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Laparoscopic appendectomy for perforated appendicitis in children has complication rates comparable with those of open appendectomy
Journal of Pediatric Surgery (2013) 48, 555–561
www.elsevier.com/locate/jpedsurg
Laparoscopic appendectomy for perforated appendicitis in children has complication rates comparable with those of open appendectomy Mohammad Reza Vahdad ⁎, Ralf-Bodo Troebs, Matthias Nissen, Lars Benjamin Burkhardt, Svenja Hardwig, Grigore Cernaianu Department of Pediatric Surgery, Marienhospital–Kinderchirurgische Klinik der Ruhr-Universität Bochum, Widumerstr. 8, 44627 Herne, Germany Received 13 January 2012; revised 23 July 2012; accepted 27 July 2012
Key words: Perforated appendicitis; Children; Laparoscopic appendectomy; Open appendectomy; Complications
Abstract Purpose: To evaluate the outcome of laparoscopic (LA) vs. open appendectomy (OA) in children with perforated appendicitis (PA). Methods: We reviewed the medical files of 221 children who underwent LA (n=75), OA (n=122), and conversion (CO) (n=24), comparing duration of operation, re-admissions, re-operations, intraabdominal abscesses (IAA), and wound infections. Results: Compared to OA, LA resulted in fewer re-admissions (1.3% vs. 12.3%; P=.006), fewer reoperations (4% vs. 17.2%; P=.006), and fewer wound infections (0% vs. 11.5%; P=.001). No differences in the duration of operation (72.9±23.0 min vs. 77.7±48.0 min; P=.392) or IAA (4% vs. 11.5%; P=.114) were observed. Compared to LA, CO had more complications. Conclusions: We report that LA is superior to OA with regard to incidence of re-admission, reoperation, and wound infection. © 2013 Elsevier Inc. All rights reserved.
Laparoscopic appendectomy (LA) is minimally invasive and associated with less postoperative pain in children [1]. It remains to be clarified whether LA is inferior to open appendectomy (OA) in terms of postoperative complications, since there is considerable discrepancy in the published data. A 2010 Cochrane study [2] performed on adults and children
reported that LA increases the rate of intra-abdominal abscess (IAA) in adults and postulated a similar trend in children. Other studies performed on children, however, found an equal [3] or decreased [4] rate of IAA. This discrepancy prompted us to investigate the impact of LA on duration of operation and complications, in children with perforated appendicitis.
⁎ Corresponding author. Tel.: +49 2323 408; fax: +49 2323 499 328. E-mail addresses: [email protected] (M.R. Vahdad), [email protected] (R.-B. Troebs), [email protected] (M. Nissen), [email protected] (L.B. Burkhardt), [email protected] (S. Hardwig), [email protected] (G. Cernaianu).
1. Methods
0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.07.066
After obtaining institutional review board approval (no. 3928-11), a retrospective review identified all children less than 18 years of age with intraoperative and histological confirmed perforated appendicitis who
556 underwent appendectomy between January 2001 and December 2010 at the Department of Pediatric Surgery of Ruhr-University in Bochum, Germany. For inclusion in our study, patients had to fulfill the criteria of the definition for perforated appendicitis published in 2008 by St Peter et al. [5]: intraoperative evidence of perforation or intra-abdominal fecalith and confirmation of the perforation during histopathological examination. Only data from those patients who fulfilled both criteria were included. All other patients with a surgical diagnosis of perforated appendicitis who did not fulfill these strict criteria were excluded in order to rule out variation in the definition of perforation from 2001 to 2010. Informed consent was obtained from each patient's guardian. The patients were divided into three groups: patients who underwent LA, patients who underwent OA, and patients who underwent a conversion (CO). LA was performed using 3 Endo-Loops® (Ethicon®, Norderstedt, Germany). The decision of whether to perform LA or OA was based on the surgeon's preference. Until 2007, COs were performed routinely if suppuration was visualized intraabdominally. Since 2007, however, the only indication for CO is the inability to continue with LA. Surgical procedures were performed by consultants and residents. Our antibiotic regimen consisted of daily intravenous administration of cefuroxim (100 mg/kg body weight in three doses) for 7 days and metronidazole (20 mg/kg body weight in two doses) for 5 days starting at the onset of anesthesia. Some patients received an adapted antibiotic therapy based on the results of their intraoperative microbiological smear. Patients' medical records were reviewed retrospectively, and the following data were collected: age, sex, surgical procedure(s), duration of operation, and incidence of re-admission, re-operation, intraabdominal abscess formation, adhesiolysis and wound infection. We excluded children presenting with additional diagnoses before the first admission. Patients with a follow-up period less than 12 months, incomplete documentation, concomitant operations, or referred after appendectomy in other hospitals were excluded.We chose 12 months for the minimum follow-up in order to include late complications such as bowel obstruction that required adhesiolysis in addition to the complications that occurred within the first 30 postoperative days. Comparative statistical analyses were undertaken using the Fisher's exact test for qualitative data and the Mann–Whitney U test for quantitative data. Qualitative and quantitative data are presented as bars, illustrating mean±standard deviation (SD). Statistical analyses were performed using SPSS® 20 (IBM®) software. Differences were considered significant at Pb.05.
2. Results 2.1. Demographic data Appendectomies were completed in 221 children with perforated appendicitis evident at operation and confirmed
M.R. Vahdad et al. by histopathology. Eleven otherwise eligible patients were excluded during the duration of the study: 8 patients with incomplete documentation, 1 patient with concomitant resection of a Meckel's diverticulum, and 2 patients referred with complications after appendectomies in other hospitals. Perforated appendicitis accounted for 221 (19.8%) of 1114 patients with appendicitis. Seventy-five (33.9%) children underwent LA, 122 (55.2%) underwent OA, and in 24 patients (10.8%) the operative procedure was converted intra-operatively from LA to OA (CO). Mean patient age was 94 months (range, 15–212 months). Twenty-five different surgeons performed the surgical procedures, and the same surgeons operated on patients from different treatment groups (Table 1). Several surgeons performed operations both as residents and subsequently as board-certified pediatric surgeons. Consequently, 136 patients (61.5%) were operated on by 8 board-certified pediatric surgeons, and 20 residents operated on the remaining 85 patients (38.5%) under the supervision of a board-certified pediatric surgeon. The incidence of perforated appendicitis (P=.137) did not significantly differ between boys (n=124) and girls (n=97), and no deaths occurred. The median followup period was 25 months (range, 12–127 months) for LA, Table 1 Count and type of surgical procedures performed by each participating surgeon. Surgeon
LA
OA
CO
Total Count
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total
1 3 0 6 3 9 3 0 0 0 4 1 4 0 0 0 0 13 0 1 3 3 16 1 4 75
0 0 7 1 0 4 0 8 13 3 21 0 20 5 4 4 5 10 2 0 5 2 6 2 0 122
0 0 0 1 0 2 0 0 0 0 5 0 5 0 0 0 0 2 0 1 0 4 3 0 1 24
1 3 7 8 3 15 3 8 13 3 30 1 29 5 4 4 5 25 2 2 8 9 25 3 5 221
% 0.5 1.4 3.2 3.6 1.4 6.8 1.4 3.6 5.9 1.4 13.6 0.5 13.1 2.3 1.8 1.8 2.3 11.3 0.9 0.9 3.6 4.1 11.3 1.4 2.3 100
LA, laparoscopic appendectomy; OA, open appendectomy; CO, conversion from LA to OA. %: percentage of all surgical procedures.
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Fig. 1 Counts of conversions, laparoscopic, and open appendectomies per year for perforated appendicitis. The vertical line marks the cutoff point between the two time frames of treatment (2001–2007 vs. 2008–2010).
Fig. 2 Impact of surgical procedure on duration of operation. The duration of operation in minutes was compared across three surgical procedures. Patients underwent laparoscopic appendectomy (LA), open appendectomy (OA), or a conversion from laparoscopic to open appendectomy (CO). Data are plotted as bars with SD. ***Pb.001.
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Table 2 Distribution and statistical analysis of duration of operation and complications for the surgical procedures divided in the time frames of treatment: 2001–2007 and 2008–2010. Parameter
2001–2007 N
Mean± SD
Duration of operation (min) LA 8 75±30 OA 116 76±44 CO 8 115±19 N % Re-admission LA OA CO Re-operation LA OA CO Abscess LA OA CO Wound infection LA OA CO
2001–2007 vs. 2008–2010 2008–2010 LA vs. LA vs. OA vs. N Mean± OA P CO P CO P SD .81
b.001
b.001
.77 .65 .29
LA vs. LA vs. OA vs. OA P CO P CO P
8 116 8
0 12.9 50
.59
.07
8 116 8
12.5 17.2 25
1
1
8 116 8
12.5 12.1 12.5
1
1
8 116 8
0 11.2 25.0
1
.46
67 6 16 N
72±22 100±99 140±44 %
.01
1.00 1.00 .67
67 6 16
1.5 0 37.5
.63
.29 1.00 .65
67 6 16
3.0 16.7 43.8
.29 1.00 1.00
67 6 16
3.0 0 12.5
n.a. .52 1.00
67 6 16
0 16.7 31.2
1
.24
LA vs. LA vs. OA vs. OA P CO P CO P .46
b.001
.04
LA vs. LA vs. OA vs. OA P CO P CO P 1
.23
1
.82
b.001
.13
b.001
.35
.16
b.001
1
.63
Mean±SD duration of operation in minutes, and % of all patients who underwent the same surgical procedure demonstrating the following complications: readmission, re-operation, intra-abdominal abscess formation, and wound infection. LA, laparoscopic appendectomy; OA, open appendectomy; CO, conversion from laparoscopic to open appendectomy; n=number of patients. Statistical analysis was performed for every surgical procedure between both time frames and also between different surgical procedures within each time frame. Not applicable (n.a.), no wound infections occurred for LA during both time frames.
89.5 months (range, 13–131 months) for OA, and 34 months (range, 12–130 months) for CO. A significant increase in the frequency of LA occurred from 2007 onward (Fig. 1).
2.2. Impact of surgical procedure on duration of operation LA and OA did not significantly differ (P = .392) concerning the mean duration of the operations (72.9 ± 23.0 min for LA, 77.6±48.0 min for OA) (Fig. 2). In contrast, CO resulted in a significantly longer operation (132.0± 39.4 min) in comparison to either LA (Pb.001) or OA (P b.001). The results were consistent within both time frames 2001–2007 and 2008–2010 (Table 2).
2.3. Impact of surgical procedure on adhesiolysis caused by bowel obstruction Redo surgery for adhesiolysis due to bowel obstruction was necessary after 3 OA at 37, 1771 and 1859 days and in only 1 CO at 21 days postoperatively (Fig. 3A). In our series,
adhesiolysis did not occur after LA. In contrast, most readmissions for observation due to abdominal pain as well as for redo surgery as a consequence of intra-abdominal abscess or wound infection occurred within the first 30 postoperative days (Fig. 3B).
2.4. Impact of surgical procedure on re-admission, re-operation, abscess formation, and wound infection We analyzed the incidence of LA and OA per year between 2001 and 2010 (Fig. 1) and, as expected found a decrease in OA and increase in LA from 2007 to 2010. Subsequently, the data were divided in two time frames: 2001–2007 and 2008– 2010 (Table 2) and compared with respect to the incidence of complications (re-admissions, re-operations, intra-abdominal abscesses, and wound infections) for LA vs. OA, LA vs. CO, and OA vs. CO. From 2001 to 2007, 8 LA were compared with 116 OA and 8 CO. From 2008 to 2010, 67 LA were compared with 6 OA and 16 CO. Additionally, for every surgical procedure statistical differences between the time frames 2001–2007 and 2008–2010 were excluded for every complication parameter (Table 2).
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Fig. 3 Impact of the follow-up period on complications and on frequency of adhesiolysis. The postoperative duration in days until readmission for observation, abscess treatment, wound revision, or adhesiolysis was plotted for the entire observation period (A) and for the first 50 postoperative days (B inlay). The vertical line in panel B marks the first 30 postoperative days.
The incidence of re-admissions (Fig. 4) was lower for LA (1.3%, 1/75) than for OA (12.3%, 15/122, P=.006). The readmission rate for CO (41.7%, 10/24) was higher than those of both LA (P=.000) and OA (P=.002). The incidence of re-operations (Fig. 4) was lower for LA (4%, 3/75) than for OA (17.2%, 21/122, P=.006). The reoperation rate for CO (37.5%, 9/24) was higher than for both LA (P =.000) and OA (P=.049). The incidence of intra-abdominal abscesses (Fig. 4) was not significantly lower for LA (4%, 3/75) than for either OA (11.5%, 14/122, P=.114) or CO (12.5%, 3/24, P=.151), but demonstrated a trend toward fewer abscesses. OA and CO did not differ (P=1.000). The incidence of wound infections (Fig. 4) was lower for LA (0%, 0/75) than for both OA (11.5%, 14/122, P=.001) and CO (29.2%, 7/24, Pb.001). OA also had a significantly lower rate of wound infections compared to CO (P=.049).
3. Discussion A number of investigators have described the advantages of LA, including reduced abdominal scarring, less postoperative pain, and earlier recovery [1,6–9]. Despite the
multitude of relevant publications—including prospective randomized studies, meta-analyses, and systematic critical reviews—the optimal surgical choice between LA and OA for children with perforated appendicitis has still not been fully clarified [4,10]. Furthermore limited information is available concerning the impact of conversion from LA to OA with regard to complications in children. The present clinical study was designed to retrospectively compare LA with OA and CO in children with perforated appendicitis in our pediatric surgery department. In contrast to previous reports showing a longer operative time for LA compared with OA in perforated appendicitis [4,9–13], we did not observe any difference in the duration of operation in our cohort. This result validates the observations of Vernon et al. [14], who reported no difference between LA and OA, neither in operative time nor in total patient time in the operating room. Increased experience of the surgeon with LA could explain the lack of a significant difference in operative time for perforated appendicitis, as reported by prior studies [6,15]. An advantage of LA over open procedures is the reduced frequency of adhesiolysis. Re-operations for adhesiolysis due to bowel obstruction occurred predominantly beyond 30 postoperative days. This complication
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M.R. Vahdad et al.
Fig. 4 Impact of surgical procedure on re-admission, re-operation, abscess formation, and wound infection. Patients underwent laparoscopic appendectomy (LA), open appendectomy (OA), or conversion from laparoscopic to open appendectomy (CO). Patients were evaluated to determine whether they fulfilled the conditions for re-admission, re-operation, abscess formation, and wound infection. The clustered bars represent the percentage of patients having the same complication among all patients who underwent the same surgical procedure. *Pb.05, **Pb.01, ***Pb.001.
was encountered in our series exclusively after initial open procedures. We elected to divide the complications into readmissions, re-operations, intra-abdominal abscess formation, and wound infections. We chose 2007 as the cut-off point between the time frames 2001–2007 and 2008–2010, because in 2007 the policy in our department changed, with COs performed routinely until 2007 if suppuration was visualized intraabdominally but more recently was indicated only upon inability to continue with LA. Accordingly, the evaluation of our surgical procedures per year revealed a change in the frequencies of LA and OA from 2007 onward. From 2001 to 2007 most appendectomies were OA, while LA was predominantly performed thereafter. For each parameter, we excluded differences between time frames. To avoid a statistical bias arising from the different sample sizes, we chose to pool both time frames to achieve a more robust statistical analysis for re-admissions, re-operations, intra-abdominal abscesses, and wound infections. The re-admission rate was reduced after LA compared with OA, confirming the results of prior studies [13,16]. The role of LA has been somewhat more controversial regarding the occurrence of intra-abdominal abscesses. A number of reports in the recent literature have emphasized the increased occurrence of postoperative intra-abdominal abscess formation after LA [17–21]. While a Cochrane review from 2010 reported a nearly threefold increase in intra-abdominal abscess formation after LA compared with
OA [2] for suspected appendicitis, a meta-analysis from 2010 [10] observed a trend toward higher abscess rate after LA, which failed to achieve statistical significance. In contrast, several recent studies have suggested that LA is safer [4] or equivalent [6,9,10,22] to OA in cases of appendicitis with regard to intra-abdominal abscess formation. One of the reasons for the discrepancy in the rate of intra-abdominal abscess formation may be that most reported studies lack a clear definition for the term “perforated appendicitis” [5]. This deficiency makes a uniform analysis of the impact of the surgical procedure on complication rates difficult. As proposed previously [5], we retrospectively included patients with perforated appendicitis based on standardized features such as a hole in the appendix, fecalith, or intraabdominal abscess observed during the operation and histological confirmation of the perforation. We observed a trend toward a lower rate of intra-abdominal abscesses after LA compared to OA, although it did not reach statistical significance. There is no clear explanation for this result; however, our general perioperative scheme of antibiotic therapy may assist in reducing the rate of intra-abdominal abscesses after LA. Our abscess rate of 4% was lower than the rates of 19% and, 20%, respectively, after either intravenous ceftriaxone and metronidazole once daily for 5 days or oral amoxicillin/clavulanate when tolerating a regular diet to complete 7 days, as published by Fraser et al. [23]. We did not use interventional radiology to drain the
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abscess followed by delayed surgery but instead, chose to drain the abscess during one operative procedure. Our results clearly indicate that LA reduces the incidence of wound infections when compared to OA. This finding concurs with most published studies [4,10,11,13,24]. One reason for this outcome is the minimally invasive approach of LA, with incisions limited to trocar entry sites, and extraction of the perforated appendix occurring without contact with the wounds. The 0% rate of wound infection in patients who underwent LA in our study is a strong argument in favor of the procedure. Wound infections and their side effects, such as secretion, appearance of pus and repeated painful bandage change traumatize children, their parents, and medical personnel. Additionally, wound infections have a negative influence on cosmesis, which has gained increasing importance, and is time-consuming for the medical community. Our results underscore the importance of avoiding conversions. In this study, we observed a conversion rate of 24%, which is slightly higher than the published range of 0–23.04% [10]. One reason for this outcome is that until 2007, CO was performed routinely if pus was visualized intra-abdominally. Since 2007, however, the only indication for CO has been the inability to continue with LA. Moreover, the duration of the study was influenced by the learning curve for the LA procedure in our department. A similar institutional bias has been identified in other long-term studies evaluating new surgical techniques [22]. However, the results from our data suggest that conversions should be avoided whenever possible, since they carry an increased risk of re-admissions, re-operations, and occurrence of wound infections compared to either LA or OA. The 0% rate of wound infections and adhesiolysis also led to a reduced rate of re-operations for LA compared to OA and CO. Laparoscopic appendectomy for perforated appendicitis in children has a comparable complication rate to that of open appendectomy. In our data, LA reduced the incidence of re-admissions, re-operations, wound infections and adhesiolysis in comparison to OA. Conversions from LA to OA, however, should be avoided wherever possible, as they lead to a higher incidence of all complications, except for intra-abdominal abscesses, compared to LA.
[4] Wang X, Zhang W, Yang X, et al. Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy—our experience. J Pediatr Surg 2009;44:1924-7. [5] St Peter SD, Sharp SW, Holcomb III GW, et al. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 2008;43:2242-5. [6] Canty Sr TG, Collins D, Losasso B, et al. Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice? J Pediatr Surg 2000;35:1582-5. [7] El-Ghoneimi A, Valla JS, Limonne B, et al. Laparoscopic appendectomy in children: report of 1,379 cases. J Pediatr Surg 1994;29:786-9. [8] Meguerditchian AN, Prasil P, Cloutier R, et al. Laparoscopic appendectomy in children: a favorable alternative in simple and complicated appendicitis. J Pediatr Surg 2002;37:695-8. [9] Schmelzer TM, Rana AR, Walters KC, et al. Improved outcomes for laparoscopic appendectomy compared with open appendectomy in the pediatric population. J Laparoendosc Adv Surg Tech A 2007;17: 693-7. [10] Li X, Zhang J, Sang L, et al. Laparoscopic versus conventional appendectomy—a meta-analysis of randomized controlled trials. BMC Gastroenterol 2010;10:129. [11] Lintula H, Kokki H, Vanamo K, et al. Laparoscopy in children with complicated appendicitis. J Pediatr Surg 2002;37:1317-20. [12] Little DC, Custer MD, May BH, et al. Laparoscopic appendectomy: an unnecessary and expensive procedure in children? J Pediatr Surg 2002;37:310-7. [13] Taqi E, Al Hadher S, Ryckman J, et al. Outcome of laparoscopic appendectomy for perforated appendicitis in children. J Pediatr Surg 2008;43:893-5. [14] Vernon AH, Georgeson KE, Harmon CM. Pediatric laparoscopic appendectomy for acute appendicitis. Surg Endosc 2004;18:75-9. [15] Phillips S, Walton JM, Chin I, et al. Ten-year experience with pediatric laparoscopic appendectomy—are we getting better? J Pediatr Surg 2005;40:842-5. [16] Mancini GJ, Mancini ML, Nelson Jr HS. Efficacy of laparoscopic appendectomy in appendicitis with peritonitis. Am Surg 2005;71: 1-4. [17] Bennett J, Boddy A, Rhodes M. Choice of approach for appendicectomy: a meta-analysis of open versus laparoscopic appendicectomy. Surg Laparosc Endosc Percutan Tech 2007;17:245-55. [18] Horwitz JR, Gursoy M, Jaksic T, et al. Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg 1997;173:80-2. [19] Krisher SL, Browne A, Dibbins A, et al. Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis. Arch Surg 2001;136:438-41. [20] Paik PS, Towson JA, Anthone GJ, et al. Intra-abdominal abscesses following laparoscopic and open appendectomies. J Gastrointest Surg 1997;1:188-92. [21] Horwitz JR, Custer MD, May BH, et al. Should laparoscopic appendectomy be avoided for complicated appendicitis in children? J Pediatr Surg 1997;32:1601-3. [22] Asarias JR, Schlussel AT, Cafasso DE, et al. Incidence of postoperative intraabdominal abscesses in open versus laparoscopic appendectomies. Surg Endosc 2011;25:2678-83. [23] Fraser JD, Aguayo P, Leys CM, et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg 2010;45:1198-202. [24] Pokala N, Sadhasivam S, Kiran RP, et al. Complicated appendicitis— is the laparoscopic approach appropriate? A comparative study with the open approach: outcome in a community hospital setting. Am Surg 2007;73:737-41.
References [1] Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children. Br J Surg 2001;88:510-4. [2] Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010: CD001546. [3] Ikeda H, Ishimaru Y, Takayasu H, et al. Laparoscopic versus open appendectomy in children with uncomplicated and complicated appendicitis. J Pediatr Surg 2004;39:1680-5.
www.elsevier.com/locate/jpedsurg
Laparoscopic appendectomy for perforated appendicitis in children has complication rates comparable with those of open appendectomy Mohammad Reza Vahdad ⁎, Ralf-Bodo Troebs, Matthias Nissen, Lars Benjamin Burkhardt, Svenja Hardwig, Grigore Cernaianu Department of Pediatric Surgery, Marienhospital–Kinderchirurgische Klinik der Ruhr-Universität Bochum, Widumerstr. 8, 44627 Herne, Germany Received 13 January 2012; revised 23 July 2012; accepted 27 July 2012
Key words: Perforated appendicitis; Children; Laparoscopic appendectomy; Open appendectomy; Complications
Abstract Purpose: To evaluate the outcome of laparoscopic (LA) vs. open appendectomy (OA) in children with perforated appendicitis (PA). Methods: We reviewed the medical files of 221 children who underwent LA (n=75), OA (n=122), and conversion (CO) (n=24), comparing duration of operation, re-admissions, re-operations, intraabdominal abscesses (IAA), and wound infections. Results: Compared to OA, LA resulted in fewer re-admissions (1.3% vs. 12.3%; P=.006), fewer reoperations (4% vs. 17.2%; P=.006), and fewer wound infections (0% vs. 11.5%; P=.001). No differences in the duration of operation (72.9±23.0 min vs. 77.7±48.0 min; P=.392) or IAA (4% vs. 11.5%; P=.114) were observed. Compared to LA, CO had more complications. Conclusions: We report that LA is superior to OA with regard to incidence of re-admission, reoperation, and wound infection. © 2013 Elsevier Inc. All rights reserved.
Laparoscopic appendectomy (LA) is minimally invasive and associated with less postoperative pain in children [1]. It remains to be clarified whether LA is inferior to open appendectomy (OA) in terms of postoperative complications, since there is considerable discrepancy in the published data. A 2010 Cochrane study [2] performed on adults and children
reported that LA increases the rate of intra-abdominal abscess (IAA) in adults and postulated a similar trend in children. Other studies performed on children, however, found an equal [3] or decreased [4] rate of IAA. This discrepancy prompted us to investigate the impact of LA on duration of operation and complications, in children with perforated appendicitis.
⁎ Corresponding author. Tel.: +49 2323 408; fax: +49 2323 499 328. E-mail addresses: [email protected] (M.R. Vahdad), [email protected] (R.-B. Troebs), [email protected] (M. Nissen), [email protected] (L.B. Burkhardt), [email protected] (S. Hardwig), [email protected] (G. Cernaianu).
1. Methods
0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.07.066
After obtaining institutional review board approval (no. 3928-11), a retrospective review identified all children less than 18 years of age with intraoperative and histological confirmed perforated appendicitis who
556 underwent appendectomy between January 2001 and December 2010 at the Department of Pediatric Surgery of Ruhr-University in Bochum, Germany. For inclusion in our study, patients had to fulfill the criteria of the definition for perforated appendicitis published in 2008 by St Peter et al. [5]: intraoperative evidence of perforation or intra-abdominal fecalith and confirmation of the perforation during histopathological examination. Only data from those patients who fulfilled both criteria were included. All other patients with a surgical diagnosis of perforated appendicitis who did not fulfill these strict criteria were excluded in order to rule out variation in the definition of perforation from 2001 to 2010. Informed consent was obtained from each patient's guardian. The patients were divided into three groups: patients who underwent LA, patients who underwent OA, and patients who underwent a conversion (CO). LA was performed using 3 Endo-Loops® (Ethicon®, Norderstedt, Germany). The decision of whether to perform LA or OA was based on the surgeon's preference. Until 2007, COs were performed routinely if suppuration was visualized intraabdominally. Since 2007, however, the only indication for CO is the inability to continue with LA. Surgical procedures were performed by consultants and residents. Our antibiotic regimen consisted of daily intravenous administration of cefuroxim (100 mg/kg body weight in three doses) for 7 days and metronidazole (20 mg/kg body weight in two doses) for 5 days starting at the onset of anesthesia. Some patients received an adapted antibiotic therapy based on the results of their intraoperative microbiological smear. Patients' medical records were reviewed retrospectively, and the following data were collected: age, sex, surgical procedure(s), duration of operation, and incidence of re-admission, re-operation, intraabdominal abscess formation, adhesiolysis and wound infection. We excluded children presenting with additional diagnoses before the first admission. Patients with a follow-up period less than 12 months, incomplete documentation, concomitant operations, or referred after appendectomy in other hospitals were excluded.We chose 12 months for the minimum follow-up in order to include late complications such as bowel obstruction that required adhesiolysis in addition to the complications that occurred within the first 30 postoperative days. Comparative statistical analyses were undertaken using the Fisher's exact test for qualitative data and the Mann–Whitney U test for quantitative data. Qualitative and quantitative data are presented as bars, illustrating mean±standard deviation (SD). Statistical analyses were performed using SPSS® 20 (IBM®) software. Differences were considered significant at Pb.05.
2. Results 2.1. Demographic data Appendectomies were completed in 221 children with perforated appendicitis evident at operation and confirmed
M.R. Vahdad et al. by histopathology. Eleven otherwise eligible patients were excluded during the duration of the study: 8 patients with incomplete documentation, 1 patient with concomitant resection of a Meckel's diverticulum, and 2 patients referred with complications after appendectomies in other hospitals. Perforated appendicitis accounted for 221 (19.8%) of 1114 patients with appendicitis. Seventy-five (33.9%) children underwent LA, 122 (55.2%) underwent OA, and in 24 patients (10.8%) the operative procedure was converted intra-operatively from LA to OA (CO). Mean patient age was 94 months (range, 15–212 months). Twenty-five different surgeons performed the surgical procedures, and the same surgeons operated on patients from different treatment groups (Table 1). Several surgeons performed operations both as residents and subsequently as board-certified pediatric surgeons. Consequently, 136 patients (61.5%) were operated on by 8 board-certified pediatric surgeons, and 20 residents operated on the remaining 85 patients (38.5%) under the supervision of a board-certified pediatric surgeon. The incidence of perforated appendicitis (P=.137) did not significantly differ between boys (n=124) and girls (n=97), and no deaths occurred. The median followup period was 25 months (range, 12–127 months) for LA, Table 1 Count and type of surgical procedures performed by each participating surgeon. Surgeon
LA
OA
CO
Total Count
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total
1 3 0 6 3 9 3 0 0 0 4 1 4 0 0 0 0 13 0 1 3 3 16 1 4 75
0 0 7 1 0 4 0 8 13 3 21 0 20 5 4 4 5 10 2 0 5 2 6 2 0 122
0 0 0 1 0 2 0 0 0 0 5 0 5 0 0 0 0 2 0 1 0 4 3 0 1 24
1 3 7 8 3 15 3 8 13 3 30 1 29 5 4 4 5 25 2 2 8 9 25 3 5 221
% 0.5 1.4 3.2 3.6 1.4 6.8 1.4 3.6 5.9 1.4 13.6 0.5 13.1 2.3 1.8 1.8 2.3 11.3 0.9 0.9 3.6 4.1 11.3 1.4 2.3 100
LA, laparoscopic appendectomy; OA, open appendectomy; CO, conversion from LA to OA. %: percentage of all surgical procedures.
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Fig. 1 Counts of conversions, laparoscopic, and open appendectomies per year for perforated appendicitis. The vertical line marks the cutoff point between the two time frames of treatment (2001–2007 vs. 2008–2010).
Fig. 2 Impact of surgical procedure on duration of operation. The duration of operation in minutes was compared across three surgical procedures. Patients underwent laparoscopic appendectomy (LA), open appendectomy (OA), or a conversion from laparoscopic to open appendectomy (CO). Data are plotted as bars with SD. ***Pb.001.
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Table 2 Distribution and statistical analysis of duration of operation and complications for the surgical procedures divided in the time frames of treatment: 2001–2007 and 2008–2010. Parameter
2001–2007 N
Mean± SD
Duration of operation (min) LA 8 75±30 OA 116 76±44 CO 8 115±19 N % Re-admission LA OA CO Re-operation LA OA CO Abscess LA OA CO Wound infection LA OA CO
2001–2007 vs. 2008–2010 2008–2010 LA vs. LA vs. OA vs. N Mean± OA P CO P CO P SD .81
b.001
b.001
.77 .65 .29
LA vs. LA vs. OA vs. OA P CO P CO P
8 116 8
0 12.9 50
.59
.07
8 116 8
12.5 17.2 25
1
1
8 116 8
12.5 12.1 12.5
1
1
8 116 8
0 11.2 25.0
1
.46
67 6 16 N
72±22 100±99 140±44 %
.01
1.00 1.00 .67
67 6 16
1.5 0 37.5
.63
.29 1.00 .65
67 6 16
3.0 16.7 43.8
.29 1.00 1.00
67 6 16
3.0 0 12.5
n.a. .52 1.00
67 6 16
0 16.7 31.2
1
.24
LA vs. LA vs. OA vs. OA P CO P CO P .46
b.001
.04
LA vs. LA vs. OA vs. OA P CO P CO P 1
.23
1
.82
b.001
.13
b.001
.35
.16
b.001
1
.63
Mean±SD duration of operation in minutes, and % of all patients who underwent the same surgical procedure demonstrating the following complications: readmission, re-operation, intra-abdominal abscess formation, and wound infection. LA, laparoscopic appendectomy; OA, open appendectomy; CO, conversion from laparoscopic to open appendectomy; n=number of patients. Statistical analysis was performed for every surgical procedure between both time frames and also between different surgical procedures within each time frame. Not applicable (n.a.), no wound infections occurred for LA during both time frames.
89.5 months (range, 13–131 months) for OA, and 34 months (range, 12–130 months) for CO. A significant increase in the frequency of LA occurred from 2007 onward (Fig. 1).
2.2. Impact of surgical procedure on duration of operation LA and OA did not significantly differ (P = .392) concerning the mean duration of the operations (72.9 ± 23.0 min for LA, 77.6±48.0 min for OA) (Fig. 2). In contrast, CO resulted in a significantly longer operation (132.0± 39.4 min) in comparison to either LA (Pb.001) or OA (P b.001). The results were consistent within both time frames 2001–2007 and 2008–2010 (Table 2).
2.3. Impact of surgical procedure on adhesiolysis caused by bowel obstruction Redo surgery for adhesiolysis due to bowel obstruction was necessary after 3 OA at 37, 1771 and 1859 days and in only 1 CO at 21 days postoperatively (Fig. 3A). In our series,
adhesiolysis did not occur after LA. In contrast, most readmissions for observation due to abdominal pain as well as for redo surgery as a consequence of intra-abdominal abscess or wound infection occurred within the first 30 postoperative days (Fig. 3B).
2.4. Impact of surgical procedure on re-admission, re-operation, abscess formation, and wound infection We analyzed the incidence of LA and OA per year between 2001 and 2010 (Fig. 1) and, as expected found a decrease in OA and increase in LA from 2007 to 2010. Subsequently, the data were divided in two time frames: 2001–2007 and 2008– 2010 (Table 2) and compared with respect to the incidence of complications (re-admissions, re-operations, intra-abdominal abscesses, and wound infections) for LA vs. OA, LA vs. CO, and OA vs. CO. From 2001 to 2007, 8 LA were compared with 116 OA and 8 CO. From 2008 to 2010, 67 LA were compared with 6 OA and 16 CO. Additionally, for every surgical procedure statistical differences between the time frames 2001–2007 and 2008–2010 were excluded for every complication parameter (Table 2).
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Fig. 3 Impact of the follow-up period on complications and on frequency of adhesiolysis. The postoperative duration in days until readmission for observation, abscess treatment, wound revision, or adhesiolysis was plotted for the entire observation period (A) and for the first 50 postoperative days (B inlay). The vertical line in panel B marks the first 30 postoperative days.
The incidence of re-admissions (Fig. 4) was lower for LA (1.3%, 1/75) than for OA (12.3%, 15/122, P=.006). The readmission rate for CO (41.7%, 10/24) was higher than those of both LA (P=.000) and OA (P=.002). The incidence of re-operations (Fig. 4) was lower for LA (4%, 3/75) than for OA (17.2%, 21/122, P=.006). The reoperation rate for CO (37.5%, 9/24) was higher than for both LA (P =.000) and OA (P=.049). The incidence of intra-abdominal abscesses (Fig. 4) was not significantly lower for LA (4%, 3/75) than for either OA (11.5%, 14/122, P=.114) or CO (12.5%, 3/24, P=.151), but demonstrated a trend toward fewer abscesses. OA and CO did not differ (P=1.000). The incidence of wound infections (Fig. 4) was lower for LA (0%, 0/75) than for both OA (11.5%, 14/122, P=.001) and CO (29.2%, 7/24, Pb.001). OA also had a significantly lower rate of wound infections compared to CO (P=.049).
3. Discussion A number of investigators have described the advantages of LA, including reduced abdominal scarring, less postoperative pain, and earlier recovery [1,6–9]. Despite the
multitude of relevant publications—including prospective randomized studies, meta-analyses, and systematic critical reviews—the optimal surgical choice between LA and OA for children with perforated appendicitis has still not been fully clarified [4,10]. Furthermore limited information is available concerning the impact of conversion from LA to OA with regard to complications in children. The present clinical study was designed to retrospectively compare LA with OA and CO in children with perforated appendicitis in our pediatric surgery department. In contrast to previous reports showing a longer operative time for LA compared with OA in perforated appendicitis [4,9–13], we did not observe any difference in the duration of operation in our cohort. This result validates the observations of Vernon et al. [14], who reported no difference between LA and OA, neither in operative time nor in total patient time in the operating room. Increased experience of the surgeon with LA could explain the lack of a significant difference in operative time for perforated appendicitis, as reported by prior studies [6,15]. An advantage of LA over open procedures is the reduced frequency of adhesiolysis. Re-operations for adhesiolysis due to bowel obstruction occurred predominantly beyond 30 postoperative days. This complication
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Fig. 4 Impact of surgical procedure on re-admission, re-operation, abscess formation, and wound infection. Patients underwent laparoscopic appendectomy (LA), open appendectomy (OA), or conversion from laparoscopic to open appendectomy (CO). Patients were evaluated to determine whether they fulfilled the conditions for re-admission, re-operation, abscess formation, and wound infection. The clustered bars represent the percentage of patients having the same complication among all patients who underwent the same surgical procedure. *Pb.05, **Pb.01, ***Pb.001.
was encountered in our series exclusively after initial open procedures. We elected to divide the complications into readmissions, re-operations, intra-abdominal abscess formation, and wound infections. We chose 2007 as the cut-off point between the time frames 2001–2007 and 2008–2010, because in 2007 the policy in our department changed, with COs performed routinely until 2007 if suppuration was visualized intraabdominally but more recently was indicated only upon inability to continue with LA. Accordingly, the evaluation of our surgical procedures per year revealed a change in the frequencies of LA and OA from 2007 onward. From 2001 to 2007 most appendectomies were OA, while LA was predominantly performed thereafter. For each parameter, we excluded differences between time frames. To avoid a statistical bias arising from the different sample sizes, we chose to pool both time frames to achieve a more robust statistical analysis for re-admissions, re-operations, intra-abdominal abscesses, and wound infections. The re-admission rate was reduced after LA compared with OA, confirming the results of prior studies [13,16]. The role of LA has been somewhat more controversial regarding the occurrence of intra-abdominal abscesses. A number of reports in the recent literature have emphasized the increased occurrence of postoperative intra-abdominal abscess formation after LA [17–21]. While a Cochrane review from 2010 reported a nearly threefold increase in intra-abdominal abscess formation after LA compared with
OA [2] for suspected appendicitis, a meta-analysis from 2010 [10] observed a trend toward higher abscess rate after LA, which failed to achieve statistical significance. In contrast, several recent studies have suggested that LA is safer [4] or equivalent [6,9,10,22] to OA in cases of appendicitis with regard to intra-abdominal abscess formation. One of the reasons for the discrepancy in the rate of intra-abdominal abscess formation may be that most reported studies lack a clear definition for the term “perforated appendicitis” [5]. This deficiency makes a uniform analysis of the impact of the surgical procedure on complication rates difficult. As proposed previously [5], we retrospectively included patients with perforated appendicitis based on standardized features such as a hole in the appendix, fecalith, or intraabdominal abscess observed during the operation and histological confirmation of the perforation. We observed a trend toward a lower rate of intra-abdominal abscesses after LA compared to OA, although it did not reach statistical significance. There is no clear explanation for this result; however, our general perioperative scheme of antibiotic therapy may assist in reducing the rate of intra-abdominal abscesses after LA. Our abscess rate of 4% was lower than the rates of 19% and, 20%, respectively, after either intravenous ceftriaxone and metronidazole once daily for 5 days or oral amoxicillin/clavulanate when tolerating a regular diet to complete 7 days, as published by Fraser et al. [23]. We did not use interventional radiology to drain the
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abscess followed by delayed surgery but instead, chose to drain the abscess during one operative procedure. Our results clearly indicate that LA reduces the incidence of wound infections when compared to OA. This finding concurs with most published studies [4,10,11,13,24]. One reason for this outcome is the minimally invasive approach of LA, with incisions limited to trocar entry sites, and extraction of the perforated appendix occurring without contact with the wounds. The 0% rate of wound infection in patients who underwent LA in our study is a strong argument in favor of the procedure. Wound infections and their side effects, such as secretion, appearance of pus and repeated painful bandage change traumatize children, their parents, and medical personnel. Additionally, wound infections have a negative influence on cosmesis, which has gained increasing importance, and is time-consuming for the medical community. Our results underscore the importance of avoiding conversions. In this study, we observed a conversion rate of 24%, which is slightly higher than the published range of 0–23.04% [10]. One reason for this outcome is that until 2007, CO was performed routinely if pus was visualized intra-abdominally. Since 2007, however, the only indication for CO has been the inability to continue with LA. Moreover, the duration of the study was influenced by the learning curve for the LA procedure in our department. A similar institutional bias has been identified in other long-term studies evaluating new surgical techniques [22]. However, the results from our data suggest that conversions should be avoided whenever possible, since they carry an increased risk of re-admissions, re-operations, and occurrence of wound infections compared to either LA or OA. The 0% rate of wound infections and adhesiolysis also led to a reduced rate of re-operations for LA compared to OA and CO. Laparoscopic appendectomy for perforated appendicitis in children has a comparable complication rate to that of open appendectomy. In our data, LA reduced the incidence of re-admissions, re-operations, wound infections and adhesiolysis in comparison to OA. Conversions from LA to OA, however, should be avoided wherever possible, as they lead to a higher incidence of all complications, except for intra-abdominal abscesses, compared to LA.
[4] Wang X, Zhang W, Yang X, et al. Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy—our experience. J Pediatr Surg 2009;44:1924-7. [5] St Peter SD, Sharp SW, Holcomb III GW, et al. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 2008;43:2242-5. [6] Canty Sr TG, Collins D, Losasso B, et al. Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice? J Pediatr Surg 2000;35:1582-5. [7] El-Ghoneimi A, Valla JS, Limonne B, et al. Laparoscopic appendectomy in children: report of 1,379 cases. J Pediatr Surg 1994;29:786-9. [8] Meguerditchian AN, Prasil P, Cloutier R, et al. Laparoscopic appendectomy in children: a favorable alternative in simple and complicated appendicitis. J Pediatr Surg 2002;37:695-8. [9] Schmelzer TM, Rana AR, Walters KC, et al. Improved outcomes for laparoscopic appendectomy compared with open appendectomy in the pediatric population. J Laparoendosc Adv Surg Tech A 2007;17: 693-7. [10] Li X, Zhang J, Sang L, et al. Laparoscopic versus conventional appendectomy—a meta-analysis of randomized controlled trials. BMC Gastroenterol 2010;10:129. [11] Lintula H, Kokki H, Vanamo K, et al. Laparoscopy in children with complicated appendicitis. J Pediatr Surg 2002;37:1317-20. [12] Little DC, Custer MD, May BH, et al. Laparoscopic appendectomy: an unnecessary and expensive procedure in children? J Pediatr Surg 2002;37:310-7. [13] Taqi E, Al Hadher S, Ryckman J, et al. Outcome of laparoscopic appendectomy for perforated appendicitis in children. J Pediatr Surg 2008;43:893-5. [14] Vernon AH, Georgeson KE, Harmon CM. Pediatric laparoscopic appendectomy for acute appendicitis. Surg Endosc 2004;18:75-9. [15] Phillips S, Walton JM, Chin I, et al. Ten-year experience with pediatric laparoscopic appendectomy—are we getting better? J Pediatr Surg 2005;40:842-5. [16] Mancini GJ, Mancini ML, Nelson Jr HS. Efficacy of laparoscopic appendectomy in appendicitis with peritonitis. Am Surg 2005;71: 1-4. [17] Bennett J, Boddy A, Rhodes M. Choice of approach for appendicectomy: a meta-analysis of open versus laparoscopic appendicectomy. Surg Laparosc Endosc Percutan Tech 2007;17:245-55. [18] Horwitz JR, Gursoy M, Jaksic T, et al. Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg 1997;173:80-2. [19] Krisher SL, Browne A, Dibbins A, et al. Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis. Arch Surg 2001;136:438-41. [20] Paik PS, Towson JA, Anthone GJ, et al. Intra-abdominal abscesses following laparoscopic and open appendectomies. J Gastrointest Surg 1997;1:188-92. [21] Horwitz JR, Custer MD, May BH, et al. Should laparoscopic appendectomy be avoided for complicated appendicitis in children? J Pediatr Surg 1997;32:1601-3. [22] Asarias JR, Schlussel AT, Cafasso DE, et al. Incidence of postoperative intraabdominal abscesses in open versus laparoscopic appendectomies. Surg Endosc 2011;25:2678-83. [23] Fraser JD, Aguayo P, Leys CM, et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg 2010;45:1198-202. [24] Pokala N, Sadhasivam S, Kiran RP, et al. Complicated appendicitis— is the laparoscopic approach appropriate? A comparative study with the open approach: outcome in a community hospital setting. Am Surg 2007;73:737-41.
References [1] Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children. Br J Surg 2001;88:510-4. [2] Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010: CD001546. [3] Ikeda H, Ishimaru Y, Takayasu H, et al. Laparoscopic versus open appendectomy in children with uncomplicated and complicated appendicitis. J Pediatr Surg 2004;39:1680-5.