88 male) with AA underwent LA in our surgical unit. A single consultant surgeon performed all the cases. Outcomes, including the length of stay, operative time, and complications, were evaluated. Follow-up assessment of patients was performed by outpatient appointment.

RESULTS

The indications for LA were clinical diagnosis of AA for 177 patients (85%) and interval appendicectomy for 23 patients (15%). The mean age of these patients was 18.8 years (range, 8-83). Operative diagnosis of inflamed appendix, including perforated appendicitis in 9 patients (7.5%), was made in 139 patients (69.5%), and the appendix was macroscopically normal in 40 patients (20%). Different pathologies were found in 21 patients (11.5%). Of the 40 (20%) macroscopically normal appendices, 10 (5%) appendices were reported as inflamed by histopathology examination. The operative time ranged from 13 to 62 minutes, with a mean of 18 minutes. Minor morbidity was reported in 11 patients (5.5%)

CONCLUSION

In experienced hands using a meticulous technique, LA provides diagnostic and therapeutic options, decreased operative time, rapid recovery, short hospital stay, fewer postoperative complications, and no intra-abdominal abscesses. Appendicectomy has cured right iliac fossa pain in almost all the patients.

Laparoscopic renal surgery in the octogenarian

OBJECTIVE

To describe our experience with laparoscopic renal surgery (LRS) in the octogenarian. Octogenarians are generally suboptimal surgical candidates but the recent upsurge of minimally invasive options for the management of kidney lesions, such as laparoscopic excision, cryoablation and radiofrequency ablation (RFA), have changed that perception.

PATIENTS AND METHODS

In all, 26 patients aged >or=80 years underwent LRS at Brown University and the University of Wisconsin between 2000 and 2006. Demographic information, anatomical location, tumour stage, comorbidities, type of laparoscopic approach, management and outcomes were assessed. Complications during and after LRS, hospital stay, analgesia requirements and return to normal activity were analysed.

RESULT

The mean age of the patients was 81 years. The procedures performed included hand-assisted laparoscopic partial nephrectomy (three patients), hand-assisted laparoscopic radical nephrectomy (10), hand-assisted laparoscopic nephroureterectomy (four), laparoscopic-assisted cryoablation (seven), laparoscopic RFA (one), and laparoscopic unroofing of a renal cyst (one). The mean (range) follow-up was 40 (8-84) months. The mean American Society of Anesthesiologists score was 2.5. The average hospital stay was 5.6 days and the mean time to normal activity after discharge was 19 days. There were two major and five minor complications. Nineteen of 22 patients evaluable had no evidence of disease at the last follow-up. The three deceased patients died of unrelated causes.

CONCLUSION

LRS in the octogenarian is safe to perform in patients with multiple comorbidities. The major and minor complication rates were 7% and 19%, respectively. Recent trends show that ablative procedures are being performed more commonly than surgical excision in this age group.

The association of the number of comorbidities and complications with length of stay, hospital mortality and LOS high outlier, based on administrative data

OBJECTIVES

With greater concern for efficient resource allocation and profiling of medical care, a case-mix classification was applied for the per-diem payment system in Japan. Many questions remain, one of which is the role of comorbidity and complication (CC) in grouping logic. We examined the association of the number of CC with the length of hospital stay (LOS) and hospital mortality as well as the proportion of LOS high outliers in 19 major diagnostic categories (MDCs).

METHODS

This study was a secondary data analysis embedded in a government research project, including anonymous claims and clinical data during a 4-month period from July 2002. Every 19 MDC, LOS, hospital mortality or proportion of LOS high outliers was compared by the number of CC and presence of any procedures.

RESULTS

From 82 special function hospitals, 241,268 patients were enrolled in this study. Among all patients, 50.5% were identified without any CCs, 32.4% with one or two, 13.4% with three or four, and 3.7% with over five CCs. The overall mean LOS was 22.15 days and hospital mortality 26.05 cases per 1,000 admissions. In any MDC, LOS and the proportion of outliers increased as the number of CC rose. The mortality rate increased prominently in the respiratory system and the hematology system.

CONCLUSIONS

This study demonstrated that the occurrence of more CC caused longer LOS and higher mortality in some major disease categories. Further study will clarify the association of the weighted CC with resource use through controlling procedures specific for MDC.

Changing trends in surgery for acute appendicitis

BACKGROUND

Laparoscopic appendicectomy (LA) offers faster recovery times and a reduced rate of wound infection compared with open appendicectomy (OA) but may be associated with more intra-abdominal abscesses. This study examines the changing trends in management of appendicitis in a regional setting during service reorganization and compares infective complication rates for each procedure.

METHODS

Data were retrieved from the Lothian Surgical Audit database on 1824 patients treated for appendicitis by OA or LA during equal 31-month periods before and after service reorganization in August 2002. Outcome measures were duration of admission, recovery time from operation to discharge and reintervention for infective complications. Analysis was by intention to treat.

RESULTS

The rate of LA in Lothian increased from 29.9 to 39.4 per cent (P < 0.001) after subspecialist service reorganization. Recovery time from operation to discharge was significantly shorter after LA than OA when results were stratified with respect to sex (mean 2.5 versus 4.4 days respectively in women, P < 0.001; 2.7 and 3.1 days in men, P = 0.023), timing of surgery (2.7 versus 3.3 days before subspecialization, P = 0.007; 2.5 versus 3.6 days after subspecialization, P < 0.001) and whether appendicitis was associated with peritoneal contamination (2.2 versus 3.0 days for uncontaminated surgery, P < 0.001; 4.3 versus 5.1 days for contaminated surgery, P = 0.060). Peritoneal contamination at primary operation was the only independent risk factor that predicted reintervention for infective complications.

CONCLUSION

LA is associated with a shorter hospital stay from operation to discharge than OA, with no evidence of an increased rate of intra-abdominal infective complications.

Impact of age and procedure on resource use for patients with ischemic heart disease

OBJECTIVES

Impact of age on healthcare expenditures should be assessed by targeting on specific diseases and controlling for procedures and severity of illness. Relationship between age and resource use in patients receiving acute care medicine for ischemic heart disease (IHD) was examined.

METHODS

We analyzed 19,874 IHD patients treated in 82 academic and 92 community hospitals. Length of stay (LOS), total charges (TC), and high outliers of LOS and TC were analyzed for every age group (under 65 years, 65-74 years, 75 years or older). Independent effects of age on LOS, TC, and high outliers of LOS and TC were determined using multivariate analysis.

RESULTS

7863 (39.6%) patients were under 65 years, 7181 (36.1%) between 65 years and 74 years, and 4830 (24.3%) aged 75 years or older. Proportion of angina or non-medical treatment was significantly different among three age categories (angina 72%, 75%, 71.4%; non-medical 37.3%, 40.9%, 38.9%, respectively). Significant association with LOS or TC was identified in patients receiving coronary artery bypass graft surgery with percutaneous intracoronary intervention, who were most associated with TC high outlier.

CONCLUSIONS

Age had a modest impact on resource use, as compared with procedures. Policy makers need to acknowledge the impact of procedures on healthcare spending.

The effect of age and procedure on resource use for patients with cerebrovascular disease

Objective

Many studies have described the impact of population ageing on health care expenditures, but few have assessed its impact on specific diseases adjusted for severity and procedure. This study examined the relationship between an ageing population and resource use in patients with cerebrovascular disease (CVD).

Methods

A total of 13,856 CVD patients were treated in 82 academic and 92 community hospitals. Demographic variables, clinical variables, length of stay (LOS) and total charges were analysed by age group (under 65 years, 65-74 years and 75 years or older). The independent effects of age on LOS and total charge were determined using multivariate analysis.

Results

There were 5172 (37%) patients under 65 years of age, 4096 (30%) 65-74 years and 4588 (33%) 75 years or older. Intracranial infarction or ischaemia was diagnosed in 69% of the patients, haemorrhage in 23% and subarachnoid haemorrhage in 9%. The overall mortality was 6% (5% in under 65 years, 5% in 65-74 years and 9% in 75 years or older; P < 0.001). There were significant differences in the proportion of procedures performed in each age category. Age and procedure were significantly associated with LOS, particularly the latter. Age had no significant association with total charge, but procedure was highly associated.

Conclusions

Ageing has no significant impact on total charge. Instead policy-makers should acknowledge the effect of procedures on health care costs, conduct economic evaluations and monitor use of procedures.

Laparoscopic Radical Prostatectomy in Men Older than 70 Years of Age with Localized Prostate Cancer: Comparison of Morbidity, Reconvalescence, and Short-Term Clinical Outcomes between Younger and Older Men

OBJECTIVES

To analyze the safety and efficacy of extraperitoneal laparoscopic radical prostatectomy (eL-RPE) in elderly versus younger men with localized prostate cancer.

METHODS

Patients undergoing eL-RPE were retrospectively subdivided into group eL-RPE1 (72 men aged 71 yr and older) and group eL-RPE2 (132 men aged 59 yr and younger). Group eL-RPE1 was compared with a group of 70 contemporary, comparable patients aged 71 yr and older undergoing open retropubic radical prostatectomy (group OPEN-RPE).

RESULTS

Compared with group eL-RPE2, patients of group eL-RPE1 had a higher pathologic stage (45% vs. 32% stage pT3 or greater, p<0.001) and higher Gleason score (median 7 vs. 6, p<0.001). Prostate-specific antigen recurrence was significantly worse compared with age-matched controls for younger patients with high-stage or high-grade lesions (p<0.001). Importantly operative time, analgesic requirements, hospital stay, convalescence, and complication rates were comparable. Urinary continence rate was significantly better in group eL-RPE2 at 6 mo (67% vs. 91%, respectively, p<0.001). Group eL-RPE1 and group OPEN-RPE patients had statistically similar pathologic stage and Gleason score (each p>0.05), similar operative time (p=0.12), but less blood loss (p<0.001), shorter hospital stay (p<0.001), and more rapid convalescence (p<0.001) occurred in eL-RPE1.

CONCLUSIONS

eL-RPE is feasible and efficacious even in elderly patients with unfavorable, large-volume disease. eL-RPE offers the advantages of decreased blood loss, shorter hospital stay, and more rapid recovery over OPEN-RPE. However, the elderly patient must be informed preoperatively about the observed higher incontinence rate.