Trends in the Use of Laparoscopic Versus Open Paediatric Appendicectomy: A Regional 12-Year Study and a National Survey.

BACKGROUND: In adult patients, it is generally accepted that laparoscopic appendicectomy (LA) is the predominant operative pathway in treating acute appendicitis. The case for a similar pathway utilising LA in children is less clear. We investigate usage, trends and complications after LA in children in a single co-located adult/paediatric centre with contemporaneous adults as controls. METHODS: A retrospective case-control study was conducted over 12 years including patients who underwent appendicectomy, and the paediatric series (<16 years) was divided into age-groups-based quartiles. An anonymous questionnaire-based national survey was circulated among general and paediatric surgeons. RESULTS: Of the 5784 appendicectomy patients, 2960 were children. LA rate in paediatric appendicitis was 65%. Yearly trends in LA reached a steady state in both groups after 2010 (Δ 0-1%/year). Rates of LA and LA IAA (respectively) differed significantly between age groups: 60, 3% (0-9 years); 65, 1% (10-13 years); 71, 2% (14-16 years) and 93, 3% (>16 years) (p = 0.001, 0.02). The national survey showed respondents believed LA was not superior to OA in paediatric patients except in terms of cosmesis. There was strong support in the use of LA in older children and children >40 kg. CONCLUSION: The use of LA in paediatric appendicectomies in the study region is similar to international rates, but not increasing over time. Irish surgeons still favour OA in younger children and prefer a case-by-case approach rather LA being the preferred pathway. This is despite the regional and international evidence showing favourable outcomes with LA in children.

[Novelties in surgery in 2016]. / Quoi de neuf en chirurgie?

The year 2016 allowed further implementation of previous years innovations with the PIPAC treatment for peritoneal carcinomatosis, the development of new surgical technologies and procedures and challenging general principles in general and digestive surgery, including cholecystectomy and appendectomy. Prevention, improved general and perioperative care (ERAS program) become an integral part of our standard surgical activity.

L'année 2016 a permis le développement des innovations des années précédentes avec le traitement PIPAC pour la carcinose péritonéale, le déploiement de nouvelles technologies et procédures chirurgicales et la remise en cause de principes généraux en chirurgie générale et digestive, notamment pour la cholécystectomie et l'appendicectomie. La prévention, l'amélioration des soins et de la prise en charge périopératoire (programme ERAS) deviennent une part intégrante de notre activité chirurgicale.

Natural-orifice transluminal endoscopic surgery.

BACKGROUND: Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial. METHODS: A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully. RESULTS: Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation. CONCLUSION: NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Pediatric negative appendectomy rate: trend, predictors, and differentials.

BACKGROUND: Appendectomy is one of the most commonly performed emergency operations in children. The diagnosis of appendicitis can be quite challenging, particularly in children. We set out to determine the accuracy of diagnosis of appendicitis by analyzing the trends in the negative appendectomy rate (NAR) using a national database. MATERIALS AND METHODS: Analysis of the Kids Inpatient Database (KID) was performed for the years 2000, 2003, and 2006 on children with appendectomy, excluding incidental appendectomies. Children (<18 y) without appendicitis but who underwent appendectomies were classified as negative appendectomies (NA), and those with appendicitis as positive appendectomies (PA). Comparisons were made between those with PA versus NA by demographic characteristics. The subset of patients with NA was then further analyzed. RESULTS: An estimated 250,783 appendectomies met the inclusion criteria. The NAR was 6.7%. Length of stay (LOS) was longer in NA versus PA (7 versus 3 d, P < 0.05). The NAR was increased in children under 5 y (21.1% versus 5.4% for among the 5-10 y versus 5.9% among the >10 y, P < 0.0001) and in females (9.3% versus 5.1%, P < 0.001). On multivariate analysis, increasing age was associated with lower odds of NA (OR = 0.92, P < 0.001). Females, rural hospitals, and Blacks were significantly more likely to experience NA. CONCLUSIONS: Younger age, female gender, Black ethnicity and rural hospitals are independent predictors of NA. These factors can be incorporated into diagnostic algorithms to improve the accuracy of diagnosis of appendicitis in children.

Laparoscopic appendectomy conversion rates two decades later: an analysis of surgeon and patient-specific factors resulting in open conversion.

BACKGROUND: The role of laparoscopy in appendicitis has gained increased popularity but remains controversial. Despite more than 20 y of experience in laparoscopy, the nationwide laparoscopic appendectomy (LA) conversion rate is reportedly 8.6%. We sought to analyze the impact of patient-specific and surgeon-specific factors that may contribute to open conversion during LA. MATERIALS AND METHODS: A retrospective analysis of 745 LAs (49.9% females and 50.1% males; average age of 37.8 y performed at a large tertiary community teaching hospital over a 5-y period (May 2004-October 2008) was performed. RESULTS: The overall conversion rate for the study period was 4.16% (n = 31). The most common reason for open conversion was severe acute inflammation (38.7%). Among converted cases, 77.42% had no prior abdominal surgery and only 25.81% of cases were converted due to adhesions. Females and patients ≥ 65-y-old had a higher likelihood of open conversion (4.30% versus 4.02%, P < 0.99 and 9.26% versus 3.76%, P < 0.1107). The overall conversion rate of cases performed by high-volume surgeons (≥ 50 total cases) in comparison to low-volume surgeons (10-49 total cases) was higher (4.86% versus 3.30%, P < 0.39). Conversion rates were lower among surgeons who completed residency training after 1990 (3.72% versus 4.35%, P < 0.82) and those with fellowship training (1.42% versus 5.18%, P < 0.034). CONCLUSIONS: Laparoscopic conversion continues to gain popularity and remains the gold standard procedure for appendectomy. Older patients have a higher likelihood of conversion with severe acute inflammation being the most common reason for conversion. Additional minimally invasive fellowship training was the only surgeon-specific factor that significantly impacted conversion rate.

Trend, variability, and outcome of open vs. laparoscopic appendectomy based on a large administrative database.

The aim of this study was to ascertain the variability and 9-year trends in the use of laparoscopic surgery for appendicitis using data from a large administrative database, to compare the effectiveness and efficiency of laparoscopic (LA) and open appendectomy, and to ascertain whether different choices of surgical approach stem from evidence-based recommendations. This was a retrospective cohort study based on administrative data collected from 2000 to 2008 in the Veneto Region (northeastern Italy). Funnel plots were used to display variability between local health units (LHUs). A total of 38,314 appendectomies were performed from 2000 to 2008 in the Veneto Region, 53% of them in males. The laparoscopic procedure was used more often for females than for males of fertile age. There was a significant rising linear trend in the use of LA, with a higher increment among females. The overall regional standardized appendectomy rate was 82.9/10,000. The mean proportion of LAs (27.3%) ranged from 2.8 to 59.4% at different LHUs, and there was no relationship between the volume of procedures undertaken and the proportion of LAs. The proportion of LAs performed in females of reproductive age also varied considerably, on no apparent evidence-based grounds. The analysis of aggregate clinical data is a powerful tool for supporting regional health management units in efforts to improve the quality of medical care and assess the appropriateness of therapeutic or diagnostic approaches in the light of practical guidelines. Variability in the treatment of a given disease that lacks any evidence-based justification remains an important issue in national health systems.

Laparoscopic appendectomy in children with complicated appendicitis: ethnic disparity amid changing trend.

BACKGROUND: Laparoscopic appendectomy (LA) has gained acceptance in the treatment of uncomplicated appendicitis in the pediatric population. The role of LA versus open appendectomy (OA) in complicated (perforated) appendicitis has remained controversial. METHODS: A 10-y review of the Nationwide Inpatient Sample (HCUP-NIS) and 3 y of non-overlapping data from the Kids' Inpatient Database (KID) (2000, 2003, and 2006) was performed on pediatric patients (age <18 y) with complicated appendicitis. Patients were classified based on gender, race, insurance status, and type of appendectomy performed. Multivariate regression was conducted adjusting for age, race, gender, and type of appendectomy, with mortality and length of hospital stay (LOS) as outcomes. RESULTS: An estimated 72,787 patients met the inclusion criteria with a median age of 11 y. The majorities of the patients were male (59.9%), Caucasian (38.1%), and insured (89.7%). Twenty-nine percent underwent LA while 71% had OA. Proportion of LA increased from 9.9% in 1999 to 46.6% in 2007. On multivariate analysis, African-Americans were less likely to undergo LA compared with Caucasians (OR: 0.80, CI = 0.69-0.92, P = 0.002) despite an increased odds of undergoing LA over the last decade from 1998 to 2007 in the entire study population (OR 6.27, 95% CI 4.73-8.30, P = 0.000). Increasing age and gender were also associated with likelihood of receiving LA (OR: 1.08, CI = 1.06-1.10 and OR 1.25, 95% CI 1.18-1.31, P < 0.001). CONCLUSIONS: LA is gradually gaining acceptance over the years as an alternative to OA for complicated appendicitis, However, minority difference still exists in choice of procedure. There is a need to further investigate this disparity as it may be related to access to skilled laparoscopic pediatric surgeons.

[Appendicitis in Hungary through the eyes of a health insurance specialist]. / Az appendicitis Magyarországon az egészségbiztosítási szakorvos szemével.

UNLABELLED: Appendicitis is the most common surgical disease. There is a very large literature for both its diagnosis and therapy. AIMS: The author examined whether patients who were admitted with the diagnosis of appendicitis underwent surgery and what admission diagnoses were reported in cases of surgically treated patients. RESULTS: In Hungary, there have been more than 92,000 appendectomies performed in the last eleven years. The proportion of laparoscopic surgery was 2.0% in 2000 and it rose to 18.8% in 2010. Using database of the national health insurance the author found that 5.6% of all surgically treated patients were referred to hospital with a diagnosis other than appendicitis. In contrast, 18.1% of the patients referred to hospital with the diagnosis of appendicitis were discharged without surgery. CONCLUSIONS: In Hungary, there are large regional differences in the proportion of surgery.

Appendectomy Versus Observation for Appendicitis in Neutropenic Children With Cancer.

BACKGROUND: Optimal management of neutropenic appendicitis (NA) in children undergoing cancer therapy remains undefined. Management strategies include upfront appendectomy or initial nonoperative management. We aimed to characterize the effect of management strategy on complications and length of stay (LOS) and describe implications for chemotherapy delay or alteration. METHODS: Sites from the Pediatric Surgery Oncology Research Collaborative performed a retrospective review of children with NA over a 6-year period. RESULTS: Sixty-six children, with a median age of 11 years (range 1-17), were identified with NA while undergoing cancer treatment. The most common cancer diagnoses were leukemia (62%) and brain tumor (12%). Upfront appendectomy was performed in 41% of patients; the remainder had initial nonoperative management. Rates of abscess or perforation at diagnosis were equivalent in the groups (30% vs 24%; P = .23). Of patients who had initial nonoperative management, 46% (17 of 37) underwent delayed appendectomy during the same hospitalization. Delayed appendectomy was due to failure of initial nonoperative management in 65% (n = 11) and count recovery in 35% (n = 6). Cancer therapy was delayed in 35% (n = 23). Initial nonoperative management was associated with a delay in cancer treatment (46% vs. 22%, P = .05) and longer LOS (29 vs 12 days; P = .01). Patients who had initial nonoperative management and delayed appendectomy had a higher rate of postoperative complications (P < .01). CONCLUSIONS: In pediatric patients with NA from oncologic treatment, upfront appendectomy resulted in lower complication rates, reduced LOS, and fewer alterations in chemotherapy regimens compared to initial nonoperative management.

Comparison of acute appendicitis before and within lockdown period in COVID-19 era: A retrospective study from rural Nepal.

INTRODUCTION: The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic. METHODS: A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis. RESULTS: There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008]. CONCLUSION: During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.

Impact of the COVID-19 pandemic on the pediatric population with acute appendicitis: Experience at a general, tertiary care hospital. / Impacto de la pandemia por COVID-19 en la población pediátrica con apendicitis aguda: experiencia en un hospital general de tercer nivel.

INTRODUCTION: Appendicitis is the leading cause of surgical acute abdomen in pediatrics. During the COVID-19 pandemic, management strategies were reassessed and the number of visits to the emergency department dropped down, which may be associated with delayed diagnoses and complications. The objective of this study was to analyze the impact of the pandemic on children with acute appendicitis. METHODS: Analytical, retrospective, comparative study of pediatric patients with acute appendicitis in the 5 months of COVID-19 lockdown versus the same period in the previous year. Incidence, clinical data, stage, surgical approach, and complications were analyzed. RESULTS: The total number of appendicitis cases went down by 25% (n = 67 versus n = 50 in 2020). The mean time to consultation was 24 hours in both periods (p = 0.989). The incidence of peritonitis was 44% (n = 22) versus 37% (n = 22) (p = 0.22) in 2019. No differences were observed in terms of appendicitis stage based on surgery reports. In 2019, all surgeries were laparoscopic; while in 2020, only 42% (n = 21). The incidence of complications was 6% versus 7.5% in the previous period (p = 0.75). One patient was COVID-19 positive. CONCLUSION: Although in our population the number of appendicitis cases dropped down, consultation was not delayed. The greater impact was associated with the reformulation of management strategies, in which the laparoscopic approach is avoided to reduce virus transmission.

Introducción. La apendicitis constituye la principal causa de abdomen agudo quirúrgico en pediatría. Durante la pandemia por COVID-19, se replantearon las estrategias de manejo y disminuyeron las consultas en las guardias, lo que podría asociarse a diagnósticos tardíos y complicaciones. El objetivo de este estudio fue analizar el impacto de la pandemia en los niños con apendicitis aguda. Métodos. Estudio analítico retrospectivo comparativo de pacientes pediátricos con apendicitis aguda durante los cinco meses del confinamiento por COVID-19 versus los meses equivalentes del año previo. Se analizaron la incidencia, la clínica, el estadio, el abordaje quirúrgico y las complicaciones. Resultados. Los casos totales de apendicitis se redujeron un 25% (n = 67 versus n = 50 en 2020). El tiempo medio hasta la consulta fue de 24 horas en ambos períodos (p = 0,989). La incidencia de peritonitis fue del 44% (n = 22) versus el 37% (n = 22) (p = 0,22) en 2019. No se evidenció diferencia en los estadios de enfermedad de acuerdo con lo informado en los partes quirúrgicos. En 2019, todas las cirugías se realizaron por vía laparoscópica; en 2020, solo un 42% (n = 21). La incidencia de complicaciones fue del 6%, contra 7,5% en el período previo (p = 0,75). Un paciente fue COVID-19 positivo. Conclusión. A pesar de la reducción en el número de casos de apendicitis, no se evidenció una demora en la consulta en nuestra población. El mayor impacto se asoció a la readecuación del manejo, evitando el abordaje laparoscópico para reducir la diseminación del virus.

National survey on the treatment of acute appendicitis in Spain during the initial period of the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. METHOD: A national descriptive study was carried out by an online voluntary specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons currently working in Spain (5203), opened from April 14th to April 24th. RESULTS: We received 337 responses from 170 centers. During the first month of the pandemic, the incidence of acute appendicitis decreased. Although conservative management increased, the surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. CONCLUSION: Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

Where have all the appendicectomies gone?

INTRODUCTION: The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised to avoid aerosol-generating procedures wherever possible. The authors hypothesised that these measures would result in a reduction in the number of patients presenting to hospital with acute appendicitis and alter treatment choices. METHODS: A multicentred, prospective observational study was undertaken during April 2020 to identify adults treated for acute appendicitis. Searches of operative and radiological records were performed to identify patients treated during April 2018 and April 2019 for comparison. RESULTS: A total of 190 patients were treated for acute appendicitis pre-lockdown compared with 64 patients treated during lockdown. Patients treated during the pandemic were more likely to have a higher American Society of Anesthesiology (ASA) score (p = 0.049) and to have delayed their presentation to hospital (2 versus 3 days, p = 0.03). During the lockdown, the use of computed tomography (CT) increased from 36.3% to 85.9% (p < 0.001), the use of an antibiotic-only approach increased from 6.2% to 40.6% (p < 0.001) and the rate of laparoscopic appendicectomy reduced from 85.3% to 17.2% (p < 0.001). The negative appendicectomy rate decreased from 21.7% to 7.1% during lockdown (p < 0.001). CONCLUSIONS: The COVID-19 lockdown was associated with a decreased incidence of acute appendicitis and a significant shift in the management approach. The increased use of CT allows the identification of simple appendicitis for conservative treatment and decreases the negative appendicectomy rate.

Appendicitis in the COVID-19 era: a modern challenge for experienced hands.

INTRODUCTION: The first wave of COVID-19 was accompanied by global uncertainty. Delayed presentation of patients to hospitals ensued, with surgical pathologies no exception. This study aimed to assess whether delayed presentations resulted in more complex appendicectomies during the first wave of COVID-19. METHODS: Operation notes for all presentations of appendicitis (n=216) within a single health board (three hospitals) during two three-month periods (control period (pre-COVID) vs COVID pandemic) were analysed, and the severity of appendicitis was recorded as per the American Association for the Surgery of Trauma (AAST) grading system. RESULTS: Presentations of appendicitis were delayed during the COVID period with a median duration of symptoms prior to hospital attendance of two days versus one day (p=0.003) with individuals presenting with higher median white cell count than during the control period (14.9 vs 13.3, p=0.031). Use of preoperative CT scanning (OR 3.013, 95% CI 1.694-5.358, p<0.001) increased significantly. More complex appendicectomies (AAST grade >1) were performed (OR 2.102, 95% CI 1.155-3.826, p=0.015) with a greater consultant presence during operations (OR 4.740, 95% CI 2.523-8.903, p<0.001). Despite the greater AAST scores recorded during the COVID period, no increase in postoperative complications was observed (OR 1.145, 95% CI 0.404-3.244, p=0.798). CONCLUSIONS: Delayed presentations during the COVID-19 pandemic were associated with more complex cases of appendicitis. Important lessons can be learnt from the changes in practice employed as a result of this global pandemic.

Trauma surgery to acute care surgery: defining the paradigm shift.

BACKGROUND: Trauma surgery is gradually evolving into acute care surgery (ACS). We sought to better define this evolution by using work relative value units (wRVU) to characterize the current practices of trauma and ACS. METHODS: Fiscal year 2007-2008 data from the UHC-AAMC Faculty Practice Solutions Center database, which is comprised of coding or billing data from 85 institutions was used. We compared averages for trauma surgeons with general, oncology, and vascular surgeons. RESULTS: Trauma surgeons are distinct from other surgical specialties; only 43% of their total wRVU were procedural compared to 69% to 75% for vascular, surgical oncology, and general surgeons. The total procedures for each specialty were similar: trauma 660, general surgery 715, surgical oncology 713, vascular 835, but trauma surgeons performed more bedside procedures. Of the top 20 total wRVU generating procedures, 20% of trauma surgeon's were bedside compared to 0% of a general surgeon's. The wRVU or surgeon for cholecystectomy were comparable between trauma and general surgery (388 vs. 452); both groups perform about 75% of the cholecystectomies laparoscopically. With respect to appendectomies, wRVU or surgeon for trauma surgeons (180) exceeded general surgeons (128). Each group performed approximately 65% laparoscopically. CONCLUSIONS: Trauma surgeons are distinctly different from their colleagues, with a greater emphasis on intensive care unit "cognitive" work. The number of procedures performed by trauma surgeons is comparable to other disciplines but with more "bedside" procedures. Trauma surgeons' high appendectomy wRVUs may be a reflection of the transition to an ACS model. The characterization of trauma surgery as nonoperative and intensive care unit-based is in part substantiated but there are indications of a paradigm shift toward more operative experience with transition to an ACS model.

Factors affecting the length of hospital stay after laparoscopic appendectomy: A single center study.

AIM: This study aimed to explore factors may affect the length of hospital stay after laparoscopic appendectomy. METHODS: The data of 636 patients undergoing laparoscopic appendectomy between July 2016 and July 2019 in Beijing Tsinghua Changgung Hospital were retrospectively analyzed. The patients were divided into group A (hospital stay ≤3 days, 348 patients) and group B (hospital stay >3 days, 288 patients) according to their hospital stay.Sex, age, disease onset time(time from onset to admission), nausea, vomiting, diarrhea, peritonitis, comorbidities, and history of appendicitis; preoperative body temperature (T), white blood cell (WBC) count, percentage of neutrophilic granulocytes, and preoperative C-reactive protein (CRP) level; time from diagnosis to surgery. appendix diameter, appendicolith, and ascites in ultrasound or CT; surgical time(the surgery start time was the time of skin incision, and the end time was the time the anesthesia intubation was removed), intraoperative blood loss (the volume of blood infiltrating into a gauze was calculated by weighing the gauze infiltrated with water and calculating the volume of water), intraoperative adhesions or effusions, and stump closure methods, convert to open appendectomy, appendix pathology(perforated or gangrenous appendicitis were defined as complicated appendicitis and simple or suppurative appendicitis were defined as uncomplicated appendicitis) and antibiotic treatment schemes were analyzed. RESULTS: Significant differences were detected between group A and group B in age (37.10 ± 13.52y vs 42.94 ± 15.57y, P<0.01), disease onset time (21.36 ± 16.56 h vs 32.52 ± 27.99 h, P <0.01), time from diagnosis to surgery (8.63 ± 7.29 h vs 10.70 ± 8.47 h, P<0.01); surgical time(64.09 ± 17.24 min vs 86.19 ± 39.96 min, P < 0.01); peritonitis(52.9% vs 74%, P < 0.01), comorbidities (12.4% vs 20.5%, P < 0.01), appendicolith (27.6% vs 41.7%, P < 0.01), ascites before the surgery(13.8% vs 22.9%, P < 0.01), intraoperative adhesions or effusions(56% vs 80.2%, P < 0.01); preoperative temperature (37.11 ± 0.64°C vs 37.54 ± 0.90°C, P < 0.01); preoperative WBC count (13.06 ± 3.39 × 109/L vs 14.21 ± 4.54 × 109/L, P = 0.04);preoperative CRP level(18.99 ± 31.72 mg/L vs 32.46 ± 46.68 mg/L, P < 0.01); appendix diameter(10.22 ± 2.59 mm vs 11.26 ± 3.23 mm, P < 0.01); intraoperative blood loss (9.36 ± 7.29 mL vs 13.74 ± 13.49 mL, P < 0.01); using Hem-o-lok for stump closure(30.7% vs 38.5%, P = 0.04); complicated appendicitis (9.5% vs 45.8%, P < 0.01); and using ertapenem for antibiotic treatment after the surgery(4.3% vs 21.5%, P < 0.01). Multivariate analysis demonstrated that age (OR = 1.021; 95%CI = 1.007-1.036), peritonitis (OR = 1.603; 95% CI = 1.062-2.419), preoperative WBC count (OR = 1.084; 95% CI = 1.025-1.046), preoperative CRP level (OR = 1.010; 95% CI = 1.005-1.015), time from diagnosis to surgery (OR = 1.043; 95% CI = 1.015-1.072), appendicolith (OR = 1.852; 95% CI = 1.222-2.807), complicated appendicitis (OR = 3.536; 95% CI = 2.132-5.863), surgical time (OR = 1.025; 95% CI = 1.016-1.034), use of Hem-o-lok for stump closure (OR = 1.894; 95% CI = 1.257-2.852), and use of ertapenem for antibiotic treatment (OR = 3.076; 95% CI = 1.483-6.378) were the risk factors for a prolonged hospital stay. CONCLUSIONS: The patient with appendicitis was older and had peritonitis, higher preoperative WBC count or CRP level, longer time from diagnosis to surgery, appendicolith, and complicated appendicitis, predicting a prolonged hospital stay. Shorter surgical time and the use of silk ligation for stump closure and cephalosporins + metronidazole for antibiotic treatment might be better choices to obtain a shorter hospital stay.

Changing trends in surgery for acute appendicitis.

BACKGROUND: Laparoscopic appendicectomy (LA) offers faster recovery times and a reduced rate of wound infection compared with open appendicectomy (OA) but may be associated with more intra-abdominal abscesses. This study examines the changing trends in management of appendicitis in a regional setting during service reorganization and compares infective complication rates for each procedure. METHODS: Data were retrieved from the Lothian Surgical Audit database on 1824 patients treated for appendicitis by OA or LA during equal 31-month periods before and after service reorganization in August 2002. Outcome measures were duration of admission, recovery time from operation to discharge and reintervention for infective complications. Analysis was by intention to treat. RESULTS: The rate of LA in Lothian increased from 29.9 to 39.4 per cent (P < 0.001) after subspecialist service reorganization. Recovery time from operation to discharge was significantly shorter after LA than OA when results were stratified with respect to sex (mean 2.5 versus 4.4 days respectively in women, P < 0.001; 2.7 and 3.1 days in men, P = 0.023), timing of surgery (2.7 versus 3.3 days before subspecialization, P = 0.007; 2.5 versus 3.6 days after subspecialization, P < 0.001) and whether appendicitis was associated with peritoneal contamination (2.2 versus 3.0 days for uncontaminated surgery, P < 0.001; 4.3 versus 5.1 days for contaminated surgery, P = 0.060). Peritoneal contamination at primary operation was the only independent risk factor that predicted reintervention for infective complications. CONCLUSION: LA is associated with a shorter hospital stay from operation to discharge than OA, with no evidence of an increased rate of intra-abdominal infective complications.