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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2018;18(8):e7369 doi: 10.5867/medwave.2018.08.7369
Laparoscopic versus open appendectomy for complicated appendicitis
Cristóbal del Pino, Rodrigo Muñoz, Gabriel Rada
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Key Words: Laparoscopic appendectomy, open appendectomy, appendicitis, Epistemonikos, GRADE.

Abstract

INTRODUCTION
The treatment of acute appendicitis using laparoscopy reduces the risk of wound infection, hospitalization time and return to normal activity. However, it increases the risk of intra-abdominal abscess, which is one the main complications of complicated appendicitis.

METHODS
We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS
We identified six systematic reviews including 55 studies overall, of which four were randomized trials. We concluded that the used of laparoscopy, compared to open appendectomy, probably reduces the time of hospital stay, and may reduce the risk of wound infection, but there's no clarity regarding the incidence of intra-abdominal abscess due to the very low certainty of the evidence available.


 
Problem

Acute appendicitis remains one of the most common surgical diseases in the emergency room. The lifetime risk might be up to 9% [1],[2]. The treatment of this condition using laparoscopy was first reported in 1983 [3]. The benefits include reduction in the risk of wound infection and the time of hospital stay, and a faster return to normal activity. Because of this, this technique has been well studied and used during the last years. However, one of the disadvantages of this approach is the increased risk of intra-abdominal abscess, particularly in patients presenting with complicated appendicitis. So, there is still controversy about the use of laparoscopy in this setting.

Methods

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others, to identify systematic reviews and their included primary studies. We extracted data from the identified reviews and reanalyzed data from primary studies included in those reviews. With this information, we generated a structured summary denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos) using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies when it is possible, a summary of findings table following the GRADE approach and a table of other considerations for decision-making.

Key messages

  • Laparoscopic appendectomy might reduce the length of hospital stay and might reduce the risk of wound infection compared to open appendectomy. 
  • Laparoscopic appendectomy probably increases the duration of surgery, but the relevance of this increase is not clear.
  • It is not clear if there are differences in the risk of intra-abdominal abscess between open or laparoscopic appendectomy in complicated appendicitis, because the certainty of the evidence is very low.
About the body of evidence for this question

What is the evidence.
See evidence matrix in Epistemonikos later

We identified six systematic reviews [4],[5],[6],[7],[8],[9], including 55 primary studies overall, of which four were randomized trials [10],[11],[12],[13]. This table, and the summary in general, is based on the latter, since the inclusion of the observational studies did not increase the certainty of the evidence or added additional information.

What types of patients were included*

A total of 857 patients were included in the trials, of which 466 presented complicated appendicitis. Their age ranged from 2 to 85 years. 

Two trials only included adults [12],[13], one only included children between 2 and 20 years [10] and one implicitly included children, but did not analyze them separately [11].

Male:female ratio was 1.3:1. 

All trials included patients with complicated appendicitis, which was defined as the presence of intestinal perforation. Only one trial included patients with and without perforation, but presented data separately [10].

What types of interventions were included*

Only one trial used 2-handed, 4-trocar technique [12], while the rest used conventional 3-trocar technique.

All trials compared against open appendectomy, whether by classic incision (McBurney) or infraumbilical.

All trials used an antibiotics scheme pre- and post-surgery. There was no information regarding the level of training of surgeons performing the interventions. 

What types of outcomes
were measured

The outcomes measured can be classified into two groups:

1. Technique

  • Duration of surgery 
  • Length of hospital stay.
  • Post-surgical analgesia.
  • Time to oral intake.

2. Post-surgical complications

  • Mortality.
  • Total complications.
  • Wound infection.
  • Intra-abdominal abscess.
  • Intestinal obstruction.

Patients were monitored for 14-30 days after surgery.

* The information about primary studies is extracted from the systematic reviews identified, unless otherwise specified.

Summary of findings

The information is based on four trials [10],[11],[12],[13], that included 466 patients with complicated appendicitis, of which 197 were treated with laparoscopic appendectomy and 269 with open appendectomy.

All trials reported the length of hospital stay, and three the duration of surgery [11],[12],[13]. All trials measured the incidence of wound infection and intra-abdominal abscess.

The summary of findings is as follows:

  • Laparoscopy might reduce the risk of wound infection in complicated appendicitis, but the certainty of the evidence is low.
  • It is not clear whether there is a difference in the incidence of intra-abdominal abscess using laparoscopic or open appendectomy because the certainty of the evidence is very low.
  • Laparoscopy probably increases the duration of surgery. The certainty of the evidence is moderate. 
  • Laparoscopy might reduce the length of hospital stay compared to open appendectomy. The certainty of the evidence is low.

Follow the link to access the interactive version of this table (Interactive Summary of Findings – iSoF)

Other considerations for decision-making

To whom this evidence does and does not apply

  • The conclusion of this article apply to patients of any age with complicated appendicitis. 
  • It does not apply to pregnant women with complicated appendicitis, given complications and consequences to the mother and fetus are different from those in the general population. Furthermore, the technique may vary substantially keeping into consideration the gravid uterus that protrudes to the abdominal cavity. 
  • This summary considers obese patients as part of the population studied, and not as a subpopulation. However, the conclusions must be applied carefully, since the laparoscopic technique may be more difficult in these cases.
About the outcomes included in this summary
  • The outcomes selected are the ones considered critical for decision-making, based on the opinion of the authors of this article. In general, it agrees with those presented in the systematic reviews and main clinical guidelines.
Balance between benefits and risks, and certainty of the evidence
  • The intervention shows some benefit, but the relevance is difficult to establish. There is uncertainty regarding the main undesirable effects, in particular the risk of intra-abdominal abscess, which makes it difficult to balance the risk and benefits of laparoscopic appendectomy.
Resource considerations
  • The intervention probably saves some resources secondary to the cost of hospitalization. However, the uncertainty about the risk of complications makes it hard to ponder the benefits against the costs.
  • It would be reasonable to make a formal economic evaluation in the settings where the implementation of this intervention is being considered.
What would patients and their doctors think about this intervention
  • There might be variability in the decision-making with the evidence presented. Clinicians who value most the length of hospital stay and the associated costs might choose laparoscopic appendectomy. On the other hand, those who give more importance to the complications may prefer an open appendectomy. 

Differences between this summary and other sources

  • The systematic reviews identified differ in their conclusions. Some conclude laparoscopic appendectomy is superior [4],[6],[7],[8], while the rest agree with this summary, stating there are risks and benefits [5],[9]. The main differences between this summary and the systematic reviews is they have a narrower coverage of the literature (none of the systematic reviews included all four randomized trials), give more relevance to non-randomized studies and they do not consider the certainty of the evidence to formulate their conclusions.
Could this evidence change in the future?
  • There is a high probability that the evidence will change in the future due to the existing uncertainty. 
  • We did not find ongoing trials evaluating laparoscopy for the treatment of complicated appendicitis in the International Clinical Trials Registry Platform of the World Health Organization.
How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.

Follow the link to access the interactive version: Laparoscopic versus open appendectomy for complicated appendicitis.

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier.

After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

This article is part of the Epistemonikos Evidence Synthesis project. It is elaborated with a pre-established methodology, following rigorous methodological standards and internal peer review process. Each of these articles corresponds to a summary, denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos), whose main objective is to synthesize the body of evidence for a specific question, with a friendly format to clinical professionals. Its main resources are based on the evidence matrix of Epistemonikos and analysis of results using GRADE methodology. Further details of the methods for developing this FRISBEE are described here (http://dx.doi.org/10.5867/medwave.2014.06.5997)

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

Potential conflicts of interest

The authors do not have relevant interests to declare.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

INTRODUCCIÓN
El tratamiento de la apendicitis aguda por vía laparoscópica reduce el riesgo de infección de la herida operatoria, disminuye el tiempo de hospitalización y acelera el retorno a las actividades. Sin embargo, aumenta el riesgo de infecciones intraabdominales, lo cual constituye uno de las principales riesgos del tratamiento quirúrgico laparoscópico de la apendicitis complicada.

MÉTODOS
Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE.

RESULTADOS Y CONCLUSIONES
Identificamos seis revisiones sistemáticas que en conjunto incluyen 55 estudios primarios, de los cuales, cuatro corresponden a ensayos aleatorizados. Concluimos que la laparoscopía, en comparación con la cirugía abierta, probablemente disminuye el tiempo de estadía hospitalaria, y podría disminuir el riesgo de infección de la herida operatoria, pero no está claro si existen diferencias en la incidencia de absceso intraabdominal porque la certeza de la evidencia es muy baja.

Authors: Cristóbal del Pino[1,2], Rodrigo Muñoz[1,3], Gabriel Rada[1,2,4]

Affiliation:
[1] Proyecto Epistemonikos, Santiago, Chile
[2] Centro Evidencia UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[3] Departamento de Cirugía Digestiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[4] Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile

E-mail: radagabriel@epistemonikos.org

Author address:
[1] Centro Evidencia UC
Pontificia Universidad Católica de Chile
Diagonal Paraguay 476
Santiago
Chile

Citation: del Pino C, Muñoz R, Rada G. Laparoscopic versus open appendectomy for complicated appendicitis. Medwave 2018;18(8):e7369 doi: 10.5867/medwave.2018.08.7369

Submission date: 10/11/2018

Acceptance date: 27/11/2018

Publication date: 11/12/2018

Origin: This article is a product of the Evidence Synthesis Project of Epistemonikos Fundation, in collaboration with Medwave for its publication.

Type of review: Non-blinded peer review by members of the methodological team of Epistemonikos Evidence Synthesis Project.

PubMed record

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  1. Crovari Eulufi, F., & Manzor Véliz, M. Manual de patología quirúrgica. Ediciones UC.
  2. Anderson JE, Bickler SW, Chang DC et al (2012) Examining a common disease with unknown etiology: trends in epidemiology and surgical management of appendicitis in California, 1995–2009. World J Surg 36:2787–2794.
  3. Semm K. Endoscopic appendectomy. Endoscopy. 1983;15:59-64.
  4. Athanasiou, C., Lockwood, S., & Markides, G. (2017). Systematic Review and Meta-Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature. World Journal Of Surgery, 41(12), 3083-3099. | CrossRef |
  5. Markar, S., Blackburn, S., Karthikesalingam, A., Evans, J., & Kinross, J. (2012). Laparoscopic Versus Open Appendectomy for Complicated and Uncomplicated Appendicitis in Children. Journal Of Gastrointestinal Surgery, 16(10), 1993-2004. | CrossRef |
  6. Markar, S., Penna, M., & Harris, A. (2014). Laparoscopic Approach to Appendectomy Reduces the Incidence of Short- and Long-Term Post-operative Bowel Obstruction: Systematic Review and Pooled Analysis. Journal Of Gastrointestinal Surgery, 18(9), 1683-1692. | CrossRef |
  7. Markides, G., Subar, D., & Riyad, K. (2010). Laparoscopic Versus Open Appendectomy in Adults with Complicated Appendicitis: Systematic Review and Meta-analysis. World Journal Of Surgery, 34(9), 2026-2040. | CrossRef |
  8. Yu, M., Feng, Y., Wang, W., Fan, W., Cheng, H., & Xu, J. (2017). Is laparoscopic appendectomy feasible for complicated appendicitis ?A systematic review and meta-analysis. International Journal Of Surgery, 40, 187-197 | CrossRef |
  9. Zhang, S., Du, T., Jiang, X., & Song, C. (2017). Laparoscopic Appendectomy in Children With Perforated Appendicitis. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 27(4), 262-266. | CrossRef |
  10. Oka, T., Kurkchubasche, A., Bussey, J., Wesselhoeft, C., Tracy, T., & Luks, F. (2004). Open and laparoscopic appendectomy are equally safe and acceptable in children. Surgical Endoscopy, 18(2), 242-245. | CrossRef |
  11. Schietroma, M., M.D., Piccione, F., M.D., Carlei, F., M.D., Clementi, M., M.D., Bianchi, Z., M.D., de Vita, F., MD, & Amicucci, G., M.D. (2012). Peritonitis from perforated appendicitis: Stress response after laparoscopic or open treatment. The American Surgeon, 78(5), 582-90.
  12. Taguchi, Y., Komatsu, S., Sakamoto, E., Norimizu, S., Shingu, Y., & Hasegawa, H. (2015). Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial. Surgical Endoscopy, 30(5), 1705-1712. | CrossRef |
  13. Thomson, J., Kruger, D., Jann-Kruger, C., Kiss, A., Omoshoro-Jones, J., Luvhengo, T., & Brand, M. (2014). Laparoscopic versus open surgery for complicated appendicitis: a randomized controlled trial to prove safety. Surgical Endoscopy, 29(7), 2027-2032. | CrossRef |
Crovari Eulufi, F., & Manzor Véliz, M. Manual de patología quirúrgica. Ediciones UC.

Anderson JE, Bickler SW, Chang DC et al (2012) Examining a common disease with unknown etiology: trends in epidemiology and surgical management of appendicitis in California, 1995–2009. World J Surg 36:2787–2794.

Semm K. Endoscopic appendectomy. Endoscopy. 1983;15:59-64.

Athanasiou, C., Lockwood, S., & Markides, G. (2017). Systematic Review and Meta-Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature. World Journal Of Surgery, 41(12), 3083-3099. | CrossRef |

Markar, S., Blackburn, S., Karthikesalingam, A., Evans, J., & Kinross, J. (2012). Laparoscopic Versus Open Appendectomy for Complicated and Uncomplicated Appendicitis in Children. Journal Of Gastrointestinal Surgery, 16(10), 1993-2004. | CrossRef |

Markar, S., Penna, M., & Harris, A. (2014). Laparoscopic Approach to Appendectomy Reduces the Incidence of Short- and Long-Term Post-operative Bowel Obstruction: Systematic Review and Pooled Analysis. Journal Of Gastrointestinal Surgery, 18(9), 1683-1692. | CrossRef |

Markides, G., Subar, D., & Riyad, K. (2010). Laparoscopic Versus Open Appendectomy in Adults with Complicated Appendicitis: Systematic Review and Meta-analysis. World Journal Of Surgery, 34(9), 2026-2040. | CrossRef |

Yu, M., Feng, Y., Wang, W., Fan, W., Cheng, H., & Xu, J. (2017). Is laparoscopic appendectomy feasible for complicated appendicitis ?A systematic review and meta-analysis. International Journal Of Surgery, 40, 187-197 | CrossRef |

Zhang, S., Du, T., Jiang, X., & Song, C. (2017). Laparoscopic Appendectomy in Children With Perforated Appendicitis. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 27(4), 262-266. | CrossRef |

Oka, T., Kurkchubasche, A., Bussey, J., Wesselhoeft, C., Tracy, T., & Luks, F. (2004). Open and laparoscopic appendectomy are equally safe and acceptable in children. Surgical Endoscopy, 18(2), 242-245. | CrossRef |

Schietroma, M., M.D., Piccione, F., M.D., Carlei, F., M.D., Clementi, M., M.D., Bianchi, Z., M.D., de Vita, F., MD, & Amicucci, G., M.D. (2012). Peritonitis from perforated appendicitis: Stress response after laparoscopic or open treatment. The American Surgeon, 78(5), 582-90.

Taguchi, Y., Komatsu, S., Sakamoto, E., Norimizu, S., Shingu, Y., & Hasegawa, H. (2015). Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial. Surgical Endoscopy, 30(5), 1705-1712. | CrossRef |

Thomson, J., Kruger, D., Jann-Kruger, C., Kiss, A., Omoshoro-Jones, J., Luvhengo, T., & Brand, M. (2014). Laparoscopic versus open surgery for complicated appendicitis: a randomized controlled trial to prove safety. Surgical Endoscopy, 29(7), 2027-2032. | CrossRef |