SAGES guideline for the diagnosis and treatment of appendicitis.

BACKGROUND: Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. METHODS: A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. RESULTS: Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. CONCLUSIONS: These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Diagnosis and treatment of appendicitis: systematic review and meta-analysis.

BACKGROUND: The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS: Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS: 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS: This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.

The Early (2009-2017) Experience With Robot-assisted Cholecystectomy in New York State.

OBJECTIVE: The aim of this study was to examine real-life patterns of care and patient outcomes associated with robot-assisted cholecystectomy (RAC) in New York State (NYS). BACKGROUND: Although robotic assistance may offer some technological advantages, RACs are associated with higher procedural costs and longer operating times compared to traditional laparoscopic cholecystectomies (LCs). Evidence on long-term patient outcomes after RAC from large population-based datasets remains limited and inconsistent. METHODS: Using NYS inpatient and ambulatory surgery data from the Statewide Planning and Research Cooperative System (2009-2017), we conducted bivariate and multivariate analyses to examine patterns of utilization, complications, and secondary procedures following cholecystectomies. RESULTS: Among 299,306 minimally invasive cholecystectomies performed in NYS between 2009 and 2017, one thousand one hundred eighteen (0.4%) were robot-assisted. Compared to those undergoing LC, RAC patients were older, travelled further for surgery, and were more likely to have public insurance and preoperative comorbidities. RAC versus LC patients were more significantly likely to have conversions to open procedure (4.9% vs 2.8%), bile duct injuries (1.3% vs 0.4%), and major reconstructive interventions (0.6% vs 0.1%), longer median length of stay (3 vs 1 day), readmissions (7.3% vs 4.4%), and higher 12-month post-index surgery hospital charges (P < 0.01 for all estimates). Other postoperative complications decreased over time for LC but remained unchanged for RAC patients. CONCLUSIONS: Patients receiving RAC in NYS experienced higher rates of complications compared to LC patients. Addressing patient-, surgeon-, and system-level factors associated with intra/postoperative complications and applying recently promulgated safe cholecystectomy strategies coupled with advanced imaging modalities like fluorescence cholangiography to RAC may improve patient outcomes.

Teaching surgery novices and trainees advanced laparoscopic suturing: a trial and tribulations.

INTRODUCTION: The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills. METHODS AND PROCEDURES: Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups. RESULTS: Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups. CONCLUSIONS: Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

BACKGROUND: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. METHODS: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. CONCLUSIONS: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

Predictors and Outcomes of Laparoscopy in Pediatric Trauma Patients: A Retrospective Cohort Study.

Introduction: Laparoscopy has been shown to offer a safe alternative to laparotomy in hemodynamically stable pediatric trauma patients. Our purpose was to identify factors predictive of this approach and examine surgical outcomes. Methods: This is a retrospective cohort study using the ACS Pediatric Trauma Quality Improvement Program to examine pediatric patients who underwent exploration for blunt or penetrating abdominal trauma in 2014 and 2015. Patients with contraindications to laparoscopy were excluded. Multivariable modeling identified predictors of a laparoscopic approach. Secondary analysis assessed differences in outcomes and resource utilization between laparoscopy and laparotomy groups. Results: A total of 160 patients met inclusion criteria. Patients undergoing surgery in the northeastern (odds ratio [OR]: 2.25, 95% confidence interval [CI]: 1.26-4.03, P = .006) and western (OR: 2.03, 95% CI: 1.06-3.88, P = .032) U.S. regions had over two times greater odds of undergoing laparoscopy as those treated in the south. Patients injured by a firearm were significantly less likely to undergo laparoscopy than those suffering blunt injury (OR: 0.27, 95% CI: 0.13-0.55, P < .001). After adjustment, patients explored laparoscopically in comparison with those through laparotomy had decreased average length of stay (LOS) (mean difference [MD]: 2.55 days, 95% CI: 1.19-3.90, P < .001) and number of intensive care unit (ICU) days (MD: 1.13 days, 95% CI: 0.28-1.98, P = .01). Conclusion: Trauma laparoscopy may decrease LOS and ICU days in select pediatric patients requiring abdominal exploration; however, laparoscopy is not uniformly practiced in the United States. Targeted education and protocols for initial use of laparoscopy should be incorporated into hospitals treating this group to minimize morbidity and resource utilization.

Influence of hospital-level practice patterns on variation in the application of minimally invasive surgery in United States pediatric patients.

BACKGROUND: Although disparities in access to minimally invasive surgery are thought to exist in pediatric surgical patients in the United States, hospital-level practice patterns have not been evaluated as a possible contributing factor. METHODS: Retrospective cohort study using the Kids' Inpatient Database, 2012. Odds ratios of undergoing a minimally invasive compared to open operation were calculated for six typical pediatric surgical operations after adjustment for multiple patient demographic and hospital-level variables. Further adjustment to the regression model was made by incorporating hospital practice patterns, defined as operation-specific minimally invasive frequency and volume. RESULTS: Age was the most significant patient demographic factor affecting application of minimally invasive surgery for all procedures. For several procedures, adjusting for individual hospital practice patterns removed race- and income-based disparities seen in performance of minimally invasive operations. Disparities related to insurance status were not affected by the same adjustment. CONCLUSION: Variation in the application of minimally invasive surgery in pediatric surgical patients is primarily influenced by patient age and the type of procedure performed. Perceived disparities in access related to some socioeconomic factors are decreased but not eliminated by accounting for individual hospital practice patterns, suggesting that complex underlying factors influence application of advanced surgical techniques. LEVEL OF EVIDENCE: II.