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Three Part Question

In [children with acute appendicitis] is [laparoscopic better than open appendicectomy] at [reducing operation time, post-operative recovery, complications, and costs]?

Clinical Scenario

A 14 year old boy presents to the paediatric assessment unit with a 24 hour history of right iliac fossa pain. After a full history and examination the clinical diagnosis is of acute appendicitis. He is booked for theatre as an emergency appendicectomy. Which is the best approach: laparoscopic or an open procedure?

Search Strategy

Pubmed search
"Child"[Mesh] AND ("Appendicitis"[Mesh] OR "Appendectomy"[Mesh] OR "Appendix"[Mesh]) AND "Laparoscopy"[Mesh] AND "open"
and a search of the BESTBet title: ‘open versus laparoscopic appendectomy (and appendicectomy) in children’
Cochrane library search
child AND appendicitis AND open AND laparoscopy

Relevant articles had their references searched for further articles.

Search Outcome

The Pubmed search produced 213 papers, of which 173 were irrelevant (last checked 07/03/10). A search of the Cochrane library search added no new papers. Of the 40 relevant papers, 14 were in English, of sufficient quality and provided additional data. The meta-analysis by Aziz et al reviewed 23 relevant articles from 1992 through to 2004.

All results are displayed as LA versus OA

LA = Laparoscopic appendicectomy; OA= Open appendicectomy; HES = Hospital Episode Statistics; NS = Not significant; m = minutes, h = hours, d = days

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wang et al. 2009 China	128 children who underwent LA (80) or OA (48) OA for acute complicated appendicitis (perforation, mass or intra-abdominal abscess) over 3 1/2 years (2005-2008)	Single-centre retrospective cohort study (2b)	Mean operative time (m)	88.5vs71.8 P=0.002	Retrospective study (particularly susceptible to selection bias). Small sample size. No age range included. No conversions from LA to OA.
			Time to resume diet (d)	1.8vs2.8 P=<0.001
			Mean length of hospital stay (d)	6.5vs7.8 P=0.005
			Wound infections	1.3%vs12.5% P=<0.05
			Intra-abdominal abscess	2.5%vs14.6% P=<0.05
Kaselas et al. 2009 France	1684 children (1 month–14 years) with acute appendicitis who underwent LA (1175) or OA (509) over 15 years (1992-2007)	Single-centre retrospective cohort study (2b)	Post-op bowel obstruction		Retrospective study. Rare complication. Does not describe LA/OA techniques used. No conversion rate included (groups based on initial approach attempted).
			Non-perforated appendicitis	1.04%vs3.35% P=0.0057
			Perforated appendicitis	1.8%vs9.78% P=0.0028
Jen et al. 2009 USA	95,806 children (1-18 years) who underwent LA (34%) or OA (66%) over 7 years (1999-2006) recorded on the California Patient Discharge Database (sourced from 386 hospitals)	State-wide retrospective cohort study (2b)	Non-perforated appendicitis		Retrospective study. Susceptible to coding errors. Coding data provides limited information (e.g. no information on techniques used, basis for procedure selection and operating surgeons). Intra-operative complications not defined. Conversion rate from LA to OA 4.2%.
			Mean length of hospital stay (d)	1.9vs2.1 P=<0.001
			Intra-operative complications	0.5%vs0.2% P=<0.001
			Intra-abdominal abscess	0.6%vs0.3% P=<0.001
			Wound infections	1.1%vs1.4% P=0.08 (NS)
			Post-operative bowel obstruction	0.5%vs0.4% P=0.67 (NS)
			Readmissions rate	2%vs1.8% P=0.42 (NS)
			Perforated appendicitis
			Mean length of hospital stay (d)	5.2vs5.5 P=<0.001
			Intra-operative complications	0.8%vs0.4% P=0.002
			Intra-abdominal abscess	4.9%vs3.8% P=<0.001
			Wound infections	5.5%vs6.4% P=0.02
			Post-operative bowel obstruction	2%vs2.6% P=0.02
			Readmissions rate	6.3%vs6.9% P=0.16 (NS)
Faiz et al. 2008 Britain	89,497 children (under 15 years) who underwent emergency LA (3%) or OA (97%) over 10 years (1996-2006) in English NHS trusts	National retrospective cohort study (2b)	Mortality 30 day	P=1.000 (NS)	Retrospective study. Inequality between LA and OA group size. Mortality is very rare. Coding data provides limited information (as above). Susceptible to coding errors notably the coding of LA requires an additional second code otherwise assumed to be OA. No information regarding conversion rates.
			Mortality 365 day	P=0.406 (NS)
			Readmission rates (28 d)	7.2%vs6.3% P=0.072 (NS)
			Comparison in length of hospital stay	P=0.068 (NS)
Thambidorai et al. 2008 Singapore	112 children (<12 years) who underwent LA (51) or OA (61) for complicated appendicitis (perforated/gangrenous/mass) over 4 years (2002-2006)	Single-centre retrospective cohort study (2b)	Mean operating time (m)	112vs72 P=<0.005	Retrospective study. Small sample size. Open to operator bias, LA performed by single senior surgeon, OA by surgical trainees. Conversion from LA to OA in six cases.
			Severe wound infection	4%vs21% P=<0.005
			Mean length of hospital stay (d)	5.7vs7.4 P=<0.005
			Intra-abdominal abscess	12%vs11.5% P=>0.05 (NS)
			Post-operative fever	20%vs11.5 % P=>0.05 (NS)
Menezes et al. 2008 Ireland	118 children (2-16 years) who underwent LA (54) and OA (64) for complicated appendicitis (perforated/gangrenous) over 6 years (2000-2006)	Single-centre retrospective cohort study (2b)	Mean length of hospital stay (d)	8.3vs7.1 P=>0.05 (NS)	Retrospective study. Small sample size. Limited information included regarding surgical techniques used, operating surgeons and group selection. One case converted from LA to OA.
			Complication rates: (Intra-abdominal abscess, wound infection, pleural effusion, prolonged ileus respectively)	9.2%vs15.6% (LA: 3,2,0,0) (OA: 5,3,1,1) P=<0.05
Schmelzer et al. 2007 USA	223 patients (under 20 years) that underwent LA (44) and OA (179) over 2 years	Single-centre retrospective cohort study (2b)	Mean operative time (m)	62vs42 P=<0.0001	Retrospective study. Inequality between LA and OA group size. Author’s noted significant difference in mean weight between groups; LA 49kg compared to OA 38kg (P= 0.0003). Detailed information on operative techniques not included. Two cases converted from LA to OA.
			Estimated blood loss (ml)	21vs26 P=0.007
			IV analgesia requirement (d)	0.8vs1.9 P=0.0003
			Mean length of hospital stay (d)	2.2vs3.4 P=0.004
			Wound infections	2.3%vs6.2% P=0.3 (NS)
			Wound complications	2%vs17% P=0.02
			Intra-abdominal abscess	4.5%vs5.6% P=0.8 (NS)
			Post-op ileus	0%vs2.2% P=0.3 (NS)
Tsao et al. 2007 USA	1105 children over 7 years who underwent LA (628) and OA (477) for acute appendicitis over 7 years (1998-2005)	Single-centre retrospective cohort study (2b)	Adhesive small bowel obstruction (in perforated appendicitis)	0.5%vs3.1% P=0.03	Retrospective study. Rare complication. Upper age range not included. Noted by authors that LA had a significantly lower proportion of perforated appendicitis (LA 30 % vs OA 40%, P= 0.03). Conversion rate from LA to OA 1.3%.
			Adhesive small bowel obstruction (for all appendicectomies)	0.2%vs1.5% P=0.01
Esposito et al. 2007 Italy	2332 children (1-17 years) who underwent LA (1506) and OA (826) over 3 years from 9 different paediatric surgical centres (multi-national)	Multi-national retrospective cohort study (2b)	Mean operating time (m)	40vs45 (NS)	Retrospective study. Three different laparoscopic techniques used, the IN, OUT and MIXED procedures. No statistical analysis included of individual complications. Conversion rate from LA to OA 1.6%.
			Complication rates	8.23%vs7.9% (NS)
			Median length of hospital stay
			Simple appendicitis (d)	3.0vs4.3
			Appendicitis +peritonitis (d)	5.2vs8.3
			Overall hospital stay	P=<0.0001
Chauhan et al. 2006 Ireland	200 children (4-15 years) who underwent LA or OA (100 in each group) for acute appendicitis	Single-centre (?retrospective/?prospective) cohort study (2c)	Mean operative time (m)	35.8vs45.66	Only outcomes, no statistical analysis published (i.e. P values, SD). No information given as to procedure selection. Unable to determine whether a retrospective or prospective study. Dates not given for study period. No conversion rate from LA to OA included.
			Post-op pain scale (0-10, 10 severe)	4.2vs6.3
			Mean time to first oral food (h)	16.7vs24.7
			Mean length of hospital stay (d)	1.6vs2.55
			Mean resumption of normal daily activities (d)	10.8vs15.78
			Post-op complications	3%vs2%
Yagmurlu et al. 2006 Turkey/USA	111 children (2-18 years) who underwent LA (59) or OA (52) with perforated appendicitis over 3 years by six paediatric surgeons	Single-centre retrospective cohort study (2b)	Mean operating time (m)	60vs57 P=0.3 (NS)	Retrospective study. Small sample size. Dates not given for study period. Three patients were converted from LA to OA.
			Time to oral intake (h)	104vs127 P=0.08 (NS)
			Length of hospital stay (h)	189vs210 P=0.3 (NS)
			Wound infection rates	6.8%vs23% P=<0.05
			Intra-abdominal abscess	13.6%vs15.4% (NS)
			Post-operative bowel obstruction	1.7%vs1.9% (NS)
Aziz et al. 2006 Britain	23 comparative studies published between 1992-2004, OA vs LA in children (6477, 43% LA and 57% OA); 12 retrospective, 11 prospective and 7 randomised studies	Meta-analysis (2a)	Mean difference in operative time (m) (11 studies)	=+5.84 P=0.09 (NS)	Meta-analysis susceptible to non-publication bias. Combining heterogeneous studies. Largest proportion of studies retrospective. Studies included from 1992 onwards, likely significant changes in costs since early data collected.
			Mean difference in length of hospital stay (d) (10 studies)	=–0.48 P=<0.00001
			Wound infection rates (13 studies)	1.5%vs5% P=0.002
			Intra-abdominal abscess rates (16 studies)	3.8%vs3.4% P=0.62 (NS)
			Post-operative bowel obstruction /ileus (9 studies)	1.3%vs2.8% P=0.01
			Post-operative fever (3 studies)	17.3%vs17.1% P=0.11 (NS)
			Mean treatment costs (4 studies)	$5801vs$4734
Li et al. 2005 China	160 children (3-15 years) undergoing LA (69) or OA (91) over 2 years (2002 – 2004) with suspected appendicitis	Single-centre prospective non-randomised cohort study (2b)	Mean op time (m)		Small sample size. Non-randomised, patients and parents chose procedure. Data for rates of intra-abdominal abscesses not included. Three patients undergoing LA were converted to OA.
			Normal appendix	17.56vs29.63 P=<0.01
			Suppurative appendix	28.73vs43.87 P=<0.01
			Gangrenous appendix	55.80vs57.94 P=>0.05 (NS)
			Mean length of hospital stay (d)
			Normal appendix	3vs5 P=<0.01
			Suppurative appendix	3.91vs6.37 P=<0.01
			Gangrenous appendix	6.33vs8.44 P=<0.01
			Wound infection	1.45%vs10.99% P=<0.05
			Intra-abdominal abscess	(NS)
Ikeda et al. 2004 Japan	100 children (2-15 years) who underwent LA (53%) and OA (47%) over 3 years (2000-2003)	Single-centre retrospective cohort study (2b)	Median operating time (m)	88vs59 P=<0.001	Retrospective study. Small sample size. One patient undergoing LA was converted to OA.
			Median length of hospital stay (d)	7vs9 P=0.001
			Complication rate <30 days	13.2%vs12.8% P=1.000 (NS)
			Median treatment costs	$5820vs$4619 P=<0.001

Comment(s)

In 1988 the first laparoscopic appendicectomy was performed on a child at the Scottish Rite Children’s Medical Centre, Texas (Naffis); subsequently it has seen a steady growth in popularity. Both open and laparoscopic appendicectomies are now common practice and despite many studies the gold standard remains undetermined. Unfortunately these studies contain no recent high quality randomised control trials, and criticisms of the included studies are: they are predominantly retrospective in design; many use a small population; and the reliance upon coding data, which removes clinical context and is susceptible to error. Although establishing a gold standard is important, the choice of how to perform an appendicectomy is ultimately up to the operating surgeon (who may offer the choice to patient/parent). There may be factors which may influence their decision, e.g. laparoscopy is often preferred in obese children as it provides better visualisation of the abdominal cavity or ‘ambiguous’ cases where laparoscopy is thought to be more sensitive at detecting alternative pathology. If a child has had previous abdominal surgery or suspected complicated appendicitis, many surgeons will opt for an open approach. There are concerns that a laparoscopic procedure extends operating time; four out of the eight studies (Wang, Thambidorai, Schmelzer and Ikeda) found the laparoscopic approach to take significantly longer. The meta-analysis by Aziz et al did not find a statistically significant difference in operating times (+ 5.84min for LA, P=0.09). One group of very experienced laparoscopists, Li et al, found the laparoscopic approach shorter for both normal appendices (P<0.01) and suppurative appendicitis (P<0.01). Schmelzer and Ikeda et al also illustrated that operative times appreciably improved as laparoscopic experience grew. Schmelzer et al looked at their 11 most recent laparoscopic cases and found no statistical difference in operative times (LA 46min vs OA 42min) in contrast to the first 11 laparoscopic cases (LA 63min vs OA 42min). With respect to post-operative recovery, various outcomes were used but only the length of hospital stay was measured with some consistency. Seven of the eleven studies showed a significantly shorter hospital stay for children undergoing the laparoscopic appendicectomy (Wang, Jen, Thambidorai, Schmelzer, Esposito, Li and Ikeda). The meta-analysis by Aziz also reported the laparoscopic group spent less time in hospital (–0.48 days, P= <0.00001). No study found a significantly longer inpatient stay for the laparoscopic group. The independent findings regarding post-operative recovery were: Wang et al reported the time to first oral feed was considerably shorter in the laparoscopic group; Chauhan et al also noted that children returned to their normal daily activities sooner, as well as having better pain scores post-operatively; and Schmelzer et al found the laparoscopic group required a shorter period of IV analgesia. There have been studies linking the adult and paediatric laparoscopic appendicectomy with higher rates of intra-abdominal abscesses (Horwitz & Tang). Jen et al (n=95,806) found a higher rate amongst the laparoscopic group with a substantial sample, although it is drawn from coding data (4.9% vs 3.8%, P= 0.001). Four studies (Thambidorai, Schmelzer, Yagmurlu & Li) and the meta-analysis concluded no statistical difference between the groups. Wang et al (n=128) reported a significant reduction in intra-abdominal abscesses in the laparoscopic group (2.5% vs 14.6%, P= <0.05). Due to the shortcomings in the study designs, the risk of intra-abdominal abscesses remains inconclusive. Five of the six studies (Wang, Jen, Thambidorai, Yagmurlu & Li) and the meta-analysis established a significant reduction of wound infections in the laparoscopic group with none finding the contrary. Similarly, post-operative bowel obstruction was also significantly reduced after laparoscopy in three out of four studies (Kaselas, Jen & Tsao) and the meta-analysis, thought to be due to the reduction in handling of the bowel and subsequent adhesion formation. Jen and Faiz et al found no statistical differences between readmission rates. Overall, complication rates show little difference (Esposito and Ikeda), although Menezes et al reported a significant reduction in complications favouring the laparoscopic group. In terms of the total cost of admission, the comparative studies found laparoscopy to be significantly more expensive than the open procedure (Aziz and Ikeda). As laparoscopy is now fundamental to many surgical specialities, it has no doubt become more cost effective. The findings are all prior to 2004 and so an up to date review is needed. The open appendicectomy has been relied upon for over a century. For the laparoscopic appendicectomy to become the gold standard it must establish a tangible advantage. There is evidence favouring the laparoscopic approach, although questions over the increased risk of intra-abdominal abscesses, costs and the expertise required still linger, particularly in the paediatric population.

Clinical Bottom Line

On the evidence available, in children with acute appendicitis, laparoscopic is better than open appendicectomy at reducing length of hospital stay, wound infections and post-operative bowel obstruction. There are still concerns regarding longer operating times, possible increase in risk of intra-abdominal abscesses and costs.

References

1. Wang X, Zhang W, Yang X, Shao J, Zhou X, Yuan J. Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy--our experience. J Pediatr Surg 2009 Oct;44(10):1924-7
2. Kaselas C, Molinaro F, Lacreuse I, Becmeur F. Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience. J Pediatr Surg 2009 Aug; 44(8):1581-5
3. Howard C. Jen, M.D., and Stephen B. Shew, M.D. Laparoscopic Versus Open Appendectomy in Children: Outcomes Comparison Based on a State-wide Analysis. Journal of Surgical Research 1–5 (2009) doi:10.1016/j.jss.2009.06.033
4. Faiz O, Blackburn SC, Clark J, Bottle A, Curry JI, Farrands P, Aylin P Laparoscopic and conventional appendicectomy in children: outcomes in English hospitals between 1996 and 2006. Pediatr Surg Int 2008 Nov;24(11):1223-7
5. Thambidorai C R, Aman Fuad Y. Laparoscopic appendicectomy for complicated appendicitis in children. Singapore Med J 2008;49 (12) : 994
6. Menezes M, Das L, Alagtal M, Haroun J, Puri P. Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children. Pediatr Surg Int 2008 24:303–305
7. Schmelzer TM, Rana AR, Walters KC, Norton HJ, Bambini DA, Heniford BT. Improved outcomes for laparoscopic appendectomy compared with open appendectomy in the paediatric population. J Laparoendosc Adv Surg Tech A 2007 Oct; 17(5):693-7
8. Tsao KJ, St Peter SD, Valusek PA, Keckler SJ, Sharp S, Holcomb GW 3rd, Snyder CL, Ostlie DJ. Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach. J Pediatr Surg 2007 Jun; 42(6):939-42; discussion 942
9. Esposito C, Borzi P, Valla JS, Mekki M, Nouri A, Becmeur F, Allal H, Settimi A, Shier F, Sabin MG, Mastroianni L. Laparoscopic versus open appendectomy in children: a retrospective comparative study of 2,332 cases. World J Surg 2007 Apr;31(4):750-5
10. Chauhan K, Kashif S, Awadalla S. Laparoscopic appendectomy versus open appendectomy in children. Ir Med J 2006 Nov-Dec;99(10):298-300
11. Yagmurlu A, Vernon A, Barnhart DC, Georgeson KE, Harmon CM. Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy. Surg Endosc 2006 Jul;20(7):1051-4
12. Aziz O, Athanasiou T, Tekkis PP, Purkayastha S, Haddow J, Malinovski V, Paraskeva P, Darzi A. Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 2006 Jan;243(1):17-27
13. Li P, Xu Q, Ji Z, Gao Y, Zhang X, Duan Y, Guo Z, Zheng B, Guo X, Wu X. Comparison of surgical stress between laparoscopic and open appendectomy in children. Pediatr Surg 2005 Aug;40(8):1279-83
14. Ikeda H, Ishimaru Y, Takayasu H, Okamura K, Kisaki Y, Fujino J. Laparoscopic versus open appendectomy in children with uncomplicated and complicated appendicitis. J Pediatr Surg 2004 Nov;39(11):1680-5
15. Naffis D. Laparoscopic appendectomy in children. Semin Pediatr Surg. 1993 Aug;2(3):174-7
16. Horwitz JR, Custer MD, May BH, Mehall JR, Lally KP. Should laparoscopic appendectomy be avoided for complicated appendicitis in children? J Pediatr Surg 1997;32:1601.
17. Tang E, Ortega AE, Anthone GJ, Beart RW Jr. Intra abdominal abscesses following laparoscopic and open appendectomies. 1996;10:327-328. 1996;10:327-328.