Laparoscopic appendectomy is safer than open appendectomy in an elderly population

Antibiotic treatment after appendectomy for acute complicated appendicitis to prevent intrabdominal abscess and wound infections

INTRODUCTION

The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis.

MATERIALS AND METHODS

In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed.

RESULTS

The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4-21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2-29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4-20.0), p = 0.016) were identified as independent risk factors for wound infections.

CONCLUSION

The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred.

The role of CT in decision for acute appendicitis treatment

PURPOSE Acute appendicitis is the most common cause of the acute abdomen requiring surgery. Although standard treatment has been surgery, it has been seen in recent years that treatment is possible with antibiotics and non-operative observation. In this study, our aim is to determine whether the CT findings in patients diagnosed with acute appendicitis can be used for directing treatment. METHODS A retrospective analysis was conducted on 138 patients with acute appendicitis who underwent CT between 2015 - 2019. In this study, medical treatment group (n = 60) versus surgical treatment group (n = 78) and successful antibiotic treatment group (n = 23) versus unsuccessful antibiotic treatment group (n = 14) were compared. Appendiceal wall thickness, appendiceal diameter, the severity of mural enhancement, intra-abdominal free fluid, the severity of periappendiceal fat stranding, size of pericecal lymph node, appendicolith, adjacent organ findings and the CT appendicitis score of groups were compared with Pearson Chi-square and Mann Whitney U tests. Multivariable logistic regression was used to identify predictors of surgical treatment, expressed as odds ratios (ORs) with 95% confidence intervals. Diagnostic efficacies of appendiceal diameter, the CT appendicitis score and developed model were quantified by ROC curves. RESULTS Appendiceal diameter (P < .001), adjacent organ findings (P = .041), the CT appendicitis score (P < .001), the severity of periappendiceal fat stranding (P = .002), appendicolith (P = .001) and intra-abdominal free fluid (P <0.001) showed statistically significant differences between the medical and surgical treatment groups. According to the logistic regression test, if the patients with appendiceal diameter ≥13mm (OR = 5.1, 95%CI 1.58 - 16.50), appendicolith (OR = 4, 95%CI 1.17 - 13.63) and intra-abdominal free fluid (OR = 3.04, 95%CI 1.28 - 7.20), surgeons should prefer surgical treatment. The AUCs for the CT appendicitis score, the appendiceal diameter and the model were 0.742 (95% CI 0,659 - 0,824), 0.699 (95% CI 0.613 - 0.786) and 0.745 (95% CI 0.671 - 0.819), respectively. As the successful and unsuccessful medical treatment groups were compared, the only significant parameter was the severity of mural enhancement (P = .005). CONCLUSION CT findings may be helpful in patients with uncomplicated acute appendicitis whose treatment surgeons are indecisive about. We can recommend surgical treatment in cases with appendix diameter ≥13mm, intraabdominal free fluid, appendicolith, high CT appendicitis score and severe mural enhancement.

The Future in Standards of Care for Gynecologic Laparoscopic Surgery to Improve Training and Education

Standards of care offer doctors and patients the confidence that an established quality, evidence-based, care is provided, and represent a tool for optimal responding to the population’s needs. It is expected that they will increasingly express a multimodal relationship with gynecologic laparoscopy. Laparoscopy is, now, a standard procedure in operative gynecology, standards are embedded in many laparoscopic procedures, standardization of the skills/competency assessment has been progressively developed, and the proof of competency in laparoscopy may become a standard of care. A continuous development of surgical education includes standard equipment (that may bring value for future advance), standardized training, testing (and performance) assessment, educational process and outcome monitoring/evaluation, patients’ care, and protection, etc. Standards of care and training have a reciprocally sustaining relationship, as training is an essential component of standards of care while care is provided at higher standards after a structured training and as credentialing/certification reunites the two. It is envisaged that through development and implementation, the European wide standards of care in laparoscopic surgery (in close harmonization with personalized medicine) would lead to effective delivery of better clinical services and provide excellent training and education.

Comparison of Ultrasonic Dissection and Suture Ligation for Mesoappendix in Laparoscopic Appendectomy

Objective

To compare the use of ultrasonic dissector and suture ligation for mesoappendix in laparoscopic appendectomy in terms of mean operative time and per-operative bleed.

Methodology

This was a randomized controlled trial conducted at Surgical Unit II, Holy Family Hospital over a period of six months. All patients with the diagnosis of acute appendicitis who presented in the emergency department of Holy Family Hospital on the call days of Surgical Unit II undergoing laparoscopic appendectomy were included in the study. After taking informed consent about the respective procedure, patients were allocated to two groups using computer-generated random numbers. Group A was operated using harmonic scalpel and in Group B suture ligation was done. Total time required to ligate the mesoappendix or to cauterize it using the harmonic scalpel was measured in minutes. Data was entered and analyzed in SPSS version 21.0 (IBM Corp., Armonk, NY).

Results

A total of 110 patients were enrolled in the study according to the inclusion criteria of the study. Patients were randomly divided into two equal groups. Patients in Group A were operated using harmonic scalpel whereas patients in Group B were operated by suture ligation for dealing the mesoappendix in laparoscopic appendectomy. Mean operative time to ligate the mesoappendix for Group A patients was 1.56 (SD = 0.68) minutes while that of Group B was 21.07 (SD = 2.84) minutes. There was no per-operative bleeding in case of Group A while its incidence was 24% of patients in Group B. Results were statistically significant.

Conclusion

The conclusion of the study is that the use of harmonic scalpel was better than suture ligation for ligating the mesoappendix in laparoscopic appendectomy in terms of mean operative time and per operative bleed, hence it's preferable over the later in laparoscopic appendectomy.

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Clinical outcomes of single-site laparoscopic interval appendectomy for severe complicated appendicitis: Comparison to conventional emergency appendectomy

AIM

Single-site laparoscopic interval appendectomy (SLIA) for severe complicated appendicitis after conservative treatment (CT) to ameliorate inflammation and eradicate the abscess should be safer and less invasive than emergency appendectomy (EA). However, only a few reports have been published regarding SLIA.

METHODS

We retrospectively collected data on 264 consecutive patients admitted to Kinan Hospital for treatment of appendicitis between 2012 and 2018. The safety and feasibility of SLIA and its perioperative outcomes for severe complicated appendicitis were investigated.

RESULTS

A total of 61 patients were included in this study, 25 of whom underwent CT and 36 EA. Among the 25 patients who underwent CT, 23 (92.0%) succeeded; a total of 16 patients (69.5%) underwent SLIA. Compared to the EA group, the SLIA group had less bleeding (median volume 8.5 vs 50 mL, P = .005) and lower rate of expansion surgery (0% vs 27.8%, P = .022). Although the postoperative hospital stay was shorter in the SLIA group than in the EA group (9 vs 12 days, P = .008), the total hospital stay, including the CT period, was longer in the SLIA group than in the EA group (24 vs 12 days, P < .001).

CONCLUSION

SLIA is safe, feasible, and less invasive than EA and may provide the advantages of minimally invasive surgery even if appendicitis is severe. SLIA may be a promising option for complicated appendicitis in select cases despite its disadvantage of prolonging the hospital stay.

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.

Efficacy of emergency laparoscopic appendectomy in treating complicated appendicitis for elderly patients

To assess the therapeutic effects of emergency laparoscopic appendectomy (LA) in treating complicated appendicitis (CA) for elderly patients (defined as age 65 years and above). Methods: We conducted a retrospective study of 115 elderly patients with CA who underwent surgical therapy in the Affiliated Huizhou Hospital of Sun Yat-Sun University, Huizhou, Guangdong Province, China between September 2014 and August 2016. Of these, 59 patients consented to open appendectomy (OA), and LA was performed in the other 56 patients. The perioperative and follow-up variables of the 2 groups were analyzed. Results: The operative time in the LA group was longer than the OA group (LA: 70.5±16.0 min versus [vs.] OA: 59.3±12.0 min, p greater than 0.001). The LA group had lower chances of incision infections (LA: 8.9% vs OA: 28.8 %, p=0.007) and shorter hospital stay (LA: 6.1± 2.5 days vs. OA: 9.6±3.5 days, p greater than 0.001). Return to soft diet (LA: 1.4 ± 0.8 days vs OA: 3.0 ± 1.6 days, p greater than 0.001) and time to out of bed (LA: 1.3±0.5 days vs OA: 2.5±0.9 days, p greater than 0.001) was faster in the LA group. The incidence of complications and 30-day readmission rate in the LA group was much lower than the OA group. Conclusion: Emergency LA in treating elderly patients with CA has the advantages of less trauma, definite curative effect, low complication rates, and fast recovery when compared with OA.

Antibiotics Versus Appendicectomy for the Treatment of Uncomplicated Acute Appendicitis: An Updated Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Uncomplicated acute appendicitis has been managed traditionally by early appendicectomy. However, recently, there has been increasing interest in the potential for primary treatment with antibiotics, with studies finding this to be associated with fewer complications than appendicectomy. The aim of this study was to compare outcomes of antibiotic therapy with appendicectomy for uncomplicated acute appendicitis.

METHOD

This meta-analysis of randomised controlled trials included adult patients presenting with uncomplicated acute appendicitis treated with antibiotics or appendicectomy. The primary outcome measure was complications. Secondary outcomes included treatment efficacy, hospital length of stay (LOS), readmission rate and incidence of complicated appendicitis.

RESULTS

Five randomised controlled trials with a total of 1430 participants (727 undergoing antibiotic therapy and 703 undergoing appendicectomy) were included. There was a 39 % risk reduction in overall complication rates in those treated with antibiotics compared with those undergoing appendicectomy (RR 0.61, 95 % CI 0.44-0.83, p = 0.002). There was no significant difference in hospital LOS (mean difference 0.25 days, 95 % CI -0.05 to 0.56, p = 0.10). In the antibiotic cohort, 123 of 587 patients initially treated successfully with antibiotics were readmitted with symptoms suspicious of recurrent appendicitis. The incidence of complicated appendicitis was not increased in patients who underwent appendicectomy after "failed" antibiotic treatment (10.8 %) versus those who underwent primary appendicectomy (17.9 %).

CONCLUSION

Increasing evidence supports the primary treatment of acute uncomplicated appendicitis with antibiotics, in terms of complications, hospital LOS and risk of complicated appendicitis. Antibiotics should be prescribed once a diagnosis of acute appendicitis is made or considered.

Training on an inexpensive tablet-based device is equally effective as on a standard laparoscopic box trainer: A randomized controlled trial

BACKGROUND

The aim of the study was to assess whether an inexpensive tablet-based box trainer (TBT) is at least equally effective compared with a standard box trainer (SBT) to learn basic laparoscopic skills (BLS). BLS training outside the operating room has been shown to be beneficial for surgical residency. However, simulation trainers are expensive and are not consistently available in all training centers. Therefore, TBT and other homemade box trainers were developed.

METHODS

Medical students were randomized to either a TBT or an SBT and trained 4 fundamentals of laparoscopic surgery (FLS) tasks for 1 hour twice a week for 4 weeks. A baseline test before the training period and a posttraining test were performed. All students then completed a questionnaire to assess their assigned box trainer. The primary outcome measure was the improvement in total test scores. Improvement in the scores for the 4 individual FLS tasks was chosen as a secondary outcome measure.

RESULTS

Thirty-two medical students were recruited. Baseline test scores did not differ significantly between the groups. BLS improved significantly in both groups for the total score and for all 4 tasks separately. Participants in the TBT group showed a greater improvement of total scores than those in the SBT group, although this did not reach statistical significance; noninferiority of the TBT compared with the SBT concerning the improvement of total scores could be demonstrated. Regarding the individual FLS tasks, noninferiority of the TBT could be shown for the pattern cutting and the suturing with intracorporeal knot-tying task. The acceptance of the TBT by the trainees was very good.

CONCLUSION

Learning BLS on a homemade TBT is at least equally effective as on an SBT, with the advantage of being very cost saving. Therefore, this readily available box trainer may be used as an effective, flexible training device outside the operating room to improve accessibility to simulation training.

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.

Physiopathology and clinical considerations of laparoscopic surgery in the elderly

OBJECTIVE

The marked improvements in medical technology and healthcare, lead an increasing number of elderly patients to take advantage of even complex surgical. Recently, laparoscopic surgery has been accepted as a minimally invasive treatment to reduce the morbidity after conventional surgery, and a number of studies have demonstrated the feasibility of laparoscopy with significant advantages also in the elderly. On the other side, the laparoscopic procedure has some drawbacks, including prolonged operation time and impact of carbon dioxide pneumoperitoneum on circulatory and respiratory dynamics. This paper will review the physiopathological implications of laparoscopy, as well as the current literature concerning the most common laparoscopic procedures that are increasingly performed in elderly patients.

MATERIALS AND METHODS

A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting the physiopathological implications of laparoscopy in the elderly. The MeSH search terms used were "laparoscopy in the elderly", "physiopathology of laparoscopy", and "pneumoperitoneum". Multiple combinations of the keywords and MeSH terms were used with particular reference to elderly patients.

RESULTS

Although laparoscopy is minimally invasive in its dissection techniques, the increased physiologic demands present particular challenges among elderly patients.

CONCLUSIONS

Laparoscopy and its safety in the elderly patients remains a challenge and the evaluation of this approach is therefore mandatory. Although many studies have demonstrated the applicability and advantages of the laparoscopy also in the geriatric population, with low rates of morbidity and mortality, in elderly patients undergoing general surgical procedures the physiologic demands of laparoscopy should be carefully considered.

Laparoscopic vs mini-incision open appendectomy

AIM: To compare laparoscopic vs mini-incision open appendectomy in light of recent data at our centre.

METHODS: The data of patients who underwent appendectomy between January 2011 and June 2013 were collected. The data included patients’ demographic data, procedure time, length of hospital stay, the need for pain medicine, postoperative visual analog scale of pain, and morbidities. Pregnant women and patients with previous lower abdominal surgery were excluded. Patients with surgery converted from laparoscopic appendectomy (LA) to mini-incision open appendectomy (MOA) were excluded. Patients were divided into two groups: LA and MOA done by the same surgeon. The patients were randomized into MOA and LA groups a computer-generated number. The diagnosis of acute appendicitis was made by the surgeon with physical examination, laboratory values, and radiological tests (abdominal ultrasound or computed tomography). All operations were performed with general anaesthesia. The postoperative vision analog scale score was recorded at postoperative hours 1, 6, 12, and 24. Patients were discharged when they tolerated normal food and passed gas and were followed up every week for three weeks as outpatients.

RESULTS: Of the 243 patients, 121 (49.9%) underwent MOA, while 122 (50.1%) had laparoscopic appendectomy. There were no significant differences in operation time between the two groups (P = 0.844), whereas the visual analog scale of pain was significantly higher in the open appendectomy group at the 1^st hour (P = 0.001), 6^th hour (P = 0.001), and 12^th hour (P = 0.027). The need for analgesic medication was significantly higher in the MOA group (P = 0.001). There were no differences between the two groups in terms of morbidity rate (P = 0.599). The rate of total complications was similar between the two groups (6.5% in LA vs 7.4% in OA, P = 0.599). All wound infections were treated non-surgically. Six out of seven patients with pelvic abscess were successfully treated with percutaneous drainage; one patient required surgical drainage after a failed percutaneous drainage. There were no differences in the period of hospital stay, operation time, and postoperative complication rate between the two groups. Laparoscopic appendectomy decreases the need for analgesic medications and the visual analog scale of pain.

CONCLUSION: The laparoscopic appendectomy should be considered as a standard treatment for acute appendicitis. Mini-incision appendectomy is an alternative for a select group of patients.

Augmenting the decision making process in acute appendicitis: A retrospective cohort study

INTRODUCTION

Acute appendicitis is a common surgical diagnosis. We investigated the use of blood markers (WCC, CRP and serum bilirubin) and diagnostic imaging (USS and CT scan) to arrive at this diagnosis, as well as the surgical approach used for appendicectomy.

METHODS

This was a retrospective analysis of consecutive patients undergoing appendicectomy in seven hospitals within GG&C Health Board during a 6 month study period. Data were collected from electronic patient records. Sensitivity and specificity of each investigation for diagnosing acute appendicitis was calculated.

RESULTS

363 patients were included. Appendicectomy was performed open in 53%, laparoscopically in 43% and converted in 4%. Diagnostic imaging was used in 38%. The overall negative appendicectomy rate was 15% (18% when no imaging was used, 23% when USS was used and 1% when CT scanning was used). Elevated bilirubin had a sensitivity of 0.44 and a specificity of 0.84 for detecting acute appendicitis. Sensitivity and specificity for elevated WCC were 0.78 and 0.55, and for elevated CRP were 0.81 and 0.59, respectively. The specificity of bilirubin for diagnosing perforated appendicitis was 0.63.

DISCUSSION

WCC and CRP were sensitive blood markers in acute appendicitis, whereas serum bilirubin was more specific. Diagnostic imaging with a CT scan was very effective at reducing the rate of negative appendicectomy, but USS was not.

CONCLUSION

Serum bilirubin has utility in diagnosing acute appendicitis, irrespective of whether perforation has occurred. CT scanning should be considered the first line imaging modality for investigation of acute appendicitis if diagnosis is in doubt.