Int J Colorectal Dis (2015) 30:397–401 DOI 10.1007/s00384-014-2095-4
ORIGINAL ARTICLE
Laparoscopic versus open appendectomy for complicated appendicitis in high risk patients G. Werkgartner & H. Cerwenka & A. El Shabrawi & H. Bacher & H. Hauser & H. J. Mischinger & M. Wagner & D. Wagner
Accepted: 8 December 2014 / Published online: 16 December 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Introduction Laparoscopic appendectomy is widely used for the treatment of complicated appendicitis. Its use in patients with high operative risk is still on debate. The aim of the presented study was to investigate the benefits of laparoscopic appendectomy in patients with high peri- and postoperative risk factors. Methods We performed a retrospective analysis of all patients who underwent appendectomy in our center between 2006 and 2013. Patients were classified according to their preoperative risk (classification of the American Society of Anesthesia—ASA score). Only patients with ASA 3 and 4 were included and were divided into two groups—open appendectomy (OA group) and laparoscopic appendectomy (LA group). Results The operation time was slightly longer in the LA group (p=0.05), but hospital stay was shorter (p=0.05). Complications graded according to the Clavien Dindo classification were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA (p=0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p=0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p=0.05).
G. Werkgartner : H. Cerwenka : A. El Shabrawi : H. Bacher : H. Hauser : H. J. Mischinger : D. Wagner (*) Department of Surgery, Division for General Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria e-mail: [email protected] M. Wagner Department of Internal Medicine, Division for Endocrinology, Medical University of Graz, Auenbruggerplatz 29, Graz, Austria
Conclusion Laparoscopic appendectomy can be recommended for patients with complicated appendicitis even with higher risk categories. Keywords Open appendectomy . Laparoscopic appendectomy . Complicated appendicitis . Acute appendicitis . ASA classification
Introduction Complicated appendicitis (CA) still represents one of the main indications for emergency surgery worldwide [1]. The clinical advantages of laparoscopic appendectomy (LA) like reduced hospital stay, lower wound infection rate, shorter time of postoperative ileus, and less postoperative pain or better cosmetic results have been demonstrated over the past years in several studies and meta-analysis [2–5]. Despite these data and despite the fact that LA is widely used for appendectomies, it is still not considered as the gold standard everywhere. Especially, CA is frequently treated by open appendectomy (OA) due to debates and publications that LA is associated with longer operating times and an elevated risk for postoperative intra-abdominal abscesses in these patients [6, 7]. The preoperative discrimination between acute appendicitis (AA) with and without complications in patients with suspected appendicitis is usually done based on laboratory parameters in addition to clinical presentation [8–10]. Conventional white blood cell count (WBC) is neither considered sensitive nor specific for the diagnosis of AA nor for the discrimination to CA [11]. C-reactive protein (CRP) has been considered more specific and more sensitive in the detection of appendiceal perforation and abscess formation. A recent review showed that CRP had the highest accuracy regarding the diagnosis of CA and the discrimination between uncomplicated and complicated appendicitis [12].
398
Postoperative complications are more frequent and achieving an acceptable benefit after operation is crucial in patients who suffer from additional comorbidities. The presented analysis aimed to evaluate the course of inflammatory response parameters, namely CRP and WBC, after open and laparoscopic appendectomy for complicated appendicitis in patients with present and severe comorbidities defined as high-risk patients for operations.
Methods We performed a retrospective review of the patient records of all patients who underwent appendectomies in our center between January 2006 and December 2013. The study was approved by the ethical board of the Medical University of Graz (ECS 1156/2013). To identify those with comorbidities and higher risk, all patients were classified using the American Society of Anesthesiologists (ASA) risk classification. Patients with ASA 3 and 4 were classified as patients at risk and were included into the presented analysis. Depending on the intraoperative evaluation, patients were classified into patients with complicated appendicitis (CA) or uncomplicated appendicitis (UA). Additionally, the postoperative pathological results were matched with the intraoperative observation in order to omit the subjective parameter of observation. Patients who were classified as suffering from CA according to both criteria were included into the presented analysis. These patients were enrolled according to the surgical approach used and divided into a group of patients after open appendectomy (OA group) and a group of patients who underwent laparoscopic appendectomy (LA group). For each patient age, gender, and duration of symptoms, pre- and postoperative white blood cell count (WBC), pre- and postoperative C-reactive protein (CRP), duration of operative procedure, length of hospital stay and postoperative complications were recorded. Postoperative complications were graded using the Clavien Dindo classification [13]. All laparoscopic procedures were performed using a three trocar technique, two 10 mm and one 5 mm ports. After coagulation of the mesoappendix, the LA was performed using a stapler or two endoscopic loop ligatures. In case of perforation or abscesses, laparoscopic lavage was performed. All open appendectomies were performed using McBurney’s incision in standard technique with inversion of the appendiceal stump. Our center protocol favors OA rather than LA in case of severe cardiac or respiratory comorbidities or geriatric patients and previous major abdominal surgeries. Additionally, the final choice upon the nature of the procedure is done by the performing surgeon.
Int J Colorectal Dis (2015) 30:397–401
All patients received perioperative antibiotic prophylaxis with tazobactam, or metronidazole in combination with ciprofloxacin in case of allergies. Our center favors the placement of a drain in case of complicated appendicitis. Statistical analysis Data obtained in the presented study were analyzed using SPSS 21.0 (SPSS Inc. Chicago, IL, USA). Data measured as quantitative variables were analyzed using the Student t test. To detect statistical significance of differences between data represented as categorical variables, the chi-square test was used. Additionally, the relation between the occurrence of complications and the used operating technique was assessed using regression analysis and AUROC analysis or Kaplan– Meier analysis as appropriate.
Results In the defined time span, 1140 appendectomies have been performed in our center. Of them, 462 patients suffered from a complicated appendicitis (CA) and 59 of those patients showed ASA classifications of 3 or 4 and were included into the presented analysis. Patient characteristics Fifty-nine patients in total showed comorbidities that classified them as ASA 3 or 4, 41 (69 %) were classified as ASA 3, and 18 (31 %) were classified as ASA 4. Patients were divided into two groups according to the operative procedure they underwent—21 (35 %) patients were treated using LA and 38 (65 %) underwent open surgery. Baseline characteristics were not completely comparable between both groups. Laparoscopy was more frequent in patients who showed ASA 3 scores as compared to ASA 4 patients (p=0.03 and 0.04, respectively). Preoperative CRP was slightly higher in patients with OA as compared to patients who underwent LA (p=0.05) as was the preoperative white blood cell count (p= 0.054). Preoperative fever was more frequent in patients who underwent open appendectomies (p=0.04) as was perforation in those patients as compared to patients in the LA group (p= 0.04). All preoperative characteristics are compiled in Table 1. Postoperative course The operation time was slightly longer in the LA group (p= 0.05), but hospital stay was shorter (p=0.05). The overall complication rate graded according to the Clavien Dindo classification was slightly higher in patients after LA, whereas
Int J Colorectal Dis (2015) 30:397–401 Table 1
399
Compiles all baseline demographic data including age, gender, and ASA-risk classification
Age (a) Gender (male %) Comorbidities (%) Diabetes mellitus Cardiomyopathy Dilative Hypertrophic NYHA III NYHA IV COPD III/IV Previous surgeries Immunosuppressive Therapy ASA risk score ASA 3 ASA 4 WBC count (109/L) preoperative CRP (mg/L) preoperative Perforation (%) Fever preoperative (>37.8 °C) (%)
OA group (n=38)
LA group (n=21)
p value
47 (18–97) 50.8 % 67 % (26/38) 39 % (15/38) 43 % (16/38) 31 % (12/38) 11 % (4/38) 7 % (3/38) 45 % (17/38) 50 % (19/38) 13 % (5/38)
36 (18–83) 44 % 56 % (12/21) 8 % (2/21) 14 % (3/21) 14 % (3/21) – 14 % (3/21) – 10 % (2/21) 23 % (5/21) 29 % (6/21)
n.s. p=0.05 n.s. p=0.02 p=0.02 p=0.01 p=0.001 p=0.02 p=0.001 p=0.01 p=0.03 p=0.001
58 % (22/38) 42 %(16/38)
90 % (19/21) 10 % (2/21)
p=0.04 p=0.03
16.8±4.8
16.1±2.9
n.s.
109±46 31.3 % 65 %
101±53 23.9 % 57 %
n.s. p=0.04 n.s.
Baseline characteristics were not completely comparable between both groups. Laparoscopy was more frequent in patients who showed ASA 3 scores as compared to ASA 4 patients. CRP was slightly higher in patients with OA as was the white blood cell count. Preoperative fever was more frequent in patients who underwent open appendectomies (ASA American Society for Anesthesia, OA open appendectomy, LA laparoscopic appendectomy, WBC count white blood cell count, CRP C-reactive protein)
Table 2
All intra and postoperative parameters are listed below OA group (n=38)
OP time (min) Hospital stay (median days) Clavien Dindo classification All Grades (%) Grade I Grade II Grade III Grade IV Grade V WBC count (109/L) POD 1 WBC count (109/L) POD 3 CRP (mg/L) POD 1 CRP (mg/L) POD 3
35 (17–75) 7 (5–98) 32 % (12/38) 42 % (5/12) 8 % (1/12) 42 % (5/12) 8 % (1/12) None 14.2±4.6 12.1±2.3 131±23 67±19
LA group (n=21) 49 (28–96) 6 (4–25) 38 % (8/21) 75 % (6/8) None 25 % (2/8) None None 16.3±1.6 14.3±2.5 105±25 58±21
p value p=0.05 p=0.05 p=0.05 p=0.05 p=0.01 p=0.02 p=0.01 n.s. p=0.03 p=0.03 p=0.05 p=0.05
The operation time was slightly higher in the LA group (p=0.05), hospital stay was shorter (p=0.05). The overall complication rate graded according to the Clavien Dindo classification was slightly higher in patients after LA, whereas severe complications occurred more frequently in patients after OA (p= 0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p=0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p=0.05) (OA open appendectomy, LA laparoscopic appendectomy, WBC count white blood cell count, CRP C-reactive protein)
400
severe complications occurred more frequently in patients after OA (p=0.01, Table 2). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p=0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p=0.05, Table 2). Clavien Dindo classification and postoperative inflammatory response Overall, 32 % of the OA patients and 38 % of the LA patients showed complications which were classified according to the Clavien Dindo classification. Patients after OA showed a lower rate of grade I complications (24 %) as compared to patients after LA (75 %). Grade II complications were more frequent in patients after LA (0 %) as compared to patients after OA (8 %). The preoperative white blood cell count was significantly elevated in patients after OA who suffered from grades III (wound healing disorders that required vacuum assisted closure) and IV (postoperative renal failure in one patient) complications as compared to patients after LA who suffered from grade III (two patients who suffered from postoperative ileus that required parenteral nutrition) complications (p=0.02). The decline of WBC was more delayed in patients after OA as compared to patients after LA. The preoperative CRP was more elevated in the OA group as compared to LA patients and increased postoperatively in OA patients with complications. This increase was significant as compared to patients after LA and complications.
Discussion Laparoscopic appendectomy (LA) has become the treatment of choice for uncomplicated appendicitis (UA) for many surgeons in the past 15 years [2–8, 14, 15]. Rates of LA have doubled over this period of time [5]. LA not only represents an important diagnostic tool for the exploration of the whole peritoneal cavity, but it has also been associated with shorter hospital stay and lower postoperative complications [4]. Complicated appendicitis (CA) marked by intra-abdominal abscesses represents a separate entity among patients with acute appendicitis. Its management via LA is still discussed controversially [16–18]. Recent reports suggest advantages of LA in the treatment of complicated appendicitis [2]. All of these reports usually include only a minority of patients with severe peri- and postoperative risk factors. In the presented study, only patients with severe comorbidities and risk factors were included. Therefore, we were able to perform a comparison between those patients. However, there is some bias in the presented analysis. OA patients showed
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higher ASA scores as compared to LA patients and subsequently their rate of comorbidities was higher (Table 1). Additionally, LA is not the first choice according to our center protocol in case of severely cardiac or respiratory conditions or their geriatric age and previous abdominal surgeries. In those cases, our center protocol favors OA rather than LA. Therefore, OA patients appear to be sicker in the presented study. This does not necessarily mean that the included LA patients were healthy. In fact, those patients showed severe comorbidities that were considered as contraindications for long. What is new about the presented analysis is that patients after LA even if they have high perioperative risks and constellations do have acceptable results. This involves geriatric patients as well, which is an extremely discussed population. In our opinion, LA showed acceptable results in these patients. Another potential limitation of our study might be its retrospective nature whereas prospective studies in these patients, namely patients being at high risk, who are usually only operated in emergency situations, are not easy to perform as appendectomies often represent emergency surgeries—a setting in which the performance of randomized prospective trials can sometimes be crucial. Designed in a prospective setting a matched pair analysis would at least be desired in these patients. Laparoscopic appendectomy was reported to have a higher rate of intra-abdominal abscesses as compared to the open approach, especially in patients with CA [16]. We did not observe any intraperitoneal infections in our LA patients. Additionally, they showed lower rates of wound infections as compared to OA patients. On the other hand, patients in the LA group were seen to have more complications classified as grade I postoperatively as compared to the OA group (p=0.05). The reported length of hospital stay is usually shorter in patients after LA as compared to OA. This was the case in our cohort as well, whereas our patients stayed longer than the average patients reported in the literature. This might also be due to the higher pre- and postoperative risks. This result is comparable to the results of the recent meta-analysis [19–21]. In our experience, patients after LA return to work earlier as compared to patients after OA; however, data in the selected group of patients were not complete enough to be included into the analysis. Additionally LA allows a better overview of the patients abdomen and therefore an ameliorated diagnosis of potiential concomittant diseases [22]. Although the costs of the laparoscopic approach can be higher than the costs of open appendectomies, the reduction in length of hospital stay compensates this effect. Therefore, LA can be performed at the same costs as OA due to the shorter hospital stay and lower rate of postoperative complications [23]. Studies on the postoperative course of LA in high-risk patients are very scarce. As some of these patients suffer from severe comorbidities like heart insufficiency, pulmonal
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deficiencies, or intra-abdominal diseases besides appendicitis, most surgeons still choose open approaches. Despite this limitation, we conclude that laparoscopic appendectomy is important in the treatment of complicated appendicitis in high-risk patients and of course a prospective randomized trial on that topic is desirable. Authors’ roles Werkgartner G and Wagner D wrote and drafted the manuscript, Cerwenka H, El Shabrawi A, Bacher H, Hauser H performed the study and analyzed the data, Mischinger HJ and Wagner D designed the study, Wagner M created the database and analyzed the data
References 1. Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, Mock C (2014) Global disease burden of conditions requiring emergency surgery. BJS 101:e9–e22 2. Minutolo V, Licciaredello A, Di Stefano B, Arena M, Arena G, Antonacci V. Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4 years experience in a district hospital. BMC Surgery 2014 epub ahead of print 3. Tannoury J, Abbound B (2013) Treatment options of inflammatory appendiceal masses in adults. Wold J Gastroenterol 19(25):3942–3950 4. Mutter D, Marescaux J (2013) Appendicitis/Diverticutlitis: Minimally invasive surgery. Dig Dis 31:76–82 5. Markides G, Subar D, Riyad K (2010) Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis. World J Surg 34:2026–2040 6. Milewczyk M, Michalik M, Ciesielski M (2003) A porspective, randomized, unicenter study comparing laparoscopic and open treatment of acute appendicitis. Surg Endosc 17:1023–1028 7. Nakhamiyayev V, Galldin L, Chiarello M, Lumba A, Gorecki PJ. Laparoscopic appendectomy is the preffered approach for appendicitis: a retrospective review of two practice patterns. Surg Endosc 2ß1ß;24: 859–864 8. Graff L, Russel J, Seashore J, Tate J, Elwell A, Prete M (2000) Flase negative and false positive errors in abdominal pain evaluation: Failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med 7:1244–1255 9. Flum DR, Morris A, Koepsell T, Dellinger EP (2001) Has misdiagnosis of appendicitis decreased over time? A population based analysis. JAMA 286:1748–1753
401 10. Flum DR, Koepsell T (2002) The clinical and economic correlates of misdiagnosed appendicitis: Nationwide analysis. Arch Surg 137: 799–804 11. Sack U, Biereder B, Elouahidi T, Bauer K, Keller T, Trobs RB (2006) Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children. BMC Surg 6:15 12. Yu CW, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC (2013) Systematic review and meta analysis of the diagnostic accuracy of procalcitonin, C reactive protein and white blood cell count for suspected acute appendicitis. Br J Surg 100:322–329 13. Dindo D, de Martines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–30 14. Varela JE, Hinojosa MW, Nguyen NT (2008) Laparoscopy should be the approach of choice for acute appendicitis in morbidly obese. Am J Surg 196:218–222 15. Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, Liu Y (2010) Laparoscopic versus conventional appendectomy—a meta-analysis of randomized controlled trials. BMC Gastroenterol 10:129 16. Krisher SL, Browne A, Dibbins A, Tkacz N, Curci M (2001) Intra abdominal abscess after laparoscopic appendectomy for perforated appendicitis. Arch Surg 136:438–441 17. Cueto J, D’Allemagne B, Váuqueu-Frias JA, Gomez S, Delgado F, Trullenque L, Fajardo R, Valencia S, Poggi L, Ballí J, Diaz J, González R, Mansur JH, Franklin ME (2006) Morbidity of laparoscopic surgery for complicated appendicitis: an international study. Surg Endosc 20:717–720 18. Gupta R, Samle C, Bamehriz F, Birch DW (2006) Infectious complications following laparoscopic appendectomy. Can J Surg 49:397– 400 19. Wei HB, Huang JL, Zheng ZH, Wei B, Zheng F, Qiu WS, Guo WP, Chen TF, Wang TB (2010) Laparoscopic verus open appendectomy: a prospective randomized comparison. Surg Endosc 24:266–269 20. Sauerland S, Lefereing R, Neugebauer E (2004) Laparoscopic versus open surgery for suspected appendicitis (review). Cochrane Database Syst Rev 4, DS001546 21. Sauerland S, Lefering R, Neugebauer EA (2010) Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 10, CD001546 22. Mischinger HJ, Berger A, Colombo T, Kornberger L (1989) Is the search for Meckels diverticulum still a current problem in common surgical practice? Chirurg 60:549–552 23. McGrath B, Buckius MT, Grim R, Bell T, Ahuja V (2011) Economics of appendicitis: cost trend analysis of laparoscopic versus open appendectomy from 1998 to 2008. J Surg Res 171:e161–168
ORIGINAL ARTICLE
Laparoscopic versus open appendectomy for complicated appendicitis in high risk patients G. Werkgartner & H. Cerwenka & A. El Shabrawi & H. Bacher & H. Hauser & H. J. Mischinger & M. Wagner & D. Wagner
Accepted: 8 December 2014 / Published online: 16 December 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Introduction Laparoscopic appendectomy is widely used for the treatment of complicated appendicitis. Its use in patients with high operative risk is still on debate. The aim of the presented study was to investigate the benefits of laparoscopic appendectomy in patients with high peri- and postoperative risk factors. Methods We performed a retrospective analysis of all patients who underwent appendectomy in our center between 2006 and 2013. Patients were classified according to their preoperative risk (classification of the American Society of Anesthesia—ASA score). Only patients with ASA 3 and 4 were included and were divided into two groups—open appendectomy (OA group) and laparoscopic appendectomy (LA group). Results The operation time was slightly longer in the LA group (p=0.05), but hospital stay was shorter (p=0.05). Complications graded according to the Clavien Dindo classification were slightly more frequent in patients after LA, whereas severe complications occurred more frequently in patients after OA (p=0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p=0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p=0.05).
G. Werkgartner : H. Cerwenka : A. El Shabrawi : H. Bacher : H. Hauser : H. J. Mischinger : D. Wagner (*) Department of Surgery, Division for General Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria e-mail: [email protected] M. Wagner Department of Internal Medicine, Division for Endocrinology, Medical University of Graz, Auenbruggerplatz 29, Graz, Austria
Conclusion Laparoscopic appendectomy can be recommended for patients with complicated appendicitis even with higher risk categories. Keywords Open appendectomy . Laparoscopic appendectomy . Complicated appendicitis . Acute appendicitis . ASA classification
Introduction Complicated appendicitis (CA) still represents one of the main indications for emergency surgery worldwide [1]. The clinical advantages of laparoscopic appendectomy (LA) like reduced hospital stay, lower wound infection rate, shorter time of postoperative ileus, and less postoperative pain or better cosmetic results have been demonstrated over the past years in several studies and meta-analysis [2–5]. Despite these data and despite the fact that LA is widely used for appendectomies, it is still not considered as the gold standard everywhere. Especially, CA is frequently treated by open appendectomy (OA) due to debates and publications that LA is associated with longer operating times and an elevated risk for postoperative intra-abdominal abscesses in these patients [6, 7]. The preoperative discrimination between acute appendicitis (AA) with and without complications in patients with suspected appendicitis is usually done based on laboratory parameters in addition to clinical presentation [8–10]. Conventional white blood cell count (WBC) is neither considered sensitive nor specific for the diagnosis of AA nor for the discrimination to CA [11]. C-reactive protein (CRP) has been considered more specific and more sensitive in the detection of appendiceal perforation and abscess formation. A recent review showed that CRP had the highest accuracy regarding the diagnosis of CA and the discrimination between uncomplicated and complicated appendicitis [12].
398
Postoperative complications are more frequent and achieving an acceptable benefit after operation is crucial in patients who suffer from additional comorbidities. The presented analysis aimed to evaluate the course of inflammatory response parameters, namely CRP and WBC, after open and laparoscopic appendectomy for complicated appendicitis in patients with present and severe comorbidities defined as high-risk patients for operations.
Methods We performed a retrospective review of the patient records of all patients who underwent appendectomies in our center between January 2006 and December 2013. The study was approved by the ethical board of the Medical University of Graz (ECS 1156/2013). To identify those with comorbidities and higher risk, all patients were classified using the American Society of Anesthesiologists (ASA) risk classification. Patients with ASA 3 and 4 were classified as patients at risk and were included into the presented analysis. Depending on the intraoperative evaluation, patients were classified into patients with complicated appendicitis (CA) or uncomplicated appendicitis (UA). Additionally, the postoperative pathological results were matched with the intraoperative observation in order to omit the subjective parameter of observation. Patients who were classified as suffering from CA according to both criteria were included into the presented analysis. These patients were enrolled according to the surgical approach used and divided into a group of patients after open appendectomy (OA group) and a group of patients who underwent laparoscopic appendectomy (LA group). For each patient age, gender, and duration of symptoms, pre- and postoperative white blood cell count (WBC), pre- and postoperative C-reactive protein (CRP), duration of operative procedure, length of hospital stay and postoperative complications were recorded. Postoperative complications were graded using the Clavien Dindo classification [13]. All laparoscopic procedures were performed using a three trocar technique, two 10 mm and one 5 mm ports. After coagulation of the mesoappendix, the LA was performed using a stapler or two endoscopic loop ligatures. In case of perforation or abscesses, laparoscopic lavage was performed. All open appendectomies were performed using McBurney’s incision in standard technique with inversion of the appendiceal stump. Our center protocol favors OA rather than LA in case of severe cardiac or respiratory comorbidities or geriatric patients and previous major abdominal surgeries. Additionally, the final choice upon the nature of the procedure is done by the performing surgeon.
Int J Colorectal Dis (2015) 30:397–401
All patients received perioperative antibiotic prophylaxis with tazobactam, or metronidazole in combination with ciprofloxacin in case of allergies. Our center favors the placement of a drain in case of complicated appendicitis. Statistical analysis Data obtained in the presented study were analyzed using SPSS 21.0 (SPSS Inc. Chicago, IL, USA). Data measured as quantitative variables were analyzed using the Student t test. To detect statistical significance of differences between data represented as categorical variables, the chi-square test was used. Additionally, the relation between the occurrence of complications and the used operating technique was assessed using regression analysis and AUROC analysis or Kaplan– Meier analysis as appropriate.
Results In the defined time span, 1140 appendectomies have been performed in our center. Of them, 462 patients suffered from a complicated appendicitis (CA) and 59 of those patients showed ASA classifications of 3 or 4 and were included into the presented analysis. Patient characteristics Fifty-nine patients in total showed comorbidities that classified them as ASA 3 or 4, 41 (69 %) were classified as ASA 3, and 18 (31 %) were classified as ASA 4. Patients were divided into two groups according to the operative procedure they underwent—21 (35 %) patients were treated using LA and 38 (65 %) underwent open surgery. Baseline characteristics were not completely comparable between both groups. Laparoscopy was more frequent in patients who showed ASA 3 scores as compared to ASA 4 patients (p=0.03 and 0.04, respectively). Preoperative CRP was slightly higher in patients with OA as compared to patients who underwent LA (p=0.05) as was the preoperative white blood cell count (p= 0.054). Preoperative fever was more frequent in patients who underwent open appendectomies (p=0.04) as was perforation in those patients as compared to patients in the LA group (p= 0.04). All preoperative characteristics are compiled in Table 1. Postoperative course The operation time was slightly longer in the LA group (p= 0.05), but hospital stay was shorter (p=0.05). The overall complication rate graded according to the Clavien Dindo classification was slightly higher in patients after LA, whereas
Int J Colorectal Dis (2015) 30:397–401 Table 1
399
Compiles all baseline demographic data including age, gender, and ASA-risk classification
Age (a) Gender (male %) Comorbidities (%) Diabetes mellitus Cardiomyopathy Dilative Hypertrophic NYHA III NYHA IV COPD III/IV Previous surgeries Immunosuppressive Therapy ASA risk score ASA 3 ASA 4 WBC count (109/L) preoperative CRP (mg/L) preoperative Perforation (%) Fever preoperative (>37.8 °C) (%)
OA group (n=38)
LA group (n=21)
p value
47 (18–97) 50.8 % 67 % (26/38) 39 % (15/38) 43 % (16/38) 31 % (12/38) 11 % (4/38) 7 % (3/38) 45 % (17/38) 50 % (19/38) 13 % (5/38)
36 (18–83) 44 % 56 % (12/21) 8 % (2/21) 14 % (3/21) 14 % (3/21) – 14 % (3/21) – 10 % (2/21) 23 % (5/21) 29 % (6/21)
n.s. p=0.05 n.s. p=0.02 p=0.02 p=0.01 p=0.001 p=0.02 p=0.001 p=0.01 p=0.03 p=0.001
58 % (22/38) 42 %(16/38)
90 % (19/21) 10 % (2/21)
p=0.04 p=0.03
16.8±4.8
16.1±2.9
n.s.
109±46 31.3 % 65 %
101±53 23.9 % 57 %
n.s. p=0.04 n.s.
Baseline characteristics were not completely comparable between both groups. Laparoscopy was more frequent in patients who showed ASA 3 scores as compared to ASA 4 patients. CRP was slightly higher in patients with OA as was the white blood cell count. Preoperative fever was more frequent in patients who underwent open appendectomies (ASA American Society for Anesthesia, OA open appendectomy, LA laparoscopic appendectomy, WBC count white blood cell count, CRP C-reactive protein)
Table 2
All intra and postoperative parameters are listed below OA group (n=38)
OP time (min) Hospital stay (median days) Clavien Dindo classification All Grades (%) Grade I Grade II Grade III Grade IV Grade V WBC count (109/L) POD 1 WBC count (109/L) POD 3 CRP (mg/L) POD 1 CRP (mg/L) POD 3
35 (17–75) 7 (5–98) 32 % (12/38) 42 % (5/12) 8 % (1/12) 42 % (5/12) 8 % (1/12) None 14.2±4.6 12.1±2.3 131±23 67±19
LA group (n=21) 49 (28–96) 6 (4–25) 38 % (8/21) 75 % (6/8) None 25 % (2/8) None None 16.3±1.6 14.3±2.5 105±25 58±21
p value p=0.05 p=0.05 p=0.05 p=0.05 p=0.01 p=0.02 p=0.01 n.s. p=0.03 p=0.03 p=0.05 p=0.05
The operation time was slightly higher in the LA group (p=0.05), hospital stay was shorter (p=0.05). The overall complication rate graded according to the Clavien Dindo classification was slightly higher in patients after LA, whereas severe complications occurred more frequently in patients after OA (p= 0.01). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p=0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p=0.05) (OA open appendectomy, LA laparoscopic appendectomy, WBC count white blood cell count, CRP C-reactive protein)
400
severe complications occurred more frequently in patients after OA (p=0.01, Table 2). The postoperative WBC decreased steadily and significantly in patients after OA, whereas the decrease in patients after LA was delayed (p=0.03). CRP slightly increased after OA and decreased thereafter, whereas it steadily decreased after LA (p=0.05, Table 2). Clavien Dindo classification and postoperative inflammatory response Overall, 32 % of the OA patients and 38 % of the LA patients showed complications which were classified according to the Clavien Dindo classification. Patients after OA showed a lower rate of grade I complications (24 %) as compared to patients after LA (75 %). Grade II complications were more frequent in patients after LA (0 %) as compared to patients after OA (8 %). The preoperative white blood cell count was significantly elevated in patients after OA who suffered from grades III (wound healing disorders that required vacuum assisted closure) and IV (postoperative renal failure in one patient) complications as compared to patients after LA who suffered from grade III (two patients who suffered from postoperative ileus that required parenteral nutrition) complications (p=0.02). The decline of WBC was more delayed in patients after OA as compared to patients after LA. The preoperative CRP was more elevated in the OA group as compared to LA patients and increased postoperatively in OA patients with complications. This increase was significant as compared to patients after LA and complications.
Discussion Laparoscopic appendectomy (LA) has become the treatment of choice for uncomplicated appendicitis (UA) for many surgeons in the past 15 years [2–8, 14, 15]. Rates of LA have doubled over this period of time [5]. LA not only represents an important diagnostic tool for the exploration of the whole peritoneal cavity, but it has also been associated with shorter hospital stay and lower postoperative complications [4]. Complicated appendicitis (CA) marked by intra-abdominal abscesses represents a separate entity among patients with acute appendicitis. Its management via LA is still discussed controversially [16–18]. Recent reports suggest advantages of LA in the treatment of complicated appendicitis [2]. All of these reports usually include only a minority of patients with severe peri- and postoperative risk factors. In the presented study, only patients with severe comorbidities and risk factors were included. Therefore, we were able to perform a comparison between those patients. However, there is some bias in the presented analysis. OA patients showed
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higher ASA scores as compared to LA patients and subsequently their rate of comorbidities was higher (Table 1). Additionally, LA is not the first choice according to our center protocol in case of severely cardiac or respiratory conditions or their geriatric age and previous abdominal surgeries. In those cases, our center protocol favors OA rather than LA. Therefore, OA patients appear to be sicker in the presented study. This does not necessarily mean that the included LA patients were healthy. In fact, those patients showed severe comorbidities that were considered as contraindications for long. What is new about the presented analysis is that patients after LA even if they have high perioperative risks and constellations do have acceptable results. This involves geriatric patients as well, which is an extremely discussed population. In our opinion, LA showed acceptable results in these patients. Another potential limitation of our study might be its retrospective nature whereas prospective studies in these patients, namely patients being at high risk, who are usually only operated in emergency situations, are not easy to perform as appendectomies often represent emergency surgeries—a setting in which the performance of randomized prospective trials can sometimes be crucial. Designed in a prospective setting a matched pair analysis would at least be desired in these patients. Laparoscopic appendectomy was reported to have a higher rate of intra-abdominal abscesses as compared to the open approach, especially in patients with CA [16]. We did not observe any intraperitoneal infections in our LA patients. Additionally, they showed lower rates of wound infections as compared to OA patients. On the other hand, patients in the LA group were seen to have more complications classified as grade I postoperatively as compared to the OA group (p=0.05). The reported length of hospital stay is usually shorter in patients after LA as compared to OA. This was the case in our cohort as well, whereas our patients stayed longer than the average patients reported in the literature. This might also be due to the higher pre- and postoperative risks. This result is comparable to the results of the recent meta-analysis [19–21]. In our experience, patients after LA return to work earlier as compared to patients after OA; however, data in the selected group of patients were not complete enough to be included into the analysis. Additionally LA allows a better overview of the patients abdomen and therefore an ameliorated diagnosis of potiential concomittant diseases [22]. Although the costs of the laparoscopic approach can be higher than the costs of open appendectomies, the reduction in length of hospital stay compensates this effect. Therefore, LA can be performed at the same costs as OA due to the shorter hospital stay and lower rate of postoperative complications [23]. Studies on the postoperative course of LA in high-risk patients are very scarce. As some of these patients suffer from severe comorbidities like heart insufficiency, pulmonal
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deficiencies, or intra-abdominal diseases besides appendicitis, most surgeons still choose open approaches. Despite this limitation, we conclude that laparoscopic appendectomy is important in the treatment of complicated appendicitis in high-risk patients and of course a prospective randomized trial on that topic is desirable. Authors’ roles Werkgartner G and Wagner D wrote and drafted the manuscript, Cerwenka H, El Shabrawi A, Bacher H, Hauser H performed the study and analyzed the data, Mischinger HJ and Wagner D designed the study, Wagner M created the database and analyzed the data
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