Moving from an era of open Appendectomy to an era of Laparoscopic Appendectomy: A Nationwide Cohort Study of Adult Patients Undergoing Surgery for Appendicitis

Early surgery for perforated appendicitis: Are we moving the needle on postoperative abscess?

BACKGROUND

Perforated appendicitis is often managed nonoperatively though upfront surgery is becoming more common. We describe postoperative outcomes for patients undergoing surgery at their index hospitalization for perforated appendicitis.

METHODS

We used the 2016-2020 National Surgical Quality Improvement Program database to identify patients with appendicitis who underwent appendectomy or partial colectomy. The primary outcome was surgical site infection (SSI).

RESULTS

132,443 patients with appendicitis underwent immediate surgery. Of 14.1% patients with perforated appendicitis, 84.3% underwent laparoscopic appendectomy. Intra-abdominal abscess rates were lowest after laparoscopic appendectomy (9.4%). Open appendectomy (OR 5.14, 95% CI 4.06-6.51) and laparoscopic partial colectomy (OR 4.60, 95% CI 2.38-8.89) were associated with higher likelihoods of SSIs.

CONCLUSIONS

Upfront surgical management of perforated appendicitis is now predominantly approached by laparoscopy, often without bowel resection. Postoperative complications occurred less frequently with laparoscopic appendectomy compared to other approaches. Laparoscopic appendectomy during the index hospitalization is an effective approach to perforated appendicitis.

Colonoscopic titanium clipping to Maddress appendiceal stump leakage: a case report

The incidence of appendiceal stump leakage (ASL) is extremely low and heterogeneous, which has been reported to be approximately 0.5%-1.0%. It is a catastrophic complication with high mortality rate despite its low morbidity. Once it occurs, it will put the doctor in a passive position because dealing with the leakage is much more cumbersome than appendectomy. We extensively reviewed the literature on ASL, focusing on the management and prognosis. Unsurprisingly, all of the physicians advocated extended resection, which apparently gave them sufficient confidence. However, partial cecum resection, cecostomy, or terminal ileectomy is extremely invasive and destructive. So, the patients had to experience great mental and physical trauma, longer hospital stays, higher rates of wound infection, more costs, and even a third surgery. Therefore, are there any better approaches for ASL? In this article, we report a case of ASL who successfully underwent endoscopic treatment. A 70-year-old male was admitted with gangrenous perforated appendicitis with a large iliopsoas abscess. Appendectomy, iliopsoas abscess debridement and sufficient drainage, appendicular stump repair and closure, and terminal ileostomy were performed. Three months later, the patient was readmitted and the stoma reversal was performed as scheduled. Seven days later, ASL was found when a liquid diet was applied routinely due to right lower quadrant pain and low fever. Finally, with the periappendiceal abscess completely drained, we clamped the appendiceal orifice with five titanium clips under an electronic colonoscope, which eventually sealed the leakage and avoided extended resection.

Validity of the coding for appendicitis, appendectomy, and diagnostic laparoscopy in the Danish National Patient Registry

BACKGROUND AND OBJECTIVE

We aimed to validate the diagnostic accuracy of appendicitis, its severity, its description, and the surgical approach, including open or laparoscopic appendectomy and diagnostic laparoscopy, in the Danish National Patient Registry (DNPR) against information from the electronic medical records.

METHODS

A random sample of 1046 patients of all ages and sexes recorded in the DNPR from the Capital Region of Denmark during 2010-2015 was investigated. Patients' admission had to include a discharge code for appendicitis (K35-K379) according to the International Classification of Disease version 10 (ICD-10) alone or in combination with a surgical code for appendectomy or the surgical code for a diagnostic laparoscopy. We calculated the positive predictive values (PPVs) with 95% confidence intervals.

RESULTS

Data from a total of 1018 patients were available for data analysis. The ICD-10 codes for appendicitis resulted in a good PPV of >95% when combined with a surgical code. ICD-10 codes combined with the surgical codes could discriminate between uncomplicated and complicated appendicitis with some caution as the PPVs ranged from 68% to 93%. Only the surgical code for laparoscopic appendectomy yielded a good PPV (99%) for the actual surgical approach. The surgical code for a diagnostic laparoscopy alone did not cover a normal diagnostic laparoscopy.

CONCLUSIONS

The diagnostic accuracy of appendicitis and appendectomy in routinely collected administrative health data is good for ICD-10 codes for appendicitis in combination with a surgical code and especially for laparoscopic appendectomy. Uncomplicated and complicated appendicitis can be distinguished with some caution.

Laparoscopic Appendectomy Translates into Less Analgesics and Faster Return to Work in Asia

Background:

Laparoscopic appendectomy (LA) is claimed to require less analgesic and allow for a faster return to work. This study examines whether these benefits hold true in Asian patient populations.

Methods:

A retrospective audit of emergency appendectomies over one year was conducted to study outcomes of postoperative pain, length of stay (LOS), duration of analgesia, and hospitalization leave (HL). A telephone questionnaire evaluated post-discharge analgesic intake, residual symptoms at follow-up, adequacy of HL and opinion on teleconsult reviews.

Results:

Of the 201 patients, 187 (93%) underwent LA. Presurgery symptoms were significantly longer in the open appendectomy (OA) group (mean: OA 3.79, LA 1.81 days; p = 0.026) which also had a higher frequency of perforation (71.4%). LA patients reported less pain compared to OA (LA 3.60 vs. OA 4.14; p = 0.068) but were prescribed the same 2 weeks of analgesics as OA. LOS was significantly less for LA (mean LA 3.09, OA 6.93 days; p = 0.006). Mean HL for LA and OA were 17.9 and 21.8 days respectively (p = 0.05). Nearly 83% patients did not complete the prescribed course of analgesics and 47% patients felt that HL was more than adequate. Seventy-five percent of patients were asymptomatic at hospital follow-up and nearly 41% agreed to teleconsult reviews.

Conclusion:

Majority of LA patients do not need 2 weeks of analgesics and their HL can be shortened for faster return to work thereby realizing the true benefits of minimally invasive surgery. Selected cases can be offered postoperative teleconsultation.

Clinical outcomes of locking polymeric clip for laparoscopic appendectomy in patients with appendicitis: a retrospective comparison with loop ligature

Purpose

This study aimed to compare the clinical outcomes of laparoscopic appendectomy (LA) according to the method of appendiceal stump closure.

Methods

Patients who underwent LA for appendicitis between 2010 and 2020 were retrospectively reviewed. Patients were classified into locking polymeric clip (LPC) and loop ligature (LL) groups. Clinical outcomes were compared between the groups.

Results

LPC and LL were used in 188 (56.6%) and 144 patients (43.4%), respectively for appendiceal stump closure. No significant differences were observed in sex, age, comorbidities, and the severity of appendicitis between the groups. The median operative time was shorter in the LPC group than in the LL group (64.5 minutes vs. 71.5 minutes, P=0.027). The median hospital stay was longer in the LL group than in the LPC group (4 days vs. 3 days, P=0.020). Postoperative incidences of intraabdominal abscess and ileus were higher in the LL group than in the LPC group (4.2% vs. 1.1%, P=0.082 and 2.8% vs. 0%, P=0.035; respectively). The readmission rate was higher in the LL group than that in the LPC group (6.3% vs. 1.1%, P=0.012).

Conclusion

Using LPC for appendiceal stump closure during LA for appendicitis was associated with lower postoperative complication rate, shorter operative time, and shorter hospital stay compared to the use of LL. Operative time above 60 minutes and the use of LL were identified as independent risk factors for postoperative complications in LA. Therefore, LPC could be considered a more favorable closure method than LL during LA for appendicitis.

A new approach to laparoscopic appendectomy in children-clipless/sutureless Harmonic scalpel laparoscopic appendectomy

BACKGROUND

The aim of this study was to investigate Harmonic scalpel performance in laparoscopic appendectomy for sealing the base of the appendix in children.

METHODS

During the study period, a total of 312 patients who underwent laparoscopic appendectomy were included in prospective bicenter clinical trial. The patients were divided in two study groups in regard to technique used for appendiceal base closure. In the first group (n = 197) the appendiceal base was secured using a polymeric clip while in the second group (n = 115) the Harmonic scalpel was used for sealing the base in a stepwise manner, without placing any clip or suture. Outcomes of treatment, including complication rates, duration of surgery and length of hospital stay were compared between the groups.

RESULTS

A total of 312 patients with a median age of 11 years (IQR 8, 15) were included in study. Of these, 191 were males (61.2%). Both groups were symmetric in regard to baseline characteristics of the patients. A total of 10 (5.1%) postoperative complications (postoperative abscess n = 7 and ileus n = 3) were recorded in the polymeric clip group while none of the patients from the clipless group had postoperative complications (P = 0.015). In the group who received a polymeric clip appendectomy, fever lasting 0-72 h and > 72 h was recorded in 16 (8.1%) and 12 (6.1%) children, respectively, while in the clipless group, it was observed in 2 (1.7%) and 5 (4.3%) children, respectively (P = 0.048). Significantly shorter surgical times were found in the clipless group compared to the polymeric clip group (21 min (IQR 18, 25) vs. 30 min (IQR 22, 40), P < 0.0001). Also, length of hospital stay was significantly shorter in the clipless group of the patients (2 days (IQR 2, 3) vs. 3 days (IQR 2, 4), P < 0.0001).

CONCLUSION

Clipless harmonic scalpel laparoscopic appendectomy is a safe and effective method in children for treatment of acute appendicitis with lesser number of complications and shorter duration of surgery compared to laparoscopic appendectomy in which the appendiceal base is secured with clip.