Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results with those achieved with open techniques. Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass, seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of 14 matched patients who had conventional palliative procedures. Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery (p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03). Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass surgery—i.e., high morbidity, high mortality, and long hospital stay. Received: 24 February 1999/Accepted: 13 May 1999     

Perforated Appendicitis: Is Laparoscopy Safe?

OBJECTIVE: The purpose of this study was to demonstrate the safety and efficacy of laparoscopy in children with perforated appendicitis. METHODS: This is a retrospective review of consecutive patients under the age of 18, operated on for perforated appendicitis between September 1997 and December 1999. RESULTS: Sixty-nine patients were operated on for perforated appendicitis. Eleven appendectomies were performed laparoscopically. Fifty-four patients underwent an open appendectomy. Four laparoscopic appendectomies were converted to an open procedure. The mean operative time was 79 minutes for the laparoscopic group, and 87 minutes for the open group. The mean length of hospital stay was 5.4 days versus 7.6 days for the laparoscopic and open groups, respectively. Neither of these differences was statistically significant. CONCLUSIONS: The above data support the use of laparoscopy in the management of perforated appendicitis in children. In conclusion, laparoscopy is as safe as open appendectomy. Laparoscopy is an effective alternative with a shorter length of hospital stay compared with that for an open appendectomy for perforated appendicitis in children.     

Pediatric laparoscopic appendectomy for acute appendicitis

Background: The benefit of laparoscopy in the treatment of pediatric acute appendicitis continues to be controversial, particularly as it relates to operative time and costs. Methods: We reviewed the charts of 200 children who underwent appendectomy for acute appendicitis concurrently over 35 months at a large teaching childrens hospital. Results: Laparoscopic (n = 106) and open (n = 95) appendectomies were performed. The operative times and postoperative lengths of hospital stay were similar for the two groups. The mean total hospital cost for the laparoscopic group ($5,572) was significantly higher than for the open group ($4,472); (p < 0.01). Conclusions: Notably, the results show similar operative times for laparoscopic and open appendectomy. The cost of laparoscopic appendectomy for acute appendicitis is higher than for the open procedure. This study challenges health care providers to reduce costs and develop new ways to measure beneficial outcomes in a pediatric population that may reveal laparoscopic benefits. Presented on 16 March 2002 at the SAGES Annual Scientific Session and 8th World Congress in New York, NY     

Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy

Background The role of laparoscopic appendectomy for perforated appendicitis remains controversial. This study aimed to compare laparoscopic and open appendectomy outcomes for children with perforated appendicitis. Methods Over a 36-month period, 111 children with perforated appendicitis were analyzed in a retrospective review. These children were treated with either laparoscopic (n = 59) or open appendectomy. The primary outcome measures were operative time, length of hospital stay, time to adequate oral intake, wound infection, intraabdominal abscess formation, and bowel obstruction. Results The demographic data, presenting symptoms, preoperative laboratory values, and operative times (laparoscopic group, 61 ± 3 min; open group, 57 ± 3 were similar for the two groups (p = 0.3). The time to adequate oral intake was 104 ± 7 h for the laparoscopic group and 127 ± 12 h for the open group (p = 0.08). The hospitalization time was 189 ± 14 h for the laparoscopic group, as compared with 210 ± 15 h for the open group (p = 0.3). The wound infection rate was 6.8% for the laparoscopic group and 23% for the open group (p < 0.05). The wounds of another 29% of the patients were left open at the time of surgery. The postoperative intraabdominal abscess formation rate was 13.6% for the laparoscopic group and 15.4% for the open group. One patient in each group experienced bowel obstruction. Conclusions Laparoscopic appendectomy for the children with perforated appendicitis in this study was associated with a significant decrease in the rate of wound infection. Furthermore, on the average, the children who underwent laparoscopic appendectomy tolerated enteral feedings and were discharged from the hospital approximately 24 h earlier than those who had open appendectomy.     

Trends in utilization and outcomes of laparoscopic versus open appendectomy

BACKGROUND: Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals. METHODS: Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs. RESULTS: Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 (P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups (US$ 6,242 vs US$ 6,260). CONCLUSIONS: Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.     

Intra-abdominal abscesses following laparoscopic and open appendectomies

Recent findings in a small number of studies have suggested a trend toward increased infectious complications following laparoscopic appendectomy. The purpose of the present review was to evaluate the incidence of postappendectomy intra-abdominal abscess formation following laparoscopic and open appendectomies. Using the surgical database of the Los Angeles County-University of Southern California Medical Center, we reviewed the records of all appendectomies performed at the center between March 1993 and September 1995. Incidental appendectomies as well as appendectomies in pediatric patients under the age of 18 years were excluded. A total of 2497 appendectomies were identified; indications for these procedures included acute appendicitis in 1422 cases (57%), gangrenous appendicitis in 289 (12%), and perforated appendicitis in 786 (31%). The intraoperative diagnosis made by the surgeon was used for classification. A two-tailedP value of <0.05 was considered significant. There was no significant difference in the rate of abscess formation between the groups undergoing open and laparoscopic appendectomies for acute and gangrenous appendicitis. In patients with perforated appendicitis, a total of 26 postappendectomy intra-abdominal abscesses occurred following 786 appendectomies for an over-all abscess formation rate of 3.3%. Eighteen abscesses occurred following 683 open appendectomies (2.6%), six abscesses occurred following 67 laparoscopic appendectomies (9.0%), and the remaining two abscesses occurred following 36 converted cases (5.6%). For perforated appendicitis, however, there was a statistically significant increase in the rate of abscess formation following laparoscopic appendectomy compared to conventional open appendectomy (9.0% vs. 2.6%,P=0.015). There was no significant difference in the rate of abscess formation between open vs. converted cases or between laparoscopic vs. converted cases. A comparison of the length of the postoperative hospital stay showed no significant difference between open and laparoscopic appendectomy for perforated appendicitis (6.1 days vs. 5.9 days). Laparoscopic appendectomy for perforated appendicitis is associated with a higher rate of postoperative intra-abdominal abscess formation without the benefit of a shortened hospital stay. Given these findings, laparoscopic appendectomy is not recommended in patients with perforated appendicitis. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese

BACKGROUND: The current study compared the outcome of morbidly obese patients undergoing laparoscopic versus open appendectomy. METHODS: We obtained data from the University HealthSystem Consortium (UHC) database on 1,943 morbidly obese patients who underwent appendectomy for acute or perforated appendicitis between 2002 and 2007. RESULTS: Compared to open appendectomy, laparoscopic appendectomy was associated with a shorter length of stay (3 vs 4 days) and a lower overall complication rate (9% vs 17%). Most notably, a lower rate of wound infection was noted (1% vs 3%). Within a subset analysis of morbidly obese patients who underwent appendectomy for perforated appendicitis, there was a higher overall complication rate (27% vs 18%) and cost ($16,600 vs $12,300) in the open appendectomy group. CONCLUSION: In the morbidly obese, laparoscopic appendectomy performed for acute and perforated appendicitis is associated with a shorter length of stay and lower morbidity and costs. Laparoscopic appendectomy should be the procedure of choice for the treatment of acute appendicitis in the morbidly obese population.     

Appendectomy in the pre- and postlaparoscopic eras

The role of laparoscopic appendectomy remains controversial since many authors have suggested that overall morbidity is primarily a function of the degree of appendicitis rather than the operative approach. We have reviewed our appendectomy experience to determine the advantages and/or disadvantages of the laparoscopic technique in cases of acute appendicitis, and furthermore to ascertain whether the extent of disease should affect the surgical approach used. Data were accumulated for all 1158 patients who underwent appendectomy at a single institution during the following three time periods that span the pre- and postlaparoscopic eras: period I (1987 to 1990), period II (1991 to 1993), and period III (1994 to 1997). Cases were categorized with regard to pathologic findings and operative approach (i.e., open or laparoscopic appendectomy). The percentage of appendectomies performed laparoscopically increased with time (0%, 27%, and 79% for periods I, II, and III, respectively). Overall, the total operating room time was slightly shorter for laparoscopic compared to open appendectomy (99 vs. 102 minutes; P <0.05). Operating room times for open appendectomy remained unchanged, but the times for laparoscopic appendectomy decreased from period II to period III (119 to 94 minutes; P <0.001). In cases of gangrenous/perforated appendicitis, the times for laparoscopic appendectomy were significantly shorter than those for open appendectomy (98/115 vs. 120/125 minutes; P <0.001 for both). Overall, the hospital stay was shorter for patients undergoing laparoscopic appendectomy (1.63 vs. 4.21 days; P <0.001), and the difference was maintained in all three time periods. The differences in length of hospital stay for laparoscopic vs. open appendectomy were most dramatic in gangrenous/perforated cases (1.8/3.0 vs. 4.0/9.0 days; P <0.001), whereas there was only a slight difference in cases of simple appendicitis, for example, 1.6 vs. 2.1 days (laparoscopic vs. open appendectomy, period III). There was a significant decrease in the percentage of perforated cases in which surgical treatment had been delayed (>8 hours) (21%, 5%, and 5%) over the three time periods, but the rate of "negative" appendectomies was similar (10%, 8%, and 8%). The complication rates following laparoscopic and open appendectomies during period II were 5.4% and 7.5%, respectively (P >0.05). Laparoscopic appendectomy results in a marked decrease in the length of hospital stay and similar postoperative morbidity compared to open appendectomy. In cases of gangrenous or perforated appendicitis, laparoscopic appendectomy appears to be especially worthwhile in regard to both operating room time and hospital stay. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998. Supported by the Harvard Center for Minimally Invasive Surgery.     

Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain

Background: Removing the normal appendix when operating for suspected acute appendicitis is the standard of care. The use of laparoscopy should not alter this practice. Methods: Retrospective review of 72 patients found to have grossly normal appendices while undergoing laparoscopy for suspected appendicitis. Twenty-eight patients underwent diagnostic laparoscopy (DL) alone while 44 patients underwent diagnostic laparoscopy with incidental laparoscopic appendectomy (ILA). Results: There was no difference in length of hospitalization (DL = 44 h, ILA = 43 h, p= 0.49) or morbidity (DL = 11%, ILA = 5%, p= 0.37). One patient required appendectomy 11 days after diagnostic laparoscopy for recurrent acute right lower quadrant abdominal pain. Five percent of resected appendices (2/44) demonstrated acute inflammation upon pathologic review. Conclusions: Laparoscopic removal of the normal appendix produces no added morbidity or increase in length of hospitalization as compared to diagnostic laparoscopy. It demonstrates cost effectiveness by preventing missed and future appendicitis. Incidental laparoscopic appendectomy is the preferred treatment option. Received 3 April 1997/Accepted: 3 July 1997     

Laparoscopic interval appendectomy for periappendicular abscess

Background: Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess. Methods: This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8–10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998. Results: Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections. Conclusion: We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay. Received: 13 May 1999/Accepted: 9 December 1999/Online publication: 12 July 2000     

Laparoscopic versus Open Appendectomy in Children: A Retrospective Comparative Study of 2,332 Cases

Aim The laparoscopic treatment of paediatric appendicitis remains controversial, especially in the presence of complications. This study evaluated the outcomes of open appendectomy (OA) and laparoscopic appendectomy (LA) by analysing the data from a multicentre study. Methods The authors retrospectively reviewed a series of 2,332 appendectomies (1,506 LA and 826 OA) performed in children and adolescents (median age 8 years) in 9 different centres of paediatric surgery. For the patients operated using laparoscopy, an IN procedure was employed in 921 (61.2%), an OUT procedure in 571 (37.9%) and a MIXED procedure in 14 (0.9%). In the open surgery, a McBurney incision was adopted in 795 patients (96.4%). Results Median duration of surgery was 40 minutes for LA and 45 minutes for OA. Median hospital stay was 3 days (LA) and 4.3 days (OA) in case of simple appendicitis and 5.2 days (LA) and 8.3 days (OA) in case of peritonitis. Complications were recorded in 124 LA cases (8.2%) and 65 OA cases (7.9%). The conversion rate in laparoscopy was only 1.6% (25 cases). The statistical analysis was performed using the Mann–Whitney test, and the main significant difference that emerged was the length of hospital stay, which was in favour of laparoscopy compared with open surgery (P < 0.0001). Conclusions We conclude that in clinical settings where laparoscopic surgical expertise and equipment are available and affordable, LA seems to be an effective and safe alternative to OA. Three out 9 centres participating in our survey perform LA in all patients with a suspicion of appendicitis. Our study shows that laparoscopy significantly reduces hospital stay in case of appendicitis and peritonitis and presents an extremely low conversion rate (1.6%) to open surgery. Laparoscopic transumbilical appendectomy (37.9%) in our series seems to be a simple option, even for less-skilled laparoscopic surgeons.     

Laparoscopic appendectomy—is it worthwhile?

Background: Clinical diagnosis of acute appendicitis is most difficult in fertile-age women. In this patient group up to 50% of open appendectomies are negative for appendicitis. We conducted a randomized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis. Methods: Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were randomized, 25 to laparoscopy and 25 to an open appendectomy. Diagnostic accuracy, rate of negative appendectomies, safety, and final outcome were compared in the two groups. Results: Diagnosis was established in 96% of patients in the laparoscopic group and in 72% in the open group. There were 11 (44%) unnecessary appendectomies in the open group, but only one (4%) in the laparoscopic group (p < 0.0005). Conclusions: In young women with right lower abdominal pain, laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies. Received: 18 March 1996/Accepted: 12 June 1996     

Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery.

BACKGROUND: Laparoscopic surgery has reduced the length of hospital stay for common operations like cholecystectomy, gastric fundoplication, and appendectomy. We have noticed a reduction in length of hospital stay for children undergoing laparoscopic appendectomy. We, therefore, looked at our data to assess whether laparoscopic appendectomy in children could be performed as fast-track or same-day surgery (< or = 24-hour postoperative stay). METHODS: We performed a retrospective review of the records of all children who underwent laparoscopic appendectomy for suspected appendicitis during a 3-year period (7/97 to 7/00). RESULTS: Laparoscopic appendectomy was performed in 79 children (44 boys and 35 girls), between 2 to 17 years of age (mean, 11 years). In 4 (5%) children with perforated appendicitis, the laparoscopic appendectomy was converted to an open appendectomy. At operation, 51 (64.5%) had acute appendicitis, 22 (27.8%) had perforated appendicitis, 4 (5%) had ruptured ovarian cysts, and 2 (2.5%) had no pathology. The median operative time was 54 minutes. Total length of stay for all 79 patients was a median of 58 hours, and median postoperative LOS was 35 hours. Complications included wound infection (2), abdominal abscess (4), drug rash (2), and epididymo-orchitis (1). In 57 (72%) children without perforated appendicitis, the total length of hospital stay was a median of 42 hours, while median postoperative length of stay was only 28 hours. Thirty-two (56%) children went home in < or = 24 hours following laparoscopic appendectomy. No significant morbidity was noted in the nonperforated group (drug rash, 1 fever > 24 hrs, 3); and no readmissions or reoperations were necessary on follow-up. CONCLUSION: Laparoscopic appendectomy is safe and effective for treating children with appendicitis. Laparoscopic appendectomy may be safely performed as fast-track or same-day surgery, in select children without perforated appendicitis, with a postoperative stay of < or = 24 hours.     

Comparison between laparoscopic and conventional omental patch repair for perforated duodenal ulcer

Background: The aim of the study is to evaluate the safety and efficacy of laparoscopic omental patch repair. Method: This is a retrospective review of 53 consecutive patients with omental patch repair for perforated duodenal ulcer; 38 underwent conventional open approach and 15 underwent laparoscopic patch repair. The only selection criterion was availability of expertise for laparoscopic repair on the day of admission. By chance, the open group had poorer ASA scores. There were four deaths and five postoperative complications in the open group. Results: Laparoscopic repair was successful in 14 cases with one postoperative complication. Operative time was longer in the laparoscopic group (80 vs 65 min in open group, p= 0.02). Patients required less postoperative analgesics in the laparoscopic group (median amount of pethidine was 75 mg vs 175 mg in the open group, p= 0.03). There was no statistically significant difference in terms of hospital stay and return to normal activities between the two procedures. Follow-up Visick scores were comparable in both groups. Conclusions: Laparoscopic omental patch repair offers a safe alternative to the conventional method and causes less postoperative pain. Received: 29 December 1995/Accepted: 3 May 1996     

Selective use of diagnostic laparoscopy in patients with suspected appendicitis

Background: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. Patients and Methods: All patients referred to our hospital with suspected appendicitis during the period 1994–1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. Results: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. Conclusions: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed. Received: 7 September 1999/Accepted: 21 February 2000/Online publication: 22 August 2000     

Laparoscopic Appendectomy for Perforated Appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p <0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p < 0.05). The surgeon’s experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.     

Macroscopic assessment of the appendix at diagnostic laparoscopyis reliable

Background: Healthy-looking appendixes are often removed at laparoscopy for suspected appendicitis. This practice may have adverse secondary effects. Methods: We reviewed the literature for the years 1978 to 1998 to analyze the negative appendectomy rates, complication rates, the accuracy of laparoscopic appendix assessment, and the incidence of false negative diagnosis of appendicitis at surgical and gynecological laparoscopy. Results: The respective negative appendectomy rates were 22% and 15% in studies that compared laparoscopic with open appendectomy. The appendix was left in situ in 37% of 4,281 surgical diagnostic laparoscopies. There were instances of missed appendicitis among the 3,367 gynecological diagnostic laparoscopies performed on women for lower abdominal pain, and there were 188 appendectomies in this group. Studies comparing the macroscopic appearance of the appendix at operation with microscopic findings from the excised specimen had a false negative error rate of 3%. Conclusions: Contrary to general opinion, there is no substantial evidence to support the assumption that the macroscopic diagnosis of appendicitis is unreliable. High rates of conflicting diagnoses of excision specimens suggest that endoappendicitis has little clinical significance. At present, negative appendectomy rates are considerably higher for laparoscopic appendectomy than for the open approach. The role of diagnostic laparoscopy in suspected appendicitis should be reconsidered. It may be useful in particular subgroups of patients, but it is no substitute for good clinical judgment. Furthermore, it is not always necessary to perform an incidental appendectomy. Received: 7 September 1999/Accepted: 21 October 1999/Online publication: 30 May 2000     

Laparoscopic vs open splenectomy in the management of hematologic diseases

Background: Laparoscopic splenectomy (LS) is becoming the gold standard in the treatment of several splenic diseases. Shorter postoperative stay and more rapid return to full activity are the primary advantages of LS. Methods: Prospective data collection of 44 consecutive LS (group 1) and comparison with a historical control group of 56 consecutive open splenectomies (OS) (group 2) were performed for hematologic diseases. Results: The LS patients started earlier on an oral diet (p < 0.0001) and left the hospital sooner (p < 0.0002) than OS patients. Less blood transfusion (p < 0.004) and pain medication (p < 0.0001) was required by LS patients. They also had fewer postoperative complications (p < 0.03). Compared by diagnosis, patients with laparoscopic idiopathic thrombocytopenic purpura or Hodgkin's disease started to eat earlier (p < 0.0001) and left the hospital sooner (p < 0.01). Multivariate analysis showed that time to oral diet and postoperative stay was related to operative technique and age. Morbidity and pain medications were related, respectively, to transfusion requirements and type of surgical approach. Conclusions: Used to manage hematologic diseases, LS is feasible, effective, and safe. It offers several advantages over the open approach. The type of surgical approach seems to be the crucial factor in determining the length of the postoperative course. Received: 16 July 1998/Accepted: 20 January 1999     

Laparoscopic versus open appendectomy for complicated appendicitis

BACKGROUND: Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis; various reports demonstrated its merits in assisting diagnosis, reducing postoperative pain, analgesic requirement, and incidence of wound infection. The role of laparoscopy in management of complicated appendicitis, ie, gangrenous, perforated appendicitis and appendiceal abscess, remains undefined. Currently, the choice of operative approach is mostly at the surgeons' discretion. A retrospective study was conducted in our institution to review the feasibility, safety, and efficacy of laparoscopic appendectomy for patients with complicated appendicitis. STUDY DESIGN: From January 1999 to January 2004, records of patients older than 14 years of age with diagnosis of appendicitis were retrieved from computer database for analysis. All patients underwent diagnostic laparoscopy to confirm diagnosis of complicated appendicitis, and patients subsequently underwent either laparoscopic or open appendectomies. Patients' demographics data and perioperative outcomes from the two groups were compared. RESULTS: During the study period, 1,133 patients with acute appendicitis underwent operations in our institution. Two hundred forty-four patients (21.5%) with complicated appendicitis were identified by laparoscopy, of which 175 underwent laparoscopic appendectomy (LA) and 69 had open appendectomy (OA). Both groups of patients were comparable in demographics. Mean operative time was 55 minutes for LA group and 70 minutes for the OA group (p<0.001). Mean hospital stay was 5 days and 6 days for LA and OA group respectively (p<0.001). There was one conversion patient (0.6%) in the LA group who suffered from wound infection, and there were seven (10%) wound infections in the OA group (p=0.001). There were 10 cases (5.7%) of intraabdominal collection in the LA group and 3 (4.3%) in the OA group (p=0.473). There was no mortality in the current series. CONCLUSIONS: Laparoscopic appendectomy for complicated appendicitis is feasible and safe. It is associated with a significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay when compared with patients who had open appendectomy.     

Laparoscopic appendectomy is safe and efficacious for the elderly: an analysis using the National Surgical Quality Improvement Project database

Background

Despite increasing use of laparoscopic appendectomy, data demonstrating outcomes of this technique exclusively among the elderly population are scarce. This study aimed to compare 30-day postoperative morbidity and length of hospital stay among elderly patients after appendectomy.

Methods

Appendicitis patients older than 65?years were extracted from the National Surgical Quality Improvement Project (NSQIP) database. Demographics and rates of complications for patients undergoing open and laparoscopic appendectomies were compared. Uni- and multivariate analyses adjusted for differences between groups compared the end points of major and minor complications as well as the days of hospital stay after initial surgery.

Results

A total of 3,335 patients underwent appendectomy, with 2,235 patients (67%) receiving a laparoscopic procedure. The open appendectomy patients were significantly older and more likely to have various preoperative comorbidities (p?<?0.05). No difference in median operative time between the two techniques was found. Both required 51?min (p?=?0.11). The open cases had higher rates of both major and minor postoperative complications than the laparoscopic cases (p?<?0.0001), both overall and before discharge. Multivariate analysis showed no association between operative approach and major complications, and a reduced risk of minor complications with laparoscopy. Length of surgical stay was longer for the open group than for the laparoscopically treated group (median, 4?days vs 2?days; p?<?0.05). After adjustment, laparoscopy still was significantly associated with a shorter hospital stay than open appendectomy (p?<?0.0001).

Conclusions

Laparoscopic appendectomy is a safe procedure for elderly patients. During the 30-day postoperative period, no correlation with major complications was found, and the findings showed a beneficial association with regard to minor complications. After adjustment for perioperative factors, laparoscopy is associated with a shorter hospital stay than open appendectomy.