Laparoscopic Appendectomy Has Clear Advantages Over Conventional Procedure

Duke University Medical Center
Monday, 22 December 2003

After analyzing a nationwide database of more than 43,000 patients, Duke University Medical Center researchers have determined that the minimally invasive laparoscopic approach to removing infected appendices has significant advantages over the traditional open surgical approach.

The researchers found that patients who received laparoscopic surgery were discharged from the hospital sooner, were more likely to be discharged home as opposed to further medical care, and had fewer complications while in the hospital. Just as importantly, the researchers added, the laparoscopic approach was as effective as the open approach in the more serious cases where the appendix is either perforated or where an abscess is present.

The results of the Duke analysis were published today (Dec. 22, 2003) in the January edition of the Annals of Surgery.

The appendix is a finger-like tube located at the juncture of the large and small intestine. While its function is not clearly understood, it can often become infected, leading to appendicitis, a condition characterized by severe abdominal pain. If not removed, the inflamed appendix can burst, spilling bacteria-laden contents into the abdomen, which can lead to life-threatening infections.

"While there have been some smaller clinical trials and studies comparing the two approaches, there has not yet been a large analysis of which approach is better for the patient," said lead author Ulrich Guller, M.D., M.H.S, who is currently completing a surgical residency at the University of Basel, Switzerland. He conducted the analysis during a surgical research fellowship at Duke.

"This study provides compelling evidence that in terms of length of stay in the hospital and routine discharge, the laparoscopic approach is better than the open approach," Guller continued. "However, we still need further studies to compare other issues, such as quality of life, costs and long-term complications."

During a laparoscopic procedure, surgeons operate through small slits in the abdomen. They are guided by a tiny camera that relays images within the abdomen to a television monitor. Surgeons use an array of cutters, staplers and cauterization instruments to perform the surgery.

Specifically, the researchers found that the median hospital stay for patients who underwent laparoscopic appendectomies was 2.06 days, compared to 2.88 days for the open approach, a statistically significant and clinically relevant difference, Guller said. These patients were also more than three times likely to be discharged home, instead of going to more intensive treatment areas, nursing homes or home health care.

Also, the researchers found that there was no significant difference in complications between the laparoscopic and open procedure in patients whose appendix was either perforated or abscessed.

"For many surgeons, if there is even the slightest suspicion of a perforation or abscess, they elect to use the open approach," Guller said. "Our findings would suggest that surgeons should consider using the laparoscopic approach for these patients."

For their analysis, the researchers consulted the 1997 National Inpatient Sample (NIS), a database supported by the Agency for Healthcare Research and Quality. It has discharge information on approximately 20 percent of all patients hospitalized during 1997 in all regions of the country.

From the NIS database, the Duke team found 43,757 patients who underwent appendectomies for acute appendicitis. Of that total, 17.4 percent of the patients underwent laparoscopic appendectomies.

"We have performed a quite powerful and sophisticated statistical analysis," said Ricardo Pietrobon, M.D., senior member of the team and research director of Duke's Center for Excellence in Surgical Outcomes.

"While the large number of patients involved is an important advantage for this kind of analysis, these are also real-world patients seen in large and small hospitals across the country," Pietrobon continued. "The data collected by the NIS is really reflective of what is really happening. Selection bias – often present in randomized clinical trials – is less of a problem. "

The researchers believe that these strengths in the data compensate for the fact the NIS is retrospective and administrative database.

"Our findings may have important implications for the health system as a whole, since improving clinical outcomes can lead to lower health care costs," Guller said. "While we have shown that there are clear benefits for some endpoints for the patients who underwent laparoscopic appendectomy, this is an important first step towards evaluating all aspects of the surgical approaches."

Guller's research was supported by the Swiss National Foundation, Kresliga beider Basel, Freiwillige Akademische Gesellschaft, and Fondazione Gustav e Ruth Jacob.

Other members of the Duke research team include Sheleika Hervey, Harriett Purves, Lawrence Muhlbaier, Ph.D., Eric Peterson, M.D., and Steve Eubanks, M.D.

For more information, or to contact Duke University Medical Center, see their website at: www.mc.duke.edu