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.     

Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study

Background

The management of an appendiceal mass remains controversial with 2 schools of thought; early surgical intervention vs nonoperative management with or without interval appendectomy. The aim is to determine the role and safety of early laparoscopic appendectomy (LA) in children with acute appendicitis presenting with an appendiceal mass.

Methods

This is a prospective study of 88 consecutive pediatric patients who underwent attempted LA for suspected acute appendicitis at KK Women's and Children's Hospital, Singapore, between May and October 2003.

Results

A total of 88 patients with a mean age of 10 ± 3 years (range, 3-16 years) underwent LA for an appendiceal mass (n = 22), simple appendicitis (n = 36), other complicated (gangrenous or perforated) appendicitis (n = 23), and a normal appendix (n = 7). There were 7 conversions to open appendicectomy, 3 of which occurred in patients with an appendiceal mass. There were no perioperative or postoperative mortalities. Morbidity occurred in only one patient who underwent LA for perforated appendicitis. He had prolonged sepsis that resolved after 2 weeks of intravenous antibiotics. None of the patients with an appendiceal mass developed complications. Patients who underwent early LA for an appendiceal mass had a statistically significant (P < .05) longer operating time (median, 103 minutes; interquartile range, 90-151 minutes, vs median, 87 minutes; interquartile range, 71-112 minutes), prolonged time to ambulation (median, 2.0 days; interquartile range, 2-2.5 days, vs median, 1.0 days; interquartile, 1-2 days), increased time to resumption of diet (median, 4 days; interquartile, 3-5 days, vs median, 2 days; interquartile, 2-3 days), and longer postoperative stay (median, 6.0 days; interquartile, 5.5-6.5 days, vs median, 4.0 days; interquartile, 3-5.5 days) compared with patients presenting with appendicitis without mass formation. However, there was no statistical difference in these parameters when LA for an appendiceal mass was compared with LA for other complicated appendicitis (perforated and gangrenous).

Conclusion

Although early LA for an appendiceal mass is a technically demanding procedure, it can be performed safely in children with minimal morbidity and mortality. In an era where patients' demand for “key-hole” surgery is rising, early LA is a safe and viable option in the management of children with an appendiceal mass. It also offers the advantage of avoiding misdiagnoses and the need for a second hospitalization.     

Does delay in appendectomy affect surgical site infection in children with appendicitis?

Purpose

The purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy.

Methods

Pediatric patients undergoing appendectomy in 2010–2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI.

Results

1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p = 0.51; SA patients, p = 0.91; CA patients, p = 0.44) or with increased time from admission to operation (all patients, p = 0.997; SA patients, p = 0.69; CA patients, p = 0.96). However, greater length of symptoms was associated with an increased risk of SSI (p < 0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p < 0.0001).

Conclusion

We found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.     

Complicated appendicitis in children: laparoscopy or Mac Burney incision?

PURPOSE: The aim of this retrospective study was to compare open (Mc Burney incision group MB n = 92) and laparoscopic (group LAP n = 58) appendectomy for complicated appendicitis (abscess or peritonitis). MATERIAL AND METHOD: 150 children, with a mean age of 8.5 years, were operated in our department from January 1990 to April 1996. Only children with complicated appendicitis and positive bacteriology of peritoneal fluid were included in this study. All children received parenteral antibiotics for an average of 5.4 days. RESULTS: The mean operating time was significantly longer in the LAP group (63 vs 43 min p < 0.0001). The conversion rate in the LAP group was 12%. The mean hospital stay was 8.4 days (3-29) without any difference between the 2 groups. There was no significant difference for the complication rate in the 2 groups, except for wound infections which were more frequent in the MB group (p = 0.008). Late postoperative complications occurred in 3 cases in the MB group (none in the LAP group) (NS). There were 2 small bowel obstructions and a wound dehiscence. CONCLUSION: Laparoscopic appendectomy is a safe procedure for complicated appendicitis in children, but the greatest short-term benefit is cosmetic. Long-term results have to be evaluated, particularly with regards to the long-term complication rate.     

Is laparoscopic appendectomy in children associated with an uncommon postoperative complication?

Background Laparoscopic appendectomy (LA) is controversial due to the high rate of intraabdominal abscess (IAA). We report a postlaparoscopic appendectomy complication (PLAC) observed in pediatric patients discharged after an uneventful postoperative period.Methods In this case series, a review of the medical records of children who underwent LA or open appendectomy (OA) during a 5-year period was performed. The diagnosis of PLAC was based on three well-defined criteria: time of appearance, clinical and laboratory findings, and ultrasonographic characteristic features.Results A total of 374 patients underwent appendectomy (LA, 129 patients; OA, 245 patients). One patient with conversion of LA to OA and 35 patients with gangrenous or perforated appendicitis (seven from the LA group and 28 from the OA group) were excluded from the study. After LA, nine children developed intraabdominal complications during their hospitalization (six infiltrate in the right lower quadrant and three IAA); these were also excluded. Discharge from the department was done when three conditions were fulfilled: normal body temperature, normal leukocyte count, and passage of a stool. Among the 112 LA patients, PLAC was observed in 15 (13.4%), aged 12.5 ± 2.9 years, who were discharged after LA in 2.7 ± 0.9 days. Number of PLAC and time of its appearance were not significantly different in patients with normal or pathological appendix. Sonographic findings of PLAC at admission were fluid alone (n = 11), edematous mesenteric fat (n = 7), thickening of bowel wall (n = 9), and more than one sign (n = 9). At repeated sonography, these signs were present in all patients, and IAA developed in one of them. All children were successfully treated with antibiotics for 10.1 ± 3.9 days, one of whom underwent a CT-guided percutaneous drainage for IAA.Conclusions PLAC may be the result of a slow development of local interstitial infection in the ileocecal area due to mesothelial damage caused by CO₂ pneumoperitoneum and local thermal effect produced by energized systems. This may explain its delayed appearance and the efficacy of the antibiotic treatment.     

Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice?

BACKGROUND/PURPOSE: Whether laparoscopic appendectomy (LA) is superior to open appendectomy (OA) for simple (SA) and perforated appendicitis (PA) in children is debatable. The operative experience of 4 senior pediatric surgeons at a single institution was studied over a 6-year period during a transition from OA in all cases to LA in all cases, to answer this question. METHODS: All appendectomies from December 1993 to December 1999 were reviewed for operative technique (OA, LA), presence of perforation (SA, PA), operating time (OT), length of stay (LOS), morbidity, and mortality. RESULTS: There were 1,128 appendectomies in children aged 14 months to 19 years, including 955 LA (653 in SA, 302 in PA) and 173 OA (86 in SA, 87 in PA). OT was equal for LA and OA in SA (52 minutes), but has dropped to less than 40 minutes for LA in the past year. OT in PA was slightly longer in LA versus OA (68 v. 58 minutes; P < .001) but recently has dropped in LA to less than 60 minutes. LOS in SA was 2 days for LA and 3 days for OA; in PA, LOS was 7 days in both LA and OA, but has dropped to 5 days for LA recently. Postoperative abscess rates and incidence of bowel obstruction did not differ between LA and OA in either group. There was no mortality. CONCLUSIONS: LA is at least as safe and effective as, if not superior to, OA for both simple and perforated appendicitis. Postoperative pain is less, and recovery is faster, thereby reducing LOS and overall cost. The growing demand for this procedure can be satisfied without increase in cost, morbidity, or mortality. Laparoscopic appendectomy is our procedure of choice in children.     

Treatment of perforated appendicitis in children: what is the cost?

Background/PurposeWe compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children.MethodsFrom June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy.ResultsPatients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies.ConclusionsPatients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.     

Perforated appendicitis: is laparoscopic operation advisable?

AIMS: A retrospective study was used to compare laparoscopic appendectomy for perforated appendicitis to open operation. METHODS: Between July 1991 and June 1999 a total of 734 patients, all over 14 years of age, underwent operation for acute appendicitis. Of these patients, 125 (17%) displayed perforated appendicitis and were treated with either a laparoscopic appendectomy (n = 80; total conversion rate 36/80, 45%) or a primary open procedure (n = 45). RESULTS: Due to selection, the 3 treatment groups (laparoscopic, laparoscopy with conversion, open operation) showed differences with respect to gender, duration of symptoms, proportion of obese patients and patients with generalized peritonitis. The median operating time was 75 min for the laparoscopic procedure, 90 min for a converted procedure and 70 min for open operation. Only 1 of 44 (2%) patients who had a laparoscopic operation, but 8 of 36 (22%) who had a converted operation, and 8 of 45 (18%) who had an open operation developed wound infection. A similar frequency of intra-abdominal abscess formation was observed in the 3 treatment groups (2/44, 5%; 3/36, 8%; 2/45, 5%). Fatal outcome occurred only in patients who underwent an open operation and presented with severe peritonitis (5/45, 11%). CONCLUSIONS: Despite limitations in comparability of patient groups, laparoscopic appendectomy was associated with a significantly lower rate of septic wound complications (p < 0.05). This was especially true for the subgroup of obese patients (BMI >26). Therefore, for patients with perityphlitic abscess or fresh purulent lower abdominal peritonitis, but not for patients with generalized peritonitis, laparoscopic appendectomy is not only justifiable but even recommended as the procedure of choice.     

Single institution’s experience in laparoscopic appendectomy as a suitable therapy for complicated appendicitis

Purpose

Although laparoscopic appendectomy (LA) for acute appendicitis (AA) is widely performed, the value of LA for the treatment of complicated appendicitis (CA) is still controversially discussed.

Methods

In a retrospective study, we analyzed the clinical records of 404 patients who underwent LA or conversion (intention-to-treat group) or open appendectomy (OA) for AA or CA at the Alfried Krupp Hospital Essen-Rüttenscheid, Germany between January 2007 and December 2010.

Results

AA was treated in 64.2 % by LA and in 35.8 % by OA; the LA-to-OA conversion rate amounts to 3.7 %. CA was treated in 56 % by LA and in 44 % by OA. The LA-to-OA conversion rate here is 13.1 %, and compared to AA, it is significantly (P?<?0.01) higher. Comparing LA with OA in both patient groups, we find no significant difference in the overall complication rate, the rate of postoperative intraabdominal abscesses and postoperative ileus. However, in both patient groups, the wound infection rate was significantly lower in patients who had undergone LA (AA P?<?0.05 versus CA P?<?0.01). In contrast to patients suffering from AA, patients with CA needed significantly less resurgery when treated by LA as compared to OA (P?<?0.001). While the duration of surgery for the treatment of AA and CA was similar, the hospitalization time was significantly shorter with LA than with OA (AA P?<?0.05 versus CA P?<?0.001).

Conclusions

The data suggest that LA is advantageous not only in the treatment of AA, but also in the therapy of CA. Thus, LA may become a proper and safe routine method if performed by an experienced surgeon.     

Perforated appendicitis in children: is there a best treatment?

Purpose

This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors’ hospital.

Methods

This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital.

Results

The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management.

Conclusions

Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm³. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.     

Laparoscopic versus open appendectomy: is the postoperative infectious complication rate different?

Despite the reported advantages of laparoscopic appendectomy (LA), there is debate about the postoperative infectious complication rate. Our study attempts to determine if the infectious complication rate between LA and open appendectomy (OA) is different. A retrospective review was conducted of all patients who underwent appendectomy at Kern Medical Center between 1999 and 2003. Age, sex, white blood cell count, temperature, pathology, and postoperative complications were identified. Fifty-seven patients underwent LA, and 159 patients underwent OA. The groups were well matched for demographics, white blood cell count, temperature, and percent perforated appendicitis. There was an overall 9.3 per cent complication rate. The infectious complication rate in OA versus LA group was statistically different (6.3% vs 17.6%, P = 0.04). The infectious complication rate in the LA group was significantly higher than in the OA group. Further large randomized trials are necessary to confirm our findings and to identify if LA is appropriate for a subset of appendicitis patients.     

Is delayed operative treatment worth the trouble with perforated appendicitis is children?

BACKGROUND: Approximately 30% to 50% of appendicitis in children is already perforated at presentation. The optimal management of these children remains controversial. METHODS: Ninety-six children (aged 2 to 16 years) were treated for perforated appendicitis. Seventy-one underwent immediate appendectomy and drainage of abscess, if present (group I). In the other 25 an attempt was made to treat with intravenous antibiotics, combined with transrectal (4) or percutaneous (2) drainage of abscess. This treatment was successful in 16 patients (group II), who underwent appendectomy 6 to 8 weeks later, and unsuccessful in 9 patients (group III), who underwent appendectomy 3 to 12 days later. RESULTS: The mean length of stay was as follows: group I, 6.7 days; group II, 8.9 days; and group III, 10.9 days (not significant). The white blood cell count (WBC) at presentation was group I, 18.6 K; group II, 17.9 K; group III, 18.8 K. The percent fall of WBC on day 4 was group I, 55%; group II, 25.5%; group III, 17% (P >0.05 versus groups I and II). Twenty of 71 patients in group I (28%) developed wound infection (5), pelvic abscess (14), and pancreatitis (1), while 2 of 16 (12.5%) of group II and 1 of 9 (11%) of group III patients required readmission (both P <0.05 versus group I). CONCLUSIONS: These data show that initial antibiotic treatment of perforated appendicitis in children, followed by interval appendectomy, is useful for a select group who present with little or no peritonitis, slightly elevated temperature, and WBC that falls at least 25% within 3 to 4 days.     

A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe?

BACKGROUND: In the era of open surgery, emergency open cholecystectomy has been shown for many reasons to be preferred to delayed surgery for acute cholecystitis. Despite the fact that elective laparoscopic cholecystectomy (LC) has become the gold standard for the treatment of symptomatic gallstone disease, the same procedure remains controversial for the management of acute cholecystitis because it is considered to be associated with more complications and an increased risk of common bile duct injuries than interval LC after resolution of the acute episode. The purpose of this report is to describe our experience with LC for acute cholecystitis during a 10-year period. METHODS: Patients undergoing laparoscopic surgery have been entered prospectively into a database since 1995. Those who underwent surgery before 1995 were added retrospectively to the same database. Patients were included in this study if they underwent emergency laparoscopic cholecystectomy for suspected acute cholecystitis. The diagnosis was based on clinical, laboratory, and echographic examinations. Analysis was performed to identify risk factors associated with conversion or morbidity. RESULTS: Of the 1,212 patients subjected to LC between 1990 and 1999, 268 (151 women and 117 men), with a mean age of 53 years, underwent surgery on an emergency basis for suspected acute cholecystitis. Their mean age (p = 0.002) and the proportion of men (p < 0.001) were higher than in the elective group. Delay before admission and surgery varied widely, but 72% of the patients underwent surgery within 48 h of admission. An intraoperative cholangiography, attempted in 218 patients, was successful in 207 (95%). Histologic examination confirmed acute cholecystitis in 82% of the patients. Conversion was necessary in 15.6% of the cases. It occurred more frequently in patients who underwent surgery later than 48 (p = 0.03) or 96 h (p = 0.006) after admission. No other predictor of conversion was found. Overall morbidity was 15.3%, and major morbidity was 4.4%. The only risk factor for morbidity was a bilirubin level greater than 20 mmol/l (p = 0.02). Three partial lesions of the common bile duct occurred. All were recognised and repaired immediately with no adverse effect. There was no difference in the overall rate of biliary complications between the patients operated for acute cholecystitis and those who underwent elective surgery. No reoperation was necessary, and there was no mortality. CONCLUSIONS: Although LC is safe and effective for acute cholecystitis, its associated morbidity and conversion rate are higher than for elective LC. The conversion rate decreases with experience. When surgery is performed within 2 or maximally 4 days of admission, in experienced hands, LC represents the treatment of choice for acute cholecystitis. Intraoperative cholangiography should be performed in every case because it helps to clarify the anatomy and allows for early diagnosis and repair of bile duct injuries.