Efficacy of emergency laparoscopic appendectomy in treating complicated appendicitis for elderly patients

Laparoscopic and robotic surgery for colorectal cancer in older patients: a systematic review and meta-analysis

INTRODUCTION

As life expectancy has been increasing, older patients are becoming more central to the healthcare system, leading to more intensive care use and longer hospital stays. Nevertheless, advancements in minimally invasive surgical techniques offer safe and effective options for older patients with colorectal diseases. This study aims to provide comprehensive evidence on the role of minimally invasive surgery in treating colorectal diseases in older patients.

MATERIAL AND METHODS

All articles directly compared the minimally invasive approach with open surgery in patients aged ≥65 years. The present metanalysis took 30-day complications as primary outcomes. Length of hospital stay, readmission, and 30-day mortality were also assessed, as secondary outcomes. Further subgroup analyses were carried out based on surgery setting, lesion features, and location.

RESULTS

After searching the main databases, 84 articles were included. Evaluation of 30-day complications rate, length of hospital stay, and 30-day mortality significantly favored minimally invasive approaches. The outcome readmission did not show any significant difference.

CONCLUSIONS

The current metanalysis demonstrates clear advantages of minimally invasive techniques over open surgery in colorectal procedures for older patients, particularly in reducing complications, mortality, and hospitalization. This suggests that prioritizing these techniques, based on available expertise and facilities, could improve outcomes and quality of care for older patients undergoing colorectal surgery.

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Intra and Postoperative Advantages of Laparoscopy in the Treatment of Complicated Appendicitis

Aim: To determine and define the advantages of the laparoscopic appendectomy in the treatment of complicated appendicitis by comparing it with the open appendectomy. Material and Methods: In this prospective interventional clinical study we compared the intraoperative data and the postoperative outcome of 77 patients presented with complicated appendicitis, operated with open and laparoscopic appendectomy within a period of 20 months. One surgeon performed all of the laparoscopic procedures and two other senior surgeons performed the open procedures. Results: Operative time was shorter in the laparoscopic group (p = 0.033). Conversion rate was 2.3%. Overall postoperative morbidity was 25.97%. There was one operative revision due to postoperative small bowel obstruction in the laparoscopic group. Appendicular stump leakage occurred in one patient in the open group. One intra-abdominal abscess occurred in the laparoscopic group (p = 0.38). Wound infection occurred only in the open group (p = 0.018). Length of stay was shorter in the laparoscopic group (p = 0.0052). One patient from the laparoscopic group was readmitted. Conclusions: Laparoscopy is a reliable method in the treatment of complicated appendicitis. It offers a shorter operative time, low conversion rate, an acceptable rate of major postoperative complications and a shorter length of stay.

Development and Validation of a Clinical Prediction Model for Complicated Appendicitis in the Elderly

Background

For elderly patients with mild clinical symptoms of uncomplicated appendicitis(UA), non-surgical treatment has been shown to be feasible, whereas emergency surgical treatment is recommended in elderly patients with complicated appendicitis(CA), but it is still challenging to accurately distinguish CA and UA before treatment. This study aimed to develop a predictive model to assist clinicians to quickly determine the type of acute appendicitis.

Methods

We retrospectively studied the clinical data of elderly patients with acute appendicitis who visited the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine from January 2012 to January 2022. The patients were divided into UA group and CA group, and the general conditions, medical history, physical examination, laboratory examination and imaging examination were compared between the two groups, and SPSS 26.0 and R 4.0.2 software were used to establish CA clinic. Predict the model, and validate it internally.

Results

The clinical data of 441 elderly patients with acute appendicitis were collected, 119 patients were excluded due to incomplete clinical data or other diseases. Finally, 332 patients were included in the study and divided into UA group (n = 229) and CA group (n = 103). By analyzing the clinical data of the two groups of patients, the duration of abdominal pain [OR = 1.094, 95% CI (1.056–1.134)], peritonitis [OR = 8.486, 95% CI (2.017–35.703))] and total bilirubin [OR = 1.987, 95% CI (1.627–2.426)] were independent predictors of CA (all p < 0.01). The model's Area Under Curve(AUC) = 0.985 (95% CI, 0.975–0.994). After internal verification by Bootstrap method, the model still has high discriminative ability (AUC = 0.983), and its predicted CA curve is still in good agreement with the actual clinical CA curve.

Conclusion

We found that a clinical prediction model based on abdominal pain duration, peritonitis, and total bilirubin can help clinicians quickly and effectively identify UA or CA before treatment of acute appendicitis in the elderly, so as to make more scientific clinical decisions.

Diffuse Appendicular Peritonitis: Laparoscopic vs Open Access — Viewpoint From Aside

The perforative acute appendicitis with the development of diffuse peritonitis increases the incidence of postoperative complications to 47%, and mortality to 3%. Mortality in the case of the development of diffuse purulent peritonitis makes 4.5-58%, and it can exceed 70% in severe forms of diffuse peritonitis with the development of infectious-toxic shock and multiple organ failure. National Clinical Guidelines for acute appendicitis with diffuse peritonitis allow for appendectomy from both the median and laparoscopic access in the absence of general contraindications to the creation of pneumoperitoneum. However, despite the proven advantages of laparoscopic appendectomy, there are opponents of its use in diffuse forms of appendicular peritonitis. An increased number of postoperative abscesses with a minimally invasive approach has been reported in literature; however, recent randomized studies refute this fact. There is also evidence that the laparoscopic method for appendicular peritonitis often leads to a lengthening of the operation time and higher operating costs, but at the same time there is a decrease in postoperative pain syndrome, a reduction in the length of inpatient treatment and early social and labor rehabilitation, which leads to an overall decrease in hospital costs. Thus, to date, there is no generally accepted opinion about the advisability of laparoscopic access for appendicular peritonitis. At the moment, the presence of diffuse peritonitis is the most common intraoperative reason for refusing a minimally invasive surgical treatment. However, there is a tendency to trying to standardize indications and contraindications, which was the objective of our literature review.

[Safety and efficacy of laparoscopic approach for widespread appendicular peritonitis]

OBJECTIVE

To analyze treatment outcomes in patients with acute appendicitis complicated by widespread peritonitis.

MATERIAL AND METHODS

The study included 165 patients acute appendicitis complicated by widespread peritonitis. Inclusion criteria: acute appendicitis complicated by widespread peritonitis MIP grade 1-2 in reactive or toxic phase (grading system by Simonyan K.S.), abdominal cavity index ≤16. Exclusion criteria: MIP grade 3, terminal phase, abdominal cavity index ≥17.

RESULTS

Analysis of postoperative data revealed no correlation between surgical approach and incidence of postoperative intra-abdominal abscesses and infiltrates. In the main group, intra-abdominal abscesses occurred in 4.9% of patients (n=5), infiltrates - 12.8% (n=13). In the control group, these parameters were 4.6% (n=2) and 18.2% (n=8), respectively. We have developed and introduced into clinical practice a differentiated approach to surgical treatment of widespread appendicular peritonitis based on laparoscopic data. Abdominal cavity was intraoperatively assessed. The proposed method included 5 criteria with establishment of appropriate points (min 3, max 14). In case of total score 3-8, laparoscopic approach was preferred. Overall score 9-11 required laparoscopic surgery with subsequent elective repeated laparoscopy, ≥12 scores - intraoperative conversion and open surgery. Thus, subject to the rules of surgical intervention, the number of intra-abdominal complications between laparoscopic and open methods is equalized.

CONCLUSION

The developed differentiated surgical strategy for patients with appendicular peritonitis is effective and reduces the incidence of wound infection, extra-abdominal complications, and hospital-stay, as well as contributes to early rehabilitation of patients.

EAES rapid guideline: appendicitis in the elderly

BACKGROUND

There is a lack of trustworthy evidence-informed guidelines on the diagnosis and management of acute appendicitis in elderly patients.

METHODS

We developed a rapid guideline in accordance with GRADE and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of three general surgeons, an intensive care physician, a geriatrician and a patient advocate. We conducted systematic reviews and the results of evidence synthesis were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus.

RESULTS

This rapid guideline provides a weak recommendation against the use of clinical scoring systems to replace cross-sectional imaging in the diagnostic approach of suspected appendicitis in elderly patients. It provides a weak recommendation against the use of antibiotics alone over surgical treatment in patients who are deemed fit for surgery, and a weak recommendation for laparoscopic over open surgery. Furthermore, it provides a summary of surgery-associated risks in elderly patients. The guidelines, with recommendations, evidence summaries and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494 .

CONCLUSIONS

This rapid guideline provides evidence-informed trustworthy recommendations on the diagnosis and management of acute appendicitis in elderly patients.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative assessment of complicated appendicitis through stress reaction and clinical manifestations

This study assessed the severity of the disease through the preoperative clinical manifestations and inflammatory reaction indicators of acute appendicitis, and established a score table to predict complicated appendicitis (CA).The clinical data of 238 patients with acute appendicitis in our hospital were retrospectively analyzed, which included 18 patients with acute simple appendicitis (7.6%), 170 patients with acute purulent appendicitis (72.0%), and 48 patients with acute gangrene and perforation (20.3%). The clinical manifestations and inflammatory reaction indicators were analyzed by univariate logistic regression. Multivariate logistic regression analysis was performed to screen out the independent risk factors of CA. The β coefficients of independent risk factors entering the multivariate model were assigned by rounding, and the total score was the sum of values of all factors. Finally, verification and analysis were performed for the predictive model, and the operating characteristic curve (ROC) curve was drawn. Then, the area under the curve (AUC) was compared with the THRIVE scale, and the Hosmer-Lemeshow method was used to evaluate whether the model fitted well.The multivariate logistic regression analysis of independent risk factors was performed, and the values were rounded to the variable assignment based on the β coefficient values. The plotted ROC and AUC was calculated as 0.857 (P < .001). Using the Hosmer-Lemeshow method, the X-value was 12.430, suggesting that the prediction model fitted well.The scoring system can quickly determine whether this is a CA, allowing for an earlier and correct diagnosis and treatment. Furthermore, the scoring system was convenient, economical, and affordable. Moreover, it is easy to popularized and promote.

Laparoscopy versus open appendectomy for elderly patients, a meta-analysis and systematic review

BACKGROUND

Appendicitis in elderly patients is associated with increased risk of postoperative complications. The choice between laparoscopy and open appendectomy remains controversial in treating elderly patients with appendicitis.

METHODS

Comprehensive search of literature of MEDLINE, Embase, Cochrane Library and ClinicalTrials was done in January 2019. Studies compared laparoscopy and open appendectomy for elderly patients with appendicitis were screened and selected. Postoperative mortality, complications, wound infection, intra-abdominal abscess and operating time, length of hospital stay were extracted and analyzed. The Review Manage 5.3 was used for data analysis.

RESULTS

Twelve studies with 126,237 patients in laparoscopy group and 213,201 patients in open group. Postoperative mortality was significantly lower following laparoscopy (OR, 0.33; 95% CI, 0.28 to 0.39). Postoperative complication and wound infection were reduced following laparoscopy ((OR, 0.65 95% CI, 0.62 to 0.67; OR,0.27, 95% CI, 0.22 to 0.32). Intra-abdominal abscess was similar between LA and OA (OR,0.44;95% CI, 0.19 to 1.03). Duration of surgery was longer following laparoscopy and length of hospital stay was shorter following laparoscopy (MD, 7.25, 95% CI, 3.13 to 11.36; MD,-2.72, 95% CI,-3.31 to - 2.13).

CONCLUSIONS

Not only laparoscopy is safe and feasible, but also it is related with decreased rates of mortality, post-operative morbidity and shorter hospitalization.