Intraabdominal abscess rate after laparoscopic appendectomy

Intrahepatic abscess secondary to retained stercolith, following laparoscopic appendectomy

Abscesses of the peritoneal cavity and in particular hepatic abscess due to stercolith retention are a rare complication of appendectomy. Their prevalence is likely to increase as laparoscopic appendectomies become more common. This potentially serious complication can be prevented by following certain technical recommendations. Percutaneous drainage is bound to failure since it leaves the coprolite that causes the recurrence of the abscess, thus when it happens it requires surgical drainage. We report a case of a 40-year-old man, who underwent laparoscopic appendectomy 8 months prior, and presented to the emergency department for acute pain of the right hypochondrium. The radiologic investigations revealed 2 abscesses of the liver and the right iliac fossa containing a central spontaneously hyperdense stercolith. The patient was treated with open surgery removing the stercoliths and draining of the abscesses, with favorable postoperative outcome.

Comparison of intra-abdominal abscess formation after laparoscopic and open appendectomy for complicated and uncomplicated appendicitis: a retrospective study

INTRODUCTION

Acute appendicitis (AA) is one of the most common causes of acute abdominal pain seen in emergency departments and appendectomy has been the preferred treatment of this disease for decades. Postoperative intra-abdominal abscess (PIAA) complicates 3% to 25% of appendectomies and the risk is highest following complicated appendicitis. However, the risk for intra-abdominal abscess formation after appendectomy is still a matter of debate.

AIM

To evaluate PIAA formation after open appendectomy (OA) and laparoscopic appendectomy (LA), in particular in complicated appendicitis.

MATERIAL AND METHODS

From January 2003 to December 2018, records of patients who underwent appendectomy with diagnosis of appendicitis were retrieved from a computer database for analysis.

RESULTS

During the study period, 1809 appendectomies were performed in our institution (939 LAs and 850 OAs). Twenty conversion cases were recorded. There was no difference between the incidences of PIAA (LA, 3.73% (35/939) and OA, 3.41% (29/850); p > 0.05). The incidence of PIAA in those with complicated appendicitis was: LA, 11/212 (5.19%) vs. OA 14/198 (7.07%); p > 0.05.

CONCLUSIONS

This retrospective study shows that the technique of appendectomy does not appear to affect the incidence of IAAs either in uncomplicated or in complicated appendicitis. However, laparoscopic appendectomy has the advantages of laparoscopic procedures, such as lower hospital stay and earlier return to activities, and should therefore be preferred for acute appendicitis.

Correlation of clinical data and the Alvarado's Score as predictors of acute appendicitis

Objective To correlate the patient's clinical data and the Alvarado's Score as predictors of acute appendicitis.

Methods This is an observational, descriptive and prospective study performed at a public urgency and emergency hospital in the city of Fortaleza, Ceará, between July and December 2016, with 34 patients undergoing open appendectomy with ages between 18 and 70 years. Statistical analysis was performed using the SPSS program.

Results The following statistical correlations were performed: number of days with abdominal pain until the operative event and degree of inflammation according to a macroscopic analysis of the appendix, Alvarado's Score and number of days with abdominal pain until the operative event, Alvarado's Score and degree of inflammation according to a macroscopic analysis of the appendix, number of days with abdominal pain until the operative event, and number of days of hospitalization in the postoperative period, degree of inflammation according to amacroscopic analysis of the appendix, number of days of hospitalization in the postoperative period and Alvarado's Score, and number of days of hospitalization in the postoperative period; the first five correlations were statistically significant (p < 0.05).

Conclusion The use of this Alvarado's Score in health services emerges as a tool for the diagnosis of acute appendicitis.

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.

Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients

Importance

Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.

Objective

To compare the outcomes of nonoperatively managed appendicitis against appendectomy.

Design, Setting, and Participants

This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.

Exposures

Appendectomy (control arm) or nonoperative management (treatment arm).

Main Outcomes and Measures

Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.

Results

Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P < .001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P < .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P < .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P = .003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.

Conclusions and Relevance

According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.

Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy

BACKGROUND

Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA.

METHODS

A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017.

RESULTS

During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1 days vs. 10.1 and 9.0 days, p = <0.003). The mean time for resolution of SIRS was significantly shorter (2.0 days vs. 3.3 and 5.2 days, p <0.02). The morbidity and length of stay were similar.

CONCLUSION

Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.

A clinical comparison of laparoscopic versus open appendectomy for the treatment of complicated appendicitis: historical cohort study

Background

Appendectomy is one of the most common operations. Laparoscopic appendectomy (LA) is considered first-line treatment, but the use of LA for treatment of complicated appendicitis remains controversial. Here, we performed a retrospective analysis to compare clinical outcomes between patients treated with LA and those who underwent open appendectomy (OA).

Methods

Data for 179 patients who underwent an operation for the treatment of complicated appendicitis at our hospital between 2011 and 2017 were retrospectively analyzed. The selection included 89 patients who underwent a conventional appendectomy and 90 patients who were treated laparoscopically. Outcome measures such as mean operative time, blood loss, time until oral intake duration of hospital stay, and postoperative complications were analyzed. Logistic regression analysis was performed to determine the concurrent effects of the examined factors on the rate of postoperative complications.

Results

The mean ages of patients in the OA and LA groups were 50.17 ± 22.77 and 50.13 ± 25.84 year. Mean operative times were longer in the LA group than OA (10.2.56 ± 44.4 versus 85.4 ± 43.11 min; p = 0.009). The duration of hospital stay was shorter for the LA group (9.61 ± 5.57 versus 12.19 ± 8.4; p = 0.016). There were no significant differences in return to consumption of oral intake between the LA and OA groups (2.03 ± 1.66 versus 2.48 ± 2.17; p = 0.123). Multivariable analysis found that the rate of postoperative complications was significantly reduced for the LA group, in comparison with the postoperative-complication rate of the OA group (16.7% versus 27%; odds ratio 0.376; 95% CI 0.153–0.923; p = 0.0327).

Conclusions

These results suggest that LA is a safe and efficient operative procedure that provides clinically beneficial advantages in comparison with OA. Thus, when possible, appendectomy for complicated appendicitis should be attempted using a laparoscopic approach.

Trial registration

Retrospectively registered.

Trends in the Use of Laparoscopic Versus Open Paediatric Appendicectomy: A Regional 12-Year Study and a National Survey

BACKGROUND

In adult patients, it is generally accepted that laparoscopic appendicectomy (LA) is the predominant operative pathway in treating acute appendicitis. The case for a similar pathway utilising LA in children is less clear. We investigate usage, trends and complications after LA in children in a single co-located adult/paediatric centre with contemporaneous adults as controls.

METHODS

A retrospective case-control study was conducted over 12 years including patients who underwent appendicectomy, and the paediatric series (<16 years) was divided into age-groups-based quartiles. An anonymous questionnaire-based national survey was circulated among general and paediatric surgeons.

RESULTS

Of the 5784 appendicectomy patients, 2960 were children. LA rate in paediatric appendicitis was 65%. Yearly trends in LA reached a steady state in both groups after 2010 (Δ 0-1%/year). Rates of LA and LA IAA (respectively) differed significantly between age groups: 60, 3% (0-9 years); 65, 1% (10-13 years); 71, 2% (14-16 years) and 93, 3% (>16 years) (p = 0.001, 0.02). The national survey showed respondents believed LA was not superior to OA in paediatric patients except in terms of cosmesis. There was strong support in the use of LA in older children and children >40 kg.

CONCLUSION

The use of LA in paediatric appendicectomies in the study region is similar to international rates, but not increasing over time. Irish surgeons still favour OA in younger children and prefer a case-by-case approach rather LA being the preferred pathway. This is despite the regional and international evidence showing favourable outcomes with LA in children.

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 Appendectomy: A Report on 1164 Operations at a Single-Institution, Safety-Net Hospital

Laparoscopic appendectomy (LA) is the standard of care for the treatment of acute appendicitis. There is an ongoing debate regarding the optimal management of appendicitis, which led us to study outcomes after an appendectomy at a large safety-net hospital. We hypothesize that despite a high-risk population, LA remains a safe and effective treatment for acute appendicitis. A retrospective review was performed of all patients who underwent an appendectomy from 2011 to 2013. The primary end point was significant morbidity defined as a score of three or greater on the Clavien-Dindo scale of surgical morbidity. Thousand hundred and sixty-four patients underwent an appendectomy. A total of 1102 (94.7%) patients underwent either an LA or laparoscopic converted to open appendectomy, and 62 (5.3%) patients underwent an open appendectomy (OA). Two hundred and forty six patients (21.1%) had complicated appendicitis. Laparoscopic converted to OA conversion rate was 4.4 per cent and differed between years (P < 0.001). LA had a significantly shorter length of stay, shorter length of postoperative antibiotics, and less postoperative morbidity. When limited to only patients with complicated appendicitis, major morbidity was still greater in the OA group (22.6 vs 52.0%, P = 0.001). Length of stay was significantly longer in the OA group [3.42 (2.01, 5.97) vs 7.04 (5.05, 10.13), P < 0.001]. Odds for complication were 2.6 times greater in the OA group compared with the LA group. In the absence of peritonitis and systemic illness necessitating urgent laparotomy, patients who are laparoscopic surgical candidates should be offered an LA. Our study demonstrates that these patients have better outcomes and shorter hospital stays.

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.

Does Conversion Adversely Impact the Clinical Outcomes for Patients with Complicated Appendicitis?

BACKGROUND

Although the feasibility of laparoscopic appendectomy (LA) in complicated appendicitis (CA) has been demonstrated, LA is typically underused in CA due to its high conversion rate. However, little is known regarding the clinical course of conversion in CA.

MATERIALS AND METHODS

Between January 2005 and April 2012, 1699 patients older than 16 years underwent an appendectomy at our institution. Of these, 207 were confirmed to have CA, which was defined as operative findings of gangrenous or perforated appendix, with or without abscess formation. Patients were divided into the following three groups: open group (OG), laparoscopy group (LG), and converted group (CG). Perioperative outcomes were compared between the three groups.

RESULTS

Thirty-eight patients underwent open surgery. Among the 169 patients for whom laparoscopic surgery was originally attempted, 20 (11.8%) were converted. Operation time was significantly longer and estimated blood loss was higher in the CG than in the other groups. Fewer overall complications were observed and the length of hospital stay (LOH) was shorter in the LG than in the OG and CG. However, no significant differences were observed between the OG and CG regarding the overall complication rate or LOH. Operation method was the only factor associated with postoperative morbidity in multivariate analysis.

CONCLUSION

While completion by laparoscopy was associated with better outcomes than the other two procedures at all levels, open conversion did not increase the overall morbidity or LOH compared with open appendectomy. Laparoscopic approach could be a viable option even in the management of CA.

Analysis of Recurrence Management in Patients Who Underwent Nonsurgical Treatment for Acute Appendicitis

The recurrence rate for acute appendicitis treated nonoperatively varies between studies. Few studies have adequately evaluated the management of these patients when appendicitis recurs. We aimed to explore the recurrence rate and management of patients with acute appendicitis that were first treated nonoperatively.We identified patients in the Taiwan National Health Insurance Research Database who were hospitalized due to acute appendicitis for the first time between 2000 and 2010 and received nonsurgical treatment. The recurrence and its management were recorded. Data were analyzed to access the risk factors for recurrence and factors that influenced the management of recurrent appendicitis.Among the 239,821 patients hospitalized with acute appendicitis for the first time, 12,235 (5.1%) patients were managed nonoperatively. Of these, 864 (7.1%) had a recurrence during a median follow-up of 6.5 years. Appendectomy was performed by an open and laparoscopic approach in 483 (55.9%) and 258 (29.9%) patients, respectively. The remaining 123 (14.2%) patients were again treated nonsurgically. Recurrence was independently associated with young age, male sex, percutaneous abscess drainage, and medical center admission by multivariable analysis. In addition, age <18, a (CCI) <2, medical center admission, and a longer time to recurrence were correlated with using laparoscopy to treat recurrence. Neither type of appendicitis, percutaneous abscess drainage, nor length of first time hospital stay had an influence on the selection of surgical approach.In conclusion, a laparoscopic appendectomy can be performed in recurrent appendicitis cases, and its application may not be related to previous appendicitis severity.

Conventional single-port laparoscopic appendectomy for complicated appendicitis in children: Efficient and cost-effective

BACKGROUND:

Laparoscopic appendectomy (LA) is gradually gaining popularity among paediatric surgeons for complicated appendicitis. A retrospective study was conducted to compare conventional single port LA, multiport LA and open appendectomy (OA) for complicated appendicitis in children.

PATIENTS AND METHODS:

From January 1995 from December 2014, 1,408 patients (604 girls, 804 boys) underwent surgery for uncomplicated and complicated appendicitis. The patient characteristics, operation times, duration of hospitalization, operative costs, and postoperative complications were recorded. A 10-mm 0^° scope with a parallel eye piece and an integrated 6 mm working channel were inserted through an 11-mm “conventional umbilical port” for single port LA.

RESULTS:

A total of 314 patients with complicated appendicitis (128 girls, 186 boys) underwent appendectomy. Among these, 102 patients (32.4%) underwent single port LA, 17 patients (5.4%) underwent multiport LA and 195 patients (62.1%) underwent OA. The hospital stay of the single port LA group was significantly less (3.88 ± 1.1) compared with multiport LA (5.41 ± 1.2) and OA groups (6.14 ± 1.1) (P < 0.001). Drain usage, wound infection and adhesive intestinal obstruction rates were significantly high in the OA group. There was no significant difference between the groups in postoperative intraabdominal abscess formation. Single-port LA performed for complicated appendicitis was cheaper compared with the other groups.

CONCLUSIONS:

The present study has shown that single-port LA for complicated appendicitis can be conducted in a reasonable operative time; it shortens the hospitalization period, markedly reduces postoperative wound infection and adhesive intestinal obstruction rates and does not increase the operative cost.

Laparoscopic Appendectomy in Children: Preliminary Study in Pediatric Hospital Albert Royer, Dakar

Appendiceal pathology's management has benefited in recent years from the advent of laparoscopic surgery. This study is to make a preliminary assessment of laparoscopic management of acute and complicated appendicitis in children after a few months of practice at the University Hospital Albert Royer, Dakar. This is a retrospective study of 22 cases of patients, all operated on by the same surgeon. The parameters studied were age, sex, clinical data and laboratory features, radiological data, and results of surgical treatment. The mean age of patients was 9.5 years with a male predominance. The series includes 14 cases of acute appendicitis and 8 complicated cases. Appendectomy anterograde is practiced in 81% of cases. Appendectomy was associated with peritoneal wash in 17 patients including 9 cases of acute appendicitis. Drainage of Douglas pouch is performed in 2 patients with complicated appendicitis; the average production was 300 cc of turbid liquids and any complications were not founded. An abscess of Douglas pouch is noted in 2 patients with complicated appendicitis undrained. These Douglas abscesses were treated medically. No conversion of laparotomy was performed in the series. After an average of 8 months no other problems were noted.

Prospective evaluation of the Sunshine Appendicitis Grading System score

BACKGROUND

Although there is a wealth of information predicting risk of post-operative intra-abdominal collection and guiding antibiotic therapy following appendicectomy, confusion remains because of lack of consensus on the clinical severity and definition of 'complicated' appendicitis. This study aimed to develop a standardized intra-operative grading system: Sunshine Appendicitis Grading System (SAGS) for acute appendicitis that correlates independently with the risk of intra-abdominal collections.

METHODS

Two-hundred and forty-six patients undergoing emergency laparoscopy for suspected appendicitis were prospectively scored according to the severity of appendicitis and followed up for complications including intra-abdominal collection. After termination of the study, the SAGS score was repeated by an independent surgeon based on operation notes and intra-operative photography to determine inter-rater agreement. The primary outcome measure was incidence of intra-abdominal collection, secondary outcome measures were all complications and length of stay.

RESULTS

SAGS score demonstrated good inter-rater agreement (kappa K_w 0.869; 95% CI 0.796-0.941; P < 0.001). A risk ratio of 2.594 (95% CI 0.655-4.065; P < 0.001) for intra-abdominal collection was found using SAGS score as a predictor. The discriminative ability of SAGS score was supported by an area under the curve value of 0.850 (95% CI 0.799-0.892; P < 0.001).

CONCLUSIONS

SAGS score can be used to simply and accurately classify the severity of appendicitis and to independently predict the risk of intra-abdominal collection. It can therefore be used to stratify risk, guide antibiotic therapy, follow-up and standardize the definitions of appendicitis severity for future research.

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.

Lessons learned with laparoscopic management of complicated grades of acute appendicitis

Background

Laparoscopy has not been consolidated as the approach of first choice in the management of complicated appendicitis. Methodological flaws and absence of disease stratification criteria have been implicated in that less evidence. The objective is to study the safe and effectiveness of laparoscopy in the management of complicated appendicitis according to laparoscopic grading system.

Method

From January 2008 to January 2011, 154 consecutive patients who underwent a laparoscopic appendectomy for complicated appendicitis were evaluated in the prospective way. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 58.3% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix and were graded as 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis) and 5 (diffuse peritonitis). The outcomes including operative time, infection complication, operative complications and conversion rate were chosen to evaluate the procedure.

Results

The grade 3A was the most frequent with 50 (32.4%) patients. The mean operative time was 69.4 ± 26.3 minutes. The grade 4A showed the highest mean operative time (80.1 ± 26.7 minutes). The wound and intra-abdominal infection rates were 2.6 and 4.6%, respectively. The base necrosis was the most important factor associated with the conversion (5.2%). The grades 4A and 5 were associated with greater possibility of intra-abdominal collection. There were no operative complications.

Conclusion

The laparoscopic management of all complicated grades of acute appendicitis is safe and effective and should be the procedure of first choice. The laparoscopic grading system allows us to assess patients in the same disease stage.

Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital

BACKGROUND

Laparoscopic appendectomy is not yet unanimously considered the "gold standard" in the treatment of acute appendicitis because of its higher operative time, intra-abdominal abscess risk, and costs compared to open appendectomy. This study aimed to compare outcomes and cost of laparoscopic and open appendectomy in a district hospital.

METHODS

A retrospective analysis of 230 patients who underwent appendectomy at the Division of General Surgery of the Civil Hospital of Ragusa, Italy, from May 2008 to May 2012 was performed. The variables analyzed included patients data (age, gender, previous abdominal surgery, preoperative WBC count, duration of symptoms, ASA risk score), rate of uncomplicated or complicated appendicitis, operative time, postoperative complications, length of hospital stay, and total costs. The patients were divided in two groups according to the surgical approach and compared for each variable. The results were analyzed using the t Student test for quantitative variables, and the Chi-square test with Yates correction and Fisher exact test for categorical.

RESULTS

Laparoscopic appendectomy was performed in 139 patients, open appendectomy in 91. Two cases (1.4%) were converted to open procedure and included in the laparoscopic group data. Patient data and rate of complicated appendicitis were similar in the two study groups. There was no statistical difference (p = 0.476) in the mean operative time between the laparoscopic (52.2 min; range, 20-155) and open appendectomy (49.3 min; range, 20-110) groups. The overall incidence of minor and major complications was significantly lower (p = 0.006) after laparoscopic appendectomy (2.9%, 4 cases) than after open appendectomy (13.2%, 12 cases); rate of intra-abdominal abscess were similar. The length of hospital stay was significantly shorter (p = 0.001) in laparoscopic group (2.75 days; range, 1-8) than in open group (3.87 days; range, 1-19). The mean total cost was 2282 Euro in laparoscopic group and 2337 Euro in open group, with a no significant difference of 55 Euro (p = 0.812).

CONCLUSION

Laparoscopic appendectomy is associated with fewer complications, shorter hospital stay, and similar operative time, intra-abdominal abscess rate, and total costs, compared with open appendectomy. Therefore, laparoscopic appendectomy can be recommended as preferred approach in acute appendicitis.

Appendiceal stump closure by metal endoclip in the management of complicated acute appendicitis

Background

Closure of appendicular stump has been performed in different ways; however, the use of the metal endoclip in complicated grades of acute appendicitis, has not been evaluated yet in a prospective way.

Objective

To establish the effectiveness of appendiceal stump closure by metal endoclip for complicated appendicitis.

Method

From January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix, which may lead to abscess formation and degrees of peritonitis. The outcomes viability, operative time, infection complication, operative complications, and conversion rate were chosen to evaluate the procedure.

Results

The appendiceal stump closure by metal endoclip was used in 90% of cases. The presence of appendix base necrosis was the most important factor involved in failure of the procedure. Laparoscopic knot (1.5%), laparoscopic endo-suture (3.8%) and video assisted laparotomy (4.7%) were the alternatives used in difficult cases. The mean operative time was (67.54 ± 28.13 minutes). The wound and intra-abdominal infection rates were 2.54% and 5.08%, respectively. There were no operative complications and the conversion rate was 0.85%.

Conclusion

The appendiceal stump closure by metal endoclip, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with appendix base necrosis it should be avoided in favor of other alternatives.

Inter-rater concordance of wound classifications in patients undergoing appendectomy

BACKGROUND

Despite the widespread utilization of a four-stage wound classification system to risk-adjust operations for surgical site infection (SSI) rates, we are not aware of any study evaluating the definitions of the wound classes for clarity. We limited our study of wound classifications to appendectomies and posed the question whether different reviewers classify individual cases differently.

METHODS

We evaluated the wound classifications of 105 consecutive appendectomies in our community hospital. Four reviewers graded retrospectively the wound classifications, first after reading the description of the appendix in the operative report and again after reading the pathology report. The wound classifications of the four reviewers were evaluated for concordance with the original operating room nurse (ORN) assignment.

RESULTS

The kappa scores for inter-observer concordance of wound classifications among the four reviewers based on their interpretation of the operative report and the ORN who originally classified the operation ranged from 0.1028 to 0.1597. By conventional standards, this represents no better than "slight agreement" for any of the reviewers. We found that 19%, 50%, 94%, 95%, or 96% of our appendectomies would be considered "high risk," Class 3 or 4, operations depending on which rater classified the operation. The additional information contained in the pathology reports did not change the distribution of wound classifications of the four reviewers significantly.

CONCLUSIONS

Our study demonstrated considerable differences in the distribution of wound classifications of appendectomies among our ORNs and retrospective reviewers. A review of the surgical literature supports our finding that the incision classification system utilized commonly lacks precision, at least in the rating of appendectomies. We recommend that further studies be performed to determine whether changes in the definitions of wound classes are warranted.

Intra-abdominal collections following laparoscopic versus open appendicectomy: an experience of 516 consecutive cases at a district general hospital

BACKGROUND

The objective of this study is to evaluate the incidence of intra-abdominal collections (IACs) in all patients undergoing laparoscopic (LA) and open appendicectomy (OA) from April 2009 to October 2011 in a district general hospital with expertise in minimally invasive surgery (MIS).

METHODS

A retrospective review of all patients undergoing appendicectomy in the specified time period was carried out. IACs were identified from various in-hospital data resources. Severity of appendicitis was assessed from histology reports.

RESULTS

516 patients were identified, of whom 242 (47 %) underwent OA and 274 (53 %) LA. Twenty-six (5 %) patients were found to have IACs postoperatively. Fifteen (5.5 %) IACs were identified in the laparoscopic group and 11 (4.5 %) in the open group. There was no statistically significant difference in the risk of developing IACs in open versus laparoscopic groups [odds ratio (OR) 1.22, confidence interval (CI) 0.55-2.70, P = 0.63]. Patients were twelve times more likely to develop IACs with an appendix identified as being necrotic or perforated on histology (OR 12.24, CI 5.29-28.32, P < 0.0001). There was a trend towards shorter total hospital stay in the LA (3.58 days, CI 3.0-4.1 days) compared with OA (4.31 days, CI 3.7-4.9 days, P = 0.082) group, although this was not statistically significant.

CONCLUSIONS

Increased rates of IAC following LA have been identified in some studies. Our series shows that, in a centre with adequate MIS experience, the IAC rate following LA is comparable to that of the open approach and should not deter surgeons with adequate support and resources.

Does laparoscopic appendectomy impart an advantage over open appendectomy in elderly patients?

BACKGROUND

The use of laparoscopy in the elderly has been increasing in recent years. The data comparing laparoscopic (LA) with open appendectomy (OA) in elderly patients are minimal. We evaluated outcomes of LA versus OA in perforated and nonperforated appendicitis in elderly patients (aged ≥ 65 years).

METHODS

Using the Nationwide Inpatient Sample database, clinical data of elderly patients who underwent LA and OA for suspected acute appendicitis were evaluated from 2006 to 2008.

RESULTS

A total of 65,464 elderly patients underwent urgent appendectomy during this period. The rate of perforated appendicitis was twice as high in elderly patients (50 vs. 25%, p < 0.01) and rate of LA in elderly patients was lower (52 vs. 63%, p < 0.01) compared with patients younger than aged 65 years. Utilization of LA increased 24% from 46.5% in 2006 to 57.8% in 2008 (p < 0.01). In elderly patients with acute nonperforated appendicitis, LA had lower overall complication rate (15.82 vs. 23.49%, p < 0.01), in-hospital mortality (0.39 vs. 1.31%, p < 0.01), hospital charges ($30,414 vs. $34,095, p < 0.01), and mean length of stay (3.0 vs. 4.8 days, p < 0.01) compared with OA. Additionally, in perforated appendicitis in elderly patients, LA was associated with lower overall complication rate (36.27 vs. 46.92%, p < 0.01), in-hospital mortality (1.4 vs. 2.63%, p < 0.01), mean hospital charges ($43,339 vs. $57,943, p < 0.01), and shorter mean LOS (5.8 vs. 8.7 days, p < 0.01).

CONCLUSIONS

Laparoscopic appendectomy can be performed safely with significant advantages compared with open appendectomy in the elderly and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.

Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children

BACKGROUND

Appendectomy is one of the most common emergency operations performed in the pediatric population. The aim of this pooled analysis is to compare the outcome from complicated appendicitis (CA) and uncomplicated appendicitis (UA) following laparoscopic appendectomy (LA) and open appendectomy (OA) in children.

METHODS

A systematic literature search was performed. Primary outcome measures were incidence of complications, intra-abdominal abscess, and wound infection. Secondary outcomes were length of operation, length of hospital stay, incidence of bowel obstruction, and readmission.

RESULTS

Seventy-three thousand one hundred fifty appendectomies for UA and 34,474 appendectomies for CA were included. For UA, the only significant difference between the groups was a reduced length of hospital stay following LA. LA in CA was associated with reduced complications (pooled odds ratio [POR] = 0.53; P < 0.05), wound infections (POR = 0.42; P < 0.05), length of hospital stay (WMD = -0.67; P < 0.05), and bowel obstruction episodes (POR = 0.8; P < 0.05), but an increased incidence of intra-abdominal abscess and length of operation.

CONCLUSION

Pooled analysis demonstrates that, in children with uncomplicated acute appendicitis, LA is associated with a reduced hospital stay but broad equivalence in postoperative morbidity when compared with the conventional approach. Although overall morbidity is reduced when the laparoscopic approach is utilized, in cases of CA, the risk of intra-abdominal abscess is increased.

[Laparoscopic apendicectomy vs open approach for the treatment of acute appendicitis]

BACKGROUND

There is no international consensus on the approach of choice for performing appendectomy.

AIMS

To analyze and compare open and laparoscopic approaches in the surgical treatment of acute appendicitis.

MATERIAL AND METHODS

A retrospective study was carried out on patients over 14-years-old operated on for suspected acute appendicitis between January 2007 and December 2009. Variables were: age, sex, body mass index, specialized surgeon or resident in training, progression duration, conversion rate, use of drains, abdominal cavity irrigation, macroscopic appearance of the appendix, onset time of anesthesia, ASA classification, postoperative hospital stay, resumption of intake of liquids, and complications. The patients were divided into two groups: laparoscopic approach (LA) and open approach (OA).

RESULTS

A total of 533 patients were enrolled (290 LA and 243 OA). Onset time of anesthesia was 75 min (30-190 min) in LA vs 55 min (20-160 min) in OA (p<0,0001).

COMPLICATIONS

intraabdominal abscesses in 17 LA cases vs 13 OA cases (p=0,79); surgical wound alterations in 16 LA cases vs 47 OA cases (p=0,0001); incisional hernias in 2 LA cases (1%) vs 10 OA cases (p=0,008). There were no statistically significant differences in postoperative hospital stay (3 days), resumption of intake of liquids (1 day) or readmission rate (8%).

CONCLUSIONS

There are fewer surgical wound alterations and incisional hernias with the laparoscopic approach, but there is higher cost, lengthier surgery duration, and a longer learning curve. Our results cannot provide a clear indication for one approach or the other, and therefore each case must be evaluated on an individual basis.

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.

Patient and surgeon factors are associated with the use of laparoscopy in appendicitis

AIM

The use of a minimally invasive approach to treat appendicitis has yet to be universally accepted. The objective of this study was to examine recent trends in Ireland in the surgical management of acute appendicitis.

METHOD

Data were obtained from the Irish Hospital In-Patient Enquiry system for patients discharged with a diagnosis of appendicitis between 1999 and 2007. An anonymous postal survey was sent to all general surgeons of consultant and registrar level in Ireland to assess current attitudes to the use of laparoscopic appendectomy.

RESULTS

The use of laparoscopic appendectomy increased throughout the study and was the most common approach for appendectomy in 2007. Multivariate analysis revealed age under 50 years (OR = 1.51), female sex (OR = 2.84) and residence in high-density population areas (OR = 4.15) as predictive factors for undergoing laparoscopic appendectomy in the most recent year of the study. While 97% of surgeons reported current use of laparoscopy in patients with acute right iliac fossa pain, in most cases it was selective. Surgeons in university teaching hospitals (42 of 77; 55%) were more likely to report using laparoscopic appendectomy for all cases of appendicitis than those in regional (six of 23; 26%) or general (13 of 53; 25%) hospitals (P = 0.048).

CONCLUSION

This study has demonstrated a significant increase in laparoscopic appendectomy, yet a variety of patient and surgeon factors contribute to the choice of procedure. Differences in the perception of benefit of the laparoscopic approach amongst surgeons appears to be an important factor in determining the operative approach for appendectomy.

A Clinical Comparison of Laparoscopic versus Open Appendectomy for Complicated Appendicitis

Purpose

Although laparoscopic appendectomies (LAs) are performed universally, a controversy still exists whether the LA is an appropriate surgical approach to complicated appendicitis (CA). We retrospectively evaluated the outcomes of laparoscopic versus open appendectomies for CA.

Methods

We retrospectively analyzed 60 consecutive patients who were diagnosed as having CA from July 2009 to January 2011. Outcomes such as operative time, time to soft diet, length of hospital stay, and postoperative complications were analyzed.

Results

There were no statistically significant differences in operative time between the LA and the open appendectomy (OA) groups. Return to soft diet was faster in the LA group (2.1 ± 1.2 vs. 3.5 ± 1.5 days; P = 0.001). Length of hospital stay was shorter for the LA group (4.4 ± 2.3 vs. 5.8 ± 2.9 days; P = 0.045). The overall complication rates showed no statistically significant difference between the two groups. In cases involving a periappendiceal abscess, the LA had a significantly higher incidence of intra-abdominal abscess (IAA) and postoperative ileus (PI; P = 0.028).

Conclusion

The LA showed good results in terms of the time to soft diet, the length of hospital stay, and surgical site infection (SSI) whereas the overall complication rates were similar for the two groups. However, the LA was associated with significantly higher incidence of IAA and PI for the cases with a periappendiceal abscess. Therefore, when using a LA, the surgeon must take great care to minimize the incidence of IAA and PI if a periappendiceal abscess is present.

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.

Incidence of postoperative intraabdominal abscesses in open versus laparoscopic appendectomies

BACKGROUND

Risk for intraabdominal abscess (IAA) after laparoscopic appendectomy (LA) remains controversial. A 2008 Cochrane Review suggests almost a threefold increase in the incidence of IAA after LA compared with open appendectomy (OA).

METHODS

The authors conducted a retrospective chart review of all appendicitis patients 18 years and older undergoing appendectomy from 1996 to 2007 at one military treatment facility and one civilian hospital in Hawaii. Data collection included demographics, procedure, presence of complicated appendicitis (defined as perforated or gangrenous appendicitis at surgical or pathologic assessment), and presence of postoperative IAA on computed axial tomography (CAT) scan.

RESULTS

The review identified 2,464 patients with appendicitis. A total of 1,924 LAs (78%) and 540 OAs (22%) were performed. The comparison of laparoscopic and open appendectomies showed no significant differences in the number of postoperative abscesses (2.2% vs 1.9%; p = 0.74). The patients with a diagnosis of complicated appendicitis were significantly associated with a higher incidence of postoperative abscess formation (67% vs 25%; p < 0.01), which had an unadjusted odds ratio of 6.1 (95% confidence interval [CI], 3.4-11.0; p < 0.01). No significant difference in the development of abscess in patients with complicated appendicitis could be found between LA and OA (5.9% vs 4.1%; p = 0.44).

CONCLUSIONS

No significant difference in the occurrence of IAA after LA versus OA was found. The patients with complicated appendicitis experienced a greater number of IAA than the patients with uncomplicated appendicitis.

Laparoscopic versus conventional appendectomy--a meta-analysis of randomized controlled trials

Background

Although laparoscopic surgery has been available for a long time and laparoscopic cholecystectomy has been performed universally, it is still not clear whether open appendectomy (OA) or laparoscopic appendectomy (LA) is the most appropriate surgical approach to acute appendicitis. The purpose of this work is to compare the therapeutic effects and safety of laparoscopic and conventional "open" appendectomy by means of a meta-analysis.

Methods

A meta-analysis was performed of all randomized controlled trials published in English that compared LA and OA in adults and children between 1990 and 2009. Calculations were made of the effect sizes of: operating time, postoperative length of hospital stay, postoperative pain, return to normal activity, resumption of diet, complications rates, and conversion to open surgery. The effect sizes were then pooled by a fixed or random-effects model.

Results

Forty-four randomized controlled trials with 5292 patients were included in the meta-analysis. Operating time was 12.35 min longer for LA (95% CI: 7.99 to 16.72, p < 0.00001). Hospital stay after LA was 0.60 days shorter (95% CI: -0.85 to -0.36, p < 0.00001). Patients returned to their normal activity 4.52 days earlier after LA (95% CI: -5.95 to -3.10, p < 0.00001), and resumed their diet 0.34 days earlier(95% CI: -0.46 to -0.21, p < 0.00001). Pain after LA on the first postoperative day was significantly less (p = 0.008). The overall conversion rate from LA to OA was 9.51%. With regard to the rate of complications, wound infection after LA was definitely reduced (OR = 0.45, 95% CI: 0.34 to 0.59, p < 0.00001), while postoperative ileus was not significantly reduced(OR = 0.91, 95% CI: 0.57 to 1.47, p = 0.71). However, intra-abdominal abscess (IAA), intraoperative bleeding and urinary tract infection (UIT) after LA, occurred slightly more frequently(OR = 1.56, 95% CI: 1.01 to 2.43, p = 0.05; OR = 1.56, 95% CI: 0.54 to 4.48, p = 0.41; OR = 1.76, 95% CI: 0.58 to 5.29, p = 0.32).

Conclusion

LA provides considerable benefits over OA, including a shorter length of hospital stay, less postoperative pain, earlier postoperative recovery, and a lower complication rate. Furthermore, over the study period it was obvious that there had been a trend toward fewer differences in operating time for the two procedures. Although LA was associated with a slight increase in the incidence of IAA, intraoperative bleeding and UIT, it is a safe procedure. It may be that the widespread use of LA is due to its better therapeutic effect.

Conservative management of post-appendicectomy intra-abdominal abscesses

PURPOSE

Appendicitis is the most common abdominal inflammatory process in children which were sometimes followed by complications including intra-abdominal abscess. This later needs classically a surgical drainage. We evaluated the efficacy of antibiotic treatment and surgical drainage.

METHODS

Hospital records of children treated in our unit for intra-abdominal post appendectomy abscesses over a 6 years period were reviewed retrospectively.

RESULTS

This study investigates a series of 14 children from 2 to 13 years of age with one or many abscesses after appendectomy, treated between 2002 and 2007. Seven underwent surgery and the others were treated with triple antibiotherapy. The two groups were comparable. For the 7 patients who receive medical treatment alone, it was considered efficient in 6 cases (85%) with clinical, biological and radiological recovery of the abscess. There was one failure (14%). The duration of hospitalization from the day of diagnosis of intra-abdominal abscess was approximately 10.28 days (range 7 to 14 days). In the other group, the efficacy of treatment was considered satisfactory in all cases. The duration of hospitalization was about 13 days (range: 9 to 20).

CONCLUSION

Compared to surgical drainage, antibiotic management of intra-abdominal abscesses was a no invasive treatment with shorter hospitalization.

The laparoscopic approach for perforated appendicitis, including cases complicated by abscess formation

BACKGROUND

Although the laparoscopic approach for perforated appendicitis is commonly performed, there is some controversy over its use because of postoperative complications. These may be associated with various types of disease entities, from gangrenous change to diffuse peritonitis with abscess formation. The aim of the present study was to evaluate the safety and benefits of the laparoscopic approach for perforated appendicitis, including cases complicated by abscess, compared to open.

MATERIALS AND METHODS

A total of 1747 patients underwent treatment for appendicitis over a period of 3 years. The diagnosis of perforated appendicitis was made by radiology, operative finding, and pathology. Of our five attending surgeons, three performed open surgery for perforated appendicitis, while two performed laparoscopy.

RESULTS

There were 474 patients (27%) with perforated appendicitis without abscess (156 underwent laparoscopy, 318 underwent open) and 113 patients (6.4%) with perforated appendicitis and abscess (44 underwent laparoscopy, 69 underwent open). The duration for resumption of diet and hospital stay was shorter in the laparoscopy group than in the open group. There were no significant differences in postoperative complications between patients who had no abscess with laparoscopy and those with open: 5 intra-abdominal abscesses and 10 wound infections versus 11 intra-abdominal abscesses and 25 wound infections (P = 0.88, 0.12), and between patients who had abscesses with laparoscopy and those with open: 4 intra-abdominal abscesses and 3 wound infections versus 6 intra-abdominal abscesses and 6 wound infections (P = 0.94, 0.72).

CONCLUSIONS

The laparoscopic approach may be a safe, effective treatment for perforated appendicitis, even in the presence of an abscess.

Perforated appendicitis: is early laparoscopic appendectomy appropriate?

BACKGROUND

Laparoscopic appendectomy for nonperforated appendicitis is associated with improved outcomes; however, laparoscopy has been challenged for perforated appendicitis owing to higher morbidity compared with open or staged procedures. The purpose of this study was to determine whether the laparoscopic approach for perforated appendicitis results in improved outcomes compared with open appendectomy.

METHODS

Postoperative patient records for confirmed perforated appendicitis from 2005 to 2008 were reviewed retrospectively. Demographics, surgical approach, conversion rate, and outcomes were tabulated, including length of stay (LOS), intra-abdominal and wound infections, and duration of antibiotic therapy.

RESULTS

The incidence of perforation was 27.9% in 885 total patients. The conversion rate from laparoscopic to open for perforated appendicitis was 16%. Hospital LOS was significantly lower in the laparoscopic group (P < .05). The incidence of postoperative abscess was not significantly different; however, the incidence of wound infection and duration of antibiotic therapy were significantly lower in the laparoscopic group (P < .05).

CONCLUSION

Successful laparoscopic appendectomy reduces LOS, antibiotic therapy, and wound infections compared with open appendectomy in perforated appendicitis without increasing the incidence of postoperative abscess. We conclude that perforated appendicitis can be managed effectively by laparoscopic appendectomy in a high percentage of patients with improved outcomes compared with open appendectomy.

Laparoscopic appendectomy for complicated appendicitis: a comparison with open appendectomy

BACKGROUND

Although laparoscopic appendectomy (LA) is widely performed in many countries, LA for complicated appendicitis, which includes perforated or gangrenous appendicitis with or without localized or disseminated peritonitis, has not become a common practice yet.

METHODS

We retrospectively analyzed the clinical records of 230 patients who had undergone appendectomy for complicated appendicitis: 141 had undergone LA, 84 had conventional open appendectomy (OA), and 5 patients had conversion to the open procedure after laparoscopy. The LA group (total LA) was subdivided into "early experience (early LA: cases 1-56)" and "late experience (late LA: case 57 and higher)." We defined the early LA group as the comparison group to minimize selection bias.

RESULTS

Patient demographics were similar in the early LA and OA groups (P > 0.05). Wound infection was significantly more frequent in the OA group (P < 0.05). Intra-abdominal infection was equally common in these two groups. The overall rate of postoperative complications was significantly higher in the OA group (32.1%) than in the early LA group (18%; P < 0.05). This incidence was 12.8% in the total LA group. Hospital stay was significantly shorter in the early LA group (10.6 +/- 3.9 days; P < 0.05), and 8.9 +/- 3.7 days in the total LA group.

CONCLUSIONS

Our findings indicate that LA is safe and useful even for the treatment of complicated appendicitis if performed by an experienced surgeon.

[Complicated acute apendicitis. Open versus laparoscopic surgery]

INTRODUCTION

Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis, especially if it is complicated due reports on the increase in intra-abdominal abscesses.

OBJECTIVE

The purpose of this study was to evaluate the morbidity in a group of patients diagnosed with complicated apendicitis (gangrenous or perforated) who had undergone open or laparoscopic appendectomy.

MATERIAL AND METHOD

We prospectively studied 107 patients who had undergone appendectomy for complicated appendicitis over a two year period. Mean operation time, mean hospital stay and morbidity, such as wound infection and intra-abdominal abscess were evaluated.

RESULTS

In the group with gangrenous appendicitis morbidity was significantly lower in laparoscopic appendectomy group (p = 0.014). Wound infection was significantly higher in the open appendectomy group (p = 0.041), and there were no significant differences in intra-abdominal abscesses (p = 0.471). In the perforated appendicitis group overall morbidity (p = 0.046) and wound infection (p = 0.004) was significantly higher in the open appendectomy group. There were no significant differences in intra-abdominal abscesses (p = 0.612).

CONCLUSION

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

Efetividade e segurança da apendicectomia videoassistida em porta única transumbilical em adolescentes e adultos

OBJETIVO: Aplicar o método apendicectomia videoassistida em porta única transumbilical (AVATU) e avaliar a sua efetividade e a sua segurança. MÉTODO: A AVATU visa combinar os benefícios do acesso laparoscópico com a segurança e simplicidade da remoção do apêndice pela técnica convencional. Analisou-se, retrospectivamente, 300 adolescentes e adultos, com diagnóstico pressuposto de apendicite aguda, nos quais indicou-se a AVATU como abordagem inicial, entre junho de 2001 e junho de 2006. A exeqüibilidade do procedimento no tratamento da apendicite aguda em todos os seus estágios de evolução, tempo operatório e a necessidade de conversão para apendicectomia convencional ou laparoscópica, foram os parâmetros utilizados para avaliação da efetividade do método. A segurança foi avaliada pela incidência de complicações transoperatórias, pós-operatórias e mortalidade. RESULTADOS: Houve necessidade de conversão para a via convencional ou laparoscópica em 9% dos casos. As principais causas de conversão foram aderências inflamatórias locais densas e apendicite aguda nas suas formas mais avançadas. A incidência de complicações pós-operatórias foi de 6,6%, incluindo 1,3% de abscesso intra-abdominal e 2,0% de infecção de sítio cirúrgico. Não ocorreram óbitos. O resultado histopatológico confirmou 11,7% de apendicite em estágio avançado. CONCLUSÃO: A AVATU mostrou-se exeqüível, efetiva e segura. Os resultados deste estudo e os atrativos da técnica, podem avalizar a recomendação do método na abordagem inicial de pacientes adolescentes e adultos, com suspeita de apendicite aguda.

Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective

OBJECTIVE

Open appendicectomy is the traditional standard treatment for appendicitis. Laparoscopic appendicectomy is perceived as a procedure with greater potential for complications and longer operative times. This paper examines the hypothesis that unsupervised laparoscopic appendicectomy by surgical trainees is a safe and time-effective valid alternative.

METHODS

Medical records, operating theatre records and histopathology reports of all patients undergoing laparoscopic and open appendicectomy over a 15-month period in two hospitals within an area health service were retrospectively reviewed. Data were analysed to compare patient features, pathology findings, operative times, complications, readmissions and mortality between laparoscopic and open groups and between unsupervised surgical trainee operators versus consultant surgeon operators.

RESULTS

A total of 143 laparoscopic and 222 open appendicectomies were reviewed. Unsupervised trainees performed 64% of the laparoscopic appendicectomies and 55% of the open appendicectomies. There were no significant differences in complication rates, readmissions, mortality and length of stay between laparoscopic and open appendicectomy groups or between trainee and consultant surgeon operators. Conversion rates (laparoscopic to open approach) were similar for trainees and consultants. Unsupervised senior surgical trainees did not take significantly longer to perform laparoscopic appendicectomy when compared to unsupervised trainee-performed open appendicectomy.

CONCLUSION

Unsupervised laparoscopic appendicectomy by surgical trainees is safe and time-effective.

Complicated Appendicitis–Is the Laparoscopic Approach Appropriate? A Comparative Study with the Open Approach: Outcome in a Community Hospital Setting

Good outcome has been reported with the laparoscopic approach in uncomplicated appendicitis, but a higher incidence of postoperative intraabdominal abscesses has been reported after laparoscopic appendectomy in complicated appendicitis. This retrospective comparative study compares outcome after laparoscopic (LA) and open appendectomy (OA) in complicated appendicitis. All patients who had LA or OA for complicated appendicitis between January 2003 and February 2006 were included in the study. Data collection included demographics, operative time, estimated blood loss, length of stay (LOS), complications, readmission, and reoperative rates. The primary end points for analysis were postoperative intraabdominal abscess and complication rates and secondary end points were LOS and operative time. All data were analyzed on an intent-to-treat basis. Of 104 patients, 43 patients underwent LA and 61 had OA. The mean age (24.8 ± 16.5 versus 31.3 ± 18.9, P = 0.08) in the LA group was lower than the OA group because there was a significantly higher proportion of pediatric patients (34.8% versus 14.8%, P = 0.02) who had LA. There was no significant difference in gender (female/male, 14/29 versus 27/34, P = 0.3) or American Society of Anesthesiologists class distribution (American Society of Anesthesiologists 1/2/3/4/, 35/7/1/0 versus 45/12/3/1, P = 0.68) between the two groups. The operative time (100.5 ± 36.2 versus 81.5 ± 29.5 minutes, P = 0.03) was significantly longer and the estimated blood loss (21 mL versus 33 mL, P = 0.01) was lower in LA when compared with OA, but there was no significant difference in the number of patients with preoperative peritonitis versus abscesses (7/36 versus 13/48, P = 0.6) in both groups. There was no difference in the median LOS (6 [interquartile range 5–9] versus 6 [interquartile range 4–8], P = 0.7) in the two groups. The conversion rate in LA was 18.6% (n = 8). There was also no significant difference in the complication (17/43 [39.5%] versus 21/61 [34.4%], P = 0.54), reoperative (3/43 [7%] versus 0/61 [0%], P = 0.07), and 30-day readmission (5/41 [11.6%] versus 3/61 [4.9%], P = 0.23) rates between the two groups. The rate of postoperative intraabdominal abscesses was significantly higher in the LA group when compared with the OA group (6/43 [14%] versus 0/61 [0%], P = 0.04) and the wound infection (1/43 [2.3%] versus 5/61 [8.2%], P = 0.4) and pulmonary complication (0/43 [0%] versus 3/61 [4.9%], P = 0.26) rate was higher in the OA group. There was no mortality in the LA group, but there was one mortality in the OA group resulting from postoperative myocardial infarction. Laparoscopic appendectomy can be performed in patients with complicated appendicitis with a comparative operative time, LOS, and complication rates but results in a significantly higher intraabdominal abscess rate and lower wound infection rate when compared with OA.

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.

Securing the appendiceal stump with the Gea extracorporeal sliding knot during laparoscopic appendectomy is safe and economical

BACKGROUND

Laparoscopic appendectomy (LA) has become very popular. One criticism of this approach is the high cost of the disposable equipment such as the linear stapler. An alternative would be suture ligation of the appendiceal base. To prove the safety of the Gea extracorporeal sliding knot (GESK) for closure of the stump after LA, a retrospective study was conducted.

METHODS

For this study, 63 LA procedures performed by one surgeon using the Gea knot (group A) were reviewed and compared with 63 LA procedures performed by two other surgeons (group B) using the linear stapler. The GESK is created with 0-prolene in the manner already described. The main variable was the presence or absence of blowout, leak, or fistula from the appendiceal stump. The secondary variables were abdominal abscess, wound infection, and need for readmission or reoperation. The results were analyzed using the appropriate statistical methods.

RESULTS

Both groups were similar in terms of age, gender, and pathologic diagnosis. No patient in group A or B experienced a colonic fistula, stump blowout, or leak. In group A, one patient experienced interloop abscesses. There were two wound infections. In group B, one patient experienced a wound infection, and another patient had a wound dehiscence of the umbilical port, which required reoperation. No statistical differences were noted between the two groups.

CONCLUSIONS

There are surgeons who routinely use sutures to secure the stump of the appendectomy. This study aimed to demonstrate that the GESK is as secure as the stapler for closure of the appendiceal stump. The GESK could be passed through a 5-mm trocar, potentially avoiding complications of a larger trocar site. The GESK seems to be an economic and safe alternative to the stapler.