Fear for the intraabdominal abscess after laparoscopic appendectomy: not realistic

Perforated appendicitis treated with laparoscopic appendicectomy or open appendicectomy: A meta-analysis

Aim

This analysis compared the impact of laparoscopic appendicectomy (LA) and open appendicectomy (OA) on treating adult perforated appendicitis (PA).

Methods

Articles relating to LA and OA in treating PA were retrieved from databases including PubMed, Cochrane Library and Embase since their founding to January 2022. These articles were independently filtered based on the inclusion and exclusion criteria by two investigators. The quality of these articles was assessed and article data were extracted. Dichotomous data were presented in the form of odd's ratio (OR), whereas continuous data were in the form of weighted mean difference (WMD). The included articles reported at least one of the following outcomes: intra-abdominal abscess (IAA), wound infection, operative time, hospital stay and complications.

Results

Three randomised control trials (198 LA cases vs. 205 OA cases) and 12 case - control trials (914 LA cases vs. 2192 OA cases) were included. This analysis revealed that although the IAA formation rate was similar in the LA and OA groups (OR: 1.28, 95% confidence interval [CI]: 0.87-1.88), the wound infection rate was lower in the LA group (OR: 0.38, 95% CI: 0.28-0.51). Furthermore, LA was associated with shorter hospital stay (WMD: -1.43 days, 95% CI: -2.33--0.52) and fewer complications than OA (OR: 0.40, 95% CI: 0.28-0.57).

Conclusion

LA has significant benefits in treating PA and is associated with better post-operative outcomes such as shorter hospital stay, lower incidence of wound infection and other complications. However, more studies with randomised and large-sample populations are still required to determine the clinical benefit of LA in treating PA.

Laparoscopic Management of Spontaneous Colonic Perforation: A Single Institution Study of 52 Patients

BACKGROUND

Spontaneous colonic perforation (SCP) is associated with an devastating result. The use of laparoscopy for SCP remains controversial. This study aimed to compare the postoperative outcomes of patients who received either laparoscopic or open surgery and to evaluate the efficacy of laparoscopic surgery and the risk factors affecting prognosis.

PATIENTS AND METHODS

A retrospective study of patients who underwent surgery for SCP from January 2005 to December 2020 was performed. Demographic data, intraoperative variables, length of stay, and surgical complications were retrieved.

RESULTS

A total of 52 patients were postoperatively diagnosed with SCP. Thirty (57.69%) procedures were performed using laparoscopic surgery (group A) and 22 (42.31%) were performed using open surgery (group B). There were no significant differences between groups A and B in terms of age, sex, chronic concomitant disease, chronic constipation, incentives, imaging findings, preoperative diagnosis, American Society of Anesthesiologists (ASA) score, Mannheim Peritonitis Index (MPI), operation time, days to resumption of liquids, site of perforation, surgical procedures, or types of perforation (P>0.05). The incidence of wound infection in group A was significantly lower than that in group B (P<0.05), but there was no significant difference in the incidence of abdominal abscess between the 2 groups (P>0.05). Significant differences were found in days to start walking and days to resumption of solids between the 2 groups (P<0.05). Group B had a longer length of hospital stay than group A (P<0.05). After multivariate analysis, the independent variables associated with worse perioperative complications were an age of 65 years and older, an ASA score of ≥3, and an MPI of >26.

CONCLUSIONS

The prognosis of SCP is poor. The operation should follow principles that are simple, rapid, and effective. If there are no contraindications, laparoscopy may be the preferred method. Hartmann procedure is a promising surgical strategy. The age, ASA score, and MPI may indicate the severity and prognosis of SCP.

Management of Complicated Appendicitis During Pregnancy in the US

IMPORTANCE

Data are sparse regarding the optimal treatment for complicated appendicitis during pregnancy.

OBJECTIVE

To compare nonoperative and operative management in complicated appendicitis during pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using National Inpatient Sample data from between January 2003 and September 2015. This database approximates a 20% stratified sample of US inpatient hospital discharges. Included individuals were pregnant women discharged with the diagnosis of complicated appendicitis. Data were analyzed from February 2020 through February 2022.

EXPOSURES

Study patients were categorized into 3 groups: those with successful nonoperative management, failed nonoperative management with delayed operation, or immediate operation for complicated appendicitis.

MAIN OUTCOMES AND MEASURES

Clinical outcomes, including maternal infectious complications and perinatal complications, hospital length of stay, and total hospital charges.

RESULTS

Among 8087 pregnant women with complicated appendicitis (median [IQR] age, 27 [22-32] years), nonoperative management of complicated appendicitis was successful among 954 patients (11.8%) and failed among 2646 patients (32.7%), who underwent delayed operation; 4487 patients (55.5%) underwent immediate operation. In multivariate analysis, successful nonoperative management was associated with higher odds of amniotic infection (odds ratio [OR], 4.35; 95% CI, 2.22-8.53; P < .001) and sepsis (OR, 1.52; 95% CI, 1.10-2.11; P = .01) compared with immediate operation, while there was no significant difference in preterm delivery, preterm labor, or abortion. However, failed nonoperative management that required delayed operation was associated with higher odds of preterm delivery, preterm labor, or abortion compared with immediate operation (OR, 1.45; 95% CI, 1.24-1.68; P < .001). Immediate operation was associated with decreased hospital charges compared with nonoperative management that was successful (regression coefficient [RC], 0.09; 95% CI, 0.07-0.11; P < .001) and that failed (RC, 0.12; 95% CI: 0.11-0.14; P < .001). In subgroup multivariate logistic regression analysis, each day in delay to surgery was associated with an increase in odds of preterm delivery, preterm labor, or abortion by 23% (OR, 1.23; 95% CI, 1.18-1.29; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that immediate operation for complicated appendicitis in pregnant women was associated with lower odds of maternal infectious complications without higher odds of perinatal or other maternal complications compared with successful nonoperative management. Failed nonoperative management was associated with worse clinical outcomes.

An evaluation of the choice of the treatment for the acute appendicitis an original research

Introduction:

Material and Methods:

Results:

Conclusion:

Post-operative abscess in inguinal hernial sac-case report of an unusual complication of perforated acute appendicitis

Acute appendicitis is a common condition, with a lifetime risk of 7–8%. Common complications of surgical management include bleeding, bowel injury, residual abscess formation and post-operative ileus. This is a rare case of a 50-year-old male who underwent laparoscopic converted to open appendicectomy for perforated acute appendicitis, with a complication of post-operative fluid collection that extended into the right inguinal hernia sac.

Peritoneal irrigation vs suction alone during pediatric appendectomy for perforated appendicitis: A meta-analysis

BACKGROUND

There currently exists no substantial evidence reporting the efficacy of peritoneal irrigation in reducing the incidence of postoperative intra-abdominal abscess in pediatric patients. The purpose of our study was to perform a meta-analysis to compare rates of intra-abdominal abscess after appendectomy between irrigation and suction alone groups.

METHODS

We identified studies by a systematic search in EMBASE, PubMed, Web of Science, and the Cochrane Library to recognize randomized controlled trials and case control studies from the 1950 to May 2019. We limited the English language studies. We checked the reference list of studies to recognize other potentially qualified trials. We analyzed the merged data with use of the Review Manager 5.3.

RESULTS

We identified 6 eligible papers enrolling a total of 1633 participants. We found no significant difference in the incidence of postoperative intraabdominal abscess, wound infection, and the length of hospitalization between 2 group, but duration of surgery is longer in irrigation group (MD = 6.76, 95% CI = 4.64 to 8.87, P < .001; heterogeneity, I = 25%, P = .26).

CONCLUSION

Our meta-analysis did not provide strong evidence allowing definite conclusions to be drawn, but suggested that peritoneal irrigation during appendectomy did not decrease the incidence of postoperative IAA. This meta-analysis also indicated the need for more high-quality trials to identify methods to decrease the incidence of postoperative IAA in pediatric perforated appendicitis patients.Trial registration number Standardization of endoscopic treatment of acute abdomen in children: 14RCGFSY00150.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Are Preoperative CT Findings Useful for Predicting Postoperative Intraabdominal Abscess in the Patients with Acute Appendicitis?

Background and objective: In patients with acute appendicitis (AA), preoperative computed tomography (CT) findings suggesting development of intraabdominal abscess (IAA) had not been widely used. The aim of this study was to investigate the preoperative clinical and radiological factors that predict the development of a postoperative IAA in patients with AA who were treated by laparoscopic appendectomy (LA). Methods: Two hundred and sixteen patients with pathologically proven AA underwent LA between January 2013 and March 2018 in our department. Medical records and preoperative CT images of these 216 patients were retrospectively reviewed and the predictive factors of postoperative IAA were investigated. In addition, patients were divided into complicated appendicitis (CA) and simple appendicitis (SA) and perioperative factors of two groups were compared. Results: One hundred and forty-seven patients were diagnosed with CA, while the other 69 patients were diagnosed with SA. Sixteen patients developed postoperative IAA in the CA group, while no patients in the SA group did. The univariate analysis revealed that time from onset to surgery more than 3 days (p = 0.011), the preoperative CT finding of periappendiceal fluid (p = 0.003), abscess (p < 0.001), and free air (p < 0.001), operation time more than 120 min (p = 0.023) and placement of a drainage tube (p < 0.001) were significantly associated with the development of IAA. Multivariate analysis revealed that the preoperative CT finding of free air was independently associated with the development of IAA (p = 0.007, odds ratio = 5.427, 95% CI: 1.586⁻18.57). Conclusions: IAA developed predominantly in patients with CA. Preoperative CT findings of free air was found to be an independent predictor for the development of IAA. Surgeons should be meticulous in managing the postoperative course of patients with this finding.

Intestinal Function after Early versus Late Appendectomy in Children with Perforated Appendicitis

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3–9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.

Post-appendectomy pelvic abscess with extended-spectrum beta-lactamase producing Escherichia coli: A case report and review of literature

BACKGROUND

Appendicitis, the inflammation of the appendix, is the most common abdominal surgical emergency requiring expedient surgical intervention. Extended-spectrum beta-lactamases (ESBLs) are bacterial enzymes that catalyse the degradation of the beta-lactam ring of penicillins and cephalosporins (but without carbapenemase activity), leading to resistance of these bacteria to beta-lactam antibiotics. Recent increases in incidence of ESBL-producing bacteria have caused alarm worldwide. Proportion estimates of ESBL-Enterobacteriaceae hover around 46% in China, 42% in East Africa, 12% in Germany, and 8% in the United States.

CASE SUMMARY

The impact of ESBL-producing bacteria on appendiceal abscesses and consequent pelvic abscesses are yet to be examined in depth. A literature review using the search words “appendiceal abscesses” and “ESBL Escherichia coli (E. coli)” revealed very few cases involving ESBL E. coli in any capacity in the context of appendiceal abscesses. This report describes the clinical aspects of a patient with appendicitis who developed a postoperative pelvic abscess infected with ESBL-producing E. coli. In this report, we discuss the risk factors for contracting ESBL E. coli infection in appendicitis and post-appendectomy pelvis abscesses. We also discuss our management approach for post-appendectomy ESBL E. coli pelvic abscesses, including drainage, pathogen identification, and pathogen characterisation. When ESBL E. coli is confirmed, carbapenem antibiotics should be promptly administered, as was done efficaciously with this patient. Our report is the first one in a developed country involving ESBL E. coli related surgical complications in association with a routine laparoscopic appendectomy.

CONCLUSION

Our report is the first involving ESBL E. coli and appendiceal abscesses, and that too consequent to laparoscopic appendectomy.

Laparoscopic Appendectomy for Complicated Acute Appendicitis in the Elderly: A Single-center Experience

BACKGROUND

The use of laparoscopic appendectomy for complicated acute appendicitis remains controversial in the elderly. This study aimed to compare the postoperative outcomes of elderly patients who received either laparoscopic appendectomy or open appendectomy.

PATIENTS AND METHODS

A single-centre retrospective analysis of the clinical records of elderly patients (age, above 65 y) who underwent operations from January 2012 to November 2015 was performed. Demographic data, intraoperative variables, length of stay, and surgical complications were retrieved.

RESULTS

A total of 145 elderly patients were preoperatively diagnosed with acute appendicitis. There were 43 (29.66%) complicated and 102 (70.34%) uncomplicated appendicitis cases. A total of 65 (44.83%) procedures were performed using the open technique (OA group) and 80 (55.17%) using the laparoscopic technique (LA group). In the laparoscopic group, 19 (23.75%) patients had complicated acute appendicitis (CLA group), and 61 (76.25%) had uncomplicated acute appendicitis (UCLA group). In the complicated group, 19 (44.19%) patients underwent operation using the laparoscopic technique (CLA group) and 24 (55.81%) using the open technique (COA group). There were no significant differences between the LA and OA groups in terms of age, sex distribution, duration of symptoms, American Society of Anesthesiologists score, white blood cells, complicated appendicitis, operation time, drain apposition, days to resumption of liquids, and postoperative complications (P>0.05). Significant differences were found in days to start walking and days to resumption of solids in the LA group (P<0.05). The OA group had a longer length of hospital stay than the LA group (P<0.05). Postoperative complications were not significantly different between the groups (P>0.05). The CLA group had a significantly longer duration of symptoms, operation times, days to resumption of liquids, and days to resumption of solids than the UCLA group (P<0.05). The COA group had significantly longer days to walking and hospital stays than the CLA group (P<0.05).

CONCLUSIONS

Our study demonstrated that using LA to treat complicated acute appendicitis in the elderly was not associated with additional surgical complications. Therefore, it seems feasible to use LA as a safe technique for complicated acute appendicitis in the elderly.

Laparoscopic Procedure is Not Independently Associated With the Development of Intra-Abdominal Abscess After Appendectomy: A Multicenter Cohort Study With Propensity Score Matching Analysis

AIM

The aim of this study was to identify independent risk factors for postoperative intra-abdominal abscess (IAA) after appendectomy for patients with acute appendicitis.

BACKGRAOUND

Although laparoscopic appendectomy (LA) has been performed universally, whether LA is associated with an increased incidence of postoperative IAA compared with open appendectomy (OA) remains controversial, which causes some surgeons' increasing concerns.

METHODS

We retrospectively analyzed 6805 consecutive adult patients with acute appendicitis who underwent LA or OA at 7 general hospitals in China. Patient characteristics, operative variables, and surgical outcomes were collected and compared between patients who underwent LA and OA. Propensity score matching analysis was used to minimize the bias in patient selection differing from various procedure of appendectomy. Independent risk factors associated with the development of postoperative IAA after appendectomy were identified by univariate and multivariate logistic regression analysis in the propensity matched cohort.

RESULTS

Over a 3-year period, 2710 (39.8%) and 4095 (60.2%) patients underwent LA and OA respectively. Patients who underwent OA had more males, American Society of Anesthesiologists score 2-3, preoperative systemic inflammatory response syndrome, and perforated appendicitis than those who underwent LA (all P<0.01). Propensity score matched analysis created 2542 pairs of patients. Univariate analysis revealed that patients who underwent LA had a higher incidence of postoperative IAA than patients who underwent OA (6.7% vs. 5.3%; P=0.039). However, multivariate logistic regression analysis identified LA not to be an independent risk factor associated with the development of postoperative IAA (odds ratio, 1.053; 95% confidence interval, 0.922-1.657; P=0.216).

CONCLUSIONS

The present study identified that laparoscopic procedure was not an independent risk factor associated with the development of postoperative IAA after appendectomy of acute appendicitis. Therefore, concerns of increased incidence of IAA because of laparoscopic procedure are unwarranted.

Laparoscopic Appendectomy Is Safe: Influence of Appendectomy Technique on Surgical-site Infections and Intra-abdominal Abscesses

PURPOSE

Surgical-site infections (SSIs) and intra-abdominal abscesses (IAAs) are the most frequent complications of appendectomy. The role of laparoscopy in the treatment of appendicitis remains controversial concerning the complication rate. The aim of this retrospective cohort study was to compare open and laparoscopic appendectomy for SSI and IAA.

METHODS

All patients undergoing appendectomy between January 1, 2007 and May 31, 2010 were included in the study. Perioperative data and data on postoperative complications were collected from patient files. A questionnaire was used to assess complications after discharge. Main outcome parameters were SSI and IAA. Open appendectomy (OAG) and laparoscopic appendectomy (LAG) were compared with univariate and multivariate analyses for the outcome parameters.

RESULTS

Four hundred thirty patients were included in the study. SSI (all: 10.6%, OAG: 11.7%, LAG: 7.5%, P=0.293) and IAA (all: 2.8%, OAG: 2.4%, LAG: 3.8%, P=0.506) were not significantly different between OAG and LAG. Risk factors for SSI were age (P=0.003), body mass index (P=0.017), ASA score (P=0.001), the intraoperative grade of inflammation (P=0.004), and the histologic grade of inflammation (P=0.015). The only risk factor for IAA was the intraoperative grade of inflammation (P=0.028). ASA score (odds ratio: 1.992, P=0.032) and the intraoperative grade of inflammation (odds ratio: 1.573, P=0.006) remained significant in the multivariate analysis for SSI.

CONCLUSIONS

A higher ASA score correlates with SSI. A higher grade of intraoperative inflammation correlates with SSI and IAA. Laparoscopy has no impact on SSI and IAA in appendectomy.

Trends and outcomes of laparoscopic appendectomy in China: A multicenter, retrospective cohort study

Aim

The present study examined the status and trends of laparoscopic appendectomy (LA) in China as a developing country and compared its surgical outcomes with open appendectomy (OA).

Patients and Methods

A retrospective study was performed on 12 586 consecutive patients who underwent appendectomy for acute appendicitis at nine hospitals in China between 2011 and 2013. A multivariate logistic regression model was used to assess independent risk factors associated with the development of postoperative complications.

Results

The annual proportion of LA increased from 11.5 per cent to 20.8 per cent to 40.7 per cent in the 3‐year period. In comparison to OA, LA was associated with a lower postoperative complication rate (7.6 per cent vs 9.5 per cent, P = 0.001), a shorter hospital stay (mean: 5.4 days vs 6.5 days, P < 0.001) and a lower 30‐day readmission rate (2.3 per cent vs 3.1 per cent, P = 0.020). Multivariate analysis revealed that LA was independently associated with a decreased postoperative complication rate for all patients [odds ratio (OR): 1.44, P = 0.01], for a subgroup of patients with perforated appendicitis (OR: 4.32, P < 0.01) and for a subgroup of patients with unperforated appendicitis (OR: 1.50, P = 0.01).

Conclusions

The use of LA has increased rapidly in China in recent years. LA has been found to significantly lower the postoperative complication rate, even in perforated appendicitis. The laparoscopic procedure could be the preferred method for the surgical treatment of acute appendicitis in China in the future.

Surgical site infection after laparoscopic and open appendectomy: a multicenter large consecutive cohort study

BACKGROUND

Laparoscopic appendectomy (LA) has been rapidly applied worldwide recently. The issue of surgical site infection (SSI) after appendectomy needs to be re-investigated and analyzed along with this trend. This study aimed to identify risk factors of SSI after appendectomy in recent years.

METHODS

This retrospective study was conducted among patients with acute appendicitis who underwent either laparoscopic or open appendectomy (OA) at 7 general hospitals in China from 2010 to 2013. The incidence of SSI, classified as incisional SSI and organ/space SSI, was investigated. A multivariate logistic regression model was used to assess independent risk factors associated with overall, incisional, and organ/space SSI, respectively.

RESULTS

Among 16,263 consecutive patients, 3,422 (21.0 %) and 12,841 (79.0 %) patients underwent LA and OA, respectively. The incidences of overall, incisional, and organ/space SSI were 6.2, 3.7, and 3.0 %, respectively. The proportion of LAs among both procedures increased yearly from 5.3 to 46.5 %, while the incidences of overall and incisional SSI after appendectomy simultaneously decreased yearly from 9.6 to 4.5 % and from 6.7 to 2.2 %, respectively. In comparison with OA, LA was associated with lower incidences of overall and incisional SSI (4.5 vs 6.7 %, P < 0.001; and 1.9 vs 4.2 %, P < 0.001), but a similar incidence of organ/space SSI (3.0 vs 3.0 %, P = 0.995). After multivariate logistic regression analyses were performed, LA was found to be independently associated with a decrease in development of overall SSI [odds ratio (95 % confidence interval) OR (95 % CI), 1.24 (1.03-1.70); P = 0.04] or incisional SSI [OR (95 % CI), 1.32 (1.10-1.68); P = 0.01].

CONCLUSION

With the increasing application trends of laparoscopic procedure, the incidence of SSI after appendectomy declined accordingly. Compared with OA, LA was independently associated with a significantly lower incidence of incisional SSI, but a similar incidence of organ/space SSI.

Laparoscopic versus open approach in the management of appendicitis complicated exclusively with peritonitis: a single center experience

BACKGROUND

Controversial evidence exists regarding the laparoscopic approach in patients with acute appendicitis complicated with peritonitis due to a higher rate of surgical complications. The aim of this study was to compare post-operatory outcomes in patients with acute appendicitis complicated exclusively with peritonitis approached by laparoscopy versus open surgery.

METHODS

Single center retrospective analysis of clinical records of patients with appendicitis complicated with peritonitis operated from January 2003 until October 2013. Demographic data, intra-operative variables, length of stay, surgical complications, mortality, readmissions and reoperations were retrieved.

RESULTS

227 patients were identified, 43% males, mean age 39±17 years (range: 12-85 years). Ninety-seven patients (43%) underwent laparoscopic appendectomy, 13 of them were converted to open surgery (13%). Ninety-four patients presented with diffuse peritonitis (41.4%). Laparoscopic appendectomy showed longer operative time but shorter hospital stay (p<0.05). There were no differences in post-operatory complications (intra-abdominal abscess, surgical site infection and prolonged ileus). Laparoscopic appendectomy was associated with lower odds for developing any surgical complication in the multivariate analysis (OR 0.301, p=0.036).

CONCLUSION

Both approaches showed no differences in complications in the management of appendicitis complicated exclusively with peritonitis. In our experience, laparoscopic appendectomy is a safe approach in cases of appendicitis complicated exclusively with peritonitis.

Underweight body mass index as a predictive factor for surgical site infections after laparoscopic appendectomy

PURPOSE

Analyses of risk factors associated with surgical site infections (SSIs) after laparoscopic appendectomy (LA) have been limited. Especially, the association of an underweight body mass index (BMI) with SSIs has not been clearly defined. This study aimed to identify the impact of underweight BMI in predicting SSIs after LA.

MATERIALS AND METHODS

The records of a total of 101 consecutive patients aged ≥16 years who underwent LA by a single surgeon between March 2011 and December 2012 were retrieved from a prospectively collected database. The rate of SSIs was compared among the underweight, normal and overweight and obese groups. Also, univariate and multivariate analyses were performed to identify the factors associated with SSIs.

RESULTS

The overall rate of SSIs was 12.8%. The superficial incisional SSI rate was highest in the underweight group (44.4% in the underweight group, 11.0% in the normal group, and 0% in the overweight and obese group, p=0.006). In univariate analysis, open conversion and being underweight were determined to be risk factors for SSIs. Underweight BMI was also found to be a significant predictor for SSIs in multivariate analysis (odds ratio, 10.0; 95% confidence interval, 2.0-49.5; p=0.005).

CONCLUSION

This study demonstrated underweight BMI as being associated with SSIs after LA. Surgeons should be more cautious to prevent SSIs in patients that are underweight when performing LA.

Analysis of endoloops and endostaples for closing the appendiceal stump during laparoscopic appendectomy

PURPOSE

An inadequate closure of the appendiceal stump can lead to intra-abdominal surgical site infections. The aim of this study was to assess the efficiency of different closure techniques by focusing on the intraoperative and postoperative complications versus cost.

METHODS

From June 2011 to June 2013, 333 patients from two different hospitals undergoing laparoscopic appendectomy were included in this study. The patients were divided into two groups based on the technique used for appendiceal stump closure: there were 104 patients in the stapler group and 229 in the loop group.

RESULTS

Among the 333 patients who underwent laparoscopic appendectomy, there were two (0.6%) intraoperative complications and 22 (6.6%) postoperative complications. There were no significant differences between the groups with respect to the intraoperative and postoperative complications. The length of the operation was 7 min shorter when the endoloop was used (p = 0.014). The mean costs of the operation were significantly lower when the loop was used (<euro> 554.93) compared to the stapler (<euro> 900.70) (p = 0.000).

CONCLUSIONS

There is no clinical evidence supporting the routine use of endoscopic staplers. The appendiceal stump can be secured safely with the use of endoloops in the majority of patients. Surgeons have to be more selective when choosing how to perform closure, and an endostapler should be used only in cases where it is clinically indicated.

Appendicitis in children less than 5 years old: influence of age on presentation and outcome

PURPOSE

Appendicitis is the most common emergency surgical condition of the abdomen in children. This study sought to delineate the presentation and the outcome of appendicitis in children younger than 5 years old.

METHODS

A retrospective review was conducted of all children younger than 5 years of age who underwent appendectomy for acute appendicitis over a 12-year period.

RESULTS

One thousand eight hundred thirty-six patients younger than 19 years of age underwent appendectomy. Two hundred eighty-one children with an age range of 6 months to 4.9 years were included in this study. Perforation rates were higher in the younger patients (86% <1 year, 74% 1-1.9 years, 60% 2-2.9 years, 64% 3-3.9 years, and 49% 4-4.9 years), but the youngest children had fewer postoperative abscesses.

CONCLUSIONS

In children less than 5 years old with appendicitis, age has a direct correlation to the stage of disease. The youngest children present with more advanced appendicitis but are less likely to develop postoperative abscesses.

Laparoscopic appendectomy for complicated acute appendicitis does not result in increased surgical complications

BACKGROUND/OBJECTIVES

Septic postoperative complications are debated in patients with complicated acute appendicitis treated with laparoscopic appendectomy (LA). The aim of this study was to investigate the results of LA in both complicated and uncomplicated cases of acute appendicitis.

METHODS

From January to December 2009, 94 patients with acute appendicitis underwent LA by the same surgeon using the three-port technique. Data were accumulated and compared between complicated and uncomplicated acute appendicitis.

RESULTS

Of the 94 patients (45 women and 49 men), 19 had complicated and 75 uncomplicated acute appendicitis. The group with complicated acute appendicitis, as compared to the uncomplicated group, was significantly older (55.7 ± 20.5 years vs. 41.0 ± 18.0 years), and had a significantly increased operation time (117.6 ± 45.5 minutes vs. 78.2 ± 39.4 minutes), longer length of hospital stay (9.0 ± 3.3 days vs. 5.2 ± 6.0 days) and higher conversion rate (21.1% vs. 2.7%). No increase in surgical complications was noted in patients with complicated acute appendicitis, as compared to those with uncomplicated acute appendicitis.

CONCLUSION

This study demonstrated no increase in surgical complications after LA in patients with complicated acute appendicitis when compared with those who had uncomplicated disease. Therefore, LA may be considered the first-choice treatment option for both uncomplicated and complicated acute appendicitis.

Consensus conference on laparoscopic appendectomy: development of guidelines

AIM

Laparoscopic appendectomy (LA) is not yet unanimously considered the gold standard treatment for appendicitis, despite the increasing use of advanced laparoscopic operations and the high incidence of the disease.

METHOD

Due to the results of an audit which classified LA as widespread in Italy, a Consensus Conference was organized, in order to give evidence-based answers to the most debated problems regarding the operation. After researching the literature, a panel of 20 experts were selected and interviewed on hot topics; a subsequent discussion using the Delphi methodology was utilized in the course of the consensus conference and submitted to the evaluation of an audience of surgeons.

RESULTS

Checkpoint statements were formulated whenever an agreement was reached. A level of evidence was then assigned to single statements and the process revised by two external reviewers.

CONCLUSION

Consensus development guidelines are herein reported and regard diagnostic pathway, diagnostic laparoscopy, indications, behaviour in case of innocent appendix, technical aspects, learning curve; however, some questions remain unsolved due to the lack of evidence.

Appendix Diameter: A Predictor of Wound Infection after Laparoscopic Appendectomy

Our aim was to investigate whether appendix diameter is an independent risk factor for wound infection in laparoscopic appendectomy (LA). Patients who underwent LA (n = 582) were grouped into those with wound infections and those without. Possible factors associated with wound infection were analyzed using univariate and multivariate logistic regression analysis. When the diameter of the appendix was greater than 15 mm, patients were 2.32 times as likely to have a wound infection (95% CI, 1.02 to 5.29; P = 0.045) than if the appendix was less than 10 mm in diameter. Patients with perforated appendices were 2.51 times as likely to have a wound infection (95% CI, 1.25 to 5.02; P = 0.010) than if the appendix was not perforated. Wound infection was associated with longer operation time, return to oral intake, and hospital stay. Appendix diameter may predict postoperative wound infection after laparoscopic appendectomy.

Does Use of Intraoperative Irrigation with Open or Laparoscopic Appendectomy Reduce Post-Operative Intra-abdominal Abscess?

To date, no study shows a decrease in postoperative abscess with the use of irrigation during appendectomy. Postoperative abscess rate for laparoscopic and open appendectomy is 3.3 and 2.6 per cent. The purpose of this study is to determine if irrigation at appendectomy decreases the postoperative intra-abdominal abscess rate. Retrospective chart review of 176 consecutive appendectomies, open (39%) and laparoscopic (61%), at a university affiliated tertiary care facility from July 2007 to November 2008 for use of intraoperative irrigation was performed. Patients under age 18 were excluded. There were no differences between the irrigation groups in regards to age, sex, or weight. Perforation was observed in 28 per cent (50/176), of which 86 per cent (43/50) of patients received intraoperative irrigation. Eleven patients (9.6%) with irrigation developed postoperative abscess compared with two (3.3%) patients without irrigation ( P = 0.22). Our results do not show decrease in postoperative intra-abdominal abscess with use of intraoperative irrigation. Thirteen patients developed postoperative abscess: 11 with irrigation, two without irrigation. Ten of 13 patients who developed abscess were perforated; nine with irrigation and one without. These results suggest routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided.

Balancing the risk of postoperative surgical infections: a multivariate analysis of factors associated with laparoscopic appendectomy from the NSQIP database

OBJECTIVE

To establish the relationship between operative approach (laparoscopic or open) and subsequent surgical infection (both incisional and organ space infection) postappendectomy, independent of potential confounding factors.

BACKGROUND

Although laparoscopic appendectomy has been associated with lower rates of incisional infections than an open approach, the relationship between laparoscopy and organ space infection (OSI) is not as clearly established.

METHODS

Cases of appendectomy were retrieved from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for 2005 to 2008. Patient factors, operative variables, and the primary outcomes of incisional infections and OSIs were recorded. Factors associated with surgical infections were identified using logistic regression models. These models were then used to calculate probabilities of OSI in clinical vignettes demonstrating varying levels of infectious risk.

RESULTS

A total of 39,950 appendectomy cases were included of which 30,575 (77%) were performed laparoscopically. On multivariate analysis, laparoscopy was associated with a lower risk of incisional infection [odds ratio (OR) 0.37, 95% confidence interval (CI) 0.32-0.43] but with an increased risk of OSI after adjustment for confounding factors (OR 1.44, 95% CI 1.21-1.73). For a low-risk patient, probability of OSI was calculated to be 0.3% and 0.4%, respectively, for open versus laparoscopic appendectomy, whereas for a high-risk patient, probabilities were estimated at 8.9% and 12.3%, respectively.

CONCLUSION

Laparoscopy was associated with a decreased risk of incisional infection but with an increased risk of OSI. The degree of this increased risk varies depending on the clinical profile of a surgical patient. Recognition of these differences in risk may aid clinicians in the choice of operative approach for appendectomy.

Current analysis of endoloops in appendiceal stump closure

BACKGROUND

An inadequate closure of the appendix stump leads to intra-abdominal surgical site infection. The effectiveness of various appendiceal stump closure methods, for instance, staplers or endoloops, was evaluated. Many analyses show that the use of a stapler for transection and closure of the appendiceal stump lowers the risk of this infection but a statistically significant risk of postoperative intra-abdominal abscess or wound infection was not considered in any randomized study. The aim of this study was to evaluate the complications after using endoloops in a high-volume center.

METHODS

The data of 1,790 patients who underwent laparoscopic appendectomy between January 1998 and December 2006 and a single center was prospectively acquired. The standard procedure used was an appendiceal stump closure using endoloops and a selective use of staplers. The outcome criteria for inclusion in the study were intra-abdominal abscess formations, other specific intraoperative and postoperative complications, and the different costs of the operation.

RESULTS

Laparoscopic appendectomy was performed in 1,790 (80.8%) patients and open appendectomy in 425 (19.2%) patients. Conversion to open surgery occurred in 74 (4.13%) patients. Laparoscopic appendectomy with stump closure using endoloops was performed in 1,670 (97.3%) patients and stump closure using a stapler in 46 (2.7%) patients. Among 851 patients with acute appendicitis, 284 patients with perforated appendicitis, and 535 patients with other or no pathology, the rate of intra-abdominal abscess after using an endoloop or a stapler was not significantly different (1.5 vs. 0%, p = 0.587; 3.5 vs. 4.2%, p = 0.870; 0.7% vs. 0, p = 0.881, respectively). There were no significant differences between the endoloop group and the stapler group with respect to the other specific intraoperative and postoperative complications.

CONCLUSION

This study shows the safety of the endoloop for clinical daily routine. A selective procedure for stump closure has been established. Appendiceal stump closure using an endoloop is an easy, safe, and cost-effective procedure.

Sonographic findings following appendectomy for uncomplicated appendicitis in children

BACKGROUND

Little is known about 'normal' local sonographic changes occurring in the postoperative period after an uneventful appendectomy.

OBJECTIVE

To analyse the local changes on US examination occurring after uneventful open (OA) or laparoscopic (LA) appendectomy in children with normal histology and with nonperforated acute appendicitis.

MATERIALS AND METHODS

US was prospectively performed in 82 children (54 boys and 28 girls) aged 1-16 years (mean 11.6+/-3.2 years), 3 days following LA (n=51, 62%) or OA (n=31, 38%) for nonperforated appendicitis. Multivariate analysis was performed using stepwise logistic regression, with the following starting variables: surgical technique, gender, pathological finding, appendix location, and histology.

RESULTS

Of the 82 patients, 35 (42.7%) had postoperative pathological US findings such as peritoneal fluid, oedematous mesenteric fat and thickening of the bowel wall. While the overall incidence of pathological US findings between OA and LA groups was not significantly different, multivariate logistic regression analysis showed that OA is associated with a reduction by a factor of 0.35 in the odds ratio of postoperative pathological US findings (P=0.007).

CONCLUSION

Pathological US findings are common in children after appendectomy, particularly after LA. Awareness of these pathological findings might prevent unnecessary postoperative treatment.

Efficacy of laparoscopy in complicated appendicitis

BACKGROUND

Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis. The role of laparoscopy in management of complicated appendicitis remains undefined. We undertook this study to evaluate the efficacy of laparoscopic appendectomy in patients with complicated appendicitis.

METHOD

This study involved a total of 110 consecutive patients who had undergone appendectomy for perforated or gangrenous appendicitis between March 2004 and December 2008. Sixty-one patients underwent open appendectomy (OA) and remaining 49 patients underwent laparoscopic appendectomy (LA). Parameters studied were operative time, conversion rate, wound infections, intra-abdominal abscess and duration of pain and hospital stay.

RESULTS

There were two conversions due to extremely friable appendix. Laparoscopic appendectomy took longer to perform (98 min versus 79 min) but was associated with less analgesic use, shorter median hospital stay (LA- 3 days; OA- 6 days, p<0.05), and lower rate of wound infections (LA, 8.2%; OA, 24.6 %, p<0.05). Intra-abdominal abscess occurred in four patients (8.2%) in LA group and fourteen patients (22.9%) in OA group (p<0.05). More patients in OA group experienced prolonged ileus than LA group but the difference was statistically insignificant. All complications were managed conservatively and there was no mortality in either group.

CONCLUSIONS

Laparoscopic appendectomy for complicated appendicitis is feasible and safe. It is associated with less postoperative pain, lower incidence of infectious complications and reduced length of hospital stay when compared with patients who had open appendectomy.

[Changes in epidemiology, etiology, diagnostics, and therapy of acute appendicitis]

The frequency of acute appendicitis has fallen in the last three decades in developed industrialized countries. From 1961 to 1991 the number of appendectomies performed annually in Hungary decreased significantly. Since 1991 the numbers are essentially unchanged. Appendix lumen obstruction was formerly believed to be crucial in the etiology of the illness, while today mixed aerobic, anaerobic bacterial infection is considered more important. The inflammation process - according to immunogenetic differences - may lead to recovery or tissue necrosis and perforation. To date, no methods are known that could timely distinguish spontaneously healing or conservatively treatable appendicitis from those resulting in tissue necrosis, although routine usage of abdominal ultrasound technique is added to the clinical picture's modern diagnostic arsenal. The operative method for removing the appendix also has changed. Experience has confirmed that laparoscopic appendectomy is usually more favorable in the treatment of acute appendicitis than traditional surgery.

[Laparoscopic or open appendectomy?]

Despite the fact that laparoscopic appendectomy was one of the first performed minimally invasive surgical procedures, the benefits and indications of its use are still controversial.

METHODS

Data of patients with the diagnosis of appendicitis operated either with laparoscopic (LA) or open (OA) appendectomy were collected and analyzed.

PATIENTS

This study involved 273 consecutive patients who had undergone appendectomy with the diagnosis of acute appendicitis at the Uzsoki Teaching Hospital, Department of Surgery between January 2005 and December 2007. 185 patients (68%) operated with the laparoscopic, 88 (32%) with the open technique, in the third year 89% of the cases underwent laparoscopic appendectomy.

RESULTS

The conversion rate was 27%, the reason of the conversion was the progression of the disease in 35 patients (70%) and technical in 15 cases (30%). The wound infection rate was 8% in the LA and 18% in the OA group ( p = 0.022). No significant difference was found in the reoperation rate and in the hospital readmission rate between the two groups. There was one insufficiency which was treated with conservative therapy. The hospital stay was significantly lower in the laparoscopic group ( p = 0.031).

CONCLUSIONS

This study demonstrated that laparoscopic appendectomy has significant advantages over open appendectomy. In our practice, laparoscopic appendectomy is the first choice of procedure in acute appendicitis.

Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children

Laparoscopic appendectomy in children is well accepted for the treatment of non complicated appendicitis. An increased risk of postoperative intraabdominal abcess formation has been reported in complicated appendicitis. The puropose of this study was to compare open (OA) versus laparoscopic appendectomies (LA) in complicated appendicitis in children and to assess the safety and feasibility of LA. The hospital records of 118 consecutive patients who underwent appendectomy for complicated appendicitis (perforated/gangrenous) from 2000 to 2006 were retrospectively analysed. Fifty-four patients had LA and 64 underwent OA. There were 74 males and 44 females. The length of hospital stay ranged from 4 to 12 days in the LA group and 4 to 17 days in the OA group. Five patients (9.2%) in the LA group had post operative complications; intraabdominal collections in 3 and wound infections in 2. Ten patients (15.6%) had postoperative complications in the OA group; intraabdominal collections in 5, wound infection in 3, pleural effusion in 1 and prolonged ileus in 1. In complicated appendicitis the complication rate is lower for LA as compared to OA. We recommend laparoscopic approach to all children presenting with complicated appendicitis.

Laparoscopic appendectomy is superior to open appendectomy in obese patients

BACKGROUND

There are minimal data comparing laparoscopic appendectomy (LA) with open appendectomy (OA) in obese patients.

METHODS

We reviewed consecutive adult patients from 2003 to 2005 who underwent an appendectomy at a University-affiliated teaching hospital. Obesity was defined as a body mass index of 30 or greater. Outcome measures included length of stay, surgical times, intra-abdominal abscesses, wound infections, and hospital charges.

RESULTS

There were 116 patients with a mean body mass index of 35. Eighty-five patients underwent LA, 12 were converted to open, 4 of 12 (31%) were perforated. Thirty-one patients underwent OA. Overall, 21 (18%) were perforated. Length of stay for LA was better, 3.4 days versus 5.5 days for OA (P = .02), and wound closure rate was better, 90% for LA versus 68% for OA (P < .01). Other outcome measures were equivalent.

CONCLUSIONS

LA is associated with shorter lengths of stay, fewer open wounds, and equivalent hospital charges and intra-abdominal abscess rates; and should be considered the procedure of choice for obese patients with appendicitis.

Day case emergency laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy (LA) is associated with a shorter hospital stay and fewer complications than conventional open appendectomy (OA). This study aimed to examine the safety and efficacy of day case emergency LA.

METHODS

The records of patients undergoing emergency LA under the care of two laparoscopic surgeons over a 3-year period (Februrary 2003 to February 2006) were reviewed to examine hospital length of stay (LOS), complications, histology, grade of the operating surgeon, and time required to perform the procedure.

RESULTS

A total of 104 patients (median age, 25 years; range, 11-72 years; 58 men) underwent LA, with 9 and 66 patients discharged in 8 and 24 hours, respectively (median LOS 22 hours: range 6-170 hours). One patient underwent conversion to OA. Histologically, 86 patients had appendicitis and 18 had normal appendices with another pathology present. The median operative time was 35 min (range, 20-80 min). The complications included three wound infections and two pelvic abscesses not requiring further operative intervention.

CONCLUSION

Day case emergency LA is safe and effective for treating selected patients.

Complicaciones sépticas intraabdominales tras apendicectomía laparoscópica: descripción de una posible nueva complicación específica de la apendicectomía laparoscópica

BACKGROUND

Controversies about laparoscopic appendectomy (LA) focus mainly on the high intraabdominal infection rate. In 2005, Serour et al described a distinct complication specific to LA, termed "postlaparoscopic appendectomy complication" (PLAC). This complication is an intraabdominal infection, without abscess formation, which develops after laparoscopic appendectomy for non-complicated appendicitis (simple, phlegmonous, or normal appendix) and is observed in patients discharged after an uneventful postoperative period. We reviewed our case series to establish our intraabdominal infection rate in appendectomy and to identify cases similar to this newly described complication.

MATERIAL AND METHOD

We retrospectively reviewed 651 clinical records of appendectomy performed by the laparoscopic (LA) or open approach (OA) over an 11-year period in our hospital. The criteria for a diagnosis of PLAC were as follows: a) clinical criteria: uneventful appendectomy (OA or LA), asymptomatic status on hospital discharge, and onset of right lower quadrant pain, fever, and elevated white blood cell count after discharge; b) pathologic criteria: non-complicated appendicitis (gangrenous or perforated appendicitis were excluded), and c) ultrasound scan showing characteristic features.

RESULTS

A total of 432 LA and 219 OA were reviewed. The conversion rate was 11.1%. The main complications (intention-to-treat analysis) were wound infection (6.3% in LA versus 7.8% in OA) and intraabdominal infection (4.2% in LA versus 2.3% in OA). Four out of 18 cases of intraabdominal infection after LA fulfilled PLAC criteria, representing 1% of all LA and 22% of intraabdominal infections after LA.

CONCLUSIONS

LA seems to be associated with an increased risk of intraabdominal infection. Our results suggest that a distinct form of intraabdominal infection specific to laparoscopic appendectomy may exist.

Complicated appendicitis: laparoscopic or conventional surgery?

BACKGROUND

The surgical treatment of complicated appendicitis remains controversial. The aim of this study was to evaluate the role of laparoscopic appendectomy in the treatment of complicated appendicitis in comparison with open surgery.

METHODS

We reviewed the medical records of all patients who underwent an appendectomy for complicated appendicitis between January 2001 and August 2005.

RESULTS

We identified 98 patients with complicated appendicitis. Forty-eight patients underwent open appendectomy, 42 laparoscopic appendectomy, and 8 initial laparoscopy with conversion to open surgery. Older patients, patients with comorbidities, and female patients were more likely to have been offered a laparoscopic appendectomy. Operating time, time to solid oral intake, and time of hospital stay were prolonged in the laparoscopic group but not significantly. There was no mortality observed in either group, and the complication rate was similar in both groups.

CONCLUSIONS

Laparoscopic appendectomy is an acceptable procedure for complicated appendicitis, with the same rate of infectious complications as the conventional approach.

Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess: is appendectomy always necessary after perforation of appendix?

BACKGROUND

The present study was designed to compare the therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of appendicitis complicated by periappendiceal abscess.

METHODS

In a prospective study, 50 patients with acute appendicitis complicated by periappendiceal abscess > or = 3 cm in size were randomly assigned to two groups. The first group received treatment with ultrasound guided-percutaneous drainage and i.v. antibiotics (ampicillin, cefuroxime, and metronidazole), and the other group received antibiotics only. Patient's baseline characteristics, duration of hospital stay, and treatment outcome and complications were analyzed.

RESULTS

Appendectomy was avoided in 16/25 patients in the drainage group and 2/25 patients in the non-drainage group during follow-up with RR of 0.39 (95% CI = 0.22-0.62; p < 0.05). One patient in the drainage group and 8 patients in the non-drainage group underwent surgery in the first month after the beginning of treatment. Eight patients in the drainage group and 15 in the non-drainage group underwent interval appendectomy. There was no statistically significant difference between the two groups regarding patient demographics, abscess size, and pretreatment clinical symptoms. Hospital stay up to the subsidence of clinical and sonographic signs was significantly shorter (p < 0.001) in the drainage group, with a mean difference of 6.4 days (95% CI = 5.0-7.9; p < 0.05).

CONCLUSIONS

Percutaneous drainage with antibiotics is a safe and effective way of treating acute perforated appendicitis. The recurrence rate for these patients is relatively low, and very often interval appendectomy is not required. For patients with periappendiceal abscess > or = 3 cm in diameter, antibiotic therapy alone is insufficient and the recurrence rate is high.

Appendicitis in the elderly: a change in the laparoscopic era

BACKGROUND

Appendicitis in elderly patients is associated with significant morbidity and mortality. Early and correct diagnosis together with minimally invasive surgery can lead to more favorable outcomes than occurred in the prelaparoscopic era.

METHODS

A retrospective review of 116 elderly patients (age > 60) from 1999 to 2004 is compared with the authors' previously published studies from 1978 to 1988 (n = 96) and from 1988 to 1998 (n = 113), respectively.

RESULTS

In our current series (1999-2004), more cases were managed laparoscopically (n = 68) than with open surgery (n = 48). Perforated appendicitis cases resulted in significantly longer hospital stays, more complications, and longer operating time than nonperforated cases. The laparoscopic cases had significantly shorter lengths of hospital stay and fewer complications than open cases, and comparable operating times. As compared with our previous studies from 1978 to 1988) and from 1988 to 1998, the current series (1999-2004) consists of patients presenting with fewer classical symptoms. Computed tomography (CT) scanning was more accurate in the current study and more routinely used. The patients in the current series had more correct preoperative diagnoses. Perforated appendicitis was encountered less frequently and associated with fewer complications. The 4% mortality rate in the previous two series decreased to less than 1% in this series.

CONCLUSION

Minimally invasive surgery combined with increased use and accuracy of preoperative CT scans has changed the clinical management of acute appendicitis in elderly patients, leading to decreased lengths of stay, decreased mortality, and more favorable outcomes.

Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess: is appendectomy always necessary after perforation of appendix?

BACKGROUND

The present study was designed to compare the therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of appendicitis complicated by periappendiceal abscess.

METHODS

In a prospective study, 50 patients with acute appendicitis complicated by periappendiceal abscess > or = 3 cm in size were randomly assigned to two groups. The first group received treatment with ultrasound guided-percutaneous drainage and i.v. antibiotics (ampicillin, cefuroxime, and metronidazole), and the other group received antibiotics only. Patient's baseline characteristics, duration of hospital stay, and treatment outcome and complications were analyzed.

RESULTS

Appendectomy was avoided in 16/25 patients in the drainage group and 2/25 patients in the non-drainage group during follow-up with RR of 0.39 (95% CI = 0.22-0.62; p < 0.05). One patient in the drainage group and 8 patients in the non-drainage group underwent surgery in the first month after the beginning of treatment. Eight patients in the drainage group and 15 in the non-drainage group underwent interval appendectomy. There was no statistically significant difference between the two groups regarding patient demographics, abscess size, and pretreatment clinical symptoms. Hospital stay up to the subsidence of clinical and sonographic signs was significantly shorter (p < 0.001) in the drainage group, with a mean difference of 6.4 days (95% CI = 5.0-7.9; p < 0.05).

CONCLUSIONS

Percutaneous drainage with antibiotics is a safe and effective way of treating acute perforated appendicitis. The recurrence rate for these patients is relatively low, and very often interval appendectomy is not required. For patients with periappendiceal abscess > or = 3 cm in diameter, antibiotic therapy alone is insufficient and the recurrence rate is high.