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Thompson L, Cohen BL, Wolde T, Yeh DD, Ramsey WA, Byers PM, Namias N, Meizoso JP. Open Versus Laparoscopic Appendectomy: A Post Hoc Analysis of the EAST Appendicitis MUSTANG Study. Surg Infect (Larchmt) 2023; 24:613-618. [PMID: 37646633 DOI: 10.1089/sur.2023.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Background: We sought to understand which factors are associated with open appendectomy as final operative approach. We hypothesize that higher American Association for the Surgery of Trauma (AAST) Emergency General Surgery (EGS) grade is associated with open appendectomy. Patients and Methods: Post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated and Gangrenous (MUSTANG) prospective appendicitis database was performed. All adults (age >18) undergoing appendectomy were stratified by final operative approach: laparoscopic or open appendectomy (including conversion from laparoscopic). Univariable analysis was performed to compare group characteristics and outcomes, and multivariable logistic regression was performed to identify demographic, clinical, or radiologic factors associated with open appendectomy. Results: A total of 3,019 cases were analyzed. One hundred seventy-five (5.8%) patients underwent open appendectomy, including 127 converted from laparoscopic to open. The median age was 37 (25) years and 53% were male. Compared with the laparoscopic group, open appendectomy patients had more comorbidities, higher proportion of symptoms greater than 96 hours, and higher AAST EGS grade. Moreover, on intraoperative findings, the open appendectomy group had a higher incidence of perforated and gangrenous appendicitis with purulent contamination, abscess/phlegmon, and purulent abdominal/pelvic fluid. On multivariable analysis controlling for comorbidities, clinical and imaging AAST grade, duration of symptoms, and intra-operative findings, only AAST Clinical Grade 5 appendicitis was independently associated with open appendectomy (odds ratio [OR], 5.63; 95% confidence interval [CI], 1.24-25.55; p = 0.025). Conclusions: In the setting of appendicitis, generalized peritonitis (AAST Clinical Grade 5) is independently associated with greater odds of open appendectomy.
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Affiliation(s)
- Lauren Thompson
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
- Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Brianna L Cohen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Tizeta Wolde
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - D Dante Yeh
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Patricia M Byers
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
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Turial S, Schwind M, Nyiredi A. Evaluation of the Appropriate LigaSure™ Device to Transect the Appendix-A Comparison between 5 mm and 10 mm Laparoscopic Devices in an Ex Vivo Trial. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050927. [PMID: 37241159 DOI: 10.3390/medicina59050927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: A topic of greatinterest in the surgical field comprises cost and time reduction operative techniques with high efficiency rates. Thus, the aim of this paper is to evaluate whether a transection of the appendix using only a laparoscopic LigaSure™ device is feasible and, if so, which size of the laparoscopic device is optimal. Materials and Methods: Appendectomy specimens were sealed and cut using LigaSureTM V (5 mm) and LigaSure AtlasTM (10 mm) devices ex vivo. Analysis criteria included handling, resistance to bursting pressure of the appendicular stump (adequacy), eligibility, durability and airtightness. Results: Twenty sealed areas were measured. While the 5 mm instrument was not able to transect the appendix in one attempt in any of the cases, the 10 mm device could be applied successfully without any handling difficulties. The adequacy of the sealed area was rated as complete and dry in all 10 cases using the 10 mm device and as oozing in 8 of the cases using the 5 mm device. There was no leakage in terms of air and liquid tightness using the 10 mm device, in contrast to six sealed segments with air and liquid leakage when using the 5 mm device. The resistance to bursting pressure was on average 285 mmHg and 60.5 mmHg with the 10 mm and 5 mm devices, respectively. The durability and eligibility of the 10 mm device were rated as very sufficient in 9 of 10 cases (1 perforation) in contrast to the 5 mm device, where the sealing in 9 of 10 cases was not sufficient (9 perforations). Conclusions: Using the 10 mm laparoscopic LigaSure™ device for the transection of the appendix seems to be feasible, safe and resistant to 300 mmHg bursting pressure. The 5 mm LigaSure™ instrument is inadequate to seal the appendix in humans.
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Affiliation(s)
- Salmai Turial
- Department of Pediatric Surgery, Pediatric Trauma and Pediatric Urology, University Medical Centre Magdeburg, 39120 Magdeburg, Germany
| | - Martin Schwind
- Department of Pediatric Surgery, University Medical Centre Mainz, 55101 Mainz, Germany
| | - Alexandra Nyiredi
- Department of Pediatric Surgery, Pediatric Trauma and Pediatric Urology, University Medical Centre Magdeburg, 39120 Magdeburg, Germany
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Surabhi A, Behura A, Behera CR, Patra RK, Panda B, Mishra A, Karnati R, Mohanty S. Post-Operative Outcomes of Laparoscopic Appendectomy in Acute Complicated Appendicitis: A Single Center Study. Cureus 2023; 15:e38868. [PMID: 37303449 PMCID: PMC10257217 DOI: 10.7759/cureus.38868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Acute appendicitis (AA) is a surgical emergency because of inflammation in the appendix leading to swelling, whereas acute complicated appendicitis is characterized by a gangrenous or perforated appendix with or without periappendicular abscess, peritonitis, and an appendicular mass. The laparoscopic approach in complicated acute appendicitis is a viable alternative method but is not practiced in all cases because of technical difficulties and unpredictable complications. Thus, the present study aimed to evaluate the primary and secondary outcome predictors of laparoscopic appendectomy in complicated appendicitis. METHODS A single-center prospective observational study was carried out after the approval of the Institutional Ethics Committee (IEC). A total of 87 complicated acute appendicitis patients were included in the study. Clinico-demographic features such as age, gender, duration of surgery, post-operative pain, and hospital stay were monitored in different age groups of <20, 20-39, and >40 years, and the primary and secondary outcomes of laparoscopic surgery in acute complicated appendicitis were measured. RESULT Acute complicated appendicitis cases were observed mostly in people older than 42 years in the total study population. Laparoscopic appendectomy was conducted in all 87 acute complicated appendicitis patients, and the major surgical outcome predictors were monitored, such as mean operating time (87.9 minutes), post-operative pain (3.9 scores), and post-operative stay (6.7 days). Post-operative complications such as drain site infection (1.14%), enterocutaneous fistula (2%), and intra-abdominal abscess (7%) were observed. CONCLUSION Based on our observations, a laparoscopic appendectomy can be considered a viable alternative with an acceptable complication rate. Operative time varies from 84 to 94 minutes in different age groups and with the extent of the disease.
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Affiliation(s)
- Anurag Surabhi
- Department of Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Aparna Behura
- Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Chinmay R Behera
- Department of Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Rajat K Patra
- Department of Surgery, Kalinga Institute of Medical sciences, Bhubaneswar, IND
| | - Bandita Panda
- Department of Research and Development, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Amaresh Mishra
- Department of Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Ranjit Karnati
- Department of Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Subrat Mohanty
- Department of Surgery (Pediatric Surgery), Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Alotaibi AM, Alfawaz M, Felemban L, Moshref L, Moshref R. Complicated appendicitis increases the hospital length of stay. Surg Open Sci 2022; 9:64-68. [PMID: 35692621 PMCID: PMC9178463 DOI: 10.1016/j.sopen.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/27/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background There are insufficient data from Saudi Arabia regarding appendectomy outcomes and hospital length of stay. Further, there is a need to compare the length of stay of Saudi patients and the literature. The purpose is to evaluate the surgical outcomes and hospital length of stay for complicated appendicitis and simple appendicitis. Method This is a single-center retrospective review of patients who had undergone an appendectomy between 2016 and 2018. The patients were divided into 2 groups: complicated appendicitis versus simple appendicitis. Results Of 449 patients who underwent appendectomy, 60 (13.4%) had complicated appendicitis. The complicated appendicitis was significantly associated with increased age, pain duration, neutrophilia, high C-reactive protein, fecalith presence, and free fluid. The incidence rate of surgical site infection was 5.8% (identified in 26 patients). Compared to simple appendicitis, complicated appendicitis was associated more with wound infection (1.8% vs 10%, respectively, P = .001), postoperative collection (1.2% vs 11.6%, respectively, P = .001), and readmission within 30 days (2.3% vs 13.4%, respectively, P = .001). By multivariate analysis, factors associated more with increased hospitalization were pain duration (hazard ratio = 2.37, 95% confidence interval = 1.09–5.16, P = .029), operative time (hazard ratio = 2.09, 95% confidence interval = 1.04–4.21, P = .038), and complicated appendicitis (hazard ratio = 6.61, 95% confidence interval = 2.67–14.21, P = .001). Conclusion Complicated appendicitis correlates with significant morbidity, readmission rate, and 6 times more hospital LOS than simple appendicitis. This review might help in appreciating the burden of complicated appendicitis on hospital length of stay, which needs allocating patients and planning the discharge day for hospitals with limited beds. Practically one fifth of acute appendicitis will be complicated. Complicated appendicitis increases conversion to open, surgical site infection, hospital length of stay, and 30-day readmission rate. Prolonged operation time and complicated appendicitis are independent risk factors to increase hospitalization.
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Affiliation(s)
- Abdulrahman Muaod Alotaibi
- Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
- Department of Surgery, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
- Corresponding author at: Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia. Office contact number: 00966 0122334444, mobile contact no. + 966 504707351. @aotaib1
| | - Mohammed Alfawaz
- Department of Medicine, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Lina Felemban
- Department of Surgery, King Abdul-Aziz Medical City, National Guard Hospital, Jeddah, Saudi Arabia
| | - Leena Moshref
- Department of Surgery, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Rana Moshref
- Department of Surgery, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
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Kim S, Jeon BH, Cho SS, Shin US, Moon SM. Clinical outcomes of locking polymeric clip for laparoscopic appendectomy in patients with appendicitis: a retrospective comparison with loop ligature. Ann Coloproctol 2022; 38:160-165. [PMID: 35038819 PMCID: PMC9021853 DOI: 10.3393/ac.2021.00598.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Seokwon Kim
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Byong Ho Jeon
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sang Sik Cho
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Ui Sup Shin
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Sun Mi Moon
- Department of Surgery, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
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Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review. Life (Basel) 2021; 11:life11090917. [PMID: 34575066 PMCID: PMC8470929 DOI: 10.3390/life11090917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 01/09/2023] Open
Abstract
A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.
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