Laparoscopy

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Laparoscopic versus open surgery for suspected appendicitis.

Jaschinski T¹, Mosch CG, Eikermann M, Neugebauer EA, Sauerland S.

BACKGROUND:

The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity. This is an update of the review published in 2010.

OBJECTIVES:

To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.

SEARCH METHODS:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We hand searched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA:

We included randomized controlled trials (RCTs) comparing LA versus OA in adults or children.

DATA COLLECTION AND ANALYSIS:

Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.

MAIN RESULTS:

We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.

AUTHORS’ CONCLUSIONS:

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.

Is laparoscopic appendectomy feasible for complicated appendicitis ?A systematic review and meta-analysis.

Yu MC¹, Feng YJ², Wang W², Fan W², Cheng HT², Xu J².

BACKGROUND:

laparoscopic appendectomy(LA) has proved to be a safe alternative to open appendectomy(OA) in uncomplicated appendicitis; however, the feasibility of LA for complicated appendicitis(CA) has not been conclusively determined.

OBJECTIVES:

To assess the feasibility and safety of LA for CA through a systematic review and meta-analysis.

METHODS:

A literature search in PubMed, Embase, Cochrane Library, and web of Science was performed for eligible studies published from the inception of the databases to January 2016. All studies comparing LA and OA for CA were reviewed. After literature selection, data extraction and quality assessment were performed by two reviewers independently, and meta-analysis was conducted using Revman software, vision 5.2.

RESULTS:

Two randomized controlled trials (RCTs) and 14 retrospective cohort studies(RCSs) were finally identified. Our meta-analysis showed that LA for CA could reduce the rate of surgical site infections (SSIs) (OR = 0.28; 95% CI: 0.25 to0.31, P < 0.00001), but LA did not increase the rate of postoperative intra-abdominal abscess(IAA) (OR = 0.79; 95% CI: 0.45 to 1.34, P = 0.40). The results showed that the operating time in the LA groups was much longer than that in the OA groups (WMD = 13.78, 95% CI: 8.99 to 18.57, P < 0.00001). However, the length of hospital stays in the LA groups were significantly shorter than those in the OA groups (WMD = -2.47, 95%CI: -3.75 to -1.19, P < 0.0002), and the time until oral intake(TTOI) was much earlier in the LA groups than in the OA groups (WMD = -0.88, 95% CI: -1.20 to -0.55, P < 0.00001). No significant difference was observed in the times of postoperative analgesia between the two groups(P > 0.05).

CONCLUSION:

LA was feasible and safe for complicated appendicitis, and it not only could shorten the hospital stays and the time until oral intake, but it could also reduce the risk of surgical site infection.

Laparoscopic versus conventional appendectomy – a meta-analysis of randomized controlled trials

Xiaohang Li,¹ Jialin Zhang,¹ Lixuan Sang,² Wenliang Zhang,² Zhiqiang Chu,¹ Xin Li,¹ and Yongfeng Liu¹

Background

Although laparoscopic surgery has been available for a long time and laparoscopic cholecystectomy has been performed universally, it is still not clear whether open appendectomy (OA) or laparoscopic appendectomy (LA) is the most appropriate surgical approach to acute appendicitis. The purpose of this work is to compare the therapeutic effects and safety of laparoscopic and conventional “open” appendectomy by means of a meta-analysis.

Methods

A meta-analysis was performed of all randomized controlled trials published in English that compared LA and OA in adults and children between 1990 and 2009. Calculations were made of the effect sizes of: operating time, postoperative length of hospital stay, postoperative pain, return to normal activity, resumption of diet, complications rates, and conversion to open surgery. The effect sizes were then pooled by a fixed or random-effects model.

Results

Forty-four randomized controlled trials with 5292 patients were included in the meta-analysis. Operating time was 12.35 min longer for LA (95% CI: 7.99 to 16.72, p < 0.00001). Hospital stay after LA was 0.60 days shorter (95% CI: -0.85 to -0.36, p < 0.00001). Patients returned to their normal activity 4.52 days earlier after LA (95% CI: -5.95 to -3.10, p < 0.00001), and resumed their diet 0.34 days earlier(95% CI: -0.46 to -0.21, p < 0.00001). Pain after LA on the first postoperative day was significantly less (p = 0.008). The overall conversion rate from LA to OA was 9.51%. With regard to the rate of complications, wound infection after LA was definitely reduced (OR = 0.45, 95% CI: 0.34 to 0.59, p < 0.00001), while postoperative ileus was not significantly reduced(OR = 0.91, 95% CI: 0.57 to 1.47, p = 0.71). However, intra-abdominal abscess (IAA), intraoperative bleeding and urinary tract infection (UIT) after LA, occurred slightly more frequently(OR = 1.56, 95% CI: 1.01 to 2.43, p = 0.05; OR = 1.56, 95% CI: 0.54 to 4.48, p = 0.41; OR = 1.76, 95% CI: 0.58 to 5.29, p = 0.32).

Conclusion

LA provides considerable benefits over OA, including a shorter length of hospital stay, less postoperative pain, earlier postoperative recovery, and a lower complication rate. Furthermore, over the study period it was obvious that there had been a trend toward fewer differences in operating time for the two procedures. Although LA was associated with a slight increase in the incidence of IAA, intra operative bleeding and UIT, it is a safe procedure. It may be that the widespread use of LA is due to its better therapeutic effect.

(# of subjects/ studies, cohort definition etc. )

– Inclusion Criteria:

Included randomized controlled trials (RCTs) comparing LA versus OA in adults or children. Included all participants regardless of age with symptoms and signs of acute appendicitis.

-85 randomised studies met the inclusion criteria with 9765 participants. Seventy‐five trials included 8520 adults and 10 trials included 1245 children.

In children, there were no differences in intra‐abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low‐quality evidence) However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate‐quality evidence

Relevant studies were searched from the PubMed, Embase, Cochrane Library, and Web of Science databases.

– Two randomized controlled trials (RCTs) and 14 retrospective cohort studies(RCSs) were finally identified.

(2)different studies had different defining criteria for complicated appendicitis (CA) and different outcome measurements, most of the studies defined CA as a perforated appendix with or without abscess formation and with or without peritonitis, but some articles also included gangrenous appendicitis as complicated appendicitis.

(3) Third, the small sample size, single-centre experience and lack of data entirely from double-blind studies might have decreased the reliability of the results. (4)The surgeons had various levels of experience in LA for CA, and treatment protocols amongst the studies differed, therefore heterogenity in the studies might have existed. (5) The degree of appendicitis in the studies might have been different; the greater the severity of appendicitis, the more complications that might occur, and the severity of appendicitis could also influence the recovery and operation time.

– Inclusion Criteria:

(1) a prospective randomized study format only; (2) a comparison of laparoscopic and open appendicectomy; (3) The study reported at least one of the desirable outcomes mentioned below and the standard deviation of the mean for continuous outcomes of interest was reported or can be calculated; (4) Studies that allocated patients depending on the availability of staff or instruments were excluded; (5) Studies that used variations on the standard laparoscopic technique, including hybrid procedures or single trochar techniques, were also excluded.

– Exclusion Criteria:

(1) Studies that allocated patients depending on the availability of staff or instruments were excluded; (2) Studies that used variations on the standard laparoscopic technique, including hybrid procedures or single trochar techniques, were also excluded.

– Forty-four randomized controlled trials with 5292 patients were included in the meta-analysis.

2) not all the studies measured data based on a double-blind.

(3) there was variation in surgical techniques and treatment protocols amongst the studies, and therefore heterogeneity in the studies might exist. (4)although most studies were comparable with regard to age and sex, fewer were matched for severity of appendicitis (represented by fever, raised WBC, peritonitis and perforated rate) and weight