Appendectomy in Pregnancy: Appraisal of the Minimally Invasive Approach

SAGES guidelines for the use of laparoscopy during pregnancy

BACKGROUND

When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD).

METHODS

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient.

RESULTS

The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy.

CONCLUSIONS

Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

Non-obstetric surgery during pregnancy and the effects on maternal and fetal outcomes: A systematic review

BACKGROUND AND OBJECTIVE

Non-obstetric surgery is fairly common in pregnant women. We performed a systematic review to update data on non-obstetric surgery in pregnant women. The aim of this review was to evaluate the effects of non-obstetric surgery during pregnancy on pregnancy, fetal and maternal outcomes.

METHODS

A systematic literature search of MEDLINE and Scopus was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search span was from January 2000 to November 2022. Thirty-six studies matched the inclusion criteria, and 24 publications were identified through reference mining; 60 studies were included in this review. Outcome measures were miscarriage, stillbirth, preterm birth, low birth weight, low Apgar score, and infant and maternal morbidity and mortality rates.

RESULTS

We obtained data for 80,205 women who underwent non-obstetric surgery and data for 16,655,486 women who did not undergo surgery during pregnancy. Prevalence of non-obstetric surgery was between 0.23% and 0.74% (median 0.37%). Appendectomy was the most common procedure with median prevalence of 0.10%. Near half (43%) of the procedures were performed during the second trimester, 32% during the first trimester, and 25% during the third trimester. Half of surgeries were scheduled, and half were emergent. Laparoscopic and open techniques were used equally for abdominal cavity. Women who underwent non-obstetric surgery during pregnancy had increased rate of stillbirth (odds ratio (OR) 2.0) and preterm birth (OR 2.1) compared to women without surgery. Surgery during pregnancy did not increase rate of miscarriage (OR 1.1), low 5 min Apgar scores (OR 1.1), the fetus being small for gestational age (OR 1.1) or congenital anomalies (OR 1.0).

CONCLUSIONS

The prevalence of non-obstetric surgery has decreased during last decades, but still two out of 1000 pregnant women have scheduled surgery during pregnancy. Surgery during pregnancy increases the risk of stillbirth, and preterm birth. For abdominal cavity surgery, both laparoscopic and open approaches are feasible.

Adverse Fetal Outcomes and Maternal Mortality Following Nonobstetric Abdominopelvic Surgery in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

To quantify the absolute risks of adverse fetal outcomes and maternal mortality following nonobstetric abdominopelvic surgery in pregnancy.

SUMMARY BACKGROUND DATA

Surgery is often necessary in pregnancy, but absolute measures of risk required to guide perioperative management are lacking.

METHODS

We systematically searched MEDLINE, EMBASE, and EvidenceBased Medicine Reviews from January 1, 2000, to December 9, 2020, for observational studies and randomized trials of pregnant patients undergoing nonobstetric abdominopelvic surgery. We determined the pooled proportions of fetal loss, preterm birth, and maternal mortality using a generalized linear random/mixed effects model with a logit link.

RESULTS

We identified 114 observational studies (52 [46%] appendectomy, 34 [30%] adnexal, 8 [7%] cholecystectomy, 20 [17%] mixed types) reporting on 67,111 pregnant patients. Overall pooled proportions of fetal loss, preterm birth, and maternal mortality were 2.8% (95% CI 2.2-3.6), 9.7% (95% CI 8.3-11.4), and 0.04% (95% CI 0.02-0.09; 4/10,000), respectively. Rates of fetal loss and preterm birth were higher for pelvic inflammatory conditions (eg, appendectomy, adnexal torsion) than for abdominal or nonurgent conditions (eg, cholecystectomy, adnexal mass). Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%).

CONCLUSIONS

Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.

EAES rapid guideline: systematic review, meta-analysis, GRADE assessment, and evidence-informed European recommendations on appendicitis in pregnancy

BACKGROUND

Clinical practice recommendations for the management of acute appendicitis in pregnancy are lacking.

OBJECTIVE

To develop an evidence-informed, trustworthy guideline on the management of appendicitis in pregnancy. We aimed to address the questions of conservative or surgical management, and laparoscopic or open surgery for acute appendicitis.

METHODS

We performed a systematic review, meta-analysis, and evidence appraisal using the GRADE methodology. A European, multidisciplinary panel of surgeons, obstetricians/gynecologists, a midwife, and 3 patient representatives reached consensus through an evidence-to-decision framework and a Delphi process to formulate the recommendations. The project was developed in an online authoring and publication platform (MAGICapp).

RESULTS

Research evidence was of very low certainty. We recommend operative treatment over conservative management in pregnant patients with complicated appendicitis or appendicolith on imaging studies (strong recommendation). We suggest operative treatment over conservative management in pregnant patients with uncomplicated appendicitis and no appendicolith on imaging studies (weak recommendation). We suggest laparoscopic appendectomy in patients with acute appendicitis until the 20th week of gestation, or when the fundus of the uterus is below the level of the umbilicus; and laparoscopic or open appendectomy in patients with acute appendicitis beyond the 20th week of gestation, or when the fundus of the uterus is above the level of the umbilicus, depending on the preference and expertise of the surgeon.

CONCLUSION

Through a structured, evidence-informed approach, an interdisciplinary panel provides a strong recommendation to perform appendectomy for complicated appendicitis or appendicolith, and laparoscopic or open appendectomy beyond the 20th week, based on the surgeon's preference and expertise.

GUIDELINE REGISTRATION NUMBER

IPGRP-2022CN210.

Laparoscopic versus open appendicectomy in pregnancy: experience from a single institution and meta-analysis

BACKGROUND

Acute appendicitis remains an uncommon cause of non-obstetric abdominal pain during pregnancy, with surgery being the preferred management option. We examined our experience with the surgical management of appendicitis during pregnancy, particularly the risk of foetal loss during the 1st and 2nd trimester and performed a meta-analysis of the available literature.

METHODS

We performed a retrospective analysis of all patients who had an appendicectomy during pregnancy (January 2010 to December 2019) and a meta-analysis comparing foetal death in open appendicectomy versus laparoscopic appendicectomy during the 1st and 2nd trimester.

RESULTS

Seventy pregnant patients were included in our study (57 laparoscopic, 13 open). There were 4 foetal deaths during the study period (7%), all of which occurred after the laparoscopic approach (P-value = 0.578). Open appendicectomies were associated with an increased risk of pre-term delivery (P-value = 0.038). The meta-analysis of 9 studies, which included 311 patients, showed that there was no significant difference between OA and LA in foetal deaths during the 1st and 2nd trimesters (1st trimester foetal deaths: 9/143 laparoscopic versus 4/57 open, M-H risk difference-0.02, 95% CI, -0.14 to 0.10): 2nd trimester foetal deaths: 7/159 laparoscopic versus 2/154 Open, M-H risk difference 0.03, 95% CI, -0.02 to 0.09).

CONCLUSION

Our findings suggest there is no increased risk of foetal loss in pregnant patients undergoing a laparoscopic appendicectomy.

Updated Evaluation of Laparoscopic vs. Open Appendicectomy During Pregnancy: A Systematic Review and Meta-Analysis

To explore the updated evaluation about the obstetrical and perioperative outcomes of laparoscopic appendicectomy (LA) for pregnancy appendicitis compared with open appendicectomy (OA). Two reviewers independently searched the PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science databases to screen eligible studies up to December 2020. Only clinical researches, no < 10 cases for LA and OA group were included. Twenty retrospective studies with 7,248 pregnant women, evaluating LA and OA in surgical and obstetrical outcomes, were included. The weighted mean difference (WMD) with 95% CI and odds ratio (OR) was used to compare continuous and dichotomous variables. It seems LA was connected with significantly shorter hospital time and lower wound infection [mean difference (MD), −0.57 days; 95% CI, −0.96 to −0.18; p = 0.004 and OR, 0.34; 95% CI, 0.18 to 0.62; p = 0.0005, respectively]. The incidence of fetal loss after LA was higher than OA (OR,1.93; 95% CI, 1.39–2.69; p < 0.0001). It was almost similar in the rate of preterm delivery (OR, 0.80; 95% CI, 0.48 to 1.34; p = 0.40) and other perioperative and obstetrical complications (p > 0.05). Our results indicated that the occurrence of fetal loss after LA should not be ignored. Caution, skillful operation, and thoroughly informed consent about the advantages and disadvantages of laparoscopy are necessary.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42021233150.

Laparoscopic Versus Open Appendectomy for Appendicitis in Pregnancy: Systematic Review and Meta-Analysis

OBJECTIVES

The clinical safety, efficacy and feasibility of laparoscopic appendectomy (LA) compared with open appendectomy (OA) in pregnancy are still controversial. Herein, we are aiming to compare the clinical outcomes of LA and OA in patients with acute appendicitis during their pregnancy.

MATERIALS AND METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and OA in pregnancy identifying using PubMed, Web of science, Embase, The Cochrane Library, Ovid and Scopus. Two independent reviewers extracted data on surgical complication, fetal loss, preterm delivery, hospital stay, Apgar score in both groups.

RESULTS

Twenty-seven studies with total of 6497 patients (4464 in open and 2031 in laparoscopic group) were included. LA was associated with lower rate of wound infection [odds risk (OR)=3.13, 95% confidence interval (CI): 1.77-5.56, P<0.0001] overall complications (OR=2.15, 95% CI: 1.47-3.14, P<0.0001) and shorter hospitalization (mean difference=0.72, 95% CI: 0.43-1.02, P<0.00001) compared with open group. LA was in a lower risk for 5-minute Apgar score (mean difference=0.09, 95% CI: 0.02-0.17, P=0.01) group than open group. No difference was found regarding preterm delivery between 2 groups. LA was associated with higher fetal loss (OR=0.57, 95% CI: 0.41-0.79, P=0.0007) compared with open surgery. However, laparoscopy was not associated with increased fetal loss after 2010 (OR=0.74, 95% CI: 0.44-1.24, P=0.26) compared with open group.

CONCLUSIONS

LA in pregnancy seems to be feasible with acceptable outcome, especially in patients with early and mid-trimester period, with sophisticated hands and experienced centers.

An Atypical Case of a Common Pregnancy Issue: Appendicitis-Like Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is a severe subtype of nausea and vomiting in pregnancy (NVP) that typically affects women in their first trimester of pregnancy. Because HG is a diagnosis of exclusion, a thorough work-up ruling out organic causes must be performed. Herein, we describe a case of a pregnant woman with HG who presented with intractable pain mimicking appendicitis. While her clinical picture and ultrasound findings were only mildly consistent with appendicitis, the only therapy that provided pain relief was empiric antibiotic treatment that was prescribed due to a mildly elevated procalcitonin of 0.61. Thereby, the detection and treatment of concurrent organic causes is important as it may provide significant symptomatic relief in cases of concurrent HG.

Validation of a cost-effective appendicectomy model for surgical training

BACKGROUND

Appendicitis is a commonly occurring condition worldwide. The gold standard treatment is appendicectomy. Although training models are commercially available for this procedure, they are often associated with high cost. Here we present a cost-effective model.

AIM

To establish construct validity of a cost-effective laparoscopic appendicectomy simulation model.

METHODS

Three groups of surgeons were recruited; novices (n = 31), of intermediate expertise (n = 13) and experts (n = 5) and asked to perform a simulated laparoscopic appendicectomy using the new model. Their performance was assessed by a faculty member and compared between the three groups using a validated scoring system (Global Operative Assessment of Laparoscopic Skills [GOALS] score).

RESULTS

One-way ANOVA test showed a significant difference in task performance between groups (p < 0.0001). Post-hoc comparisons after the application of Bonferroni correction (statistically significant p value <0.017) demonstrate a significant difference in performance between all groups for all GOALS categories as well as the total score. Effect size calculations showed that experience level had moderate (Eta-squared >0.5 and <0.8) and significant (>0.8) impact on the performance of the simulated procedure.

CONCLUSION

The model described in this study is cost-effective, valid and can adequately simulate appendicectomy. The authors recommend inclusion of this model to postgraduate surgical training.

Is the laparoscopic approach a safe choice for the management of acute appendicitis in pregnant women? A meta-analysis of observational studies

INTRODUCTION

Acute appendicitis is a common and serious situation during pregnancy, because of the increased risk of fetal loss and perforation in the third trimester, as well as a diagnostic difficulty. During recent years laparoscopic approach has been introduced to clinical practice with encouraging results. The purpose of this meta-analysis is to compare the surgical and obstetrical outcomes between laparoscopic and open appendectomy during pregnancy.

MATERIALS AND METHODS

MEDLINE, SCOPUS, Clinicaltrials.gov, CENTRAL and Google Scholar were searched for studies reporting on postoperative outcomes between laparoscopic and open appendectomy during pregnancy. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when high heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented.

RESULTS

Twenty-one studies that enrolled 6276 pregnant women are included in the present meta-analysis. Of these women, 1963 underwent laparoscopic appendectomy and 4313 underwent an open appendectomy. Women who underwent laparoscopic appendectomy demonstrated an increase in fetal loss risk, while neonates of women that underwent open appendectomy presented decreased Apgar score at five minutes after birth. All the rest outcomes were similar between the two groups. The time that each study took place seemed to affect the comparison of birth weight and postoperative hospital stay between the two groups.

CONCLUSION

Laparoscopic appendectomy seems to be a relatively safe therapeutic option in pregnancy when it is indicated. Thus, it should be implemented in clinical practice, always considering the experience of the surgeon in such procedures. Nevertheless, the need of new studies to enhance this statement remains crucial.

Safety of laparoscopic appendicectomy during pregnancy: a systematic review and meta-analysis

BACKGROUND

Acute appendicitis is the most common non-obstetric surgical presentation during pregnancy. There were concerns that laparoscopic appendicectomy increases the risk of foetal loss compared to an open approach. Therefore, with recent advances in perioperative care, it is likely the risk has changed. Here, we performed an updated meta-analysis assessing the safety of laparoscopic appendicectomy in pregnant women.

METHODS

A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was undertaken between 2000 and 2017 on Ovid Medline and Embase. The primary outcome measures were foetal loss and preterm delivery, whereas secondary outcome measures were operative time and hospital length of stay. A random-effect model was performed to pool odds ratio (OR) and standardized mean difference (SMD).

RESULTS

Seventeen observational studies were included, with 1886 patients in the laparoscopic and 4261 patients in the open group. Comparing laparoscopic versus open appendicectomy, there were 54 (5.96%) and 136 (3.73%) foetal losses, respectively. However, preterm delivery was much higher in the open approach (8.99%) compared to laparoscopic approach (2.84%). Pooled OR for foetal loss was 1.84 (95% confidence interval (CI) 1.31-2.58, P < 0.001), whereas OR for preterm delivery was 0.39 (95% CI 0.27-0.55, P < 0.001). There was no significant difference between both approaches for operative time (SMD -0.07; 95% CI -0.43 to 0.30, P = 0.71) or hospital length of stay (SMD -0.34; 95% CI -0.83 to 0.16, P = 0.18).

CONCLUSION

In a pooled analysis of level III evidence, laparoscopic appendicectomy posed a higher risk of foetal loss but lower risk of preterm delivery. Caution and informed consent are crucial when offering a laparoscopic approach.

Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis

OBJECTIVES

Acute appendicitis is the most prevalent cause of non-obstetrical surgical disease during pregnancy. There is no consensus on the optimal surgical management of acute appendicitis in pregnancy. Our aim is to identify surgical and obstetrical outcomes of laparoscopic (LA) and open approach (OA) in pregnant patients with acute appendicitis.

STUDY DESIGN

Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases were searched for articles published up to May 2017, along with the references of all articles. Prospective and retrospective trials reporting outcomes among pregnant women undergoing laparoscopic and open appendectomy were included. Of the 493 records screened, 20 were eligible for meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Statistical meta-analysis was performed using the RevMan 5.3 software.

RESULTS

A total of 6210 pregnant women from twenty studies were included in meta-analysis. Laparoscopic appendectomy was associated with significantly lower overall complication rates and shorter hospital stays (1835 patients OR 0.48 95% CI 0.29, 0.80 p = 0.005). While the open appendectomy group showed prolongation of gestational age for term deliveries, laparoscopic appendectomy patients had higher rates of fetal loss (543 patients MD -0.46 weeks 95% CI-0.87 to -0.04, p = 0.03 and 4867 patients OR 1.82 95% CI 1.30 to 2.57, p = 0.0006, respectively).

CONCLUSIONS

Current literature remains inconclusive on the optimal approach of appendectomy in pregnant women. Further larger-volume studies are needed in order to elucidate the critical effect of laparoscopic appendectomy on fetal loss rates.