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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

A call for a standardized definition of perforated appendicitis

BACKGROUND

Abscess rates have been reported to be as low as 1% and as high as 50% following perforated appendicitis (PA). This range may be because of lack of universal definition for PA. An evidence-based definition (EBD) is crucial for accurate wound classification, risk-stratification, and subsequent process optimization. ACS NSQIP-Pediatric guidelines do not specify a definition of PA. We hypothesize that reported postoperative abscess rates underrepresent true incidence, as they may include low-risk cases in final calculations.

METHODS

Local institutional records of PA patients were reviewed to calculate the postoperative abscess rate. The ACS NSQIP-Pediatric participant use file (PUF) was used to determine cross-institutional postoperative abscess rates. A PubMed literature review was performed to identify trials reporting PA abscess rates, and definitions and rates were recorded.

RESULTS

20.9% of our patients with PA developed a postoperative abscess. The ACS NSQIP-Pediatric abscess rate was significantly lower (7.61%, p<0.001). In the eighteen published studies analyzed, average abscess rate (14.49%) was significantly higher than ACS NSQIP-Pediatric (p<0.001). There was significantly more variation in trials that do not employ an EBD of perforation (Levene's test F-value =6.980, p=0.018).

CONCLUSIONS

A standard EBD of perforation leads to lower variability in reported postoperative abscess rates following PA. Nonstandard definitions may be significantly altering the aggregate rate of postoperative abscess formation. We advocate for adoption of a standard definition by all institutions participating in ACS NSQIP-Pediatric data submission.

LEVEL OF EVIDENCE

III.

Complications in common general pediatric surgery procedures

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

Laparoscopic versus Open Surgery in Complicated Appendicitis in Children Less Than 5 Years Old: A Six-Year Single-Centre Experience

Introduction. Acute appendicitis is the most common surgical emergency in the pediatric population. The peak incidence occurs in the first decade of life, while it is uncommon to face appendicitis in children younger than 5 years of age. Laparoscopy is now demonstrated to be the optimal approach also to treat complicated appendicitis, but in very young children this standardized operation is not always easy to perform. Material and Methods. From January 2009 to December 2015 we operated on 525 acute appendicitis, with 120 patients less than 5 years of age. Results. 90 children had a complicated appendicitis (localized or diffuse peritonitis): 43 (48%) were operated on by open approach and 47 (52%) by laparoscopy. The overall incidence of postoperative complications was greater in the open appendectomy group (63% versus 26%) and all severe complications requiring reintervention (6% of cases: 3 postoperative abscesses resolved with ultrasound guided percutaneous abscess drainage; 1 tubal surgery for salpingitis; 1 adhesion-related ileus requiring relaparotomy) were mostly associated with open surgery. Conclusions. Laparoscopic surgery resulted as the best approach for treating complicated appendicitis also in younger children, with minor and less severe postoperative complications compared to open surgery.

Wound classification in pediatric surgical procedures: Measured and found wanting

PURPOSE

Surgical wound classification has emerged as a measure of surgical quality of care, but scant data exist in the era of minimally invasive procedures, especially in children. The aim of this study is to examine the surgical site infection (SSI) rate by wound classification during common pediatric surgical procedures.

METHODS

A retrospective analysis of the 2013 Pediatric-National Surgical Quality Improvement Program (Peds-NSQIP) dataset was conducted. Patients undergoing pyloromyotomy, cholecystectomy, ostomy reversal, and appendectomy were included. Wound classification, SSI rate, reoperation, and readmission were analyzed.

RESULTS

A total of 10,424 records were included. Pyloromyotomy, a clean case, had a 0.7% SSI rate, while ostomy reversal, a clean contaminated case, had an SSI in 6.9% of cases. Appendectomy for nonperforated acute appendicitis and laparoscopic cholecystectomy for cholecystitis, both contaminated cases, had SSI rates of 2.1% and <1%, respectively. Appendectomy for perforated appendicitis, a dirty procedure, had a 9.1% SSI rate, below the expected >40% for dirty cases. Reoperations and readmission rates ranged from <1% to 9% and increased with case complexity.

CONCLUSION

Current wound classifications systems do not reflect surgical risk in children and remain questionable tools for benchmarking surgical care in children. Role of readmissions and reoperations as quality of care indices needs further investigation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

2c, Outcomes Research.

Management of paediatric acute appendicitis in the general hospital setting: a national survey of preferred surgical technique

BACKGROUND

The advent of laparoscopic surgery has facilitated the management of acute appendicitis in the adult population. In the paediatric population (<12 years), management varies according to institution and/or consultant expertise. The aim of this study was to analyse consultant preference for laparoscopic versus open appendicectomy in the management of acute appendicitis in children under 12 years presenting to general hospitals.

METHODS

A 15-point questionnaire was distributed to 81 consultant surgeons identified from the specialist register of the Irish Medical Council and practicing as general surgeons outside of specialist paediatric centres.

RESULTS

A response rate of 83 % (67/81) was obtained. Of the 67 surgeons surveyed, 11 (16 %) had formal paediatric training. Sixty percent (40/67) of surgeons expressed a preference for the open technique. The median frequency of on-call rota was >1 in 5 (32/67) and only 3 % (2/67) claimed that the on-call commitment influenced decision-making regarding surgical approach. The average minimum age (9.3 years, range 1-14) and average minimum weight (25 kg, range 12-70) at which the operating surgeon would perform a laparoscopic appendicectomy were also recorded. Thirty percent (20/67) of consultant general surgeons had immediate access to specialist paediatric laparoscopic equipment.

DISCUSSION

This study has shown wide variability amongst consultant general surgeons when considering open versus laparoscopic appendicectomy in children under 12 years. Restricted access to specialist paediatric laparoscopic equipment, combined with declining exposure to paediatric surgical training, may continue to limit the numbers of paediatric laparoscopic appendicectomies performed in the general setting.