Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors

Background The use of laparoscopic appendectomy for complicated appendicitis is controversial. Outcomes were compared between patients who had complicated appendicitis and those who had uncomplicated appendicitisMethods Consecutive patients (n = 304) who underwent laparoscopic appendectomy were studied. Patients undergoing open appendectomies also were compared ad hoc. Analgesia use, length of hospital stay, return to activity, and complication rates for the complicated and uncomplicated appendicitis subgroups were analyzed.Results Complete data were available for 243 patients (80%). There were no statistical differences in characteristics between the two groups. The operating times, lengths of hospital stay, return to activity times, complication rates, and analgesia requirements, both in the hospital and after discharge, were equivalent. A greater number of complicated cases required open conversion. Considering those with complicated appendicitis, the open group had a significantly longer mean hospital stay and a higher complication rate than those treated with laparoscopic appendectomy.Conclusions The minimally invasive laparoscopic technique is safe and efficacious. It should be the initial procedure of choice for most cases of complicated appendicitis.Presented at the Canadian Association of General Surgeons meeting in Vancouver, British Columbia, Canada, 18 September 2003     

Routine interval appendectomy is unnecessary after conservative treatment of appendiceal mass

Objective The traditional management of appendiceal mass is initial conservative treatment followed by interval appendicectomy. Recently interval appendicectomy has been questioned by a growing amount of evidence. The purpose of this study was to clarify the role of interval appendicectomy after successful initial conservative treatment. Method The study included 98 patients with a mass in the right iliac fossa. Four (4%) patients were excluded wing to another diagnosis of appendiceal mass including caecal cancer (two), diverticulitis (one), and Crohn’s disease (one). The remaining 94 patients were treated conservatively. Routine interval appendicectomy was not performed after successful conservative treatment. Results Ultrasound (US)‐guided drainage was performed in seven (7.4%) patients. Two were drained surgically because of a persistent abscess despite a previous US‐guided drainage. In five (5.3%) patients, a delayed operation was necessary because of complications. One patient developed small bowel obstruction, and in three patients, conservative treatment was unsuccessful with the abscess remaining unresolved. Within 3 months, seven out of the 89 patients were readmitted to hospital with a recurrent mass in two patients and acute appendicitis without a mass in five patients. Six (6.7%) patients were readmitted with recurrent appendicitis after 3 months. The recurrence rate after successful conservative treatment was 14.6%. The majority (nine patients; 10.1%) of the recurrences occurred within the first 6 months, and after 1 year the recurrence rate was very low (two patients; 2.2%). Conclusion Routine interval appendicectomy after initial successful conservative treatment is not justified and should be abandoned. At present, there is no consensus for the management of appendiceal mass. There is, therefore, a need to develop a protocol for the management of this common problem.     

Interval laparoscopic appendectomy for appendicitis complicated by pylephlebitis.

BACKGROUND: Although rare, portal mesenteric venous thrombosis and pylephlebitis remain potential life-threatening sequelae of ruptured appendicitis in children. Treatment recommendations from recent reports have included urgent exploratory laparotomy with appendectomy, prolonged intravenous antibiotic therapy, and anticoagulation for up to a year. METHODS: This report describes successful management of pylephlebitis and mesenteric venous thrombosis complicating ruptured appendicitis with intravenous antibiotics and anticoagulation followed by interval laparoscopic appendectomy. RESULTS: A previously healthy 5-year-old girl was diagnosed with ruptured appendicitis complicated by pylephlebitis and mesenteric venous thrombosis at the time of presentation. She was treated with intravenous antibiotics and anticoagulated for 3 months. She subsequently underwent interval laparoscopic appendectomy. At 3-year follow-up, she is healthy without evidence of adverse sequelae. DISCUSSION: This is the first reported case of successful, minimally invasive management of ruptured appendicitis complicated by mesenteric venous thrombosis and pylephlebitis. CONCLUSION: Similar treatment of other children with this rare presentation seems reasonable.     

Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial

Purpose

The current study examined the impact of immediate laparoscopic surgery vs nonoperative initial management followed by interval appendectomy for appendicitis with abscess on child and family psychosocial well-being.

Methods

After obtaining Internal Review Board approval, 40 patients presenting with a perforated appendicitis and a well-formed abscess were randomized to surgical condition. Parents were asked to complete child quality of life and parenting stress ratings at presentation, at 2 weeks postadmission, and at approximately 12 weeks postadmission (2 weeks postoperation for the interval appendectomy group).

Results

Children in the interval arm experienced trends toward poorer quality of life at 2 and 12 weeks postadmission. However, no group differences in parenting stress were observed at 2 weeks postoperation. At 12 weeks postadmission, participants in the interval condition demonstrated significant impairment in both frequency and difficulty of problems contributing to parenting distress.

Conclusion

Families experience significant parenting distress related to the child's functioning and disruption in the child's quality of life that may be because of the delay in fully resolving the child's medical condition. In addition, parents experience negative consequences to their own stress as a result of the delay before the child's appendectomy.     

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

Background

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

Methods

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using χ², Fisher exact, and Student t tests.

Results

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain).We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 ± 5.7 vs 8.8 ± 6.7 days, P = .08).

Conclusions

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.     

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy

Background

Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA.

Methods

Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks.

Results

Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count > 15,000, WBC > 15,000 plus fecalith on imaging, and WBC > 15,000 plus duration of symptoms > 48 hours were all significantly associated with higher rates of readmission (p = 0.01, p = 0.04, p = 0.02) and need for interval AP prior to the planned ≥ 8 weeks (p = 0.003, p = 0.05, p = 0.03).

Conclusions

Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.     

Complicated appendicitis in children: a clear role for drainage and delayed appendectomy

INTRODUCTION: Children presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. METHODS: A retrospective review of all children undergoing appendectomy over a 5-year period was performed. RESULTS: We identified 1,106 children: 360 had evidence of perforation and 92 had an intra-abdominal abscess or right lower quadrant phlegmon. Of these 92, 60 underwent primary appendectomy and 32 underwent drainage and/or antibiotic therapy with delayed appendectomy. Children undergoing delayed appendectomy had a longer prodrome of symptoms (6.9 vs 4.6 days, P = .002), slightly higher presenting white blood cell count (19.3 vs 16.6, P = .08), and had the same hospital length of stay, yet had a lower complication rate requiring readmission to the hospital (0% vs 10%) compared to those undergoing immediate appendectomy. CONCLUSION: In children presenting with prolonged symptoms and a discrete appendiceal abscess or phlegmon, drainage and delayed appendectomy should be the treatment of choice.     

Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy

PurposeAlthough conservative management followed by readmission for interval appendectomy is commonly used to manage perforated appendicitis, many studies are limited to individual or noncompeting pediatric hospitals. This study sought to compare national outcomes following interval or same-admission appendectomy in children with perforated appendicitis.MethodsThe Nationwide Readmission Database was queried (2010–2014) for patients <18 years old with perforated appendicitis who underwent appendectomy using ICD9-CM Diagnosis codes. A propensity score-matched analysis (PSMA) utilizing 33 covariates between those with (Interval Appendectomy) and without a prior admission (Same-Admission Appendectomy) was performed to examine postoperative outcomes.ResultsThere were 63,627 pediatric patients with perforated appendicitis. 1014 (1%) had a prior admission for perforated appendicitis within one calendar year undergoing interval appendectomy compared to 62,613 (99%) Same-Admission appendectomy patients. The Interval Appendectomy group was more likely to receive a laparoscopic (87% vs. 78% same-admission) than open (13% vs. 22% same-admission; p < 0.001) operation. Patients receiving interval appendectomy were more likely to have their laparoscopic procedure converted to open (5% vs. 3%) and receive more concomitant procedures. PSMA demonstrated a higher rate of small bowel obstruction in those receiving Same-Admission appendectomy while all other complications were similar. Although those receiving Interval Appendectomy had a shorter index length of stay (LOS) and lower admission costs, they incurred an additional $8044 [$5341-$13,190] from their prior admission.ConclusionPatients treated with interval appendectomy experienced more concomitant procedures and incurred higher combined hospitalization costs while still having a similar postoperative complication profile compared to those receiving same-admission appendectomy for perforated appendicitis.Level of evidenceIII.Type of studyRetrospective Comparative Study.     

Morbidity of laparoscopic surgery for complicated appendicitis: an international study

Background Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses. Methods A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions. Results One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days). Conclusions The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar. Presented in part at the 12th European Association for Endoscopic Surgery (EAES) International Congress, 9–12 June 2004, in Barcelona, Spain     

复杂性阑尾炎术式的抉择：腹腔镜术抑或开腹手术

目的：探讨腹腔镜应用于复杂性阑尾炎的可行性。方法：回顾分析手术治疗复杂性阑尾炎213例患者的临床资料，213例分为腹腔镜阑尾切除术（laparoscopic appendectomy，LA）128例，开腹阑尾切除术（open appendectomy，OA）85例。比较两组的手术时间、术中出血量、切口长度、术中引流管留置率及术后留置时间、术后疼痛视觉模拟评分（visual analogue scale，VAS）、恢复进食时间、感染性并发症（即切口感染、腹腔内脓肿）发生率、术后住院天数、住院费用等指标。结果：LA组比OA组手术时间长，住院总费用高，差异有统计学意义；术中出血量、切口长度、术中引流管留置率及术后留置时间、术后疼痛VAS、恢复进食时间及术后住院天数等指标，IA组均优于OA组；LA组切口感染率较OA组低，腹腔内脓肿发生率两组无显著性差异。两组均无死亡病例。结论：LA具有创伤小、疼痛轻、肠道功能恢复快、切口感染率低、住院时间短等优势，用于治疗复杂性阑尾炎可行、安全、有效。     

Dollars and sense of interval appendectomy in children: a cost analysis

Purpose

Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy.

Methods

Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates.

Results

Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios.

Conclusion

Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.     

Clinical analysis of the predictive factors for recurrent appendicitis after initial nonoperative treatment of perforated appendicitis

BACKGROUND: The purpose of this study was to study the clinical symptoms, laboratory data, and the characteristics of computed tomography (CT) imaging of nonoperated perforated appendicitis for predicting the recurrence of appendicitis. METHODS: Thirty-five patients with nonoperated perforated appendicitis were retrospectively reviewed for this study. During a median follow-up period of 1155 days, 7 patients had to receive an appendectomy owing to recurrent appendicitis. Accordingly, the patients were divided into 2 groups: the recurrence and the nonrecurrence group. The clinical characteristics between these 2 groups were compared. RESULTS: Both of the 2 patients who had a past history of appendicitis suffered recurrent appendicitis (the recurrence versus the nonrecurrence group, P<.05). The only CT imaging relating to the recurrence of appendicitis is the presence of calcified appendicolith (the recurrence versus the nonrecurrence group, P<.001). CONCLUSIONS: It is most likely that appendicitis will recur if a calcified appendicolith on CT imaging or a past history of appendicitis is presented. Interval appendectomy may be reserved only for those patients who possess one of these risk factors of recurrent appendicitis.     

Early appendectomy vs. conservative management in complicated acute appendicitis in children: A meta-analysis

BackgroundNo consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children (CAA). Existing studies present heterogeneity of data and only few studies analyzed free perforated appendicitis (FPA) separately from appendicular abscess (AAb) and appendicular phlegmon (AP).MethodStudies which have been judged eligible for this systematic review and consequent meta-analysis are those comparing non-operative management (NOM) with operative management (OM) in children with CAA. Studies were subgrouped between those analyzing mixed patients with CAA, those focusing on patients with AAb/AP and those focusing on patients with FPA.ResultsFourteen studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 1288 patients. In the fixed-effects model the complication rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.07, 95%CI = 0.02–0.27) and to the OM arm for the FPA subgroup (RR = 1.86, 95%CI = 1.20–2.87); the re-admission rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.35, 95%CI = 0.13–0.93) and to the OM arm for the FPA subgroup (RR = 1.49, 95%CI = 1.49–7.44). There was no statistical heterogeneity for the two subgroups of patients. The costs weren't significantly different between NOM and OM. The length of stay was favorable to OM. The pooled proportion rate of NOM success was 90%, the pooled relapse rate of appendicitis was 15.4%.ConclusionsChildren with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM.Level of evidenceII     

Comparison of laparoscopic and open appendectomy on wound infection and healing in complicated appendicitis

The aim of this study was to investigate the effects of laparoscopic and open surgery on the development of postoperative surgical wound infection and wound healing between complicated appendicitis patients. Patients with complicated appendicitis were divided into those underwent laparoscopic and open surgical procedures according to the surgical method. Patients were followed up with regard to development of any postoperative wound infection, and medical, radiological, and surgical treatment methods and results were recorded. A total of 363 patients who underwent appendectomy were examined, of which 103 (28.4%) had complicated appendicitis. Postoperative wound infection rate in patients who underwent open surgery was 15.9%, while it was 6.8% in the laparoscopic surgery group. There was no statistically significant difference between the two groups in terms of infection development rates (P > .05). The rate of surgical drainage use and rehospitalisation was significantly higher in the group with wound infection than in the group without wound infection. (P < .05). We suggest that in terms of wound infection and wound healing, laparoscopic surgery should be the method of choice for patients with complicated appendicitis. In order to reduce the frequency of wound infection, drains should not be kept for a long time in patients undergoing appendectomy.     

Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis with abscess

Objective

Given the perceived technical demands of laparoscopic appendectomy and the expected postoperative morbidity in patients with a well-defined abscess, initial percutaneous drainage has become an attractive option in this patient population. This strategy allows for a laparoscopic appendectomy to be performed in an elective manner at the convenience of the surgeon. However, the medical burden on the patient and on the quality of patient outcomes has not been described in the literature. Therefore, we audited our experience with initial percutaneous drainage followed by laparoscopic interval appendectomy to evaluate the need for a prospective trial.

Methods

After institutional review board approval, a retrospective chart review was performed on all children who presented with perforated appendicitis and a well-defined abscess and were treated by initial percutaneous aspiration/drainage followed by interval appendectomy between January 2000 and September 2006. Continuous variables are listed with standard deviation.

Results

There were 52 patients with a mean age of 9.0 ± 3.9 years and weight of 34.4 ± 18.8 kg. The mean duration of symptoms at presentation was 8.4 ± 7.6 days. Percutaneous aspiration only was performed in 2 patients. The mean volume of fluid on initial aspiration/drain placement was 76.3 ± 81.1 mL. The mean time to appendectomy was 61.9 ± 25.2 days. The laparoscopic approach was used in 49 patients (94.2%), of which one was converted to an open operation. The mean length of hospitalization after interval appendectomy was 1.4 ± 1.4 days. A recurrent abscess developed in 17.3% of the patients. Six patients (11.5%) required another drainage procedure. The mean total charge to the patients was $40,414.02. There were 4 significant drain complications (ileal perforation, colon perforation, bladder perforation, and buttock/thigh necrotizing abscess). The child with the ileal perforation after drain placement is the only patient who failed initial nonoperative therapy.

Conclusions

The use of initial percutaneous aspiration/drainage of periappendiceal abscess followed by interval appendectomy is an effective approach. However, this management poses complication risks and uses considerable resources. Therefore, this strategy should be compared with early operation in a prospective trial.     

开腹和腹腔镜阑尾切除术治疗妊娠期急性阑尾炎的对照研究

目的 比较开腹阑尾切除术（open appendectomy,OA）和腹腔镜阑尾切除术（laparoscopic appendectomy,LA）治疗妊娠期急性阑尾炎的安全性及疗效.方法 回顾性分析我院2008年1月至2013年1月收治的68例妊娠早、中期急性阑尾炎的临床资料,其中OA组36例,LA组32例,并进行比对分析.结果 两组病例手术均顺利完成,OA组和LA组在妊娠相关并发症发生率上无明显差异（P＞0.05）;而在术后肛门排气时间、住院时间及术后并发症上,LA组均明显优于OA组,差异有统计学意义（P＜0.05）.结论 LA治疗妊娠早、中期急性阑尾炎是安全可行的,具有创伤小、术后恢复快、并发症少等优点.     

经脐单孔腹腔镜阑尾切除术联合加速康复外科治疗急性阑尾炎的可行性研究

目的 比较腹腔镜辅助阑尾切除术（TSLAA）与传统腹腔镜阑尾切除术（LA）的临床疗效和安全性。方法 回顾性分析2017年1月至2019年10月行腹腔镜阑尾切除术且围手术接受加速康复外科（ERAS）方案的急性阑尾炎患者,并根据手术方式分为两组：TSLAA组（47例）和TLA组（92例）。分析比较两组围手术期资料的异同。结果 TSLAA组与LA组在术前一般资料方面具有可比性;TSLAA组的病人术前BMI较低,腹痛持续时间较短。两组患者手术时间及术中出血量无差异。TSLAA组患者在住院期间疼痛控制及满意度评分均优于LA组。但两组术后胃肠功能恢复情况相似。TSLAA组总并发症、感染性并发症、非感染性并发症发生率低于LA组,但并无统计学差异。TSLAA组术中、围手术期费用均明显低于LA组（P<0.05）。结论 TSLAA是一种安全可行的技术,是急性阑尾炎的另一种有效且微创的选择。     

Time to appendectomy for acute appendicitis: A systematic review

Objective

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations regarding time to appendectomy for acute appendicitis in children within the context of preventing adverse events, reducing cost, and optimizing patient/parent satisfaction.

复杂性阑尾炎的腹腔镜术中处理及术后处理(附237例报告)

目的:探讨腹腔镜阑尾切除术(laparoscopic appendectomy,LA)治疗复杂性阑尾炎的术中及术后处理措施。方法:回顾分析为237例复杂性阑尾炎患者行LA的临床资料。结果:237例均顺利完成腹腔镜手术,无一例中转开腹。手术时间30～115 min,平均65 min;术中均放置腹腔引流管,一般于术后2～5 d拔除;住院4～12 d,平均7.8 d;切口感染9例,予以换药一周后好转;无肠管、输尿管损伤及肠漏发生。结论:LA具有患者创伤小、疼痛轻、肠功能恢复快、切口感染率低、住院时间短等优势,治疗复杂性阑尾炎可行、安全、有效,值得推广应用。