Laparoscopic versus open appendectomy in children: the effect of surgical technique on healthcare costs

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database.

METHODS

We queried the Pediatric Health Information System (PHIS) for patients ages 3-18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 - 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation.

RESULTS

In total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8-14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 - 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 - 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis.

CONCLUSION

SBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method.

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Retrospective Comparative Study.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Controversy in the classification of appendicitis and utilization of postoperative antibiotics

BACKGROUND

There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees.

METHODS

A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression.

RESULTS

In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice.

CONCLUSIONS

Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics.

Laparoscopy is increasingly used for pediatric inguinal hernia repair

INTRODUCTION

Inguinal hernia repairs (IHR) are commonly performed by pediatric surgeons in the United States. The operative approach depends on surgeon preference with no definitive prospective studies comparing laparoscopic inguinal hernia repair (LIHR) versus traditional inguinal hernia repair (TIHR). We aim to assess current practice, hypothesizing that laparoscopy is increasingly used for pediatric IHR.

MATERIAL & METHODS

The Children's Hospital Association (CHA) Pediatric Health Information System was queried for IHRs performed between 01/01/2009 and 12/31/2018. Demographics, procedure type, hernia laterality, and cost were obtained. Patients were grouped by procedure type (laparoscopic/traditional).

RESULTS

125,249 IHRs were performed at 32 CHA hospitals during the ten-year study period. 115,782 (92.4%) were TIHR and 9467 (7.6%) LIHR. Use of laparoscopy increased 5-fold from 3% to 15% over the study period. When comparing laparoscopic to traditional IHR groups, there were more females (28.3% vs 12.6%), African-Americans (19.7% vs 14.4%), government-insured (50% vs 45.2%), younger patients (4.2 vs 4.4 years), bilateral IHRs (11.4% vs 7.9%), and higher adjusted total hospital cost ($3,791 vs $2995) in the laparoscopic group (p<0.0001, all comparisons).

CONCLUSIONS

Laparoscopy for pediatric IHR is increasing at CHA hospitals where nearly 1 in 6 children currently undergoes a laparoscopic repair. The long-term outcomes with laparoscopic repair are worthy of future study.

Advances and Trends in Pediatric Minimally Invasive Surgery

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.

Laparoscopic versus open appendectomy in complicated appendicitis in children: a single center study

Background

Acute complicated appendicitis is a common abdominal emergency in children. Unlike simple appendicitis, laparoscopic appendectomy has not been considered yet the first choice in management of complicated appendicitis. This prospective randomized controlled clinical trial was conducted at Pediatric Surgery Department, Zagazig University Hospitals, Egypt, during the period from December 2018 to August 2019. The aim of the study was to evaluate the role of laparoscopic appendectomy in such cases compared to open appendectomy.

Results

Sixty patients were included in the study, divided randomly into 2 equal groups: laparoscopic and open appendectomy groups. The mean operative time was significantly longer with laparoscopic appendectomy than open appendectomy, 85 vs. 61 min, respectively (p < 0.001**). The time taken to start oral intake was significantly shorter with laparoscopic appendectomy than open appendectomy, 1.9 vs. 2.73 days, respectively (p = 0.025*). The mean hospital stay was significantly lower with laparoscopic appendectomy than open appendectomy, 4.23 vs. 5.13, respectively (p = 0.044*). There were no statistical differences between the two groups regarding wound infection, occurrence of postoperative ileus, intraperitoneal collection, or readmission.

Conclusions

Laparoscopic appendectomy is safe, feasible, and effective procedure in the management of complicated appendicitis in children, with no evidence of any increase in the postoperative complications.

The increasing cost of pediatric otolaryngology care

INTRODUCTION

Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses.

METHODS

A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period.

RESULTS

Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%.

CONCLUSIONS

The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.

Outcomes and Costs of Common Surgical Procedures at Children's and Nonchildren's Hospitals

BACKGROUND

Variations in the management of pediatric patients at children's hospitals (CHs) and non-CHs (NCHs) have been well described, especially within the trauma literature. However, little is known about the outcomes and costs of common general surgical procedures at NCHs. The purpose of this study was to evaluate the effect of CH designation on the outcomes and costs of appendectomy and cholecystectomy.

METHODS

The Kids' Inpatient Database (2003-2012) was queried for patients aged under 18 y who underwent appendectomy or cholecystectomy at CHs and NCHs. Outcomes analyzed included disease severity, complications, laparoscopy, length of stay (LOS), and cost.

RESULTS

Most of appendectomies and cholecystectomies were performed at NCHs. Overall, CHs cared for younger children were more likely to be teaching hospitals, had higher costs, and longer LOS. On multivariate analysis for appendectomies, CHs were associated with higher rates of perforated appendicitis (OR = 1.53, 95% CI = 1.42-1.66, P < 0.001), less complications (OR = 0.68, 95% CI = 0.61-0.75, P < 0.001), increased laparoscopy (OR = 2.93, 95% CI = 2.36-3.64, P < 0.001), longer LOS (RR = 1.13, 95% CI = 1.09-1.17, P < 0.001), and higher costs (exponentiated log $ = 1.19, 95% CI = 1.13-1.24, P < 0.001). Multivariate analysis for cholecystectomies revealed that CHs were associated with less laparoscopy (OR = 0.58, 95% CI = 0.50-0.67, P < 0.001), longer LOS (RR = 1.26, 95% CI = 1.19-1.34, P < 0.001), and higher costs (exponentiated log $ = 1.29, 95% CI = 1.22-1.37, P < 0.001) with similar complications. Independent predictors of LOS and cost included CH designation, negative appendectomy, perforated appendicitis, complications, younger age, black patients, and public insurance.

CONCLUSIONS

Variations in surgical management, outcomes, and costs after appendectomy and cholecystectomy exist between CHs and NCHs. CHs excelled in treating complicated appendicitis. NCHs effectively performed cholecystectomies. These differences in outcomes require further investigation to identify modifiable factors to optimize care across all hospitals for these common surgical diseases.

Occurrence and Treatment of Pediatric Appendicitis in Finland 2004-2014

BACKGROUND

We aimed to investigate the trends in occurrence and the treatment approaches of appendicitis in Finnish children.

MATERIAL AND METHODS

All patients aged <16 y hospitalized for appendicitis in Finland in 2004-2014 were included. Data were retrospectively collected from the Finnish Care Register for Health Care and Statistics Finland.

RESULTS

Altogether 8494 children were hospitalized for appendicitis, with standardized incidence rate of 80.7 (95% confidence interval 79.0-82.0)/100,000 person years. The incidence rate of appendicitis decreased by 3.3% per year during the study period. Appendicitis was more common with increasing age, in boys compared to girls at 8 to 15 y of age, and during the summer compared to the other seasons. Most children (83.2%) were treated with conventional open appendectomy, but laparoscopic appendectomies were slowly increasing during the study period. The length of hospital stay (LOS) was shorter in boys than girls, in those treated laparoscopically, and in those with uncomplicated appendicitis. There was no significant seasonal variation in the LOS. However, the LOS decreased during the study period.

CONCLUSIONS

The incidence of pediatric appendicitis is decreasing, and there is a decreasing trend in LOS. While still relatively rare in the Finnish pediatric surgical centers, the use of laparoscopic appendectomy is increasing.

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.

The necessity of sociodemographic status adjustment in hospital value rankings for perforated appendicitis in children

BACKGROUND

Hospitals are increasingly focused on demonstration of high-value care for common surgical procedures. Although sociodemographic status (SDS) factors have been tied to various surgical outcomes, the impact of SDS factors on hospital value rankings has not been well explored. Our objective was to examine effects of SDS factors on high-value surgical care at the patient level, and to illustrate the importance of SDS adjustment when evaluating hospital-level performance.

METHODS

Perforated appendicitis hospitalizations were identified from the 2012 Kids' Inpatient Database. The primary outcome of interest was high-value care as defined by evaluation of duration of stay and cost. SDS factors included race, health insurance type, median household income, and patient location. The impact of SDS on high-value care was estimated using regression models after accounting for hospital-level variation. Risk-adjusted value rankings were compared before and after adjustment for SDS.

RESULTS

From 9,986 hospitalizations, 998 high-value encounters were identified. African Americans were less likely to experience high-value care compared with white patients after adjusting for all SDS variables. Although private insurance and living in nonmetro counties were associated independently with high-value care, the effects were attenuated in the fully adjusted models. For the 136 hospitals ranked according to risk-adjusted value status, 59 hospitals' rankings improved after adjustment and 53 hospitals' rankings declined.

CONCLUSION

After adjustment for patient and hospital factors, SDS has a small but significant impact on risk-adjusted hospital performance ranking for pediatric appendicitis. Adjustment for SDS should be considered in future comparative performance assessment.