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PubMed1994

[Laparoscopic or classical appendectomy? A prospective randomized study].

Though laparoscopic appendectomy started endoscopic surgery in general surgery, it has yet not reached the acceptance as is the case with cholecystectomy. The application of this technique in possibly bland appendices and reports that the technique was accompanied by severe complications, increases the scepticism about it. This made us decide to start a randomized controlled trial: laparoscopic vs. conventional appendectomy. More than 1000 endoscopic interventions mainly performed at the gallbladder and the stomach and 165 prospectively documented and partly treated patients with acute appendicitis were the basis to start this trial. "Acute Appendicitis" was diagnosed on the basis of clinical symptoms by means of the computer-aided questionnaire of the EC-study "Acute Abdominal Pain", a self-developed validated diagnostic score, the macroscopic findings and the careful assessment of the histology of the resected appendix. Beside the technical feasibility, principle end-points were mainly intensity and course of postoperative pain measured by means of the Visual Analogue Scale (VAS) in lying, standing and moving position and the postoperative consumption of analgesics. We assessed a difference of 15 points on the VAS as clinically relevant. Of 57 patients with acute appendicitis we performed open appendectomy in 23 and laparoscopy in 34 patients according to randomization. In 9 patients of the laparoscopy group it was necessary to change over to open appendectomy for different reasons resulting in a direct comparison of 25 laparoscopies versus 23 open appendectomies. There were no differences between sociodemographic and preclinical data in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1993

[Laparoscopic appendectomy in clinical practice. Aesthetic and functional advantages].

The mortality rate following traditional (open) surgical appendectomy has declined over the past 60 years to almost zero. Many surgeons question the utility of laparoscopic surgery for appendicitis as the appendix can often be removed through a small incision and the degree of trauma to the patient may be minimal. However, some patients suffer wound infection, prolonged hospitalization and delay in returning to full normal activity. Moreover, postoperative adhesions have been recorded in as many as 63 per cent of cases. Although recent studies have shown that laparoscopic appendectomy is safe and feasible, controversies still exist concerning indications and limits of the procedure. The aim of the present study is to clarify the advantages of the laparoscopic technique in performing appendectomy for both acute and chronic appendicitis. The Authors report on their experience of laparoscopic appendectomy performed at the Surgical Department of Montecchio Maggiore Hospital (VI) from July 1992 to December 1992. Ten laparoscopic appendectomies were performed in 8 female and 2 male patients with a mean age of 19 years (range 14-31). There were no conversions to laparotomy; mean operative time was 57 minutes (range 28-92). As far as the position of trocars is concerned, the Authors utilize a particular technique which presents an aesthetic advantage but requires the use of an endolaparoscopic stapler (Multifire Endo GIA 30 Autosuture). There was no mortality; the postoperative course was uneventful in all cases. Patients were discharged from the hospital the day after laparoscopic intervention. Follow up showed no postoperative pain, short bed stay at home and fast return to full activity; functional and aesthetic results were most satisfactory.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1998

Appendectomy protects against ulcerative colitis.

We conducted a case-control study of the protective effect of appendectomy on the development of ulcerative colitis. We calculated the risk of ulcerative colitis in 716 incident cases of ulcerative colitis and 2,747 controls according to appendectomy status, using data from the United Kingdom General Practice Research Database. We also studied a random sample of 100 cases and 100 controls to validate the subject's history of appendectomy. Fifteen cases (2%) and 109 (4%) controls had a computer-recorded history of appendectomy [odds ratio (OR) = 0.5; 95% confidence interval (CI) = 0.3-0.9]. In the sample, the OR was 0.3 (95% CI = 0.1-0.9). Appendectomy appears to protect against ulcerative colitis.

Adult↗
PubMed1998

Should a laparoscopic appendectomy be done?

For a laparoscopic appendectomy to be part of a surgical armamentarium, it should: 1) decrease hospital stay, 2) lessen narcotic requirement, 3) speed return to normal activity, 4) be cost effective, and 5) have fewer complications. To this end, we reviewed 60 consecutive cases of each appendectomy performed, laparoscopically and by open technique, during the period of 1993-1996. We looked not only at the above criteria, but also at the type of employment. Laparoscopic appendectomy did not decrease hospital stay (2.1 versus 1.4 days), or morphine equivalent narcotic requirement (38.5 mg versus 19.8 mg). However, laparoscopic appendectomy did carry a hospital bill of $3650.00 more than the open technique ($7923 versus $4273). This results not only from chargeable disposable items, but also from an increase in operative time (47 vs. 36 minutes) and room and anesthesia time (88 vs. 63 minutes), because of the increased length of preparation time. In only one category, patients involved in heavy manual activity (17 patients), the return to normal activity decreased by 1 week. There was no difference in complication rate in each category. Based on these findings, laparoscopic appendectomy cannot be recommended in suspected cases of appendicitis.

Adult↗
PubMed1998

[Laparoscopic versus conventional appendectomy--a comparison with reference to early postoperative complications].

OBJECTIVE AND METHODS: To compare the complications of laparoscopic appendectomy (LA) and conventional appendectomy (CA) 930 consecutive patients from 1989 until 1997 were analysed retrospectively. RESULTS: Conventional appendectomy was performed in 330 patients, laparoscopic in 554 patients and another 46 patients required conversion after laparoscopy. The groups were similar in sex ratio, age and degree of inflammation. Postoperative complications occurred in 8.78%. There were less complications in the LA-group (4.69%) than in the CA-group (13.33%) (p < 0.01), especially wound infections were found less in the LA-group (1.8% vs. 11.21%, p < 0.01). The incidence of intraabdominal abscesses was similar in the LA and CA group (1.44% vs. 1.52%). The differences between the groups are not influenced by complicating appendicitis (perforation or abscess). Systemic complications were similar for LA and CA (0.72% and 0.61%), but were seen more often after conversion (6.52%, p < 0.01). CONCLUSIONS: This retrospective analysis shows that laparoscopic appendectomy significantly reduces postoperative complications, especially wound infections. The authors consider laparoscopic appendectomy to be the procedure of choice in patients with acute appendicitis.

Adolescent↗
PubMed1998

[Appendectomy: evaluation of medical record maintenance in a series of 200 cases].

To improve the management of appendicular syndromes, two hundred files of patients undergoing appendectomy in an emergency surgery department between January 1993 and August 1994 were submitted to a retrospective and descriptive study with evaluation of the medical file content. To evaluate clinical and investigations data collecting, a histopathological review protocol was elaborated to obtain an objective and reliable criterion of the degree of inflammation of the appendix. This review was possible only for 197 files that were included. Data collecting rates are inferior than expected rates, particularly for the association of temperature, abdominal defence and white blood cells count that was found in only 159 files (80.7%). Data were less collected for women, patients operated by celioscopy and when histopathologic review concluded to absence of acute inflammation. Rate of acute appendicitis was 73.6% (145/197). Appendectomies without acute inflammation were higher for women (34.6% = 37/107) than for men (16.7% = 15/90) and for patients who underwent celioscopic appendectomy (42.9% = 33/77) than for patients who underwent Mac Burney appendectomy (16% = 19/119). These results highlight the need to improve competition of medical files with better collection of clinical data, which could lead to improve care quality and management of operated appendicular syndromes, first step to a reduction of the number of appendectomies. A global assessment of file completion could be proposed on the basis of clinical audit.

Adolescent↗
PubMed1991

Does atrial appendectomy aggravate secretory function of atrial natriuretic polypeptide?

The present study was designed to clarify how atrial appendectomy affects hemodynamics and secretory function of atrial natriuretic polypeptide in the failing heart. Eleven mongrel dogs were prepared for the experimental model of high-output heart failure by creation of arteriovenous fistulas between femoral arteries and veins. Two months after the first operation, effects of bilateral atrial appendectomies on basal and pacing-induced secretions of atrial natriuretic polypeptide were investigated in five dogs with simultaneous measurement of various hemodynamic indices. In the remaining six dogs, used as a control group, pacing-induced secretion of atrial natriuretic polypeptide was examined in the same way as in the appendectomy group. After excision of the atrial appendages, neither systolic blood pressure nor either atrial pressure changed, but plasma atrial natriuretic polypeptide level was decreased (292 +/- 54 to 188 +/- 47 pg/ml, p less than 0.01) and cardiac output fell (3.7 +/- 0.9 to 3.0 +/- 0.8 L/min, p less than 0.01). During pacing-induced tachycardia, the peak level of plasma atrial natriuretic polypeptide was lower in the appendectomy group than in the control groups (593 +/- 213 versus 1170 +/- 324 pg/ml, p less than 0.05), despite similar left atrial pressures in the two groups. The excised appendages contained approximately 30% of the total amount of atrial natriuretic polypeptide. These results demonstrate that atrial appendectomy decreases secretory function of atrial natriuretic polypeptide and reduces cardiac output in dogs with experimental high-output heart failure.

Animals↗
PubMed2005

Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis.

BACKGROUND: The role of interval appendectomy (IA) after an episode of acute appendicitis is debated. HYPOTHESIS: Patients treated nonoperatively for acute appendicitis do not require routine IA. DESIGN: Retrospective cohort study using discharge abstract data. SETTING: Twelve regional Kaiser Permanente hospitals in Southern California. PATIENTS: A total of 32 938 patients were hospitalized with acute appendicitis. INTERVENTIONS: Appendectomy or nonoperative treatment with or without abscess drainage. MAIN OUTCOME MEASURES: Hospitalization for recurrent appendicitis or IA. RESULTS: The type of appendicitis was abscess in 7% of patients, peritonitis in 18%, and no peritonitis or abscess in 75%. Emergency appendectomy was performed in 31 926 (97%) patients. Nonoperative treatment was used initially in 1012 patients (3%). Of these, 148 (15%) had an IA and the remaining 864 (85%) did not. Thirty-nine patients (5%) recurred after a median follow-up of 4 years. Using Cox regression, sex had a slight influence on recurrent appendicitis (hazard ratio males vs females = 0.52, 95% CI, 0.27-0.99, P = .05). Age, Charlson comorbidity index, type of appendicitis, or percutaneous abscess drainage had no influence on recurrence. Median length of hospital stay was 4 days for the admission for recurrent appendicitis compared with 6 days for the IA admission (P = .006). CONCLUSIONS: Most patients with acute appendicitis undergo appendectomy initially. For those treated nonoperatively, the recurrence rate is low. Routine IA after initial successful nonoperative treatment is not justified and should be abandoned.

Abdominal Abscess↗
PubMed1996

Laparoscopic appendectomy for complicated appendicitis.

BACKGROUND: Acute gangrenous and perforating appendicitis are associated with an increased risk for postoperative complications and have been considered a relative contraindication of laparoscopic appendectomy. OBJECTIVE: To determine the complication rate following laparoscopic appendectomy for gangrenous of perforating appendicitis. DESIGN: A retrospective analysis of patients who underwent laparoscopic appendectomy for gangrenous or perforating appendicitis. SETTING: A multispecialty clinic. RESULTS: Fifteen patients underwent laparoscopic appendectomy for gangrenous appendicitis and 19 patients for perforating appendicitis. In the gangrenous appendicitis group, average operating time was 85 minutes; average length of hospitalization, 2 days; and morbidity rate, 7% (one patient with abdominal abscess). The perforating appendicitis group had an average operating time of 84 minutes, hospitalization of 7 days, and a morbidity rate of 42%. This morbidity included five patients (26%) who developed intra-abdominal abscesses, two patients (10%) in whom wound infections developed, and one patient (5%) who died of Candida sepsis and multisystem organ failure.

Adolescent↗
PubMed1997

Laparoscopic vs open appendectomy. Prospective randomized study of outcomes.

OBJECTIVE: To compare open appendectomy (OA) with laparoscopic appendectomy (LA) for length of the operation, complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. DESIGN: Prospective randomized clinical trial of patients with acute appendicitis. SETTING: Tertiary care, urban teaching hospital. PATIENTS: A population-based sample of patients (aged > or = 12 years; weight, > 49.7 kg) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis. Patients were prospectively randomized to either OA or LA during a 20-month period (from April 1, 1994, to December 31, 1995). Fifty-seven patients were initially enrolled in the study; 7 did not complete the study because of a protocol violation. All remaining patients completed the study, including postdischarge follow-up. INTERVENTIONS: Two (7.4%) of the 27 patients in the LA group required conversion to OA because of technical difficulties. One patient (in the OA group) underwent a second surgical procedure for drainage of a pelvic abscess. Three patients (in the LA group) required second surgical procedures. For analysis, no crossovers were allowed and all patients remained in their originally randomized group. MAIN OUTCOME MEASURES: Length of the operation, intraoperative and postoperative complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. RESULTS: Fifty patients (19 women and 31 men) were examined. Twenty-seven patients underwent LA, 2 requiring conversion to an OA. Twenty-three patients underwent an OA. Patient demographics were similar between groups. Statistical differences between the 2 groups were found for (1) length of the operation (median, 81.7 vs 66.8 minutes, LA vs OA groups: P < .002), (2) operating room charges (median, $3191 vs $1514, LA vs OA group; P < .001), and (3) total hospital charges (median, $5430 vs $3673, LA vs OA group; P < .001). No statistical differences between the 2 groups were found for (1) length of hospitalization (median, 1.1 vs 1.2 days, LA vs OA group), (2) pain control (mean, 4 vs 3.7 of 10 [0 indicates least pain; 10, most pain], LA vs OA group), (3) recovery time (time necessary before returning to work or school) (median, 14.0 days for both groups), and (4) complications (5 vs 1, LA vs OA group). CONCLUSIONS: Laparoscopic appendectomies and OAs are comparable for complications, postoperative pain control, length of hospitalization, and recovery time. Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges. Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis.

Adolescent↗
PubMed1995

Outpatient laparoscopic appendectomy.

Laparoscopy has allowed surgeons the ability to perform procedures which result in less postoperative discomfort, earlier return to daily activities, and better cosmesis. For example, laparoscopic cholecystectomy has virtually replaced open cholecystectomy, and many of these operations are performed in the outpatient setting. The role of laparoscopic appendectomy is yet to be defined, however. Over an 18-month period from February 1992 to July 1993, 75 laparoscopic appendectomies were performed at Kaiser Permanente Medical Center in Los Angeles. Thirty-five of the patients undergoing this procedure were outpatients. While there were a total of three complications, including two intraabdominal abscesses, there were no complications in the outpatient appendectomy group. Laparoscopic appendectomy may be safely performed in the outpatient setting in patients with acute nonperforated appendicitis.

Ambulatory Surgical Procedures↗
PubMedDate not supplied

Elective laparoscopic appendectomy in patients with familial Mediterranean fever.

Familial Mediterranean fever (FMF) also known as hereditary polyserositis, is an inherited disorder commonly found in Armenians, Turks, Arabs, Balkans, and Jews originating from North African countries. The diagnosis of FMF is based on clinical findings and family history, as no specific diagnostic test is yet available. One of its main clinical features is recurrent acute episodes of peritonitis. During such an episode, physical examination and laboratory findings may be similar to those for acute appendicitis. Therefore up to two-thirds of FMF patients undergo emergency appendectomy, with the appendix being normal in most cases. As laparoscopic appendectomy has proved to be safe and advantageous, and to prevent misdiagnosis and unnecessary emergency surgery, we performed elective laparoscopic appendectomy in 13 FMF patients ranging in age from 8 to 32 years. They had been suffering from the disease for 1 to 12 years (mean 3.8) and had had an average of 3.5 yearly episodes of FMF peritonitis. All procedures were concluded by laparoscopy without conversion to open surgery. The average postoperative hospital stay was 3.07 days. The only complication was superficial wound infection in one patient (7.6%), and the mean time to regain full normal activity was 8.5 days. We conclude that elective laparoscopic appendectomy in FMF patients is safe. It helps to exclude appendicitis as a cause for peritonitis in these patients and may prevent unnecessary emergency surgery.

Adolescent↗
PubMed1998

Laparoscopic or open appendectomy? Critical review of randomized, controlled trials.

PURPOSE: A randomized, controlled trial is considered to be the "gold standard" to evaluate a new procedure. Thus, this critical review assessed whether the published randomized trials on laparoscopic appendectomy show that it is superior to the open approach. METHODS: Twelve original articles involving a randomized, controlled trial on laparoscopic appendectomy in adults published between January 1990 and December 1996 were selected. We studied first whether each trial was positive (a procedure is superior to the other) or negative (no difference). We reviewed for each trial the methodology used and the following outcomes: operating time, intraoperative and postoperative complications, time until resumption of diet, postoperative pain, hospital stay, cost, and quality of life analyses. Postoperative morbidity was considered as the major primary outcome. RESULTS: There were six positive and six negative trials. Postoperative complication rates were similar, but the two approaches had specific potential complications, wound infections following open appendectomy, and intra-abdominal abscesses following laparoscopic appendectomy. This review failed to show a superiority of the laparoscopy for the other outcomes, particularly postoperative pain. CONCLUSION: Differences in positive trials concerned subjective and controversial outcomes, and the flaw in negative trials was their lack of power. Thus, nothing is definitively well established, even after 12 randomized trials.

Appendectomy↗
PubMed1999

The occurrence of an abdominal wall abscess 11 years after appendectomy: report of a case.

Most complications after appendectomy occur within 10 days; however, we report herein the unusual case of a patient in whom a wound abscess was detected more than 10 years after an appendectomy. A 26-year-old woman presented to our hospital with nausea and vomiting, pain, and a mass in the right lower abdominal wall. She had undergone an appendectomy 11 years previously. Physical examination revealed a tender mass, 5 cm in diameter, under the appendectomy scar. An abdominal ultrasonography demonstrated a low-echoic mass lesion measuring 9.0 x 5.0 x 2.0 cm. Incision of the connective tissue revealed about 3 ml of cream-colored and odorless fluid in the abscess cavity. Fistulography revealed an abscess cavity not communicating with the bowel lumen. Floss was discovered in the connective tissue and removed. Debridement of the abscess wall was performed and a piece of the wall was sent for histologic examination. Pathological examination revealed panniculitis of the subcutaneous tissue, and panniculitis with granulation and granuloma of the abscess wall. This case report demonstrates that a preoperative diagnosis should be based not on one finding, but on all findings collected, inclusively.

Abdominal Abscess↗
PubMedDate not supplied

Is laparoscopic better than open appendectomy?

Laparoscopic appendectomy is becoming increasingly popular as surgeons strive to manage surgical problems via minimally invasive techniques. We reviewed our early experience in 38 patients with laparoscopic appendectomy and compared it to open appendectomies done during the same time period. We found no difference in hospital costs, stay, or wound infection rate. There was a significant difference in OR time: the laparoscopic approach took longer. We conclude that this new approach is not clearly superior to open appendectomy despite theoretical advantages. Newer instruments and further studies are needed.

Adult↗
PubMed2006

Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial.

BACKGROUND: Appendectomy has been the treatment for acute appendicitis for over 120 years. Antibiotic treatment has occasionally been used in small uncontrolled studies, instead of operation, but this alternative has never before been tried in a multicenter randomized trial. PATIENTS AND METHODS: Male patients, 18-50 years of age, admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study. No women were enrolled by decision of the local ethics committee. If appendectomy was planned, patients were asked to participate, and those who agreed were randomized either to surgery or to antibiotic therapy. Patients randomized to surgery were operated on with open surgery or laparoscopically. Those randomized to antibiotic therapy were treated intravenously for 2 days, followed by oral treatment for 10 days. If symptoms did not resolve within 24 hours, an appendectomy was performed. Participants were monitored at the end of 1 week, 6 weeks, and 1 year. RESULTS: During the study period 252 men participated, 124 in the surgery group and 128 in the antibiotic group. The frequency of appendicitis was 97% in the surgery group and 5% had a perforated appendix. The complication rate was 14% in the surgery group. In the antibiotic group 86% improved without surgery; 18 patients were operated on within 24 hours, and the diagnosis of acute appendicitis was confirmed in all but one patient, and he was suffering from terminal ileitis. There were seven patients (5%) with a perforated appendix in this group. The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14% during the 1-year follow-up. CONCLUSIONS: Acute non-perforated appendicitis can be treated successfully with antibiotics. However, there is a risk of recurrence in cases of acute appendicitis, and this risk should be compared with the risk of complications after appendectomy.

Adolescent↗
PubMed2007

Laparoscopic appendectomy: differences between male and female patients with suspected acute appendicitis.

BACKGROUND: The role of laparoscopy in the management of patients with suspected acute appendicitis remains controversial. It has been suggested that laparoscopy is useful mainly in young women of reproductive age because of the high incidence of wrong diagnosis in these patients. METHODS: Different management protocols for patients with suspected acute appendicitis were prospectively used in male and female patients; women of reproductive age were treated laparoscopically, while men were randomised to open or laparoscopic appendectomy. RESULTS: From September 2002 to September 2005, 132 patients-54 women and 78 men-with suspected acute appendicitis were treated according to the protocol. The incidence of wrong diagnosis in female patients was high (26% and the conversion rate low (5.5%). In contrast, in the laparoscopic male subgroup, these rates showed a reverse relationship (5.2% and 18.5%, respectively). Morbidity did not differ between female and male patients or between the 2 arms of the male group. Laparoscopic appendectomy took longer to perform without affecting significantly the needs for postoperative analgesia, the duration of hospital stay and the time to return to normal activities when compared with open appendectomy in men. CONCLUSION: Laparoscopic appendectomy is at least as safe as the open procedure in the male population, although it does not appear to offer any obvious advantage over the open procedure. The diagnostic advantage that laparoscopy offers to fertile women makes the procedure attractive for this population.

Adolescent↗
PubMed2000

Antibiotic prophylaxis for appendectomy in children: critical appraisal.

Prophylactic antibiotics are widely used during surgery, above all for clean-contaminated or contaminated procedures. Because factors other than the degree of contamination play a critical role in regard to postoperative infectious complications, it is not evident that recommendations for antibiotic prophylaxis for an adult population can be transferred to children. The aim of the study was to analyze the incidence of postoperative infections in children undergoing appendectomy for suspected appendicitis to evaluate critically the effectiveness of prophylaxis. The charts of all children undergoing appendectomy between 1988 and 1998 were analyzed. In general, appendectomies were performed without antimicrobial prophylaxis. If a perforated appendicitis was found at operation, antibiotics were given intraoperatively. Postoperative infectious complications were defined as wound infections, intraabdominal infections, or prolonged postoperative pyrexia. During the study period of 10 years, 954 patients underwent appendectomy. In 24% of cases the appendix was perforated. Patients received prophylactic antibiotics at the surgeon's discretion. These patients were excluded from further analysis. Among those with non-perforated appendicitis (n = 633), Infectious complications occurred in 19 (3%). Analyzing subgroups according to histologic diagnosis, the incidence was 4.2% (16/382) for gangrenous appendicitis and 1.2% (3/251) for simple appendicitis or normal appendix. These figures are clearly lower than those reported from an adult population, indicating that results from adults cannot a priori be transferred to children, and that general recommendations concerning antimicrobial prophylaxis must be considered carefully for this age group.

Antibiotic Prophylaxis↗