Value of diagnostic laparoscopy in fertile women with suspected appendicitis

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.

OBJECTIVES

To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.

Should the macroscopically normal appendix be removed during laparoscopy for acute right iliac fossa pain when no other explanatory pathology is found?

BACKGROUND

Acute appendicitis remains the most common surgical emergency and although diagnosis should be made on clinical grounds, sometimes this can be difficult. Laparoscopy has gained increasing favour as a method of both investigating right iliac fossa pain and treating the finding of appendicitis. The aim of this study was to determine the accuracy of intraoperative diagnosis of appendicitis.

PATIENTS AND METHODS

Records of all patients who underwent laparoscopy for possible appendicitis at the Norfolk and Norwich University Hospital over a 1-year period were reviewed. Notes of those patients who underwent an open appendicectomy were also reviewed for comparison. Intraoperative findings were recorded, as were the subsequent pathologic findings.

RESULTS

Over the 1-year period from September 2005 to September 2006, 355 operations for suspected appendicitis were performed. In 277 (78%) cases, these were performed laparoscopically. Seventy-three out of 78 open appendectomies were confirmed as appendicitis. Only 1 of these was not macroscopically evident to the surgeon. The appendix was removed in 259 of the 277 laparoscopic procedures. Correct intraoperative diagnosis was made in 217 (84%) of removed appendices, 12 (29%) of the appendices thought to be macroscopically normal and removed were found to be appendicitis after histologic examination. Eighteen patients undergoing the laparoscopic procedure had their appendix left in situ due to normal appearance; none had represented at 6 months postsurgery.

CONCLUSIONS

Laparoscopy may aid in the diagnosis of acute right iliac fossa pain. However, intraoperative diagnosis is not easy with almost one-third of apparently normal appendices being inflamed histologically. We would therefore advocate the removal of a normal looking appendix in the absence of other explanatory pathology.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.

SEARCH STRATEGY

We searched the Cochrane Library, MEDLINE, EMBASE, LILACS, CNKI, SciSearch, study registries, and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis.

MAIN RESULTS

We included 67 studies, of which 56 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.43; CI 0.34 to 0.54), but the incidence of intraabdominal abscesses was increased (OR 1.87; CI 1.19 to 2.93). The duration of surgery was 10 minutes (CI 6 to 15) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (CI 5 to 11 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.7 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Seven studies on children were included, but the results do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01).

AUTHORS' CONCLUSIONS

In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.

Routine use of laparoscopy in patients with clinically doubtful diagnosis of appendicitis

BACKGROUND

Therapeutic and diagnostic laparoscopy, a minimal invasive technique, has been used effectively and frequently for appendicitis by surgeons. There is still controversy about whether this technique should be applied to all patients or in the setting of a doubt of the diagnosis of appendicitis, especially for women. Based on these controversies, the aim of this study was to assess the safety and efficacy of diagnostic and therapeutic laparoscopy for patients with suspected peritonitis imitating acute appendicitis.

PATIENTS AND METHODS

Between May 2002 and September 2006, a consecutive series of 74 patients operated on for suspected acute lower quadrant peritonitis were studied retrospectively. Despite being unclear, the preoperative diagnoses were thought to be suspected peritonitis imitating acute appendicitis. Therefore, patients all had diagnostic and therapeutic laparoscopy.

RESULTS

Seventy-four patients included in this study were successfully operated on by laparoscopy. Thirty-five of these patients were diagnosed with appendicitis and had an appendectomy by laparoscopy. Six of the 35 patients were converted to a conventional open appendectomy because of retrocecal localization and perforated appendicitis. In the 29 of the remaining 39 patients, pelvic inflammatory disease, mesenteric lenfadenopathy, torsed omentum and ruptured hemorrhagic, and endometrial or simple ovarian cysts were revealed. So, these 29 patients' (39.1%) appendices were left in place, and an unnecessary appendectomy was avoided, thereby reducing the negative appendectomy rate. In the remaining 10 patients, nothing was found to explain the clinical signs. After a mean follow-up period of 16 months, postoperative evaluations of the patients were satisfactory.

CONCLUSION

Laparoscopy, a single procedure and an accurate modality for the diagnosis and treatment of patients with acute abdominal conditions, can be recommended in patients, especially fertile women, with suspected peritonitis imitating acute appendicitis when the diagnosis cannot be made by physical examination and noninvasive methods.

A prospective audit of 300 consecutive young women with an acute presentation of right iliac fossa pain

INTRODUCTION

A prospective study of 300 women of child-bearing age presenting with right iliac fossa pain was carried out to determine what proportion had appendicitis and whether active observation resulted in a delay in diagnosis to the detriment of the patient.

PATIENTS AND METHODS

Data were prospectively collected for 300 consecutive women of childbearing age referred with right iliac fossa pain to general surgeons at a district general hospital.

RESULTS

After clinical assessment, 71 were discharged home immediately. Two others were found to be pregnant and 4 admitted to gynaecology. The remaining 223 women were admitted to the general surgical unit, 112 of whom underwent immediate appendicectomy. Of these, 97 had acute appendicitis. Two suffered deep infection and two had a superficial wound infection. A further decision to operate was made in 42 of 111 patients admitted for active observation, with 36 having acute appendicitis and 2 having a carcinoid tumour. Four had a wound infection. The average in-patient stay of those admitted for active observation and not operated on was 2 days (range, 1-4 days) compared with a length of stay of 2 days (range, 1-7 days) for those who underwent 'immediate' appendicectomy.

CONCLUSIONS

Most women of child-bearing age who present with right iliac fossa pain do not have appendicitis. Those who do not have the classical features of appendicitis or peritonism can be safely managed by active observation.

Randomized clinical trial of laparoscopic versus open appendicectomy for confirmed appendicitis

BACKGROUND

Laparoscopy is safe for diagnostic and therapeutic purposes in patients with suspected acute appendicitis. This study compared recovery after laparoscopic (LA) and open appendicectomy (OA) for confirmed appendicitis, carried out by experienced surgeons in an educational setting.

METHODS

One hundred and sixty-three patients with laparoscopically confirmed appendicitis suitable for LA were randomized prospectively to either LA or OA in a blinded fashion. The primary endpoint was time to full recovery. Secondary endpoints were operating time, complications, hospital stay and functional status.

RESULTS

There was no significant difference between LA and OA in time to full recovery (9 and 11 days respectively; P = 0.225). Operating time was 55 min in the LA group and 60 min in the OA group (P = 0.416). The complication rate was 8.6 and 11.0 per cent respectively (P = 0.696), and median hospital stay was 2 days in both groups (P = 0.192). Functional status was significantly better in the LA group 7-10 days after operation (P = 0.045).

CONCLUSION

There was no difference in time to full recovery after LA and OA in patients with laparoscopically confirmed appendicitis. A trend towards better physical activity was noted after the laparoscopic procedure.

Surgical validation of unenhanced helical computed tomography in acute appendicitis

BACKGROUND

Surgery for pain in the right lower quadrant of the abdomen remains a clinical dilemma. This prospective study assessed the accuracy of preoperative unenhanced helical computed tomography (CT) in the evaluation of patients with suspected acute appendicitis.

METHODS

One hundred and three adult patients with suspected acute appendicitis underwent unenhanced helical CT of the abdomen. Subsequently, all patients underwent laparoscopic inspection of the abdominal cavity by a surgeon who was blinded to the diagnosis suggested by CT. Patients underwent appropriate surgical therapy accordingly. Follow-up was at least 6 weeks.

RESULTS

Appendicitis was diagnosed by CT in 83 patients (80.6 per cent). Acute appendicitis was identified during laparoscopy in 87 patients (84.5 per cent). Prospective interpretation of CT images yielded a sensitivity of 95.4 per cent and a specificity of 100 per cent for the diagnosis of acute appendicitis. There were four false-negative scans. In 12 of 20 patients without signs of appendicitis on CT, the scan established the presence of other pathology. At operation no additional pathology was observed in this group and all other diagnoses proved to be correct.

CONCLUSION

Plain helical CT in patients with suspected acute appendicitis provides an accurate diagnosis without the disadvantages of contrast enhancement.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciSearch, the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis.

MAIN RESULTS

We included 54 studies, of which 45 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for LA. Pain on day 1 after surgery was reduced after LA by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Five studies on children were included, but the result do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01).

REVIEWERS' CONCLUSIONS

In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.

Institutional variations in the management of patients with acute appendicitis

The purpose of this study was to evaluate institutional differences in preoperative workup, operative approach, complications, and cost in patients with acute appendicitis. A retrospective chart review was performed of all adults operated on for acute appendicitis from June 1999 to November 2000 at the University of New Mexico Hospital (UNMH) and Stanford University Medical Center (SUMC). Variables compared included age, race, sex, duration of symptoms, type of symptoms, results of radiographic evaluation, time from emergency room to operating room, operative approach (open vs. laparoscopic), operative time, length of hospital stay, pathologic findings, and complications. Statistical analysis was performed by means of Fisher's exact test. A total of 154 appendectomies were performed for acute appendicitis at UNMH and 165 at SUMC. Statistically significant differences were found at UNMH vs. SUMC in time from emergency room to operating room (9.1 hours vs. 13.7 hours; P<0.001), operative approach (48% laparoscopic vs. 29% open; P<0.001), and negative appendectomy rate (13% vs. 4.8%; P<0.001). There were no differences in the perforation rate or other complications. Cost analysis showed that $56,744 more was spent at UNMH for the additional negative appendectomy operations, whereas $99,842 more was spent at SUMC for the additional CT scans. Institutional differences in the management of patients with acute appendicitis can result in significant differences in cost without clinically significant differences in outcome. The use of clinical examination and laparoscopy as diagnostic modalities instead of CT scanning resulted in a more cost-effective approach.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery has been proposed to have diagnostic and therapeutic advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery in the treatment of suspected acute appendicitis.

SEARCH STRATEGY

We searched for original articles and abstracts published until end of 2000. As main search tools we employed the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE and SciSearch. CCTR and MEDLINE searches were repeated until 10 October 2001, all other databases were searched 10 October 2000. We also handsearched the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included clinical trials that assessed either: (1) Therapeutic effects of laparoscopic appendectomy (LA) versus open appendectomy (OA) in adults, (2) Therapeutic effects of LA versus OA in children, (3) Diagnostic effects of diagnostic laparoscopy (LAP) followed by LA or OA if necessary versus immediate OA, (4) Therapeutic effects of diagnostic laparoscopy (LAP) followed by OA if necessary versus immediate OA. We included only randomized studies and excluded those with unconcealed allocation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed each study's eligibility and quality. One reviewer extracted the data, 10% of which were later cross-checked by a second reviewer. Abstract authors and authors of articles lacking important information on trial design or results were contacted.

MAIN RESULTS

We included 45 studies, of which 39 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were about half as likely (Peto OR 0.47; 95%-CI 0.36 to 0.62) after LA than after OA, but intraabdominal abscesses were increased nearly threefold after LA (Peto OR 2.77; 95%-CI 1.61 to 4.77). The duration of surgery was 14 minutes (95%-CI 10 to 19) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (95%-CI 3 to 13 mm) on a 100 mm VAS. Hospital stay was reduced by 0.7 days (95%-CI 0.4 to 1.0). Return to normal activity, work, and sport were 6 days (95%-CI 4 to 8), 3 days (1 to 5), and 7 days (3 to 12) earlier after LA than after OA. While the operation costs of LA were significantly higher than that of OA, the costs outside hospital were reduced. Strong heterogeneity was found for most outcomes, but not for wound infections and intraabdominal abscesses. In children, much less data were available, but the result do not seem to be much different when compared to adults. Pain which was measured blindly in two paediatric trials, was similar after LA and OA (-1 mm VAS; 95%-CI -8 to +7 mm). In trials on unselected patients, diagnostic laparoscopy led to large but variable reductions in the rate of negative appendectomies (RR 0.21; 95%-CI 0.13 to 0.33). In parallel, the rate of unestablished diagnoses was significantly decreased after laparoscopy (RR 0.34; 95%-CI 0.22 to 0.53). In fertile women, these effects were even more pronounced: rate of negative appendectomies: RR 0.19; 95%-CI 0.11 to 0.34; rate of patients without a final diagnosis established: RR 0.24; 95%-CI 0.15 to 0.38.

REVIEWER'S CONCLUSIONS

In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. In gangrenous or perforated cases, however, LA may possibly carry a higher risk of intraabdominal infections.

Laparoscopy reduces unnecessary appendicectomies and improves diagnosis in fertile women. A randomized study

BACKGROUND

The aim of this study was to study the value of diagnostic laparoscopy prospectively in fertile women scheduled for acute appendectomy.

METHODS

For this study, 110 women, with acute abdominal pain ages 15 to 47 years, in whom the surgeon had decided to perform an appendectomy, were randomized to either open appendectomy or diagnostic laparoscopy, then open appendectomy if necessary.

RESULTS

Appendicitis was diagnosed in 66% of the women after open surgery, and in 73% after laparoscopy. During laparoscopy, was appendicitis misdiagnosed in only 7% of the women, from whom the appendix unnecessarily removed, whereas 34% in the open surgery group had a healthy appendix removed. No appendicitis was missed in the laparoscopic group. The relative risk of removing a healthy appendix in open surgery was 6.6 relative risk (range, 2-21 C.I.) as compared with laparoscopy. Among the women with a healthy appendix, a gynecologic diagnosis was found in 73% after laparoscopy, as compared with 17% after open surgery.

CONCLUSIONS

Laparoscopy reduces unnecessary appendectomies and improves diagnosis in fertile women.

A normal appendix found during diagnostic laparoscopy should not be removed

BACKGROUND

Diagnostic laparoscopy has been introduced as a new diagnostic tool for suspected appendicitis. While the normal appendix used to be removed routinely, laparoscopy allows us to leave a normal looking appendix in place. This latter strategy is, however, not generally accepted. The long-term results of not removing a normal looking appendix were evaluated.

METHODS

This was a prospective evaluation of 109 diagnostic laparoscopies for suspected appendicitis in which a normal looking appendix was left in place. After a median follow-up of 4.4 years a telephone questionnaire was performed.

RESULTS

There were no false-negative laparoscopies. In 65 patients (60 per cent) another diagnosis was obtained (group 1). In 44 patients (40 per cent) no diagnosis was obtained (group 2). After a median interval of 8 months, 15 patients presented to the emergency department for symptoms possibly involving the appendix, during the median follow-up of 4.4 years. This resulted in readmission of nine patients, of whom eight were reoperated. In only one patient (1 per cent) was a histologically proven appendicitis found and the appendix removed. Some 105 patients were eligible for follow-up. Of the 100 patients interviewed (95 per cent), nine patients (9 per cent) (six in group 1 and three in group 2) still had recurrent pain in the right lower abdominal quadrant. There were no differences between patients with or without another diagnosis obtained during preceding laparoscopy.

CONCLUSION

It is safe to leave a normal looking appendix in place when a diagnostic laparoscopy for suspected appendicitis is performed, even if another diagnosis cannot be found at laparoscopy.