Laparoscopic Appendectomy: Valuable. Joel Baumgartner UCHSC Surgery Grand Rounds Resident Debate November 20, 2006

Transcription

1 Valuable Joel Baumgartner UCHSC Surgery Grand Rounds Resident Debate November 20, 2006

2 History National Library of Medicine

3 History First open appendectomy in 1889 McBurney C. NY Med J 1889;50:

4 History exactly between an inch and half and two inches from the anterior spinous process of the ileum on a straight line drawn from that process to the umbilicus. McBurney C. NY Med J 1889;50:

5 History BMJ 2003;327:397, doi: /bmj

6 History Kurt Semm German gynecologist Performed first laparoscopic appendectomy in years prior to first laparoscopic cholecystectomy Semm K. Endoscopy 1983;15(2):59-64.

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11 Literature Review 1057 articles on PubMed search for laparoscopic appendectomy At least 57 randomized controlled trials (RCTs) At least 10 Meta-analyses analyses Even more case series, retrospective studies and literature reviews

12 Poor data Literature Review 2006 review of methodologic and statistical aspects of 38 RCTs Concluded most studies had pitfalls and can provide no consolidated findings on which to make recommendations Kapischke M, et al. Surg Endosc 2006;20(7):

13 2004 Cochrane Review Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

14 2004 Cochrane Review Most comprehensive meta-analysis analysis to date Reviewed 54 RCTs of nearly 5000 patients Quality of included studies was moderate to poor Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

15 2004 Cochrane Review Divided primary outcomes into therapeutic and diagnostic types Primary therapeutic outcome measures Wound infection rate Intra-abdominal abdominal abscess rate Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

16 2004 Cochrane Review Divided primary outcomes into therapeutic and diagnostic types Primary diagnostic outcome measures Negative appendectomy rate Patients with diagnosis not established Rationale: normal appendix left only if another pathology was discovered, therefore increased diagnostic accuracy may decrease negative appendectomy rate Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

17 2004 Cochrane Review Secondary therapeutic outcome measures Operative time Anesthesia time Pain on POD 1 Length of hospital stay Time until reintroduction of liquids & solids Time until first stool Time until return to normal activity Time until return to full activity Time until return to sport Cosmesis Costs of operation, within hospital stay, outside hospital stay Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

18 2004 Cochrane Review Results: Primary therapeutic outcomes Wound Infections Intra-abdominal abdominal Abscesses Lap Rate Open Rate OR [95% CI] 3.6% 7.3% 0.45 [0.35, 0.58] 1.6% 0.6% 2.48 [1.45, 4.21] Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

19 2004 Cochrane Review Results: Primary therapeutic outcomes Wound Infections Intra-abdominal abdominal Abscesses Lap Rate Open Rate OR [95% CI] 3.6% 7.3% 0.45 [0.35, 0.58] 1.6% 0.6% 2.48 [1.45, 4.21] Laparoscopic appendectomy saves 3 wound infections for every 1 intra-abdominal abdominal abscess Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

20 2004 Cochrane Review Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD Weighted/Standardized Mean Difference [95% CI] Operation Time (min) [6.90, 16.04] Pain POD 1 (cm/10cm VAS) [-1.26,[ -0.47] Hospital Stay (days) [-1.49,[ -0.62] Return to normal activity (days) [-8.11,[ -3.61] Return to work (days) 0.00 [-1.97,[ 1.98] Operative cost 4.55 [3.27, 5.82] In-hospital cost 0.20 [-0.29,[ 0.68] Outside hospital cost [-0.63,[ -0.07]

21 2004 Cochrane Review Results: Primary diagnostic outcomes RR [95% CI] Negative appendectomy, all 0.37 [0.13, 1.01] Negative appendectomy, fertile women 0.20 [0.11, 0.34] Uncertain diagnosis, all 0.43 [0.17, 1.08] Uncertain diagnosis, fertile women 0.27 [0.17, 0.44] Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

22 Conclusion 2004 Cochrane Review Recommend laparoscopic approach in suspected appendicitis Especially in young female, obese and employed patients Sauerland S, et al. Cochrane Database Syst Rev 2004;18(4):CD

23 Randomized Controlled Trial Katkhouda N, et al. Ann Surg 2005;242(3):

24 Randomized Controlled Trial 247 patients randomized Double blinded Katkhouda N, et al. Ann Surg 2005;242(3):

25 Randomized Controlled Trial Results No difference in complications Katkhouda N, et al. Ann Surg 2005;242(3):

26 Randomized Controlled Trial Katkhouda N, et al. Ann Surg 2005;242(3):

27 Randomized Controlled Trial Results No difference in post-operative operative pain or time of return to activity Significant differences in operative and anesthetic times Katkhouda N, et al. Ann Surg 2005;242(3):

28 Randomized Controlled Trial Katkhouda N, et al. Ann Surg 2005;242(3):

29 Randomized Controlled Trial Results Significant difference in quality of life (SF-36 form) Katkhouda N, et al. Ann Surg 2005;242(3):

30 Randomized Controlled Trial Conclusion Laparoscopic and open appendectomy are equivalent techniques in terms of complications and outcomes choice of procedure based on surgeon or patient preference Katkhouda N, et al. Ann Surg 2005;242(3):

31 Case Series Guller U, et al. Ann Surg 2004;239(1):43-52.

32 Case Series Series of 43,757 patients from US hospital discharge records Guller U, et al. Ann Surg 2004;239(1):43-52.

33 Case Series Guller U, et al. Ann Surg 2004;239(1):43-52.

34 Case Conclusion Series Advantages of laparoscopic appendectomy in length of stay, routine discharge and morbidity Guller U, et al. Ann Surg 2004;239(1):43-52.

35 Conclusions Similar morbidity Possibly higher rate intra-abdominal abdominal abscesses but absolute risk increase of only 1% Possibly lower rate wound infections Higher operative time (cost) Outside hospital costs may be less Improved diagnostic capabilities Advantageous in certain subgroups (ie( ie.. obese) Improved QOL, patient preference