Endoscopic retrograde appendicitis therapy vs. Laparoscopic appendectomy for uncomplicated acute appendicitis

Background and study aims: To assess the efficacy and clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT) versus laparoscopic appendectomy (LA) for patients with uncomplicated acute appendicitis (AA). Patients and methods: We adopted propensity score matching (1:1) to compare ERAT and LA patients with uncomplicated AA from April 2017 to March 2020. We reviewed a total of 2880 patients with suspected acute appendicitis, of whom 422 patients with uncomplicated AA met the matching criteria (ERAT, 79; LA, 343), yielding 78 pairs of patients. Results: The rate of curative treatment within one year after ERAT was 92.1%; 95% CI, [83.8% - 96.3%]. The percentage of Visual Analog Scale (VAS) ≤ 3 at six hours after treatment was 94.7%; 95% CI [87.2% - 97.9%] in the ERAT group, and significantly higher than that in the LA group 83.3%; 95% CI [73.5% - 90.0%]. Median operative/procedure time and median hospital length of stay in the ERAT group were significantly lower compared to the LA group. At one year, the median recurrence time was 50 days (IQRs, 25-127) in the ERAT group. The overall adverse event rate was 24.3%; 95% CI [14.8% - 33.9%] in the LA group and 18.4%; 95% CI [9.7% - 27.1%] in the ERAT group, with no significant difference between the two groups. Conclusions: ERAT is a technically feasible method to treat uncomplicated AA compared to LA.

ANALYSIS AND EVALUATION OF ADVANTAGES FROM LAPAROSCOPIC APPENDECTOMY

Purpose: The aim of the study is to evaluate the advantages of laparoscopic appendectomy fromour clinical experience in UMHATEM "Pirogov" which resulted in reduced postoperative complications, pain, length of hospital stay, and early return to work. Material and Methods: Data from a study of a patient group in the Department of General, Visceral and Emergency Surgery of UMBALSM "H. I. Pirogov "for the six-month period (01.01.2019 до 01.07.2019) were collected.Eighty-one patients with acute appendicitis who underwent laparoscopic appendectomy were selected. Indicators characterizing basic clinical and pathological features (epidemiology, demography, degree of pathological impairment), surgical approach and its outcomes (postoperative complications, postoperative duration), influence of concomitant factors were studied. Results: The study included 81 patients. The majority of patients were women - 46 (56.79%), men- 35 (43.21%). The mean age of male patients was 31.4 years and for female-28.6 years respectively. Hospitalization times are usually short - most patients are given up to 72 hours (70- 86.42%). Only eleven patients (13.58%) had an extended hospital stay for observation and additional therapy. Conclusion: Laparoscopic appendectomy was verified as an optimal and safe surgical procedure. Laparoscopic approach reduces post-operative pain, shortens hospital stay, reduces complications, and thereby reducing treatment costs.

APPENDECTOMY AT THE CONTEMPORARY STAGE (LITERATURE REVIEW)

В первую очередь, острый аппендицит (ОА) - клинический диагноз. Согласно проведенному обзору, по всему миру заболеваемость острым аппендицитом составляет около 100 случаев на 100 тыс. населения в год. Острый аппендицит чаще встречается у пациентов от подросткового возраста и до 50 лет. Также определяется незначительное преобладание мужчин над женщинами. В 1894 г. McBurney описал новую по тем временам технику лечения острого аппендицита. Данный метод до сих пор используется, а во многих странах является золотым стандартом при оперативном лечении острого аппендицита. В 1981 году Семмом была произведена первая лапароскопическая аппендэктомия. В настоящее время хирургия с использованием эндовидео технологий приобретает первостепенное значение во многих хирургических учреждениях. Однако, даже с учетом большого количества проведенных операций и клинических исследований, среди хирургов возникает вопрос: является ли лапароскопическая операция оптимальным выбором при аппендэктомии. Цель. Сравнить лапароскопическую аппендектомию с открытой аппендектомией. Материалы и методы. Для поиска и отбора статей использовался принцип PRISMA (Предпочтительный Метод Отчета Для Систематических Обзоров и Метаанализов). В настоящем обзоре были использованы базы данных MedLine, Cochrane, PubMEd. Глубина поиска составила 10 лет, за исключением исторических данных. Все источники изучены без лимитирования по языку. Обзор литературы проводился в электронном и в ручном режимах. Для обзора были отобраны статьи, соответствующие ключевым словам - острый аппендицит, лапароскопическая аппендэктомия, открытая аппендэктомия. Было найдено 389 статьи, в поиск включались систематические обзоры, метаанализы, рандомизированные клинические исследования. Для удаления дубликатов и отбора статей использовался ресурс «https://rayyan.ai/» После отбора статей было выбрано 119 источников, которые были включены в итоговый синтез. Вывод. Лапароскопическая аппендектомия показывает преимущество перед открытой аппендектомией по интенсивности боли в первый день, раневым инфекциям, продолжительности пребывания в больнице и времени до возвращения к нормальной активности у взрослых. В нескольких исследованиях сообщалось о более высоких показателях качества жизни у взрослых. Однако, некоторые клинические эффекты лапароскопической аппендектомии описаны авторами как небольшие и имеющие ограниченное клиническое значение. Необходимы крупные исследования, направленные на снижение уровня систематической ошибки. First of all, acute appendicitis (OA) is a clinical diagnosis. According to the survey, the worldwide incidence of acute appendicitis is about 100 cases per 100 thousand rubles. population per year. Acute appendicitis is more common in patients from adolescence to 50 years of age. There is also a decisive predominance of men over women. In 1894, McBurney described a new technique for the treatment of acute appendicitis. This method is still used, it is used by the gold standard in the surgical treatment of acute appendicitis. In 1981, Semm performed the first laparoscopic appendectomy. Nowadays, surgery using endovideo technology is gaining paramount importance in many surgical institutions. However, even taking into account the large number of operations performed and clinical trials, the question arises among surgeons: is laparoscopic surgery the optimal choice for appendectomy? Target. Compare laparoscopic appendectomy with open appendectomy. Materials and methods. For the search and selection of articles, the PRISMA principle (Preferred Reporting Method for Systematic Reviews and Meta-analyzes) was used. In this review, the databases MedLine, Cochrane, PubMEd were used. Search depth excludes 10 years. All sources have been studied without language limitation. The literature review was carried out in electronic and manual modes. For were selected articles, the relevant keywords - acute appendicitis, laparoscopic appendectomy, open appendectomy. 389 articles were found, systematic reviews, meta-analyzes, randomized clinical trials were included in the search. To remove duplicates and select articles, the resource "https://rayyan.ai/" was used for the selection of articles, 119 sources were selected, which were included in the final synthesis. Output. Laparoscopic appendectomy shows an advantage over open appendectomy in first day pain, wound infections, length of hospital stay, and time to return to normal activity in adults. Several studies have reported higher rates of quality of life in adults. However, some of the authors' approximating effects of laparoscopic vendectomy are small and of limited clinical relevance. Large studies are needed, the error is to lower the systematic level.

Association of treatments for acute appendicitis with pregnancy outcomes in the United States from 2000 to 2016: Results from a multi-level analysis

Background Open appendectomy, laparoscopic appendectomy, and non-surgical treatment are three options to treat acute appendicitis during pregnancy. Previous studies on the association of different treatment methods for acute appendicitis with pregnancy outcomes have been limited by small sample sizes and residual confounding, especially with respect to hospital-level factors. This study aimed to investigate the association of treatment method for acute appendicitis with pregnancy outcomes using a multi-level analysis. Methods A retrospective cohort study was conducted based on a large electronic health records database in the United States during the period 2000 to 2016. All pregnancies diagnosed with acute appendicitis and treated in participating hospitals during the study period were included. We conducted multi-level hierarchical logistic regression to analyze both individual- and hospital-level factors for abortion, preterm labor, and cesarean section. Results A total of 10,271 acute appendicitis during pregnancy were identified during the study period. Of them, 5,872 (57.2%) were treated by laparoscopic appendectomy, 1,403 (13.7%) by open appendectomy, and 2,996 (29.2%) by non-surgical treatment. Compared with open appendectomy, both laparoscopic appendectomy (adjusted OR, 0.6, 95% CI, 0.4, 0.9) and non-surgical treatment (adjusted OR, 0.4; 95% CI, 0.3–0.7) showed a decreased risk of preterm labor. Other important individual-level determinants of adverse pregnancy outcomes included maternal age, gestational hypertension, and anemia during pregnancy, the hospital-level determinant included the number of beds. Conclusions Compared with open appendectomy, both laparoscopic appendectomy and non-surgical treatment may be associated with a lower risk of preterm labor, without increased risks of abortion and cesarean section.

Hierarchical Task Analysis Reimagined as a Planning Tool for Surgery During Exploration Space Flight

Background: Preparation for exploration class space flight requires planning to support human life in many circumstances including healthcare emergencies such as the need for acute surgical care, a notable example of which is appendicitis. Although performing a laparoscopic appendectomy on Earth is routine for a trained general surgeon, it is far from routine for a non-surgeon working in microgravity where IVs do not drip, drains do not drain, and gaseous anesthetic is out of the question. Because the procedure for laparoscopic appendectomy is so well documented, it was the ideal procedure on which to base a study on how to deconstruct a surgical procedure to examine all actions, skills, equipment, and supplies needed for success by non-surgeons working in an extreme environment. Study Design: Our challenge was to develop a task analysis model robust enough to include 3 performers (in the roles of surgeon, assistant, and anesthesiologist) including each action and instrument or supply item needed in chronological order, while indicating which actions were completed independently and which were done in tandem. We also had to indicate where variations in the actions would be determined by the negative response of the patient (failure mode), and which actions and supply items needed further research to accommodate working in microgravity. We opted to begin with a hierarchical task analysis model (HTA) because the steps in the task are sequential; but we expanded the typical linear presentation of data to a multi-column spread sheet with active links to instructional video clips where needed. Content development was an iterative process beginning with a scoping review of literature to select a baseline task analysis of the procedure. The SAGES 2010 approach was selected as most comprehensive, but logically focused on the surgeon’s performance with few references to the assistant or anesthesiologist. Those gaps were filled using content from training materials developed for surgical technicians and nurse anesthetists. The second step was an expert review of the spread sheet to identify gaps and inadequacies. The third step was a minute comparison of spread sheet content to actions and equipment as documented on 2 videotapes of the procedure performed by our team surgeon on otherwise healthy patients. The final review was accomplished by replicating the procedure on 360° video (with narration) using the spread sheet as a guide, then cross checking and correcting the spread sheet to correspond with the 360° video. This test procedure was performed on a lightly preserved, fresh cadaver since working at that very slow, deliberate pace would not be in the best interest of an actual patient. Results: In this study, simulation was actually used to test the expanded HTA rather than to evaluate a learner. The final spread sheet included 178 lines, 13 columns, 13 illustrations, and 4 active links to instructional video clips. Thirteen items or issues were identified as needing further research, 8 action sequences were identified as generalizable skills, and 27 supply or equipment items were identified as multipurpose. Excluding the pharmaceuticals necessary for IV general anesthesia (that research is on-going), we were able to replicate a laparoscopic appendectomy on a fresh cadaver using no more than 30 items. The procedure was done using 3 trocars with very few instrument exchanges through the trocars since the surgical assistant assumed the role of laparoscopic camera operator during the procedure. Conclusion: An expanded HTA of a surgical procedure can produce many useful outcomes including integrated training for all team members, review of instrumentation and supplies and, in our case, identifying areas for adapting to an extreme environment. Using an interdisciplinary team including instructional designers, subject matter experts from medicine and biomedical engineering, and media production enriched the process.

Inappropriate manipulation and drainage exacerbate post-operative pain and prolong the hospital stay after laparoscopic appendectomy for pediatric complicated appendicitis

Background This study examined whether drain placement or not is associated with the postoperative outcomes of pediatric patients following trans-umbilical single-port laparoscopic appendectomy (TUSPLA) for complicated appendicitis. Methods The medical records of pediatric patients undergoing TUSPLA for acute complicated appendicitis from January 2012 to September 2018 in Kaohsiung Chang Gung Memorial Hospital were reviewed retrospectively. They were classified according to whether they received passive drainage with a Penrose drain (Penrose group) (19), active drainage with a Jackson-Pratt drain with a vacuum bulb (JP group) (16), or no drain (non-drain group) (86). The postoperative outcomes of the three groups were compared. Results Postoperative visual analog scale pain score was significantly higher in the non-drain group than in either the JP group or Penrose group. Patients in the Penrose group had a significantly longer postoperative hospital stay than those in the non-drain group and a higher rate of intra-abdominal abscess, while patients in the JP group had a significantly shorter postoperative hospital stay; moreover, no patient in JP group developed a postoperative intra-abdominal abscess. Conclusions Compared to passive drainage with a Penrose drain or no drain, active drainage with a JP drain shorter the postoperative hospital stay and decreased the risk of postoperative intra-abdominal abscess.

Laparoscopic surgery produced less surgical smoke and contamination comparing with open surgery: the pilot study in fresh cadaveric experiment in COVID-19 pandemic

Background The SARS-CoV2 virus has been identified in abdominal cavity of the COVID-19 patients. Therefore, the potential viral transmission from any surgical created smoke in these patients is of concern especially in laparoscopic surgery. This study aimed to compare the amount of surgical smoke and surgical field contamination between laparoscopic and open surgery in fresh cadavers. Methods Cholecystectomy in 12 cadavers was performed and they were divided into 4 groups: laparoscopic approach with or without smoke evacuator, and open approach with or without smoke evacuator. The increased particle counts in surgical smoke of each group were analyzed. In the model of appendectomy, surgical field contamination under ultraviolet light and visual contamination scale between laparoscopic and open approach were compared. Results Open cholecystectomy significantly produced a greater amount of overall particle sizes, particle sizes < 5 μm and particle sizes ≥ 5 μm than laparoscopic cholecystectomy (10,307 × 103 vs 3738 × 103, 10,226 × 103 vs 3685 × 103 and 81 × 103 vs 53 × 103 count/m3, respectively at p < 0.05). The use of smoke evacuator led to decrease in the amount of overall particle sizes of 58% and 32.4% in the open and laparoscopic chelecystectomy respectively. Median (interquatile range) visual contamination scale of surgical field in open appendectomy [3.50 (2.33, 4.67)] was significantly greater than laparoscopic appendectomy [1.50 (0.67, 2.33)] at p < 0.001. Conclusions Laparoscopic cholecystectomy yielded less smoke-related particles than open cholecystectomy. The use of smoke evacuator, abeit non-significantly, reduced the particles in both open and laparoscopic cholecystectomy. Laparoscopic appendectomy had a lower degree of surgical field contamination than the open approach.

Single incision laparoscopic appendectomy: A prospective study

Background: Appendicitis is one of the common pathologies encountered in surgical practice. Except in minority of the cases, the treatment is usually surgical. Till recent past, open appendectomy has been the procedure of choice for appendicitis. With increasing expertise in laparoscopic surgeries more and more surgeons are utilizing the laparoscopic approach for appendectomy. Laparoscopic surgeries have distinct advantages such as less surgical trauma, improved and quick postoperative recovery, and esthetic results. Single-incision laparoscopic surgery (SILS) is rapidly gaining acceptability in young population because of its cosmetic advantages. Moreover, these surgeries also avoid the risk of port-site hernias and the possibility of wound infection. Aims and Objective: The purpose of this study is to present our initial experience with this surgery using a single incision laparoscopic appendectomy (LA) using conventional instruments. Materials and Methods: This was a prospective cohort study conducted in the department of surgery of a tertiary care medical college situated in an urban area. The duration of the study was 2 years. All adult patients diagnosed to be having uncomplicated appendicitis and undergoing appendectomy by SILS were included in this study on the basis of a predefined inclusion and exclusion criteria. Pre-operative data collected included age, sex, weight, duration of complaint, concomitant medical conditions (like ischemic heart disease, chronic obstructive airway disease, diabetes mellitus, pancreatitis, and liver cirrhosis) and previous upper or lower abdominal surgery. All patients were treated by SILS except 1 patient in whom the procedure was converted to open surgery. Mean surgical time, Intraoperative procedure details and postoperative complications were studied in all the cases. p < 0.05 was taken as statistically significant. Statistical analysis was done using SSPS 21.0 software. Results: Out of 30 patients in this study 26 patients were female and 4 patients were male. The male to female ratio was found to be 1:6.15. Mean age of studied cases was found to be 26.2 years. Operative time required for the first 15 cases in an average was 120.00 min however it was reduced for the next 15 cases was 73.73 min. Overall time required in an average was 96.86 min. Out of 30 cases, The procedure was completed with Single Incision LA in 23 Patients, i.e., 76.6 %. In the initial cases, we started with two 5 mm and one 10mm port. To reduce crowding we replaced the 5 mm port to 3 mm port. The 10 mm port was also replaced by 5 mm in the past few cases in 1 patient the procedure was converted to open surgery. The analysis of postoperative complications showed that five patients had Post-Operative wound Infection. One patient had post-operative peritonitis. Conclusion: SILS is a feasible and safe surgical method for appendectomy and is being increasingly preferred particularly by young patients due to its excellent cosmetic results.