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Feasibility of Laparoscopic Interval Appendicectomy as a Day Case Procedure

Caroline Pardy¹, Anies Mahomed²

¹Department of Pediatric Surgery, Royal Alexandra Children’s Hospital, Brighton, UK

²King Faisal Specialist Hospital and Research Centre, Jeddah, Kingdom of Saudi Arabia

 

Correspondence:

Anies Mahomed

King Faisal Specialist Hospital and Research Centre

P O Box 40047, Jeddah 21499

Kingdom of Saudi Arabia

Fax: +966 2 667 7777 Ext. 65815

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Introduction: The role of interval appendicectomy in the management of appendix mass remains controversial. Advocates argue that the risk of recurrent appendicitis justifies an elective procedure, whilst others believe that this risk is low enough for an appendix mass to be managed conservatively . Our centre is a proponent of interval appendicectomy and sought to determine the feasibility of performing interval appendicectomy as a day case procedure.

Methods: We performed a prospective data collection for children undergoing elective laparoscopic interval appendicectomy for appendix mass, managed by a single surgeon over a 9 year period. Statistical analysis was performed using Mann-Whitney U Test using Graphpad Prism version 6.

Results: Sixteen children with a median age of 9 (2-16), 10 of whom were female, underwent elective laparoscopic interval appendicectomy between January 2005 – September 2014. Operating time was a median of 45 minutes (20-60 minutes). 2 cases were performed using Single Incision Laparoscopic Surgery (SILS). There were no conversions, and no intra-operative complications. Nine patients (56%) were discharged the day of their procedure. One patient undergoing SILS was discharged the same day, the other patient was discharged the following day. The median length of stay for patients who could not be discharged on the day of surgery was 1 day (1-4). One patient who was discharged on day 1 post-surgery was re-admitted 3 days after discharge with pain and vomiting that settled with antibiotics. There was a trend towards younger patients being able to be managed as a day case procedure (median 9 years vs. 11 years), although this was not statistically significant (P = 0.31). Perhaps not surprisingly, patients who were discharged the day of surgery had shorter operating time (P = 0.03, median 30 minutes vs. 60 minutes), likely to reflect a less technically challenging procedure, and although not significant (P = 0.15), trended towards a shorter time to full feeds (median 6 hours vs. 8 hours).

Conclusions: This series has demonstrated that just over half of patients undergoing elective laparoscopic interval appendicectomy can be discharged safely on the day of surgery. It appears that the surgeon alone may be the best judge of whether a patient is suitable for discharge on the day of surgery, depending on the technical difficulty and length of procedure.

Keywords: interval appendicectomy, laparoscopy, day case surgery.

 

Introduction

With a lifetime risk of 9% in men and 7% in women [1], appendicitis represents one of the most common surgical conditions managed by both adult and pediatric surgeons. Despite this, significant variation and controversy persists in its management [2, 3].

An appendix mass has been defined as appendicitis localized by oedematous, adherent omentum and loops of small bowel [4], and has been identified in 10% of children presenting with appendicitis [5]. Most pediatric surgeons advocate initial conservative management of an appendix mass with subsequent interval appendicectomy [3, 6], on the basis that surgery in the acute phase can be technically challenging with an increased risk of associated complications. More recently however, the indication for interval appendicectomy has been challenged. Arguments against interval appendicectomy include the cost of a potentially unnecessary hospital admission and procedure, and the risk of associated complications [7, 8].

Our centre is a proponent of interval appendicectomy following conservative management of an appendix mass, and sought to determine the feasibility of performing this procedure as a day case.

Method

Data was collected prospectively between 2005 and 2014, for all interval laparoscopic appendicectomies performed by a single surgeon, following conservative management of an appendix mass. Diagnosis of an appendix mass was confirmed with both clinical and ultrasound examination. Data collected included patient demographics, intra-operative findings, duration of surgery, intra-operative complications, technical difficulty of procedure, length of stay, and post-operative complications. All procedures were carried out on a morning list with the senior author as first surgeon. Fitness for discharge was determined by consensus between the nurse caring for the child, and the surgical registrar on call.

Data was compared for those children discharged on the day of surgery, and those who required an inpatient stay. Statistical analysis was performed using Mann-Whitney U Test using Graphpad Prism version 6. Data is presented as median and range.

Results

Sixteen children, 10 whom were female underwent laparoscopic interval appendicectomy. The median age was 9 years (2-16). Two appendicectomies were performed using single incision laparoscopic surgery (SILS), with the remainder performed using standard 3-port technique. There were no intra-operative complications, and no conversions to an open procedure. The median duration of surgery was 45 minutes (20-60).

Nine out of 16 (56%) children were discharged on the day of surgery. Five out of 16 (31%) children were discharged on the first post-operative day. One patient was discharged two days post-operatively, and another child on the fourth post-operative day.

One child, who had been discharged one day post-operatively, was re-admitted with abdominal pain and vomiting on the third post-operative day. Their symptoms settled with conservative management. This child had undergone a SILS procedure, which had been determined to be ‘straightforward’. No histological abnormality was identified in the resected appendix. Histological evidence of inflammation was demonstrated in 10/16 (63%) of the appendixes removed. Pinworm was identified in 3 appendixes, one of which had otherwise normal histology.

When comparing children who were fit for discharge on the day of surgery, and those who required an inpatient stay, there was no difference in the sex of the child (P = 0.63). The median age of children who were managed as a day case was 9 years compared to a median of 11 years for children requiring admission, but this was not significant (P = 0.31). One of the two children who had a SILS procedure was discharged on the day of surgery, and the other was discharged on the first post-operative day. Patients who were successfully managed as a day case procedure had a significantly shorter duration of surgery, with a median of 30 minutes compared to 60 minutes (P = 0.03). This is likely to reflect the technical difficulty of the procedure, with all patients discharged on the day of surgery having had a procedure that was deemed ‘straightforward’ by the primary surgeon. Three out of 7 patients requiring admission who were deemed to have a ‘straightforward’ procedure were discharged on the first post-operative day. Of the 3 children admitted who were judged to have had a ‘moderately difficult’ procedure, 2 were discharged on the first post-operative day, and 1 was discharged the second post-operative day. The only child determined to have had a technically ‘difficult’ procedure required the longest admission, having been discharged on the fourth post-operative day.

Three out of 16 children were found to have a persistent appendix mass at the time of interval appendicectomy. Two of these children required the longest admissions (2 and 4 days), with their procedures having been judged to be ‘moderately difficult’ and ‘difficult’ respectively. The third child found to have a persistent appendix mass had a ‘moderately difficult’ procedure and was discharged on the first post-operative day.

Discussion

This study has demonstrated that laparoscopic interval appendicectomy for management of an appendix mass can be safely performed as a day case procedure. None of the patients discharged on the day of surgery were re-admitted. The single patient in this cohort who required re-admission following discharge on the first post-operative day, had undergone what had been deemed to be a ‘straightforward’ SILS procedure. Intra-operative findings had been unremarkable, and no evidence of suppurative inflammation was identified in the appendix removed.

Perhaps unsurprisingly, our findings suggest that the only means of determining whether a child is likely to be fit for discharge the day of surgery, is the judgment of the primary surgeon, based on the technical difficulty of the procedure. Although this makes pre-operative planning with respect to beds more difficult, our data suggests that over half of children undergoing this procedure can be successfully managed as a day case, reducing both cost and bed pressure.

Those who argue that interval appendicectomy is unnecessary cite the low risk (approximately 7-20%) of recurrent appendicitis [7, 9]. However, even in uncomplicated acute appendicitis, the APPAC randomised clinical trial comparing antibiotic therapy with appendicectomy in adults, found that 27% of patients managed with antibiotic therapy alone underwent appendicectomy within a year of their initial presentation [10]. Consistent with the findings of previous studies [11, 12], histological evidence of persistent inflammation was identified in the 63% of appendixes removed. Despite an early interval appendicectomy, 3/16 children (19%) were found to have a persistent appendix mass at laparoscopy. The combination of histological and macroscopic findings in our series, suggest that the treatment of an appendix mass with conservative management alone is often incomplete, with the risk of recurrent appendicitis. The difficulty remains determining which children managed non-operatively are at risk of developing recurrent appendicitis.

Early laparoscopic appendicectomy has been reported as feasible for the management of appendiceal mass in children [13]. Compared with laparoscopic appendicectomy for uncomplicated appendicitis, the operative time, post-operative admission, time to ambulation and enteral autonomy was longer, and although not statistically significant, there was a higher conversion rate to an open procedure. The authors comment however, that when compared with other complicated appendicitis (perforated), there was no difference in operative time, conversion rate, duration of post-operative admission, or morbidity.

A meta-analysis performed by Simillis et al. comparing conservative management with acute appendicectomy for complicated appendicitis (either an appendix abscess or mass), included 1 572 patients from 17 studies [14]. The study found that conservative management was associated with fewer complications compared with acute appendicectomy. In the group managed conservatively, there was a lower incidence of ileus/bowel obstruction, abscess formation and wound infection. There were a greater number of patients requiring further surgery when initially managed with an acute appendicectomy, but this did not reach significance. When only paediatric patients included in the study were analysed, conservative management was associated with significantly few complications overall, including wound infection and abscess formation.

Of the 847 patients in this study whose initial management was conservative, 483 proceeded to interval appendicectomy. When subsequent admissions (including for interval appendicectomy) were compared, there was no significant difference in the duration of hospitalization between patients managed conservatively, and those managed with acute appendicectomy. The outcomes for those patients managed conservatively without subsequent interval appendicectomy were unfortunately not included in the study.

The weakness of the majority of the available data upon which to base our current practice of managing appendiceal mass, is the retrospective nature, and likely selection bias. It is conceivable that patients that are more unwell at presentation may be more likely to proceed to early surgery, whereas the surgeon will be more confident managing a relatively well patient with initial conservative therapy.

The Children’s Interval Appendicectomy (CHINA) [15] study is a prospective multi-centre randomised evaluation comparing conservative management of appendix mass followed by interval appendicectomy, with conservative management alone. The study is now closed and currently in its follow-up stage. The results of this study are keenly awaited, and will hopefully provide some more reliable evidence upon which to base practice.

Conclusion

A significant risk of recurrent appendicitis remains following conservative management of an appendix mass, and currently there is no reliable means available to predict which patients will re-present. Day case laparoscopic interval appendicectomy for an appendix mass is safe, and feasible in the majority of children. However, the likelihood of discharge on the day of surgery may only be judged post-operatively by the operating surgeon, based on technical difficulty of the procedure.

 

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