Open Appendectomy: The Gold Standard Appendectomy: The Gold Standard John Weaver Department of...

Open Appendectomy:The Gold Standard

Open Appendectomy:The Gold Standard

John WeaverDepartment of General Surgery

University of ColoradoDecember 3, 2007

John WeaverJohn WeaverDepartment of General SurgeryDepartment of General Surgery

University of ColoradoUniversity of ColoradoDecember 3, 2007December 3, 2007

OutlineOutline

History of appendectomy Comparison - OA vs. LA

Adults and childrenPregnancy

Financial analysis Conclusion

History of appendectomyHistory of appendectomy Comparison Comparison -- OA vs. LAOA vs. LA

Adults and childrenAdults and children PregnancyPregnancy

Financial analysisFinancial analysis ConclusionConclusion

AppendicitisAppendicitis 6-8% lifetime risk of

appendicitis 1/766 pregnant women are

seen for presumed appendicitis

1/1500 pregnant womensuffer from appendicitis

Overall mortality 0.05%-0.3%

66--8% lifetime risk of 8% lifetime risk of appendicitisappendicitis

1/766 pregnant women are 1/766 pregnant women are seen for presumed seen for presumed appendicitisappendicitis

1/1500 pregnant women1/1500 pregnant womensuffer from appendicitissuffer from appendicitis

Overall mortality 0.05%Overall mortality 0.05%--0.3%0.3%

History of AppendectomyHistory of Appendectomy

1522 - Appendix described by BereugariusCarpus

1894 - Dr. Charles McBurney performed open appendectomy (McBurney 1894)

1983 - First laparoscopic appendectomy performed by Dr. Kurt Semm (Semm 1983)

Dramatic rise in universal health care costs since 1983…coincidence?

1522 1522 -- Appendix described by Appendix described by BereugariusBereugariusCarpusCarpus

1894 1894 -- Dr. Charles Dr. Charles McBurneyMcBurney performed open performed open appendectomy appendectomy ((McBurneyMcBurney 1894)1894)

1983 1983 -- First laparoscopic appendectomy First laparoscopic appendectomy performed by Dr. Kurt performed by Dr. Kurt SemmSemm ((SemmSemm 1983)1983)

Dramatic rise in universal health care costs since Dramatic rise in universal health care costs since 19831983……coincidence?coincidence?

Sages Appropriateness Conference

Sages Appropriateness Conference

Level 1a evidence Longer operative times in LA Infectious wound rate decreased in LA. Diminished when

analyzed with ITT 2-3 fold increase in deep abscess rate, most apparent in

pediatric population Level 2a and 3 evidence

Safety and efficacy of laparoscopy in pregnancy Obese patients (BMI >26) may be beneficial Controversial in pediatric population

Level 1a evidenceLevel 1a evidence Longer operative times in LALonger operative times in LA Infectious wound rate decreased in LA. Diminished when Infectious wound rate decreased in LA. Diminished when

analyzed with ITTanalyzed with ITT 22--3 fold increase in deep abscess rate, most apparent in 3 fold increase in deep abscess rate, most apparent in

pediatric populationpediatric population Level 2a and 3 evidenceLevel 2a and 3 evidence

Safety and efficacy of laparoscopy in pregnancySafety and efficacy of laparoscopy in pregnancy Obese patients (BMI >26) may be beneficialObese patients (BMI >26) may be beneficial Controversial in pediatric populationControversial in pediatric population

Glasgow et al. Surg Endo 2003.

The Cochrane DatabaseThe Cochrane Database

• 54 studies analyzed• 45 studies compared LA vs. OA in adults• All randomized control trials• 63% of studies analyzed as intention-to-

treat (ITT)• Only 5 trials blinded patient and/or

investigator

•• 54 studies analyzed54 studies analyzed•• 45 studies compared LA vs. OA in adults45 studies compared LA vs. OA in adults•• All randomized control trialsAll randomized control trials•• 63% of studies analyzed as intention63% of studies analyzed as intention--toto--

treat (ITT)treat (ITT)•• Only 5 trials blinded patient and/or Only 5 trials blinded patient and/or

investigatorinvestigator

Sauerland S, et al. The Cochrane Collaboration, 2007.


Wound infections less likely in LA (CI 0.35-0.58)

Threefold increase in IAA increased after LA (CI 1.45-4.28)

Significantly higher operation costs in LA

OA offers shorter operative times for adults (CI 7-16)

and children (CI 6-16)

Wound infections less likely in LA Wound infections less likely in LA (CI 0.35(CI 0.35--0.58)0.58)

Threefold increase in IAA increased after LA Threefold increase in IAA increased after LA (CI 1.45(CI 1.45--4.28)4.28)

Significantly higher operation costs in LASignificantly higher operation costs in LA

OA offers shorter operative times for adults OA offers shorter operative times for adults (CI 7(CI 7--16)16)

and children and children (CI 6(CI 6--16)16)

Sauerland S, et al. The Cochrane Collaboration, 2007.


Return to work was similar in LA and OA with a difference of 0 days (CI 2-2)

“Not a single study reported a significant increase in hospital stay”

Pain reported as slight decrease after LA in adults

9mm out of 100mm on visual analogue scale

Return to work was similar in LA and OA Return to work was similar in LA and OA with a difference of 0 days with a difference of 0 days (CI 2(CI 2--2)2)

““Not a single study reported a significant Not a single study reported a significant increase in hospital stayincrease in hospital stay””

Pain reported as slight decrease after LA in Pain reported as slight decrease after LA in adultsadults

9mm out of 100mm on visual analogue scale9mm out of 100mm on visual analogue scale


Conclusions:Trend of longer operative times in adults and

children

Higher operative costs in LA

Decreased IAA in OA, but slight increased in wound infection rate - significance of wound infection vs. IAA?

Reduction of pain in LA – statistically significant, but not a clinically relevant outcomes

Conclusions:Conclusions: Trend of longer operative times in adults and Trend of longer operative times in adults and

childrenchildren

Higher operative costs in LAHigher operative costs in LA

Decreased IAA in OA, but slight increased in wound Decreased IAA in OA, but slight increased in wound infection rate infection rate -- significance of wound infection vs. significance of wound infection vs. IAA?IAA?

Reduction of pain in LA Reduction of pain in LA –– statistically significant, but statistically significant, but not a clinically relevant outcomesnot a clinically relevant outcomes

Meta-analysis 1992-200423 studies analyzed (Retrospective, NR/RCT)

7 randomized trials (3 RCT with >50 patients/arm)

Non-blinded studies

6477 children43% laparoscopic; 57% open

Not matched for severity of appendicitis

MetaMeta--analysis 1992analysis 1992--20042004 23 studies analyzed 23 studies analyzed (Retrospective, NR/RCT)(Retrospective, NR/RCT)

7 randomized trials 7 randomized trials (3 RCT with >50 patients/arm)(3 RCT with >50 patients/arm)

NonNon--blinded studiesblinded studies

6477 children6477 children 43% laparoscopic; 57% open43% laparoscopic; 57% open

Not matched for severity of appendicitisNot matched for severity of appendicitis

Aziz O, et al. Annals of Surgery, 2006.

Wound infection Meta-analysis: LA 1.5% vs. OA 5% CI .27-.75 RCT or PS: no statistical significance

IAA RCT: LA 7.4% vs. OA 4.2% CI 1.0-2.87

Postoperative ileus No individual trial showed a statistical difference RCT: LA 1.3% vs. OA 4.8% NSS

Postoperative fever: not statistically significant

Wound infectionWound infection MetaMeta--analysis: LA 1.5% vs. OA 5% CI .27analysis: LA 1.5% vs. OA 5% CI .27--.75.75 RCT or PS: no statistical significanceRCT or PS: no statistical significance

IAAIAA RCT: LA 7.4% vs. OA 4.2% CI 1.0RCT: LA 7.4% vs. OA 4.2% CI 1.0--2.872.87

Postoperative Postoperative ileusileus No individual trial showed a statistical differenceNo individual trial showed a statistical difference RCT: LA 1.3% vs. OA 4.8% NSSRCT: LA 1.3% vs. OA 4.8% NSS

Postoperative fever: Postoperative fever: not statistically significantnot statistically significant


Conclusions: Variation in study type, protocols, instruments,

type of randomization and outcome assessment Few analyzed on ITT basis When analyzed through RCT, no statistical

difference in complication rates LOS decreased in LA by 0.48 days. Statistically

significant, but factor in pediatric population? Hospital costs decreased 18% for OA

Conclusions:Conclusions: Variation in study type, protocols, instruments, Variation in study type, protocols, instruments,

type of randomization and outcome assessmenttype of randomization and outcome assessment Few analyzed on ITT basisFew analyzed on ITT basis When analyzed through RCT, no statistical When analyzed through RCT, no statistical

difference in complication ratesdifference in complication rates LOS decreased in LA by 0.48 days. Statistically LOS decreased in LA by 0.48 days. Statistically

significant, but factor in pediatric population?significant, but factor in pediatric population? Hospital costs decreased 18% for OAHospital costs decreased 18% for OA


Prospective double-blind randomized study Patients randomized by computer 3 abdominal dressings and abdominal binder

247 patients 134 OA; 113 LA

Analyzed on intention to treat basis 8% conversion to OA

1 center, 4 surgeons and all cases were performed by residents

Prospective doubleProspective double--blind randomized studyblind randomized study Patients randomized by computerPatients randomized by computer 3 abdominal dressings and abdominal binder3 abdominal dressings and abdominal binder

247 patients247 patients 134 OA; 113 LA134 OA; 113 LA

Analyzed on intention to treat basisAnalyzed on intention to treat basis 8% conversion to OA8% conversion to OA

1 center, 4 surgeons and all cases were 1 center, 4 surgeons and all cases were performed by residentsperformed by residents

Katkhouda N, et al. Annals of Surgery, 2005.

Wound infection rate: LA 6.2% vs. OA 6.7%(p=1.00)

Intraabdominal abscess: LA 5.3% vs. OA 3%(P=0.51)

Operative time: LA 80 min vs. OA 60 min(p=0.00)

No difference in activity of pain QOL scores

Time to liquid/solid, LOS, pain, oral analgesics -NSS

Wound infection rate: LA 6.2% vs. OA 6.7%Wound infection rate: LA 6.2% vs. OA 6.7%(p=1.00)(p=1.00)

IntraabdominalIntraabdominal abscess: LA 5.3% vs. OA 3%abscess: LA 5.3% vs. OA 3%(P=0.51)(P=0.51)

Operative time: LA 80 min vs. OA 60 minOperative time: LA 80 min vs. OA 60 min(p=0.00)(p=0.00)

No difference in activity of pain QOL scoresNo difference in activity of pain QOL scores

Time to liquid/solid, LOS, pain, oral analgesics Time to liquid/solid, LOS, pain, oral analgesics --NSS NSS


Conclusions:Using ITT analysis and appropriate blinding LA

fails to offer benefit over OASimilar complication ratesLonger operative time means more anesthetic

and higher OR costsNo statistical variance in subjective or objective

pain scores

Conclusions:Conclusions:Using ITT analysis and appropriate blinding LA Using ITT analysis and appropriate blinding LA

fails to offer benefit over OAfails to offer benefit over OA Similar complication ratesSimilar complication rates Longer operative time means more anesthetic Longer operative time means more anesthetic

and higher OR costsand higher OR costsNo statistical variance in subjective or objective No statistical variance in subjective or objective

pain scorespain scores


Retrospective Study 1995-2002 3,133 pregnant appendectomies (3.3% of all

appendectomies in women) OA 2,375 vs. LA 454

Negative appendectomy rate Pregnant 23% vs. nonpregnant 18% (p<0.05)

Complicated appendicitis 30% pregnant women vs. 29% non-pregnant

Retrospective Study 1995Retrospective Study 1995--20022002 3,133 pregnant appendectomies (3.3% of all 3,133 pregnant appendectomies (3.3% of all

appendectomies in women)appendectomies in women) OA 2,375 vs. LA 454OA 2,375 vs. LA 454

Negative appendectomy rateNegative appendectomy rate Pregnant 23% vs. Pregnant 23% vs. nonpregnantnonpregnant 18% 18% (p<0.05)(p<0.05)

Complicated appendicitisComplicated appendicitis 30% pregnant women vs. 29% non30% pregnant women vs. 29% non--pregnantpregnant

McGory M, et al. Am Col Surg 2007.

Journal of the American College of SurgeonsCopyright © 2007 American College of Surgeons

Early delivery (same hospitalization)

Complicated appy 11%; Negative appy 10%OA 8% vs LA 1%

Fetal loss4% of all appendectomiesOA 3% vs. LA 7% (p<0.05) Odds Ratio OA 1.00; LA 2.31 (CI 1.51-3.55)

Negative LA (27%) - 8% fetal lossComplicated LA - 13% fetal loss

Early delivery Early delivery (same hospitalization)(same hospitalization)

Complicated Complicated appyappy 11%; Negative 11%; Negative appyappy 10%10%OA 8% OA 8% vsvs LA 1%LA 1%

Fetal lossFetal loss 4% of all appendectomies4% of all appendectomiesOA 3% vs. LA 7% OA 3% vs. LA 7% (p<0.05)(p<0.05) Odds Ratio OA 1.00; LA 2.31 (CI 1.51Odds Ratio OA 1.00; LA 2.31 (CI 1.51--3.55)3.55)

Negative LA Negative LA (27%)(27%) -- 8% fetal loss8% fetal lossComplicated LA Complicated LA -- 13% fetal loss13% fetal loss



Conclusions:Need for larger randomized control trials

Higher early delivery rate in OA, but no outcome data and no post-hospital followup

Other studies have shown no difference (Affleck et al. Am J Surg 1999)

LA has higher fetal loss rate…balance against diagnostic capabilities

Conclusions:Conclusions:Need for larger randomized control trialsNeed for larger randomized control trials

Higher early delivery rate in OA, but no outcome Higher early delivery rate in OA, but no outcome data and no postdata and no post--hospital hospital followupfollowup

Other studies have shown no difference Other studies have shown no difference (Affleck et al. Am J (Affleck et al. Am J SurgSurg 1999)1999)

LA has higher fetal loss rateLA has higher fetal loss rate……balance against balance against diagnostic capabilitiesdiagnostic capabilities



Retrospective study 2003-2004 247 patients 152 OA vs. 88 LA

OR time (min) - LA 95.7 vs. OA 90.5 (p<0.05)

Operating time (min) - LA 57.4 vs. OA 56.3 (p<0.05)

LOS (days) - LA 2.2 vs. OA 2.6 (p<0.05)

Retrospective study 2003Retrospective study 2003--20042004 247 patients247 patients 152 OA vs. 88 LA 152 OA vs. 88 LA

OR time OR time (min)(min) -- LA 95.7 vs. OA 90.5 LA 95.7 vs. OA 90.5 (p<0.05)(p<0.05)

Operating time Operating time (min)(min) -- LA 57.4 vs. OA 56.3 LA 57.4 vs. OA 56.3 (p<0.05)(p<0.05)

LOS LOS (days)(days) -- LA 2.2 vs. OA 2.6 LA 2.2 vs. OA 2.6 (p<0.05)(p<0.05)

Cothren C, et al. Am J Surg 2005.

The American Journal of SurgeryCopyright © 2007 Elsevier Inc. All rights reserved

The American Journal of Surgery Copyright © 2007 Elsevier Inc. All rights reserved

The American Journal of Surgery Copyright © 2007 Elsevier Inc. All rights reserved

Operating room charges Equipment charge: OA $125.32 vs. LA $1,078.70 (p<0.05)

Operative time charge: OA $3,022.16 vs. LA $4065.24 (p<0.05)

Total Hospital Charges All appendectomies: OA $12,310 vs. LA $16,773 (p<0.05)

Non-perforated: OA $9,632 vs. LA $14,251 (p<0.05)

Perforated: OA $12,215 vs. LA $27,639 (p<0.05)

Operating room chargesOperating room charges Equipment charge: OA $125.32 vs. LA $1,078.70Equipment charge: OA $125.32 vs. LA $1,078.70 (p<0.05)(p<0.05)

Operative time charge: OA $3,022.16 vs. LA $4065.24Operative time charge: OA $3,022.16 vs. LA $4065.24 (p<0.05)(p<0.05)

Total Hospital ChargesTotal Hospital Charges All appendectomies: OA $12,310 vs. All appendectomies: OA $12,310 vs. LA $16,773LA $16,773 (p<0.05)(p<0.05)

NonNon--perforated: OA $9,632 vs. LA $14,251perforated: OA $9,632 vs. LA $14,251 (p<0.05)(p<0.05)

Perforated: OA $12,215 vs. LA $27,639Perforated: OA $12,215 vs. LA $27,639 (p<0.05)(p<0.05)

Cost prohibitive to resident teaching in an academic institution? Is laparoscopy routinely worth the cost?

$953/case difference in equipment charges alone between OA vs LA ($253,000 if all LA)

Estimated $800,000 in hospital charges lost to laparoscopy during study

Cost prohibitive to resident teaching in an Cost prohibitive to resident teaching in an academic institution? Is laparoscopy routinely academic institution? Is laparoscopy routinely worth the cost?worth the cost?

$953/case difference in equipment charges $953/case difference in equipment charges alone between OA alone between OA vsvs LA LA ($253,000 if all LA)($253,000 if all LA)

Estimated $800,000 in hospital charges lost Estimated $800,000 in hospital charges lost to laparoscopy during studyto laparoscopy during study

Cothren C, et al. Am J Surg 2005.

The American Journal of SurgeryCopyright © 2007 Elsevier Inc. All rights reserved

Conclusions: Open versus LaparoscopicConclusions: Open versus Laparoscopic

Wound infection rate slightly lower in LA…NSS in double blinded RCT.

IAA rate less in OA. Clinically relevant despite marginally not statistically significant.

LOS smaller in LA by <1 day. Multiple studies show no statistical difference.

LA claims small decrease in pain scale over OA. Double blinded RCT using SF-36 questionnaire shows NSS.

Wound infection rate slightly lower in LAWound infection rate slightly lower in LA……NSS in double NSS in double blinded RCT.blinded RCT.

IAA rate less in OA. Clinically relevant despite marginally IAA rate less in OA. Clinically relevant despite marginally not statistically significant.not statistically significant.

LOS smaller in LA by <1 day. Multiple studies show no LOS smaller in LA by <1 day. Multiple studies show no statistical difference. statistical difference.

LA claims small decrease in pain scale over OA. Double LA claims small decrease in pain scale over OA. Double blinded RCT using SFblinded RCT using SF--36 questionnaire shows NSS.36 questionnaire shows NSS.

Conclusions: Open versus LaparoscopicConclusions: Open versus Laparoscopic

Analysis in pregnant women…LA may offer diagnostic advantages, but at higher risk to fetus.

LA in pediatrics showed no statistical difference in complication rates in RCT, but higher operative costs.

Longer operative times and higher equipment costs when done laparoscopically.

Analysis in pregnant womenAnalysis in pregnant women……LA may offer LA may offer diagnostic advantages, but at higher risk to diagnostic advantages, but at higher risk to fetus.fetus.

LA in pediatrics showed no statistical LA in pediatrics showed no statistical difference in complication rates in RCT, but difference in complication rates in RCT, but higher operative costs.higher operative costs.

Longer operative times and higher equipment Longer operative times and higher equipment costs when done costs when done laparoscopicallylaparoscopically..

ReferencesReferences Affleck D, Handrahan D, Egger M, Price R. The laparoscopic management

of appendicitis and cholelithiasis during prenancy. American Journal of Surgery 1999; 178: 523-529.

Aziz O, Athanosiou T, Tekkis P, Purkayastha S, Haddow J, Malinovski V, Paraskeva P, Darzi A. Laparoscopic versus open appendectomy in children: A meta-analysis. Annals of Surgery 2006; 243:17-27.

Cothren C, Moore E, Johnson J, Moore J, Ciesla D, Burch J. Can we afford to do laparoscopic appendectomy in an academic hospital? Am J Surg2005; 190:973-977.

Glasgow R, Fingerhut A, Hunter J. SAGES appropriateness conference. Surgical Endoscopy 2003; 17:1729-1734.

Katkhouda N, Rodney J, Towfigh S, Gevorgyan A, Essani R. Laparoscopic versus open appendectomy: A prospective randomized double blind study. Annals of Surgery 2005; 242:439-448.

McGory M, Zingmond D, Tillou A, Hiatt J, Ko C, Cryer H. Negative appendectomy in pregnant women is associated with substantial risk of fetal loss. Am Col Surg 2007; 205:535-540.

Rueda, C. Laparoscopic Appendectomy Overrated. UCHSC resident debate forum. 2006.

Sauerland S, Lefering R, Neugebauer E. Laparoscopic versus open surgery for suspected appendicitis. The Cochrane Collaboration 2007; 4:1-74.

Affleck D, Affleck D, HandrahanHandrahan D, Egger M, Price R. The laparoscopic management D, Egger M, Price R. The laparoscopic management of appendicitis and of appendicitis and cholelithiasischolelithiasis during during prenancyprenancy. American Journal of . American Journal of Surgery 1999; 178: 523Surgery 1999; 178: 523--529.529.

Aziz O, Aziz O, AthanosiouAthanosiou T, T, TekkisTekkis P, P, PurkayasthaPurkayastha S, S, HaddowHaddow J, J, MalinovskiMalinovski V, V, ParaskevaParaskeva P, P, DarziDarzi A. Laparoscopic versus open appendectomy in A. Laparoscopic versus open appendectomy in children: A metachildren: A meta--analysis. Annals of Surgery 2006; 243:17analysis. Annals of Surgery 2006; 243:17--27.27.

CothrenCothren C, Moore E, Johnson J, Moore J, C, Moore E, Johnson J, Moore J, CieslaCiesla D, Burch J. Can we afford D, Burch J. Can we afford to do laparoscopic appendectomy in an academic hospital? Am J to do laparoscopic appendectomy in an academic hospital? Am J SurgSurg2005; 190:9732005; 190:973--977.977.

Glasgow R, Fingerhut A, Hunter J. SAGES appropriateness conferenGlasgow R, Fingerhut A, Hunter J. SAGES appropriateness conference. ce. Surgical Endoscopy 2003; 17:1729Surgical Endoscopy 2003; 17:1729--1734.1734.

KatkhoudaKatkhouda N, Rodney J, N, Rodney J, TowfighTowfigh S, S, GevorgyanGevorgyan A, A, EssaniEssani R. Laparoscopic R. Laparoscopic versus open appendectomy: A prospective randomized double blind versus open appendectomy: A prospective randomized double blind study. study. Annals of Surgery 2005; 242:439Annals of Surgery 2005; 242:439--448.448.

McGoryMcGory M, M, ZingmondZingmond D, D, TillouTillou A, Hiatt J, A, Hiatt J, KoKo C, C, CryerCryer H. Negative H. Negative appendectomy in pregnant women is associated with substantial riappendectomy in pregnant women is associated with substantial risk of sk of fetal loss. Am Col fetal loss. Am Col SurgSurg 2007; 205:5352007; 205:535--540.540.

RuedaRueda, C. Laparoscopic Appendectomy Overrated. UCHSC resident , C. Laparoscopic Appendectomy Overrated. UCHSC resident debate forum. 2006.debate forum. 2006.

SauerlandSauerland S, S, LeferingLefering R, R, NeugebauerNeugebauer E. Laparoscopic versus open E. Laparoscopic versus open surgery for suspected appendicitis. The Cochrane Collaboration surgery for suspected appendicitis. The Cochrane Collaboration 2007; 4:12007; 4:1--74.74.

Open Appendectomy: The Gold Standard Appendectomy: The Gold Standard John Weaver Department of...

Documents

Transcript of Open Appendectomy: The Gold Standard Appendectomy: The Gold Standard John Weaver Department of...