Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis

Clinical-epidemiological profile of acute appendicitis: retrospective analysis of 638 cases

OBJECTIVE

to describe the clinical and epidemiological profile of acute appendicitis (AA) of the patients treated at a referral center in the Juiz de Fora macro-region, Minas Gerais State, Brazil.

METHODS

we conducted a retrospective, observational study in the Dr. Mozart Geraldo TeixeiraEmergency Hospital. We selected 638 patients diagnosed with AA, and analyzed the variables gender, age, evolutionary phase, length of hospital stay, pathological diagnosis, use of antibiotics, use of drains, complications and mortality.

RESULTS

AA was more prevalent in young adults (19-44 years) and males (65.20%). The mean hospital stay was seven days and phase II was the most prevalent. We found the histopathological diagnosis of primary tumor of the appendix in six patients (0.94%), adenocarcinoma being the most common histologic type (66.7%). Regarding the use of antibiotics, 196 patients underwent antibiotic prophylaxis and 306 received antibiotic therapy. Eighty-one patients used some kind of drain, for an average of 4.8 days. Seventeen patients died (2.67%), predominantly males (70.59%), with mean age of 38.47 years.

CONCLUSION

AA has a higher prevalence in males and young adults. The length of stay is directly associated with the evolutionary phase. The most common complication is infection of the surgical site. Mortality in our service is still high when compared with developed centers.

OBJETIVO

avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes.

MÉTODOS

estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período.

RESULTADOS

a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses.

CONCLUSÃO

de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

Hospital preference of laparoscopic versus open appendectomy: Effects on outcomes in simple and complicated appendicitis

PURPOSE

We hypothesize that laparoscopic (LA) or open appendectomy (OA) outcomes are associated with hospital procedure preference.

METHODS

We queried Kids' Inpatient Database (1997-2009) for simple (ICD-9-CM 540.9) and complicated (540.0, 540.1) appendicitis.

RESULTS

On PS-matched analysis of simple appendicitis (91,118 LA vs. 97,496 OA), LA had increased transfusion (1.7) rates, but lower wound infection (0.6) and perforation/laceration (0.3) rates. LA had shorter length of stay (LOS; 1.7 vs. 2.1days), but higher total charges (TC; 19,501 vs. 13,089 USD) and cost (7121 vs. 5968) vs. OA. For complicated appendicitis (28,793 LA vs. 30,782 OA), LA had increased nausea/vomiting rates (1.9), but lower wound infection (0.5) and transfusion (0.6) rates. LA had shorter LOS (5.1 vs. 5.9), but higher TC (32,251 vs. 28,209). MVA demonstrated shorter LOS (0.9) for LA at laparoscopic-preferring hospitals vs. open-preferring hospitals for simple appendicitis. For complicated appendicitis, higher complication rates (1.1) were associated with OA at laparoscopic-preferring hospitals. Laparoscopic-preferring hospitals had higher TC in all categories.

CONCLUSION

Complications and resource utilization for appendicitis are associated with surgical technique and hospital procedure preference. Laparoscopic-preferring hospitals had higher complication rates with OA for complicated appendicitis and higher charges regardless of appendectomy technique or appendicitis type.

LEVEL OF EVIDENCE

2c, Outcomes Research.

Laparoscopic appendectomy in children: experience in a single centre in chittagong, bangladesh

Background. Since the latter half of 1980s laparoscopy has become a well accepted modality in children in many surgical procedures including appendectomy. We present here the experience of laparoscopic appendectomy in children in a tertiary care hospital in Bangladesh.  Subjects & Methods. From October 7, 2005 to July 31, 2012, 1809 laparoscopic appendectomies were performed. Laparoscopy was performed in all the cases using 3 ports. For difficult and adherent cases submucosal appendectomy was performed. Feeding was allowed 6 h after surgery and the majority was discharged on the first postoperative day. The age, sex, operative techniques, operative findings, operative time, hospital stay, outcome, and complications were evaluated in this retrospective study. Results. Mean age was 8.17 ± 3.28 years and 69% were males. Fifteen percent were complicated appendicitis, 8 cases needed conversion, and 27 cases were done by submucosal technique. Mean operating time was 39.8 ± 14.2 minutes and mean postoperative hospital stay was 1.91 days. About 5% cases had postoperative complications including 4 intra-abdominal abscesses. Conclusions. Laparoscopic appendectomy is a safe procedure in children even in complicated cases.

[The transvaginal approach in acute appendicitis]

INTRODUCTION

The purpose of this work is to present 8 minilaparoscopic-assisted transvaginal appendectomies using rigid instruments in patients with acute appendicitis.

MATERIAL AND METHODS

Eight minilaparoscopic-assisted transvaginal appendectomies were performed from the 10th of August 2009 to the 30th of June 2010. The inclusion criteria were women between 18 and 65 years of age with a diagnosis of acute appendicitis. The exclusion criteria were palpable masses, appendicular abscesses, ASA III and IV; morbid obesity (BMI > 35); gynaecological infections; virgin patients and pregnant women. The surgical intervention was performed with rigid instruments. Surgical time, the need for post-operative analgesics, and post-surgical complications.

RESULTS

The age range varied between 18 and 42 years, with a mean of 29.6 years. The mean surgical time was 48.3 minutes (37-75). Analgesics were given to 2 patients after surgery (1 parenteral and 1 oral). Five patients were discharged before 24 hours and 3 at 48 hours. There were no post-operative complications.

CONCLUSIONS

Minilaparoscopic-assisted transvaginal appendectomy with rigid instruments, in selected women is a feasible and safe method, and with better aesthetic results than laparoscopic appendectomy, but future studies will be required that can demonstrate its advantages.

Laparoscopic appendectomy for acute appendicitis is more favorable for patients with comorbidities, the elderly, and those with complicated appendicitis: a nationwide population-based study

BACKGROUND

Laparoscopic appendectomy (LA) is not routinely performed for appendicitis because the costs associated with that procedure are higher than those for open appendectomy (OA). However, few studies have investigated the economic influence of LA and OA on specific subpopulations including the elderly, patients with comorbidities, and patients with complicated appendicitis. This population-based study was designed to investigate determinants of costs and hospital length of stay (LOS) for patients undergoing appendectomy. Furthermore, the differences in costs and LOS were compared between LA and OA for various subpopulations.

METHODS

Inpatients who underwent LA or OA for appendicitis during the period 2001-2008 were identified from claims data obtained from Taiwan's National Health Insurance program. Costs and LOS were evaluated by multiple linear regression models for various subpopulations stratified according to age, number of comorbidities, and severity of appendicitis.

RESULTS

Between 2001 and 2008, 22,252 patients (13.3%) underwent LA and 14,4438 (86.7%) had OA. Age, comorbidity, and severity of appendicitis were determinants of costs and LOS for both LA and OA. Although the costs and LOS for appendectomy increased with age and number of comorbidities, a sharper increase was noted for OA patients. Laparoscopic appendectomy mildly decreased LOS at the expense of significantly higher costs for young patients, those without comorbidities, and patients with uncomplicated appendicitis. In contrast, compared with OA, LA was associated with comparable costs and reduced LOS for the elderly, patients with comorbidities, and those with complicated appendicitis. In addition, hospital mortality and readmission rates for postoperative complications did not differ significantly between LA and OA.

CONCLUSION

Considering costs and LOS, patients older than 65 years, patients with comorbidities, and patients with complicated appendicitis benefit more from the laparoscopic approach for the treatment of appendicitis.

Competitive edge of laparoscopic appendectomy versus open appendectomy: a subgroup comparison analysis

BACKGROUND

With the advances in laparoscopic instruments and surgical techniques, the use of laparoscopic appendectomy (LA) has been increasing rapidly in recent years. In this retrospective analysis, we aimed to determine the competitive edge of LA versus open appendectomy (OA) in different settings of disease complexity, gender, and age difference.

METHODS

A retrospective analysis of the patients diagnosed with acute appendicitis at Changhua and Chang-Bing Show-Chwan Memorial Hospitals from January 1, 2004 to December 31, 2009 was conducted. Trend and indication of OA and LA were recorded, combined with a comparison of medical costs, complication rates, wound infection rates, and hospital stays in different settings of disease complexity, gender, and age group.

RESULTS

A total of 1366 appendicitis patients were enrolled, and the rate of LA use increased rapidly, from 8.1% in 2004 to 90.3% in 2009. The increased use of LA was seen in both the uncomplicated and complicated appendicitis patients and in both gender and age groups (pediatric, adult, and elderly). Compared with OA, LA was associated with a lower complication rate (9.5% versus 5.8%; P = .013), a lower wound infection rate (8.6% versus 4.2%; P = .001), and a shorter hospital stay (4.60 ± 3.64 versus 4.06 ± 1.84 days; P = .001), but a higher mean cost (32,670 ± 28,568 versus 37,567 ± 12,064 New Taiwan dollars). In the subgroup analysis, the patients with complicated appendicitis, female patients, and pediatric and elderly patients benefited from a reduced hospital stay. LA is about 15% more expensive than OA.

CONCLUSIONS

LA is as safe and effective as OA in many settings of appendicitis and may be selectively advantageous in patients with complicated appendicitis and in elderly subgroups.

Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis

BACKGROUND

The goal of the present study was to critically review and identify the strength of available evidence in the literature on the use of laparoscopic appendectomy (LA) in complicated appendicitis (CA).

METHODS

The Cochrane Library and Controlled Trials Registry, MEDLINE (Ovid), PubMed, Web of knowledge, and SCOPUS databases were electronically searched, using the keywords "appendectomy," "laparoscopy," "appendicitis." "complicated appendicitis." "gangrenous appendicitis," "perforated appendicitis," with English language as a limit. Backward chaining was also employed. The NHS Public Health Resource Unit Critical Appraisal Skills Programme Tools were used for critical appraisal.

RESULTS

Twelve retrospective case-control studies were included in the review. Overall methodological quality was moderate to poor, with heterogeneity, absence of randomization and blinding, and presence of important methodological flaws. Meta-analysis showed that LA in CA has reduced surgical site infection (SSI) rates compared to open appendectomy (OA), odds ratio (OR) 0.23, 95% confidence intervals (CI): 0.14-0.37 (level 3a evidence), and no difference with regard to intra-abdominal abscess (IAA) complication rates OR: 1.02, 95% CI 0.56-1.86 (level 3a evidence).

CONCLUSIONS

When compared to OA, laparoscopic appendectomy is advantageous in CA with regard to SSIs, with no significant additional risk of IAA (level 3a evidence).

Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals

BACKGROUND

The benefit of laparoscopic (LA) versus open (OA) appendectomy, particularly for complicated appendicitis, remains unclear. Our objectives were to assess 30-day outcomes after LA versus OA for acute appendicitis and complicated appendicitis, determine the incidence of specific outcomes after appendectomy, and examine factors influencing the utilization and duration of the operative approach with multi-institutional clinical data.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2008), patients were identified who underwent emergency appendectomy for acute appendicitis at 222 participating hospitals. Regression models, which included propensity score adjustment to minimize the influence of treatment selection bias, were constructed. Models assessed the association between surgical approach (LA vs OA) and risk-adjusted overall morbidity, surgical site infection (SSI), serious morbidity, and serious morbidity/mortality, as well as individual complications in patients with acute appendicitis and complicated appendicitis. The relationships between operative approach, operative duration, and extended duration of stay with hospital academic affiliation were also examined.

RESULTS

Of 32,683 patients, 24,969 (76.4%) underwent LA and 7,714 (23.6%) underwent OA. Patients who underwent OA were significantly older with more comorbidities compared with those who underwent LA. Patients treated with LA were less likely to experience an overall morbidity (4.5% vs 8.8%; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.54-0.68) or a SSI (3.3% vs 6.7%; OR, 0.57; 95% CI, 0.50-0.65) but not a serious morbidity (2.6% vs 4.2%; OR, 0.86; 95% CI, 0.74-1.01) or a serious morbidity/mortality (2.6% vs 4.3%; OR, 0.87; 95% CI, 0.74-1.01) compared with those who underwent OA. All patients treated with LA were significantly less likely to develop individual infectious complications except for organ space SSI. Among patients with complicated appendicitis, organ space SSI was significantly more common after laparoscopic appendectomy (6.3% vs 4.8%; OR, 1.35; 95% CI, 1.05-1.73). For all patients with acute appendicitis, those treated at academic-affiliated versus community hospitals were equally likely to undergo LA versus OA (77.0% vs 77.3%; P = .58). Operative duration at academic centers was significantly longer for both LA and OA (LA, 47 vs 38 minutes [P < .0001]; OA, 49 vs 44 minutes [P < .0001]). Median duration of stay after LA was 1 day at both academic-affiliated and community hospitals.

CONCLUSION

Within ACS NSQIP hospitals, LA is associated with lower overall morbidity in selected patients. However, patients with complicated appendicitis may have a greater risk of organ space SSI after LA. Academic affiliation does not seem to influence the operative approach. However, LA is associated with similar durations of stay but slightly greater operative times than OA at academic versus community hospitals.

Clinical outcomes of laparoscopic versus open appendectomy

BACKGROUND

Appendectomy, being the most common surgical procedure performed in general surgery, is still being performed by both open and laparoscopic methods due to a lack of consensus as to which is the most appropriate method. Because further trials are necessary and few such studies have been performed in developing countries, we decided to evaluate the outcomes of the 2 procedures to share our experience with the international community.

METHODS

Consecutive patients with suspected acute appendicitis who underwent laparoscopic (LA) (n=48) and open (n=52) appendectomy (OA) over a period of 3 years were studied. Clinical outcomes were compared between the 2 groups in relation to operative time, analgesia used, length of hospital stay, return to work, resumption of a regular diet, and postoperative complications.

RESULTS

Mean age of patients was 25.8 years in the laparoscopic and 25.5 years in the open group. Patient demographics were similar in both groups (P>0.05). There was significantly less need for analgesia (1.0+/-0.5 in LA and 1.5+/-0.6 doses in OA), a short hospital stay (1.4+/-0.7 in LA and 3.4+/-1.0 days in OA), early return to work (12.6+/-3.3 in LA and 19.1+/-3.1 days in OA), and less time needed to return to a regular diet (20.1+/-2.9 in LA and 22.0+/-4.7, P<0.05 in OA) in the laparoscopic appendectomy group. Operative time was significantly shorter (54.9+/-14.7 in LA and 13.6+/-12.6 minutes in OA) in the open group. Total number of complications was less in the laparoscopic group; however, there was no statistically significant difference.

CONCLUSION

The laparoscopic technique is a safe and clinically beneficial operative procedure. It provides certain advantages over open appendectomy, including short hospital stay, decreased requirement of postoperative analgesia, early food tolerance, and earlier return to normal activities. Where feasible, laparoscopy should be undertaken as the initial procedure of choice for most cases of suspected appendicitis.

[Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy]

BACKGROUND

The diagnosis of acute appendicitis in the elderly bears many pitfalls due to a broad range of differential diagnoses and uncommon clinical presentation. This may result in late detection of appendicitis leading to poor outcome. The aim of this study was to examine the characteristics of appendicitis in elderly patients in order to facilitate early diagnosis.

MATERIALS AND METHODS

All patients who underwent appendectomy in our institution were prospectively recorded over a 30 month period. Data on patient's age (>60 years versus < or =60 years), clinical findings, the inflammatory parameters leucocytes and C-reactive protein (CRP) and histological-findings (perforated versus non-perforated) were collected. Statistical analysis was carried out by ROC analysis, chi(2) and t-tests.

RESULTS

In the examination period 403 patients underwent appendectomy and 11.2% (n=45) were older than 60 years. These patients were characterized by significantly more frequent perforations compared to those patients < or =60 years (35.6% versus 7.0%, p< or =0.05), peritonitis (42.2% versus 9.5%, p< or =0.05), conversion to open surgery (23% versus 5%, p< or =0.005), longer postoperative hospital stay (9.2 days versus 4.3 days, p< or =0.05) and a higher complication rate (28.9% versus 3.6%, p< or =0.005). CRP values in patients >60 years were on average 123.2 mg/l and significantly higher than in patients < or =60 years (35.5 mg/l, p< or =0.005). The ROC analysis resulted in a CRP cut-off value of 101.9 mg/l for patients >60 years for the existence of a perforation with a specificity of 72.4% and a sensitivity of 81.3% (AUC 0.811).

CONCLUSIONS

The CRP value showed a strong correlation with respect to the grade of inflammation and perforation. In conclusion, elderly patients with symptoms of appendicitis and a CRP value higher than 102 mg/l should undergo early diagnostic laparoscopy.

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.

Value of laparoscopic appendectomy in perforated appendicitis

BACKGROUND

The purpose of this clinical study was to evaluate the efficacy of laparoscopic appendectomy in patients with perforated appendicitis.

METHODS

This study involved a total of 73 consecutive patients who had undergone appendectomy for perforated appendicitis between January 1999 and December 2004. While 39 patients underwent open appendectomy (OA) during the first 3 years, the remaining 34 patients underwent laparoscopic appendectomy (LA) during the last 3 years.

RESULTS

There was no case of LA converted to OA. No significant difference was found in the operating time between the two groups. Laparoscopic appendectomy was associated with less analgesic use, earlier oral intake restart (LA, 2.6 days; OA, 5.1 days), shorter median hospital stay (LA, 11.7 days; OA, 25.8 days), and lower rate of wound infections (LA, 8.8%; OA, 43.6%).

CONCLUSIONS

These results suggest that LA for perforated appendicitis is a safe procedure that may prove to have significant clinical advantages over conventional surgery.

Examination Under Anesthesia Prior Laparoscopic Appendicectomy

The clinical finding of a mass in the right iliac fossa during the course of diagnosis of acute appendicitis may affect the management approach. A mass is sometimes only evident when the abdomen is examined under anesthesia. This study was conducted to assess the significance of examination under anesthesia and analyze the outcome of laparoscopic exploration and its correlation with the finding of a mass that can be felt only under anesthesia. We conducted a prospective study over 12 months on patients diagnosed with acute appendicitis who were treated with laparoscopic approach. There were 179 patients (101 females) who underwent laparoscopic appendicectomy; 20 cases (11%) were converted to open appendicectomy. Examination under anesthesia revealed a mass in 20 patients (11%). The rate of conversion to open operation was 65% (13 patients) in those who had palpable mass and 4% (7 patients) in those who had no mass (P<0.0001). This study has shown that most patients with a mass found under anesthesia will need conversion of the laparoscopic procedure to an open operation. The recommendation from this study therefore is that all patients planned to have a laparoscopic appendicectomy should have examination under anesthesia; if a mass is found, then the procedure should be converted to open operation from the beginning.

Classificação laparoscópica da apendicite aguda: correlação entre graus da doença e as variáveis perioperatórias

OBJETIVO: Apresentar a classificação laparoscópica da apendicite aguda e verificar a relação entre os graus da doença com o tempo de sintomas, tempo operatório, permanência hospitalar, complicações infecciosas e uso de antimicrobianos. MÉTODO: Estudo prospectivo, transversal, envolvendo 105 pacientes com diagnóstico de apendicite aguda e submetidos a apendicectomia laparoscópica entre Janeiro de 2000 e Julho de 2001. A doença foi classificada em grau 0 - Normal; 1 - Hiperemia e edema; 2 - Exsudato fibrinoso; 3 - Necrose segmentar; 4A - Abscesso; 4B - Peritonite regional; 4C - Necrose da base do apêndice; 5 - Peritonite difusa. RESULTADOS: A distribuição dos pacientes segundo a classificação foi: grau 0 (10,4%); 1 (40%); 2 (29,5%); 3 (2,9%); 4A (1,9%); 4B (4,8%); 4C (3,8%) e 5 (6,7%). O tempo médio de início de sintomas acima de 40 h correlacionou-se com possibilidade de necrose e peritonite. O tempo operatório variou de 18 a 126 minutos, média de 31,4 minutos. A permanência hospitalar variou de 12 a 192 h, média de 39,5 h. A maior incidência de complicações Infecciosa ocorreu nos graus 4 e 5. O antimicrobiano foi de uso profilático graus 0, 1 e 2 e terapêutico nos demais. A laparotomia foi necessária duas (1,9%) vezes e não houve óbito. CONCLUSÕES: A classificação laparoscópica da apendicite aguda contemplou todas as formas clínicas da doença, possibilitou correlação com os tempos início de sintomas, operatório e de permanência hospitalar. Permitiu ainda, prever complicações infecciosas e racionalizar o uso de antimicrobianos.

Videolaparoscopic appendectomy: the current outlook

BACKGROUND

Mini-invasive techniques have revolutionized surgery, but the superiority of laparoscopic access for appendectomy is widely debated. The authors analyze their monocentric experience with 1,347 laparoscopic appendectomies.

METHODS

Between October 1991 and December 2002, all the patients with an indication for appendectomy underwent surgery (301 emergency and 1,046 interval appendectomies) using the laparoscopic approach.

RESULTS

For 1,248 patients, appendectomy was performed laparoscopically, whereas for 99 patients (7.3%), it was converted to an open procedure because of technical reasons (90 patients, 6.7%) or intraoperative complications (9 patients, 0.6%). For 59 patients (4.4%), the appendectomy was associated with another procedure. Histology showed "acute" alterations in 261 of the 301 emergency surgeries and in 148 of the 1,046 elective operations. Postoperative complications arose in 37 patients (2.7%), with 5 patients (0.3%) requiring invasive treatment. The mean postoperative stay was 30 h.

CONCLUSIONS

Laparoscopic appendectomy offers unquestionable advantages, but it is not yet considered the "gold standard" for appendiceal pathology. Many centers reserve it for selected patients (e.g., obese patients and women suspected of having other pathologies). No randomized trials or metaanalyses have definitively proved its superiority.

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.

Laparoscopic appendectomy in patients with endometriosis

STUDY OBJECTIVE

To report the frequency and spectrum of histologically proved diseases of the appendix in patients undergoing laparoscopic surgery for chronic pelvic pain in conjunction with endometriosis in a tertiary referral center.

DESIGN

Patient database with retrospective chart review (Canadian Task Force classification II-3).

SETTING

University ambulatory endoscopic surgery center-tertiary referral center.

PATIENTS

Two hundred thirty-one women.

INTERVENTIONS

Appendectomy during laparoscopic surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS

We reviewed the medical records of 231 patients who underwent appendectomy during laparoscopic treatment of endometriosis performed from January 1994 through July 2004. Of the 231 patients with pelvic endometriosis, concomitant appendiceal pathology was present in 115.

CONCLUSION

The appendix may be involved and may contribute to pelvic pain in patients with endometriosis.

Insurance status and race represent independent predictors of undergoing laparoscopic surgery for appendicitis: secondary data analysis of 145,546 patients

BACKGROUND

Studies have shown that racial and socioeconomic differences lead to inequality in access to health care. It is unknown whether insurance status and race affect the choice of surgical treatment for patients presenting with appendicitis.

STUDY DESIGN

Patients with primary ICD-9 procedure codes for laparoscopic and open appendectomy were selected from the 1998, 1999, and 2000 Nationwide (US) Inpatient Samples. The primary predictor variables were insurance status (private, Medicare, Medicaid, other) and race (Caucasian, African American, Hispanic, other). Multiple logistic regression models were used to assess whether insurance status and race are associated with the choice of surgical procedure for patients presenting with appendicitis.

RESULTS

Discharge abstracts of 145,546 patients were used for our analyses. There were 32,407 patients (22.3%) who underwent laparoscopic appendectomy and 113,139 patients (77.7%) who had open appendectomy. Although 24.2% of privately insured patients underwent laparoscopic appendectomy, only 16.9% of Medicare patients, 17.4% of Medicaid patients, and 19.6% of patients in the "other" insurance category were treated using the laparoscopic procedure (p < 0.001). Caucasian patients underwent laparoscopic surgery in 24.8%, African Americans in 18.6%, Hispanics in 19.6%, and other ethnicities in 18.8% of patients (p < 0.001). Compared with the Medicaid subset, and after adjusting for potential confounders such as age, gender, race, patient comorbidity, median ZIP code income, hospital location and teaching status, and presence of abscess or perforation, privately insured patients (odds ratio [OR] = 1.26, 95% [CI [1.20, 1.33], p < 0.001) and Medicare patients (OR = 1.17, 95% CI [1.05, 1.30], p = 0.004) were significantly more likely to undergo laparoscopic surgery. Caucasian patients (OR = 1.42, 95% CI [1.33, 1.51], p < 0.001) and Hispanics (OR = 1.12, 95% CI [1.04, 1.20], p = 0.002) were significantly more likely to have laparoscopic appendectomy, compared with African Americans, even after adjusting for the previously mentioned confounders and insurance status.

CONCLUSIONS

Even after adjusting for potential confounders, insurance status and race are marked independent predictors of having laparoscopic surgery in patients treated for appendicitis in this sample.

The Efficacy of Postoperative Oral Antibiotics in Appendicitis: A Randomized Prospective Double-Blinded Study

The conventional treatment of acute appendicitis is appendectomy followed by intravenous (IV) antibiotics until intraabdominal infection has resolved. It is controversial as to whether it is efficacious to add a course of oral antibiotics after cessation of IV antibiotics. All consenting patients who presented to Kern Medical Center between October 2000 and June 2003 with acute appendicitis were entered into the study. Perforated/gangrenous appendicitis was equally represented in the two study arms. After appendectomy, and when IV antibiotics were ready to be discontinued, patients were randomized to receive a 7-day outpatient course of either placebo (Group 1) or oral antibiotics (Group 2). Patients were monitored for infectious complications for a minimum of 3 months, and there was no statistical difference (11.5% in Group 1 vs 12.1% in Group 2, P = 0.61). The data suggest that adding a course of outpatient oral antibiotics, after completing a course of IV antibiotics, does not decrease postoperative infectious complications in appendicitis patients.

Laparoscopic appendicectomy is associated with a lower complication rate even during the introductory phase

BACKGROUND

The benefit of laparoscopic appendicectomy is under debate. To study the beneficial clinical effects of laparoscopic appendicectomy during the introductory phase we analysed, retrospectively, 493 patients from one district general hospital.

PATIENTS AND METHODS

During a period of 3 years 250 patients were operated on prospectively by open appendicectomy, and 243 patients were operated on laparoscopically. Both groups were compared with regard to their demographic data, operation time, body mass index and complication rate.

RESULTS

The conversion rate was 4.5%. The distribution of histological stages of inflammation was comparable in both groups. The median operating time was significantly longer for the open (40 min) than for the laparoscopic procedure (35 min, P=0.002). The body mass index in the laparoscopic group was significant higher (23.7 kg/m(2) vs 22.6 kg/m(2), P=0.009). Perioperative white blood cell count, C-reactive protein and body temperature were equal in both groups. There was no significant difference with regard to the analgesia required postoperatively between the open and the laparoscopic group. Nevertheless, the specific complication rate after open appendicectomy (18.4%) was significantly higher than that following laparoscopic appendicectomy (10.8%, P=0.03).

CONCLUSION

Even during the introductory phase, laparoscopic appendicectomy is a safe and clinically beneficial operating procedure.

Laparoscopic appendectomy in the elderly

BACKGROUND

Evidence suggests that laparoscopic appendectomy (LA) has advantages over open appendectomy (OA) in the treatment of appendicitis. It remains, however, unclear whether LA is indicated in the elderly patient population.

METHODS

Patients with primary International Classification of Diseases, revision 9, procedure codes for LA (n=32406 patients) and OA (n=112884 patients) were selected from the 1998, 1999, and 2000 Nationwide Inpatient Samples. The end points that were under investigation were the length of hospital stay, the rate of routine discharge, and in-hospital morbidity and mortality rates. Multiple linear and logistic regression analyses were performed to assess the risk-adjusted association between the surgery type and the patient outcomes. Stratified analyses were performed according to age (65 years and older; less than 65 years old) and to the presence of appendiceal perforation or abscess.

RESULTS

After risk adjustment, patients who underwent LA had a significantly shorter mean length of stay (LA, 2.45 days; OA, 3.71 days; P <. 0001), higher rate of routine discharge (odds ratio, 2.80; P <.0001), lower overall complication rate (odds ratio, 0.92; P=.03), and mortality rate (odds ratio, 0.23; P=.001) compared with OA patients. Similar benefits of LA were found in the strata of patients who were less than 65 years old, in elderly patients, and in patients with appendiceal perforation or abscess.

CONCLUSION

LA has statistically significant advantages over OA with respect to the length of hospital stay, the rate of routine discharge, and postoperative morbidity and mortality rates for patients who are less than 65 years old, in elderly patients, and in patients with appendiceal abscess or perforation.

Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors

BACKGROUND

The use of laparoscopic appendectomy for complicated appendicitis is controversial. Outcomes were compared between patients who had complicated appendicitis and those who had uncomplicated appendicitis.

METHODS

Consecutive patients (n = 304) who underwent laparoscopic appendectomy were studied. Patients undergoing open appendectomies also were compared ad hoc. Analgesia use, length of hospital stay, return to activity, and complication rates for the complicated and uncomplicated appendicitis subgroups were analyzed.

RESULTS

Complete data were available for 243 patients (80%). There were no statistical differences in characteristics between the two groups. The operating times, lengths of hospital stay, return to activity times, complication rates, and analgesia requirements, both in the hospital and after discharge, were equivalent. A greater number of complicated cases required open conversion. Considering those with complicated appendicitis, the open group had a significantly longer mean hospital stay and a higher complication rate than those treated with laparoscopic appendectomy.

CONCLUSIONS

The minimally invasive laparoscopic technique is safe and efficacious. It should be the initial procedure of choice for most cases of complicated appendicitis.

Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database

OBJECTIVE

To compare length of hospital stay, in-hospital complications, in-hospital mortality, and rate of routine discharge between laparoscopic and open appendectomy based on a representative, nationwide database.

SUMMARY BACKGROUND DATA

Numerous single-institutional randomized clinical trials have assessed the efficacy of laparoscopic and open appendectomy. The results, however, are conflicting, and a consensus concerning the relative advantages of each procedure has not yet been reached.

METHODS

Patients with primary ICD-9 procedure codes for laparoscopic and open appendectomy were selected from the 1997 Nationwide Inpatient Sample, a database that approximates 20% of all US community hospital discharges. Multiple linear and logistic regression analyses were used to assess the risk-adjusted endpoints.

RESULTS

Discharge abstracts of 43757 patients were used for our analyses. 7618 patients (17.4%) underwent laparoscopic and 36139 patients (82.6%) open appendectomy. Patients had an average age of 30.7 years and were predominantly white (58.1%) and male (58.6%). After adjusting for other covariates, laparoscopic appendectomy was associated with shorter median hospital stay (laparoscopic appendectomy: 2.06 days, open appendectomy: 2.88 days, P < 0.0001), lower rate of infections (odds ratio [OR] = 0.5 [0.38, 0.66], P < 0.0001), decreased gastrointestinal complications (OR = 0.8 [0.68, 0.96], P = 0.02), lower overall complications (OR = 0.84 [0.75, 0.94], P = 0.002), and higher rate of routine discharge (OR = 3.22 [2.47, 4.46], P < 0.0001).

CONCLUSIONS

Laparoscopic appendectomy has significant advantages over open appendectomy with respect to length of hospital stay, rate of routine discharge, and postoperative in-hospital morbidity.

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p < 0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p < 0.05). The surgeon's experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.

Laparoscopic appendectomy in modern gynecology

Gynecologists frequently manage women with acute or chronic pain in the right iliac fossa. Appendicitis is one of the common conditions encountered in this setting. From the gynecologic perspective, issues regarding the role of laparoscopic appendectomy include radioimaging and laparoscopic diagnosis, operative technique, advantages and disadvantages, and laparoscopic appendectomy in pregnancy and in complicated appendicitis. Most studies are in favor of the procedure, and it seems reasonable to include it in training programs in gynecology.

Results of laparoscopic vs. conventional appendectomy in complicated appendicitis

BACKGROUND

Although many trials show some advantages of laparoscopic appendectomy over open appendectomy, the value of laparoscopic appendectomy is still controversial. Specifically the question of whether there are benefits of laparoscopic appendectomy over open appendectomy in complicated appendicitis remains to be answered.

METHODS

Of 1,106 consecutive appendectomies (717 laparoscopic appendectomies, 330 open appendectomies, and 59 conversions) between 1989 and 1999, the results of 299 patients with complicated appendicitis (defined by perforation, abscess, or peritonitis) were analyzed retrospectively to compare the complications of laparoscopic appendectomy and conversion (intention-to-treat group) with those of open appendectomy.

RESULTS

Complicated appendicitis (n = 299) was treated by laparoscopic appendectomy in 171 patients, by open appendectomy in 82 patients, and by conversion in 46 patients. Laparoscopic appendectomy and conversion showed fewer abdominal wall complications than open appendectomy (13/217; 6 percent vs. 15/82; 18.3 percent; P < 0.003), which led to a decrease of the total complication rate in the intention-to-treat group (21/217; 9.7 percent vs. 19/82; 23.1 percent; P = 0.004). The rate of intra-abdominal abscess formation was nearly the same after laparoscopic appendectomy (4.1 percent) and open appendectomy (4.9 percent). The total complication rate was higher in complicated appendicitis than in acute appendicitis (P < 0.005) but was independent of the laparoscopic technique. The conversion rate was higher in complicated appendicitis than in acute appendicitis (21.2 vs. 2.3 percent; P < 0.001).

CONCLUSION

In comparison with open appendectomy, laparoscopic appendectomy (by itself and in an intention-to-treat view) leads to a significant reduction of early postoperative complications in complicated appendicitis and therefore should be considered as the procedure of choice.

Perforated appendicitis: is laparoscopic operation advisable?

AIMS

A retrospective study was used to compare laparoscopic appendectomy for perforated appendicitis to open operation.

METHODS

Between July 1991 and June 1999 a total of 734 patients, all over 14 years of age, underwent operation for acute appendicitis. Of these patients, 125 (17%) displayed perforated appendicitis and were treated with either a laparoscopic appendectomy (n = 80; total conversion rate 36/80, 45%) or a primary open procedure (n = 45).

RESULTS

Due to selection, the 3 treatment groups (laparoscopic, laparoscopy with conversion, open operation) showed differences with respect to gender, duration of symptoms, proportion of obese patients and patients with generalized peritonitis. The median operating time was 75 min for the laparoscopic procedure, 90 min for a converted procedure and 70 min for open operation. Only 1 of 44 (2%) patients who had a laparoscopic operation, but 8 of 36 (22%) who had a converted operation, and 8 of 45 (18%) who had an open operation developed wound infection. A similar frequency of intra-abdominal abscess formation was observed in the 3 treatment groups (2/44, 5%; 3/36, 8%; 2/45, 5%). Fatal outcome occurred only in patients who underwent an open operation and presented with severe peritonitis (5/45, 11%).

CONCLUSIONS

Despite limitations in comparability of patient groups, laparoscopic appendectomy was associated with a significantly lower rate of septic wound complications (p < 0.05). This was especially true for the subgroup of obese patients (BMI >26). Therefore, for patients with perityphlitic abscess or fresh purulent lower abdominal peritonitis, but not for patients with generalized peritonitis, laparoscopic appendectomy is not only justifiable but even recommended as the procedure of choice.

Intraabdominal abscess rate after laparoscopic appendectomy

BACKGROUND

Studies suggest increased intraabdominal abscess (IA) rates following laparoscopic appendectomy (LA), especially for perforated appendicitis. Consequently, an open approach has been advocated. The aim of our study is to compare IA rates following LA performed by a laparoscopic surgery and a general surgical service within the same institution.

METHODS

Data of LA patients treated at Los Angeles County-University of Southern California (LAC-USC) Medical Center between March 1992 and June 1997 were reviewed. The main outcome measure was postoperative IA.

RESULTS

In all, 645 LA were reviewed. A total of 413 LA (285 acute, 61 gangrenous, 67 perforated appendicitis) were performed by three general surgical services (10 attendings). Ten abscesses occurred postoperatively (2.4%), 6 with perforated appendicitis. After the laparoscopic service was introduced, 232 standardized LA (126 acute, 46 gangrenous, 60 perforated) were performed by two attendings. One IA occurred (gangrenous appendicitis). The IA rate for perforated appendicitis was significantly lower on the laparoscopic service (P = 0.025). There was no difference in IA rates for acute and gangrenous appendicitis. There was no mortality in either group.

CONCLUSION

IA rate following LA for perforated appendicitis was significantly reduced on the laparoscopic service. Mastery of the learning curve and addition of specific surgical techniques explained this improved result. Therefore, laparoscopic appendectomy for complicated appendicitis may not be contraindicated, even for perforated appendicitis.

Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice?

BACKGROUND/PURPOSE

Whether laparoscopic appendectomy (LA) is superior to open appendectomy (OA) for simple (SA) and perforated appendicitis (PA) in children is debatable. The operative experience of 4 senior pediatric surgeons at a single institution was studied over a 6-year period during a transition from OA in all cases to LA in all cases, to answer this question.

METHODS

All appendectomies from December 1993 to December 1999 were reviewed for operative technique (OA, LA), presence of perforation (SA, PA), operating time (OT), length of stay (LOS), morbidity, and mortality.

RESULTS

There were 1,128 appendectomies in children aged 14 months to 19 years, including 955 LA (653 in SA, 302 in PA) and 173 OA (86 in SA, 87 in PA). OT was equal for LA and OA in SA (52 minutes), but has dropped to less than 40 minutes for LA in the past year. OT in PA was slightly longer in LA versus OA (68 v. 58 minutes; P < .001) but recently has dropped in LA to less than 60 minutes. LOS in SA was 2 days for LA and 3 days for OA; in PA, LOS was 7 days in both LA and OA, but has dropped to 5 days for LA recently. Postoperative abscess rates and incidence of bowel obstruction did not differ between LA and OA in either group. There was no mortality.

CONCLUSIONS

LA is at least as safe and effective as, if not superior to, OA for both simple and perforated appendicitis. Postoperative pain is less, and recovery is faster, thereby reducing LOS and overall cost. The growing demand for this procedure can be satisfied without increase in cost, morbidity, or mortality. Laparoscopic appendectomy is our procedure of choice in children.

The use of laparoscopy in the management of adnexal pathologies in children

BACKGROUND

The authors' experience of using laparoscopy in the management of 23 girls (mean age: 8.9 years; range: 3 months-15 years) with various adnexal pathologies over a 3-year period is reviewed.

METHODS

Of the 23 patients, seven were evaluated for congenital gonadal pathologies, 15 presented with abdominal pain and one patient had an antenatally diagnosed adnexal mass. Detailed laparoscopic examination of the pelvic cavity and laparoscopic gonadectomy were successfully performed in all seven patients with congenital gonadal pathologies: mosaic Turner's syndrome (n = 2), gonadal dysgenesis (n = 3) and testicular feminization syndrome (n = 2). Of 15 patients presenting with abdominal pain, 11 had an adnexal mass, two had acute appendicitis and two had pelvic inflammatory disease.

RESULTS

Laparoscopic excision of the adnexal masses were successfully performed in 10 of 11 patients. Conversion to open surgery was required in one patient with a huge teratoma. Laparoscopic appendicectomy was successfully performed in both patients with acute appendicitis while diagnostic laparoscopy was the only procedure required in the two patients with pelvic inflammatory disease. Laparoscopy in the infant with an antenatally diagnosed adnexal mass confirmed this to be an omental cyst, which was successfully excised. All patients recovered without complications and good cosmetic result was universally achieved.

CONCLUSION

Laparoscopy is safe and effective in both diagnosis and treatment of adnexal pathologies in children.

The road to ambulatory laparoscopic management of perforated appendicitis

BACKGROUND

This study examines the contribution of increased laparoscopic skills to ambulatory management of perforated appendicitis.

METHODS

All 38 perforated appendicitides from 151 laparoscopic appendectomies done by one surgeon were studied and ambulatory management (discharge less than 24 hours after surgery) of the last 18 perforations reported.

RESULTS

Over 4 years, rate of attempted laparoscopic appendectomy rose from 67% to 100% for perforations. Conversion rate fell from 100% to 22%. Ileus and pain control were not problems for most laparoscopic perforations, so by the end of 1997, experience suggested these patients might be discharged within 24 hours. Ambulatory rate was 57% (conversions excluded). There were no readmissions for wound infections or postoperative abdominal abscesses.

CONCLUSIONS

Increasing laparoscopic skills allows laparoscopic treatment of complicated appendicitis with a low conversion rate and no infectious complications. Over one half of these patients can be managed as outpatients without jeopardy to outcome.