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 lap-aroscopic 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.

Acute Disease↗

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Interval appendectomy in the laparoscopic era.

In the acute setting, patients with periappendiceal masses generally improve with broad-spectrum antibiotics with or without percutaneous catheter drainage, but whether or not to perform an interval appendectomy remains controversial. We have analyzed our experience over the past decade, comparing results from interval laparoscopic appendectomy (ILA) and interval open appendectomy (IOA). Medical records were reviewed for 56 patients who initially presented with the diagnosis of periappendiceal mass or abscess and who subsequently underwent interval appendectomy. Data were accumulated for both the initial hospitalization and interval appendectomy. Comparisons were made between period 1 (1987 to 1993) and period 2 (1994 to 1997). Follow-up data were obtained via telephone conversations with the patients. Patient characteristics with regard to age, sex, and comorbidities did not differ between the ILA and IOA groups. The number of patients undergoing CAT scan increased from 33% to 55%, whereas the initial hospital stay decreased from 7. 42 to 4.61 days (P<0.001). The percentage of interval appendectomies performed by the laparoscopic method increased from 30% to 85%. The total operating room time did not differ (95 vs. 103 minutes), but the hospital stay was much shorter in the ILA group (0.55 vs. 3.07 days, P<0.001). There were no instances of intra-abdominal or wound infections in either group. In the later time period the mean hospital stay decreased to 0.38 days, with 59% of the operations performed on an outpatient basis. Following ILA, narcotic pain medication was used for an average of 1.3 days and the reported "time to return to full activities" was 2.5 days. ILA is a simple and safe procedure that can usually be performed on an outpatient basis. Given the minimal morbidity of the procedure, we believe that ILA should be considered for most patients who initially present with periappendiceal masses.

Appendectomy↗

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The role of luminal factors in prostaglandin protection against ethanol-induced gastric mucosal injury.

Prostaglandins (PG) protect the gastric mucosa against damage by several irritants, but the mechanisms remain unclear. A standard rat model of gastric injury induced by 50% ethanol was used to test the hypothesis that PG protection occurs either by increasing luminal fluid volume and hence diluting the irritant, or by production of protective factors within this fluid. Quantitative histology was used to assess microscopic mucosal damage. The increase in luminal fluid volume in prostaglandin E2 (PGE2)-treated animals was measured, and the ability of this increased fluid to protect saline-treated animals via dilution of the irritant was assessed. The transfer of protection by exchange of luminal fluid from PG to non-PG treated animals was also tested. Results showed that PGE2 induced a specific increase in luminal fluid volume of 45.6%. When given together with ethanol treatment the extra fluid volume was not protective. Removal of luminal fluid after PG and before ethanol treatment did not abolish protection and no protective factor was transferred with the luminal fluid. In conclusion, this study has shown that neither dilution of ethanol by accumulation of luminal fluid nor the presence of luminal factors is responsible for PG protection.

Animals↗

PubMedDate not supplied

Hypertension complicating carotid endarterectomy.

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Blood Pressure↗