Tuesday, December 23, 2003

DB links to this CNN story about the advantages of laparoscopic appendectomy compared with the more traditional open method, citing a paper in the January 2004 Annals of Surgery. While I have not received my print copy of Annals I have read the full article online and have the following comments.
The first paragraph in the CNN story reads as follows:

Patients who had laparoscopic appendectomies had fewer complications, left the hospital faster and went back to work sooner, two Duke University researchers found after reviewing results of studies involving 43,000 patients.

I wonder if the person who wrote this story read the article or even the abstract. Since the authors' begin their conclusion with:

In summary, we have shown that LA has significant advantages over OA with respect to length of hospital stay, rate of routine discharge, and postoperative in-hospital morbidity.

The authors then go on to explain some shortcomings of the study, such as conversions (lap to open) being coded as open which may affect in-hospital complications and length of stay. The authors also point out that since only inpatient data was collected that complications that arose outside the hospital may be missed. A potential bias may also rest with the use of inpatient data. A patient could have developed appendicitis during the hospitalization. If these patients were severely ill, or explored without a definitive diagnosis of appendicitis, they would not be likely to be offered a laparoscopic approach. The study did show that the infection rate was the same for both procedures in patients with abscess or perforation. The "in hospital morbidity" when broken down showed that the risk-adjusted wound complication rate was higher for open appendectomy, but other complications (cardiovascular, urinary, ect..) were not significantly higher for open appendectomy.
The problems that have hampered the wider acceptance of laparoscopic appendectomy are related to 1) cost and 2)operating time. Lap appendectomy has a higher cost than open appendectomy due to the laparoscopic instruments that are used. Does the increased procedural cost even out with the decreases in LOS seen with lap appendectomy? The jury is still out. As the authors themselves point out:

However, all aspects of LA and OA must be compared, including postoperative pain, patient's quality of life, days away from work, procedural costs, total costs, and long-term complications. The present investigation is only a first step towards an assessment of all these aspects based on representative US-nationwide patient samples. Further analyses to evaluate the above-mentioned endpoints are required to define whether LA should be considered the treatment of choice for appendicitis.

Operative time is increased for lap appendectomy, especially at three in the morning when the OR staff is not familiar with the procedures and equipment.
My routine is to perform an open appendectomy through a McBurney muscle-splitting incision for all patients unless the diagnosis is in doubt (usually a young female, and with the wider use of CT in diagnosis this is becoming less frequent) in which case I perform laparoscopy and go from there. I use generous amounts of local anesthetic and discharge my uncomplicated (unruptured) patients within 24-36 hours (Shorter than the average LOS in the paper). They can return to light duty within a few days and are at unrestricted activity in 2-3 weeks. The ruptured/abscessed ones usually stay in for 4-5 days with IV antibiotics and local wound care with delayed primary closure just before discharge.
But the LOS in the United States is nothing compared with Europe:

For instance, although Hebebrand et al from Germany reported a length of hospital stay of 5.3 days for LA and 7.6 days for OA, 28 Mutter and colleagues (UK/France) found 5.3 versus 4.9 days, 35 and Minne et al (USA) 1.1 (LA) and 1.2 days (OA). 36

A week in hospital for an appendectomy in Germany? My goodness!! Anyway, lap appendectomy is far from the standard of care, but may be soon.
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