The significant impact of age on the clinical outcomes of laparoscopic appendectomy : results from the Polish Laparoscopic Appendectomy multicenter large cohort study

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults. Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1- 8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days). The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome

Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy : results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95%CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95%CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes

Surgery of the elderly in emergency room mode. Is there a place for laparoscopy?

Introduction : An important yet difficult problem is qualification for surgery in elderly patients. With age the risk of comorbidities increases – multi-disease syndrome. Elderly patients suffer from frailty syndrome. Many body functions become impaired. All these factors make the elderly patient a major challenge for surgical treatment. Aim : Analysis of the possibility of developing the indications and contraindications and the criteria for surgical treatment of the elderly based on our own cases. Discussion whether there is a place for laparoscopy during surgery of the elderly in emergency room (ER) mode. Material and methods: The analysis was performed based on seven cases involving surgical treatment of elderly patients who were admitted to the hospital in emergency room mode. The patients were hospitalized in the General and Minimally Invasive Surgery Clinic in Olsztyn in 2016. Results : Surgical treatment of elderly patients should be planned with multidisciplinary teams. Geriatric surgery centers should be developed to minimize the risk of overzealous treatment and potential complications. Laparoscopy should always be considered in the case of ER procedures or diagnostics. Conclusions : Elderly patients should not be treated as typical adults, but as a separate group of patients requiring special treatment. Due to the existing additional disease in the elderly, the frailty syndrome, any surgical intervention should be minimally invasive. The discussion about therapy should be conducted by a team of specialists from a variety of medical fields

Hybrid (laparoscopy + stent) treatment of celiac trunk compression syndrome (Dunbar syndrome, median arcuate ligament syndrome (MALS))

Introduction : Celiac trunk (CT) compression syndrome caused by the median arcuate ligament (MAL) is a rarely diagnosed disease because of its nonspecific symptoms, which cause a delay in the correct diagnosis. Intestinal ischemia occurs, which causes symptoms of abdominal angina. One method of treatment for this disease is surgical release of the CT – the intersection of the MAL. Laparoscopy is the first step of the hybrid technique combined with percutaneous angioplasty and stenting of the CT. Aim: To demonstrate the usefulness and advantages of the laparoscopic approach in the treatment of Dunbar syndrome. Material and methods : Between 2013 and 2016 in the General and Minimally Invasive Surgery Department of the Medical Sciences Faculty of the University of Warmia and Mazury in Olsztyn, 6 laparoscopic procedures were performed because of median arcuate ligament syndrome. During the laparoscopy the MAL was cut with a harmonic scalpel. One month after laparoscopy 5 patients had Doppler percutaneous angioplasty of the CT with stent implantation in the Vascular Surgery Department in Pomeranian Medical University in Szczecin. Results : In one case, there was a conversion of laparoscopic surgery to open due to unmanageable intraoperative bleeding. In one case, postoperative ultrasound examination of the abdominal cavity demonstrated the presence of a large hematoma in the retroperitoneal space. All patients reported relief of symptoms in the first days after the operation. Conclusions : The hybrid method, combining laparoscopy and angioplasty, seems to be a long-term solution, which increases the comfort of the patient, brings the opportunity for normal functioning and minimizes the risk of restenosis

Surgical treatment of acute appendicitis in older patients

Introduction: Acute appendicitis (AA) is the most common indication for emergency surgery and it occurs more often in children and young adults than in patients of advanced age. AA in older patients is a challenging surgical problem because of its atypical presentation. This study was performed to determine whether the age of a patient impacts the outcomes and whether laparoscopic appendectomy (LA) is a feasible method for treatment of patients > 65 years. Material and methods: We performed a retrospective study of 355 patients with AA who were admitted to the Department of General, Minimally Invasive and Elderly Surgery in Olsztyn from 2014 to 2017. The patients were divided into three age groups: 18 to 40, 41 to 65 and >65 years. The histopathological diagnoses were divided into three types: simple AA, phlegmonous AA, and gangrenous AA. Results. LA was performed in 96% of young adults and in 67% of older patients. The patients older than 65 years had higher preoperative white blood cell counts, higher C-reactive protein (CRP) levels and had a longer length of stay (LOS) than younger patients (P=0.05, P=0.03, and P=0.03, respectively). We found a positive correlation among the CRP levels, open appendectomy (OA), and gangrenous appendicitis. Conclusions: Patients older than 65 years more frequently underwent OA than LA, had higher preoperative CRP levels and had a longer LOS than younger patients. Higher CRP levels were associated with a greater risk of gangrenous appendicitis. LA is a safe and feasible treatment method for patients older than 65 years

Chirurgiczne leczenie ostrego zapalenia wyrostka robaczkowego u pacjentów w wieku podeszłym

Wprowadzenie: Ostre zapalenie wyrostka robaczkowego (AA) jest najczęstszym wskazaniem do nagłych operacji. Występuje częściej u dzieci i młodych dorosłych niż u pacjentów w wieku podeszłym. U starszych pacjentów stanowi problem chirurgiczny ze względu na jego nietypową prezentację. Nasze badanie przeprowadziliśmy w celu ustalenia: 1) czy wiek pacjenta wpływa na wyniki leczenia, 2) czy laparoskopowa appendektomia (LA) jest bezpieczną metodą leczenia pacjentów powyżej 65. roku życia. Materiał i metody: Przeprowadziliśmy retrospektywne badanie 355 chorych z AA, którzy byli pacjentami kliniki w latach 2014–2017. Chorzy zostali podzieleni na trzy grupy wiekowe: 18–40 lat, 41–65 lat i powyżej 65. roku życia. Rozpoznania histopatologiczne podzielono na trzy typy: prosty AA, ropowiczy AA i zgorzelinowy AA. Wyniki LA przeanalizowano u 96% młodszych pacjentów i u 67% starszych. Pacjenci w wieku powyżej 65. roku życia mieli wyższą przedoperacyjną liczbę białych krwinek, wyższe poziomy białka C-reaktywnego (CRP) i byli dłużej hospitalizowani niż młodsi pacjenci (p=0,05; p=0,03 i p=0,03). Odkryliśmy dodatnią korelację pomiędzy poziomami CRP, otwartą appendektomią (OA) i zgorzelowym zapaleniem wyrostka robaczkowego. Wnioski: Pacjenci powyżej 65. roku życia częściej byli poddawani otwartej appendektomii niż laparoskopowej appendektomii, mieli wyższy przedoperacyjny poziom CRP i byli dłużej hospitalizowani niż chorzy młodsi. Wyższe wartości CRP wiązały się z większym ryzykiem zgorzelinowego zapalenia wyrostka robaczkowego. Laparaskopowa appendektomia jest bezpieczną metodą leczenia pacjentów w wieku powyżej 65. roku życia

Clinical evaluation of C-reactive protein and procalcitonin for the early detection of postoperative complications after laparoscopic sleeve gastrectomy

Introduction : Among the most common early complications after bariatric surgery are anastomosis leak and bleeding. In order to react quickly and perform accurate treatment before the clinical signs appear, early predictors should be found. In the study C-reactive protein (CRP) and procalcitonin (PCT) levels were investigated. Characterized by a relatively short half-life, they can predict surgical complications. Aim : To develop and implement certain standards for early detection of complications. Material and methods : The study involved 319 adults who underwent laparoscopic sleeve gastrectomy (LSG) as a surgical intervention for morbid obesity at the Department of General Surgery of Ceynowa Hospital in Wejherowo. Every patient had CRP and PCT levels measured before the surgery and on the 1st and 2nd postoperative day (POD). Results : Early postoperative complications occurred in 19 (5.96%) patients. Septic and non-septic complications occurred in 3 and 16 patients respectively. Among the patients with septic postoperative complications CRP level increased significantly on the 2nd POD compared to the remainder (p = 0.0221). Among the patients with non-septic postoperative complications CRP level increased significantly on the 1st and 2nd POD compared to the remainder. Among the patients with septic and non-septic postoperative complications PCT level increased significantly on the 2nd POD compared to the remainder. Conclusions : The CRP and PCT level are supposed to be relevant diagnostic markers to predict non-septic and septic complications after LSG