Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

Single-incision laparoscopic surgery in children: initial single-center experience

Background

In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures.

Method

A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010.

Results

There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients.

Conclusion

This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.     

Laparoscopic versus open appendectomy in children with uncomplicated and complicated appendicitis

Purpose

To address whether laparoscopic appendectomy could be an alternative to conventional open appendectomy in children with complicated appendicitis as well as uncomplicated appendicitis, a retrospective study comparing laparoscopic and open appendectomies was performed.

Methods

One hundred patients who were treated by immediate appendectomy, either laparoscopically or by the open method, between May 2000 and August 2003 were included in the study. There were 53 patients in the laparoscopic appendectomy group and 47 patients in the open appendectomy group.

Results

The operating time was significantly longer for laparoscopic appendectomy than for open appendectomy (P < .001). The length of hospital stay was significantly shorter in laparoscopic appendectomy in patients with uncomplicated appendicitis (P = .001). Thirteen of the 100 patients (13.0%) had 15 postoperative complications including wound infection (n = 8), intraabdominal abscess (n = 4), stitch abscess (n = 2), and small bowel obstruction (n = 1). In both uncomplicated and complicated appendicitis, there was no significant difference between laparoscopic and open appendectomies in the complication rates, and the incidences of each complication did not differ between the procedures. Among the 14 patients with generalized peritonitis, postoperative complications were seen in 5 patients (35.7%). Although the presence of generalized peritonitis was associated significantly with postoperative complications (P = .017), there was no significant association between the procedure and complications. Overall treatment costs were increased by 26.0% in laparoscopic appendectomy.

Conclusions

Laparoscopic appendectomy should remain an option in children with uncomplicated and complicated appendicitis, and when laparoscopy is selected, consideration of the advantages and disadvantages of the procedure is essential.     

Single-incision laparoscopic surgery: feasibility for pediatric appendectomies

Introduction

Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery using a single incision. The end result is a lone incision at the umbilicus for a perceived scarless abdomen. We report our early experience using the SILS technique for appendectomies in the pediatric population.

Methods

A retrospective chart review was performed on our first patients to undergo SILS appendectomy (SILS-A) or laparoscopic appendectomy (LAP-A) during the same period at a freestanding children's hospital.

Results

Thirty-nine patients were reviewed. Nineteen patients underwent SILS-A (8.7 ± 0.76 [SEM] years old), and 20 patients underwent LAP-A (10.5 ± 0.87 years old, 2-17). Ages were 19 months to 14 years in the SILS-A group, with 21% (4 patients) not older than 6 years. Median weight for SILS-A was 32 kg (14.5-80.3). Twelve patients had acute nonperforated appendicitis (62%). Mean duration of operation was 58 ± 5.6 (30-135) minutes vs 43 ± 3.6 (30-85) minutes for standard LAP-A. Two patients were converted to a transumbilical appendectomy, one for inability to maintain a pneumoperitoneum and one for extensive adhesions. Postoperative complications consisted of one wound seroma. No wound infections, hernias, readmissions, or difference in length of stay were noted.

Conclusion

The SILS approach for acute appendicitis is feasible in the pediatric population even in patients as young as 19 months. Operating room times are somewhat longer than with LAP-A, but should decrease with improved instrumentation and experience. Larger studies and further technical refinements are needed before its widespread implementation.     

Oncologic outcomes after resection of rectal cancer: Laparoscopic versus open approach

Background

This study examined outcomes of laparoscopic and open rectal cancer surgery in a community hospital setting.

Methods

A community health care system cancer registry was reviewed retrospectively (2004-2007) for rectal cancer patients undergoing surgical treatment. Primary end points were rates of recurrence and survival.

Results

Both open and laparoscopic resection groups had similar demographic, treatment, and tumor characteristics. Most patients in the open resection and laparoscopic resection populations experienced no recurrence (79% vs 83%, respectively; P = .5). Overall, the groups had similar mean (88% vs 96%, respectively; P = .4) and disease-free (21 and 23 months, respectively; P = .5) survival.

Conclusions

In a community hospital setting, laparoscopic resection of rectal cancer was found to be as safe and effective as open resection in selected patients.     

Laparoscopic drainage of intraabdominal abscess after appendectomy: an alternative to laparotomy in cases not amenable to percutaneous drainage

Purpose

Postoperative abscesses after appendectomy occur in 3% to 20% of cases and are more common in cases of perforated appendicitis. Smaller abscesses are often amenable to antibiotic therapy, but surgical drainage remains the mainstay of treatment for larger collections. Surgical options generally include percutaneous drainage and open laparotomy. Laparoscopic drainage of these abscesses has not been well characterized in the pediatric population.

Objective

The aim of this study was to describe our experience with laparoscopic drainage of postappendectomy abscesses that were not amenable to percutaneous drainage.

Methods

This study is a retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis at a tertiary pediatric medical center during a 4-year period (2006-2009). The review focuses on patients who developed abscesses after appendectomy, were unable to undergo percutaneous drainage, and were treated with laparoscopic abscess drainage.

Results

Twelve patients (7 male and 5 female) underwent laparoscopic drainage of postappendectomy abscesses. The mean age was 8.5 years old (range, 3-14 years). A clinical diagnosis of postoperative abscess was made when fevers, pain, and leukocytosis persisted despite broad-spectrum antibiotics. Computed tomography was performed in all patients. Abscesses ranged between 3 and 11 cm in size. The mean length of time between initial appendectomy and drainage procedure was 10 days. There were no complications specifically related to the laparoscopic drainage procedure. The mean length of the drainage procedure was 77 minutes (range, 30-196 minutes). The mean hospital length of stay after laparoscopic drainage was 6.5 days (range, 3-13 days) with patients maintained on intravenous antibiotics until afebrile and without leukocytosis.

Conclusion

Laparoscopic drainage is a safe and effective alternative for intraabdominal abscesses that occur after laparoscopic appendectomy. We recommend it as an alternative to open laparotomy when percutaneous drainage is not an option.     

Laparoscopic Appendectomy in Children

Background and Objectives:

The advantages of laparoscopic appendectomy over open appendectomy have not yet been clearly demonstrated. The present study evaluated our early experience with laparoscopic appendectomy in children, in terms of its safety, effectiveness, technical difficulties, and economics.

Methods:

We reviewed the records of 50 cases involving laparoscopic appendectomy performed at our affiliated institutions between September, 1994, and September, 1996. Patient age ranged from 6 to 18 years (mean, 14 years). Thirty-two patients had acute nonperforated appendicitis, six had perforated appendicitis, two had fibrosis of the appendix, and ten had a histologically normal appendix.

Results:

In five patients the laparoscopic procedures were converted to open appendectomies because of technical difficulties. There were postoperative complications in four patients: one incomplete appendectomy which subsequently required an open appendectomy for completion, one pelvic abscess, one bowel obstruction, and one minor wound infection.

Conclusions:

Laparoscopic appendectomy is a safe and effective procedure. It takes longer operative time than open appendectomy. Length of hospitalization and incidence of postoperative complications are equivalent to those of open appendectomy. Economic benefits are difficult to assess at present. In sum, we believe that with better training, surgical techniques and equipment, laparoscopic appendectomy will eventually become the surgical procedure of choice in appendicitis.     

Accuracy of computed tomography in predicting appendiceal perforation

Background

Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans.

Methods

A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups.

Results

In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%.

Conclusions

This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.     

The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study

Purpose

Cyst excision with hepaticojejunostomy has been the classic procedure for treating choledochal cysts. Recently, laparoscopic treatment of the disease has gained popularity worldwide. The aim of this study is to evaluate whether laparoscopic management of choledochal cysts is as feasible and safe as conventional open surgery in children with this disease.

Methods

A retrospective study comparing the laparoscopic and the open procedures was performed in 77 consecutive patients with choledochal cyst in our hospital. Thirty-nine patients operated on between June 2001 and September 2003 were in the laparoscopic group, whereas 38 patients in the open group were operated on between February 1999 and May 2001.

Results

Patient demographics were similar between the 2 groups. The duration of operation was significantly longer in the laparoscopic group than in the open group (median, 230 vs 190 minutes; P < .001). In contrast, the durations of delayed oral feeding and hospital stay postoperatively were significantly shorter in the laparoscopic group (median, 4 vs 5 days [P < .01] and median, 5 vs 7 days [P < .01], respectively.) There were no differences in the early and late complication rates between the 2 groups.

Conclusions

Laparoscopic treatment of choledochal cyst in children is feasible and safe. For experienced centers, this procedure can be recommended.     

Post-operative antibiotic use in nonperforated appendicitis

Background

The appropriate use of preoperative antibiotics in patients undergoing appendectomy for acute appendicitis has been shown to decrease the rate of surgical site infections (SSIs). The benefits of postoperative courses of antibiotics in these patients, however, remain unclear.

Methods

The authors retrospectively reviewed all cases of nonperforated appendicitis performed at their institution over a 10-year period from 1997 to 2007. Patient outcomes were evaluated to include the postoperative development of SSIs, urinary tract infections, diarrhea, and Clostridium difficile infections.

Results

A total of 763 patients who underwent appendectomy for nonperforated appendicitis during the study period were identified. Five hundred seven of these patients had appropriate follow-up data and were the subjects of this study. Comparing patients who did and did not receive postoperative antibiotics, no significant differences in the rates of all SSIs (10% vs 9%, P = .64), superficial SSIs (9.3% vs 5.4%, P = .13), deep SSIs (.3% vs .5%, P = 1.0), organ space SSIs (2.8% vs 2.7%, P = .87), urinary tract infections (.6% vs .5%, P = 1.0), and diarrhea (2.5% vs 1.1%, P = .34) were found between groups.

Conclusions

The use of postoperative antibiotics in patients with nonperforated appendicitis does not decrease the rate of SSIs, while it may increase the cost of care.     

Single center experience in single-incision laparoscopic surgery in children in Turkey

Purpose

Minimally invasive surgery has evolved into single-incision laparoscopic surgery (SILS) in the recent years. Few reports have addressed the practicality of SILS in children. Our current experience with regard to feasibility and effectiveness of SILS in children is presented.

Methods

A retrospective review of the operative database for patients operated on using SILS in our department from March 2009 to July 2010 was performed. Data regarding the type of the procedure, age, sex, operative performance, hospital stay, and complications were collected.

Main Results

Among 43 patients, cholecystectomy was performed in 11; appendectomy, in 10; unroofing for ovarian cysts, in 5; unroofing for splenic cysts, in 4; oophorectomy, in 6 (ovarian torsion, 2; teratoma, 4); ovary-preserving teratoma excision, in 1; splenectomy, in 1; gonadectomy, in 3; and varicocelectomy, in 2. There were no conversions to standard laparoscopic or open techniques. The only postoperative complication was a wound infection that occurred after an appendectomy.

Conclusion

Although currently more expensive, SILS can be performed in children in almost every pediatric surgical procedure that can be accomplished with conventional laparoscopic techniques. The most significant contribution of SILS procedure is cosmesis. Postoperative pain and length of hospital stay were not improved.     

Comparison of the incidence of complications in open and laparoscopic pyloromyotomy: a concurrent single institution series

Purpose

The purpose of this study was to compare the incidence and type of technical complications seen in a concurrent series of pyloromyotomies done open and laparoscopically.

Methods

The medical records of all patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis over a 66-month period were reviewed (n = 457). Information obtained included age, sex, weight, operating time, and intraoperative and postoperative complications.

Results

Four hundred fifty-seven pyloromyotomies were equivalently divided between the 2 techniques (232 laparoscopic, 225 open). Demographic characteristics and operating times were similar. There were no deaths in the series. The overall incidences of complications were similar in the 2 groups (open, 4.4%; laparoscopic, 5.6%). There was a greater rate of perforation with the open technique and a higher rate of postoperative problems including incomplete pyloromyotomy in the laparoscopic group.

Conclusions

The open and laparoscopic approaches have similar overall complication rates. The distribution and the type of complications differ, however.     

Smaller scars--what is the big deal: a survey of the perceived value of laparoscopic pyloromyotomy

Purpose

Laparoscopic and open pyloromyotomies are equally safe and effective, with the principal benefit of laparoscopy being better cosmesis. The goal of this study was to measure the perceived value of laparoscopic pyloromyotomy.

Methods

Four hundred sixteen subjects (177 college freshmen, 126 first-year medical students, and 101 parents) were asked to complete a questionnaire after photographs of mature pyloromyotomy (open and laparoscopic) scars were shown to them. To measure the perceived value, subjects' willingness to pay hypothetical additional out-of-pocket expenses for their preferred operation was assessed. Data were analyzed using Cochran-Mantel-Haenszel test, t test and multivariable regression.

Results

Four hundred four surveys were complete. Overall, 74% preferred the appearance after laparoscopy. Eighty-eight percent would pay an additional out-of-pocket amount for their daughter and 85% for their son to have the cosmetic outcome after laparoscopy. Respondents were willing to pay more for their daughters (P < .0001) and sons (P < .0001) than themselves. As expected, income level (P < .0001) influenced the willingness to pay, whereas ethnicity, education, number of children, and sex did not.

Conclusions

The cosmetic benefit of laparoscopic pyloromyotomy was valued by a wide demographic with 85% being willing to pay additional expenses for their children to have smaller scars.     

Early experience with single incision laparoscopic surgery: eliminating the scar from abdominal operations

Purpose

Single incision laproscopic surgery (SILS) involves performing abdominal operations with laparoscopic instruments placed through a single, small umbilical incision. The primary goal is to avoid visible scarring. This is the first report of SILS cholecystectomy in children and the first report in the literature of SILS splenectomy.

Methods

A retrospective chart review was performed in 20 consecutive inpatient SILS procedures (13 males, 7 females; ages 2-17 years) from May to December 2008. Outcome measures included need for conversion, operative time, time to oral analgesia, length of hospitalization, cosmetic outcome, and complications.

Results

There were 4 total splenectomies, 3 cholecystectomies, 2 combined splenectomy/cholecystectomies, and 11 appendectomies performed. All procedures were completed successfully without need for conversion to standard laparoscopy or open surgery. Mean operative time was 90 minutes for splenectomy, 68 minutes for cholecystectomy, 165 minutes for combined splenectomy/cholecystectomy, and 33 minutes for appendectomy. Mean hospital stay was 1 day for appendectomy, 1 day for cholecystectomy, and 2.5 days for splenectomy. One splenectomy patient received 1 U packed red blood cell transfusion. All appendectomy patients were converted to oral analgesia within 24 hours and splenectomy patients within 48 hours. All families were very pleased with the cosmetic outcome.

Conclusion

Single incision laparoscopic surgery is feasible for a variety of pediatric general surgical conditions, allowing for scarless abdominal operations. This early experience suggests that outcomes are comparable to standard laparoscopic surgery but with improved cosmesis, however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain or recovery. Surgeons performing SILS should have a firm foundation of advanced minimal access surgical skills and a cautious, gradated approach to attempting the various procedures. Technological refinements will further enable SILS.     

Incidence and risk factors for the development of incisional hernia following elective laparoscopic versus open colon resections

Background

There are few studies that compare the incidence of incisional hernia following elective laparoscopic colon resection to open colectomy and determine the risk factors for its development.

Methods

Elective open and laparoscopic colon resections performed between February 2002 and May 2007 were reviewed. In the laparoscopic group, mesenteric transection was performed via intracorporeal division for left-sided colectomy and via extracorporeal technique for right-sided colectomy. The ileocolic anastomosis was performed by extracorporeal stapling for right colectomies and by intracorporeal for left colectomies.

Results

Two hundred eighteen patients (mean age 62 years, 52% male) underwent elective colon resection (50% open, 5% hand-assisted, and 45% laparoscopic). Six percent of the cases that started as laparoscopic were converted and are included in the open group. Mean follow-up was 26 months. The overall incisional hernia rate was 16% (open and minimally invasive group 17% vs 15%, P = .14). Hernia was not dependent on the type of resection, indication, or extraction site. Body mass index >36 kg/m², male gender, and surgical site infection were risk factors for hernia development.

Conclusions

Laparoscopic colectomy does not reduce the development of incisional hernia.     

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

Objective

The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.

Data Source

Data were obtained from PubMed, MEDLINE, and citation review.

Study Selection

We conducted a literature search using “appendicitis” combined with “antibiotics” with children as the target patient population. Studies were selected based on relevance for the following questions:

(1)

What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis?

(2)

For patients with perforated appendicitis treated with appendectomy:

a.

What perioperative intravenous antibiotics should be used?

b.

How long should perioperative intravenous antibiotics be used?

c.

Should oral antibiotics be used?

(3)

For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?

Results

Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.

Conclusions

Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.     

Factors affecting innovation in pediatric surgery: hospital type and appendectomies

Background

There are little data on whether patient or hospital characteristics affect utilization of innovative surgical techniques in children, especially with respect to laparoscopic appendectomy (LA), whose benefit over existing treatment remains unproven. This study examines the patterns of LA using a national database, focusing on variations in care between children's and general hospitals.

Methods

Using data from the 2000 Healthcare Costs and Utilization Project Kid's Inpatient Database for patients aged 5 to 20 years with a discharge diagnosis of appendectomy, we analyzed the relationship between LA and patient demographic and hospital characteristic variables.

Results

The Healthcare Costs and Utilization Project Kid's Inpatient Database included 50,825 pediatric appendectomies (26% LA) representing 97,205 cases in the nation. Children's hospitals and children's units were significantly more likely to provide LA (36% and 28%, respectively) than general hospitals (25%). Higher LA rates were also associated with greater patient age, female sex, nonperforated appendicitis, private insurance, and white patient race. The children's hospital effect compared to general hospitals (adjusted odds ratio, 2.11; 95% confidence interval, 1.88-2.38) and all other relationships remained significant in the multivariate model.

Conclusion

Utilization of LA is significantly higher in children's hospitals. Children's hospitals appear more likely to adopt innovative surgical procedures, such as LA, even when clear benefit over standard treatment has not yet emerged.     

The use of vacuum assisted closure therapy in the management of Fournier's gangrene

Background

Vacuum Assisted Closure (VAC; Kinetic Concepts, Inc., San Antonio, TX) has been used to successfully treat a variety of complex wounds. This technique was investigated for use in managing Fournier's gangrene following initial debridement.

Methods

Ten patients with Fournier's gangrene were treated in this study. After initial surgical debridement, 5 were treated using conventional therapy and 5 were treated with VAC at each dressing change. The effectiveness and cost of VAC for this indication were assessed; patient and physician satisfaction were also determined.

Results

Conventional and VAC treatment were equally effective in healing the wounds. The total costs of each treatment were similar. With the use of VAC, patients had fewer dressing changes, less pain, fewer skipped meals, and greater mobility. Hands-on treatment time was decreased for physicians using VAC.

Conclusions

VAC therapy is an effective and economical way to manage Fournier's gangrene. Patients and physicians were more satisfied with VAC therapy than with conventional treatment.     

An evidence-based definition for perforated appendicitis derived from a prospective randomized trial

Purpose

Appendicitis is the most common urgent condition in general surgery, and yet there is no evidence-based definition for perforation. Therefore, all retrospective data published on perforated appendicitis are unreliable because of an ill-defined denominator. For approximately 2 years beginning in April 2005, we performed a prospective randomized trial investigating 2 different antibiotic regimens for perforated appendicitis. During this study, we strictly defined perforation as a hole in the appendix or a fecalith in the abdomen. Before this prospective study, perforation was staff surgeon opinion. We investigated the abscess rates in both the perforated and nonperforated appendicitis populations before and during the study to determine if our definition was safe and that there was not an increased risk of abscess formation in patients treated as nonperforated.

Methods

Records of all patients undergoing laparoscopic appendectomy for appendicitis during the immediate 2 years before using the definition were compared to those treated in the 2 years after the definition was implemented. Interval and incidental appendectomies were ruled out. The postoperative abscess rate (when perforation was not defined) was compared to the abscess rate of those for whom perforation was strictly defined.

Results

There were 292 patients treated for acute nonperforated appendicitis in the 2 years before the definition and 388 patients after the definition. There were 131 patients treated for perforated appendicitis before the definition and 161 after the definition was implemented. The abscess rate in those with perforated appendicitis increased from 14% to 18% after the definition was used. However, after the definition began to be used, the abscess rate for those patients treated as nonperforated decreased from 1.7% to 0.8%.

Conclusions

Defining perforation as a hole in the appendix or a fecalith in the abdomen is effective in identifying the patients at risk for postoperative abscess formation. Application of these criteria would allow substantial reduction in therapy for patients with purulent or gangrenous appendicitis who do not possess the same abscess risk. These data outline the first evidence-based definition of perforation.     

Quality of surgery for rectal carcinoma: comparison between open and laparoscopic approaches

Background

Macroscopic evaluation of a tumor specimen is an independent prognostic factor of oncologic outcome after total mesorectal excision (TME) for rectal cancer. This study aimed to assess macroscopic quality of specimens acquired after laparoscopic versus open TME in patients with low rectal cancer.

Patients and methods

Seventy-two patients with low rectal cancer underwent TME either by open (n = 39) or laparoscopic (n = 33) approach. In all specimens, the cut edge of the peritoneal reflection at the anterior mid-rectum, the Denonvillier's fascia, the visceral fascia covering the mesorectum both posteriorly and laterally, and the bowel wall below the mesorectum were macroscopically assessed.

Results

Colorectal anastomoses were located significantly lower in the laparoscopic than in the open group (P < .001). The Denonvillier's fascia was violated in 7 patients after open surgery (P = .01). A significantly more complete TME with intact visceral pelvic fascia was performed after laparoscopy compared with open surgery (P = .025).

Conclusions

Laparoscopy offers a macroscopically more complete specimen after TME for rectal cancer than the open approach because it offers a better view in the pelvis.