[Laparoscopic appendectomy. The new standard?]

Closure of the appendiceal stump in laparoscopic appendectomy: A systematic review of the literature

Background

Closure of the appendiceal stump is a key step performed during laparoscopic appendicectomy. Inadequate management of the appendiceal stump has the potential to cause significant morbidity. Several methods of stump closure have been described, however high-level evidence is limited. We performed a systematic review evaluating clinical outcomes and quality of the evidence for the methods of appendiceal stump closure.

Methods

A systematic literature search was performed using Medline, Embase, Cochrane Database and Google Scholar to identify studies comparing appendiceal stump closure methods in laparoscopic appendectomy for acute appendicitis from inception to October 2019. Data regarding operative duration, peri-operative complications, length of stay and costs were collated from all included studies.

Results

From 160 identified studies, 19 met the inclusion criteria. Endoloops and endoclips provide equivalent clinical outcomes at lower cost, while operative duration was shortest with endoclip closure. Endostapler devices have the lowest rate of peri-operative complications (3.56%), however their cost limits their regular use in many healthcare environments. Post-operative complication rate and length of stay were similar for all stump closure methods. Conclusion: Although there are no significant differences in method of stump closure in laparoscopic appendectomy, closure with endoclips provides the shortest operative duration. There is a need for robust and standardized reporting of cost data when comparing stump closure methods, together with higher level evidence in the form of multi-centre randomized controlled trials before firm conclusions can be drawn regarding the optimal method of stump closure.

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Currently there is no robust higher order evidence which assesses clinical outcomes, cost and time efficiency of methods of stump closure in laparoscopic appendicectomy.

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This is the first systematic review to investigate clinical outcomes, cost and quality of current evidence for all methods of laparoscopic appendiceal stump closure in acute appendicitis.

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No difference was observed in methods of stump closure in complication rate, length of stay, cost, and time efficiency.

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Endostaplers appear to provide most robust closure, albeit at a higher economic cost.

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Endoloops appear to provide efficient and successful closure, and are currently the most frequently studied method of closure.

[Perioperative CRP quantification for appendectomy: Clinically useful or a waste of money?]

BACKGROUND

Appendectomy is the most frequently performed non-elective surgical procedure in general surgery. Despite the questionable benefit, inflammatory markers, such as leukocyte count and C-related protein (CRP) are often determined before and after the surgical procedure. Clinicians are not infrequently confronted with the question whether a patient can be discharged despite an increase in inflammatory laboratory parameters.

OBJECTIVES

The aim of the current study was to retrospectively evaluate the clinical course of patients after appendectomy and the correlation with inflammatory laboratory findings.

MATERIAL AND METHODS

A total of 969 patients underwent a surgical procedure due to clinically suspected acute appendicitis. All clinical, laboratory and histopathological data were obtained from the patient records and a quality control database. Laboratory results were correlated with clinical and histopathological data (e.g. t-test, χ (2)-test, regression analysis and ROC curves).

RESULTS

In patients without acute appendicitis operative trauma caused an increase in CRP up to a median of 31 mg/dl on the first postoperative day and up to 47 mg/dl on postoperative day 2. The overall morbidity was 6.2%. The strongest predictive parameter for complications was a CRP of more than 108 mg/l on the first postoperative day with an odds ratio of 16.6 (96% CI 6.4/42.8, p < 0.001, specificity 88% and sensitivity 69%). Patients with CRP values below the threshold suffered from complications in 1.1 % of cases in contrast to patients above the threshold in 16.8% of cases (p < 0.001).

CONCLUSION

A moderate postoperative elevation of CRP values is not a general contraindication for discharge; however, postoperative determination of CRP serum values after appendectomy might be an effective predictor for complications and should therefore be measured in the clinical routine.

[Stump closure in laparoscopic appendectomy. Influence of endoloop or linear stapler on patient outcome]

BACKGROUND

Even though laparoscopic appendectomy is one of the most frequent procedures in abdominal surgery, the technique of appendiceal stump closure is still not standardized. The aim of this retrospective study was to analyze the effect of the use of endoloops or linear staplers for appendiceal stump closure concerning surgical site infections (SSI) and intra-abdominal abscesses (IAA).

PATIENTS AND METHODS

All laparoscopic appendectomies between January 1st 2007 and May 31st 2010 were split into an endoloop group (ELG) and a linear stapler group (LSG). The groups were compared with respect to the outcome parameters SSI and IAA.

RESULTS

A total of 430 appendectomies were performed in the study period of which 105 operations were conducted laparoscopically. In this study 47.6 % (n = 50) were alloted to the LSG and 52.4 % (n = 55) to ELG. In LSG 3.1 % (n = 1) developed an SSI versus 10.0 % (n = 4, p = 0.254) in ELG. No IAAs occurred in LSG compared to 2 (5.1 %, p = 0.499) in ELG.

CONCLUSION

The use of EL for appendiceal stump closure is safe and cost effective for low-grade appendicitis but high-grade appendicitis should be treated with LS.

Increased complication rate in obese patients undergoing laparoscopic adrenalectomy

OBJECTIVES

Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with healthy weight patients.

METHODS

A retrospective chart review was performed on patients undergoing laparoscopic adrenalectomy between January 2000 and February 2010. Intraoperative and postoperative complications in the patients were compared. A patient with a body mass index >30kg/m(2) was considered obese.

RESULTS

Eighty patients underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were considered obese based on the body mass index criteria. Operative time, estimated blood loss, and length of stay did not differ significantly between the 2 cohort groups. There was no 30-day mortality in the population. There were 9 complications in the obese population and no complications in the healthy weight population (P<.011). Four obese patients had intraoperative complications, and 5 obese patients had postoperative morbidity.

CONCLUSIONS

A significant increase occurred in intraoperative and postoperative complications for obese individuals undergoing laparoscopic adrenalectomy compared with healthy weight individuals. However, high body mass index should not preclude elective laparoscopic adrenalectomy.

Appendix stump closure with titanium clips in laparoscopic appendectomy

Purpose

Different techniques, including clips, have been used to close the stump in laparoscopic appendectomy. The aim was to investigate the results after application of a newly developed titanium clip for this operation.

Methods

From June 2008 to February 2010, 104 patients from two different hospitals undergoing laparoscopic appendectomy were included in this prospective study. Closure of the appendix base was generally intended with a titanium double-shanked clip (DS-Clip). The variables of interest were intra-and postoperative complications, operation time and hospital stay. Furthermore, an evaluation of the clip's practicability by the surgeon was performed using a standardised questionnaire.

Results

In 104 patients screened intraoperatively, four patients had to be excluded as the operating surgeon felt that the clip was not adequate for closing the stump, generally because of severe inflammation of the base of the appendix with involvement of the caecum. One patient developed an intra-abdominal abscess which had to be drained interventionally; no reoperations were necessary. The overall complication rate, the operation time and the hospital stay were well comparable with other devices for appendix stump closure such as staplers, loops or polymeric clips. The practicability of the clip was mainly rated as excellent or good by the operating surgeons.

Conclusion

This study suggests that the presented titanium DS-Clip is a safe and cost-effective technique for securing the appendix base in laparoscopic appendectomy. The application is easy and can be learned quickly, making it a good option also for teaching hospitals.