How well do DRGs for appendectomy explain variations in resource use? : An analysis of patient-level data from 10 European countries

Appendectomy is a common and relatively simple procedure to remove an inflamed appendix, but the rate of appendectomy varies widely across Europe. This paper investigates factors that explain differences in resource use for appendectomy. We analysed 106,929 appendectomy patients treated in 939 hospitals in ten European countries. In stage one, we tested the performance of three models in explaining variation in the (log of) cost of the inpatient stay (seven countries) or length-of-stay (three countries). The first model used only the Diagnosis Related Groups (DRGs) to which patients were coded; the second used a core set of general patient-level and appendectomy-specific variables; and the third model combined both sets of variables. In stage two, we investigated hospital-level variation. In classifying appendectomy patients, most DRG systems take account of complex diagnoses and comorbidities, but use different numbers of DRGs (range: 2 to 8). The capacity of DRGs and patient-level variables to explain patient-level cost variation ranges from 34% in Spain to over 60% in England and France. All DRG systems can make better use of administrative data such as the patient’s age, diagnoses and procedures, and all countries have outlying hospitals that could improve their management of resources for appendectomy

Therapeutic approach for Amyand’s hernia; a case report

In very few cases stated in the literature, the vermiform appendix might be contained in a hernial sac. This distinctive pathology is described as Amyand\u27s hernia and has the very small occurrence of about 1%. We report the case of a 62-year-old man that presented for a reducible tumoral mass located in the right inguinal region. Amyand’s hernia was the intraoperative diagnostic. We performed hernioplasty (using the Lichtenstein tension-free mesh repair with a composite polypropylene mesh) without appendectomy. This case matches the type 1 Lossanoff and Basson’s classification and has no facile management. Due to the clinical specificities of each case that presents with defining features of an Amyand’s hernia, surgical management depends on the recommendations stated in the literature, as well as the surgeon’s judgment based on experience

Evaluation of laparoscopic appendectomy vs. open appendectomy: a retrospective study at Aga Khan University Hospital, Karachi, Pakistan

OBJECTIVE: To compare open and laparoscopic appendectomies and to evaluate the level of efficacy of both types of appendectomy performed at Aga Khan University Hospital (AKUH). METHODS: Based on this strong study rationale, a clinical audit of patient\u27s records was performed to evaluate the significance of this technique as a treatment modality. The study population comprised of patients with appendicitis admitted in the Department of Surgery from January 2004 to December 2004. The patients\u27 charts were reviewed to ascertain whether the procedure was done as an acute case or as an elective procedure. The predictor variables explored in this study were: age, gender, ultrasound and CT focused procedure, operative time, post-operative stay, number of hours required for the return of bowel function, use of narcotic analgesia and the total hospital bill of the respective patients. RESULTS: A total of 49 patients\u27 clinical charts were reviewed. Of these, 29 patients had had laparoscopic appendectomies and the remaining 20 had open appendectomies. The mean post-operative stay in days was relatively shorter for laparoscopic appendectomy (1.97 +/- 2.3) compared to open appendectomy (3.1 +/- 1.8). The average time for the return of bowel movement was remarkably lesser for laparoscopic appendectomy (10.6 +/- 8.2) hours than open appendectomy (21 +/- 13) hours. Two of the independent variables: CT focused (P-value: 0.01) and operative times in minutes (P-value: 0.06) were found to be significantly associated with the types of appendectomy. Hence our study found that laparoscopic appendectomy, although relatively expensive, is a safe and effective procedure for the removal of appendix over open appendectomy

Single-incision vs. conventional laparoscopic appendectomy : a case-match study

Background: Three-port laparoscopic appendectomy is considered standard in many countries for the surgical treatment of acute appendicitis. Single-incision laparoscopic technique has been recently introduced and is supposed to minimize the aggression induced by surgery. Regarding appendectomy, comparison with standard laparoscopy, benefits and drawbacks of this novel technique remain to be evaluated. The goal of this study was to assess single-incision laparoscopic appendectomy compared to conventional laparoscopic appendectomy in terms of operation time, length of hospital stay, complication rate, and postoperative antibiotherapy rate. Methods: From February 2011 to December 2011, single-incision laparoscopic appendectomy was proposed to patients admitted to the emergency room of the University Hospital of Lausanne (CHUV, Lausanne, Switzerland), diagnosed with uncomplicated acute appendicitis. Preoperative patients' information, technical difficulties during the operation, and postoperative follow-ups were recorded. Every patient who underwent single-incision laparoscopic appendectomy (n = 20) was matched 1:3 conventional laparoscopic appendectomy (n = 60), controlling for age, gender, body mass index, American Society of Anesthesiologists score, and histopathological findings. Results: No statistically significant differences for median operation time, length of hospital stay, complication rate, and need for postoperative antibiotherapy were found. In 5 out of 20 single-incision laparoscopic appendectomy patients the Endoloop® Ligature was judged difficult to put in place. Conclusion: This study suggests that single-incision laparoscopic appendectomy is a feasible and effective operative technique for uncomplicated acute appendicitis

Acute appendicitis: Standard treatment and the role of laparoscopic surgery

V. Conclusion: M. W. Büchler, Bern. Acute Appendicitis: The Role of Laparoscopic Surgery. The conclusion at the end of the meeting by M. W. Büchler, Bern, was that the standard treatment for acute appendicitis remains the classic open technique described by McBurney in 1894. Only between 1% (United Kingdom) and 20% (USA) of all cases are removed laparoscopically. However, 12% of all surgical cases are performed for appendicitis and 40% of all small bowel obstructions are related to open appendectomy. The metaanalysis comparing laparoscopic versus open appendectomy showed that laparoscopic appendectomy is more expensive and takes longer, the complication rates are equal and there are no differences concerning pain, recovery and cosmesis. Despite the fact that laparoscopic appendectomy is a safe procedure, open appendectomy remains the standard procedure for clear diagnosis. However, the role of laparoscopic appendectomy in young females, obese patients and unclear diagnosis must be further evaluate

Securing the appendiceal stump in laparoscopic appendectomy: Evidence for routine stapling?

Background: This metaanalysis aimed to compare endoscopic linear stapling and loop ligatures used to secure the base of the appendix. Methods: Randomized controlled trials on appendix stump closure during laparoscopic appendectomy were systematically searched and critically appraised. The results in terms of complication rates, operating time, and hospital stay were pooled by standard metaanalytic techniques. Results: Data on 427 patients from four studies were included. The operative time was 9 min longer when loops were used (p = 0.04). Superficial wound infections (odds ratio [OR], 0.21; 95% confidence interval (CI), 0.06-0.71; p = 0.01) and postoperative ileus (OR, 0.36; 95% CI, 0.14-0.89; p = 0.03) were significantly less frequent when the appendix stump was secured with staples instead of loops. Of 10 intraoperative ruptures of the appendix, 7 occurred in loop-treated patients (p = 0.46). Hospital stay and frequency of postoperative intraabdominal abscess also were comparable in loop-treated and staple-treated patients. Conclusions: The clinical evidence on stump closure methods in laparoscopic appendectomy favors the routine use of endoscopic staplers

Two-trocar appendectomy in children – description of technique and comparison with conventional laparoscopic appendectomy

Background: The aim of the study was to describe the technique of two-trocar laparoscopic appendectomy and compare the outcome between two- and three-trocar techniques in children. Methods: All children who underwent laparoscopic surgery for suspected appendicitis from 2006 to 2014 in a center for pediatric surgery were included in the study. Converted surgeries and patients with appendiceal abscess or concomitant intestinal obstruction were excluded. A total of 259 children underwent appendectomy with either two (35 %) or three (65 %) laparoscopic trocars according to the surgeons' preference and intraoperative judgment. Patient demographics, clinical symptoms, surgery characteristics, and complications were reviewed. Results: The mean age of the children was 10.4 years (range, 1-14 years). The mean follow-up time was 41.2 months (SD ± 29.2). No significant differences in age, gender, weight, or signs and symptoms were found between the two- and three-trocar groups. The mean surgery time was significantly shorter in the two-trocar group (47 min) than in the three-trocar group (66 min; p < 0.001). The rates of surgical complications were 2 % vs. 4 %, (p = 0.501), and the rates of postoperative complications were 0 % vs. 5 % (p = 0.054), in the two- and three-trocar groups. The overall incidence of postoperative wound infection was low (<1 %) and did not differ between groups. Conclusions: Two-trocar laparoscopic appendectomy seems to be a safe and feasible technique with a low rate of postoperative wound infections. The present findings demonstrate that when the two-trocar technique could be applied, it is a good complement to the conventional three-trocar technique

The suprapubic approach for laparoscopicappendectomy

Background: Because it produces superior cosmetic results, patients prefer laparoscopic appendectomy over open appendectomy. We developed two alternative laparoscopic routes of access to the abdominal cavity for appendectomy that use suprapubic incisions placed below the line of pubic hair. We then compared the results for these three different modes of access. Methods: Operative characteristics, morbidity, outcome, and patient preference regarding three different approaches to laparoscopic appendectomy were compared in a retrospective study. In addition, a group of 24 healthy women were surveyed by questionnaire about their preferred technique and expected cosmetic results. Results: Between January 1997 and August 2000, 149 patients underwent laparoscopic appendectomy and were assigned to undergo one of the three techniques. Operative results, morbidity, and hospital stay were similar. Twenty-five percent of patients submitted to technique 1 (no suprapubic trocars) were satisfied with their method, vs 54% of patients with technique 2 (one suprapubic port, angled working trocars) and 100% of patients with technique 3 (two suprapubic parallel trocars). Almost all patients (92% of those who had technique 1 and 100% of those who had techniques 2 and 3) chose the standard laparoscopic access as the cosmetically least attractive method. All of the healthy controls we interviewed preferred technique 3. Conclusion: The placement of suprapubic trocars improves the surgeon's working position during laparoscopic appendectomy. A laparoscopic approach using two suprapubic trocars yields the best cosmetic results in the opinion of the majority of patients and healthy interviewee

ارزیابی مقایسه¬ای عوارض آپاندکتومی لاپاراسکوپیک با آپاندکتومی باز در بیمارستان بعثت همدان در سال 1387

زمینه و هدف: آپاندیسیت حاد یکی از شایعترین اورژانس¬های جراحی است. هرچند بیشتر از 20 سال از انجام آپاندکتومی لاپاراسکوپیک می¬گذرد، توافقی در زمینه مزایا و معایب آن در مقایسه با روش معمول وجود ندارد. تعدادی از مطالعات اخیر برتری روش لاپاراسکوپیک را از نظر طول مدت اقامت در بیمارستان، درد بعد از عمل و عوارض عفونی نشان داده¬اند. این یافته¬ها توسط برخی مطالعات دیگر که تفاوت معنی¬داری را بین دو روش نشان نداده¬اند به چالش کشیده شده¬اند. مطالعه حاضر با هدف مقایسه آپاندکتومی لاپاراسکوپیک با روش باز در درمان آپاندیسیت حاد انجام شد. مواد و روش‌ها: 70 بیمار مبتلا به آپاندیسیت که برای درمان جراحی به بیمارستان بعثت همدان ارجاع شده بودند، بطور تصادفی در دو گروه 35 نفره (گروه A بیماران با آپاندکتومی باز و گروه B بیماران با آپاندکتومی لاپاراسکوپیک) مورد مطالعه قرار گرفتند. موارد مورد بررسی در این مطالعه شامل سن و جنس بیماران، طول مدت عمل (از زمان انسزیون پوستی تا زمان بستن زخم)، درد بعد از عمل، طول مدت اقامت در بیمارستان، بازگشت به فعالیت¬های عادی و عوارض بعد از عمل بودند. تجزیه و تحلیل اطلاعات به کمک نرم افزار آماری SPSS ویرایش 17 انجام شد. یافته‌ها: اختلاف معنی¬داری بین دو گروه از نظر سنی و جنسی وجود نداشت. میانگیـن طول مدت عمل در دو گروه تفاوت معنی¬داری داشت (09/16±71/35 دقیقه در گروه باز و 14/17±42/54 دقیقه در گروه لاپاراسکوپیک، 032/0=P). همچنین تفاوت طول مدت اقامت در بیمارستان در دو گروه نیز از نظر آماری معنی¬دار بود (02/27±77/54 ساعت در گروه باز و 85/11±25/30 ساعت در گروه لاپاراسکوپیک، (