Transcript Document

Improving Outcomes in Laparoscopic Appendicectomy (LA)
E Dinneen, T Tilmann, J Preston, MS Nair, R Navaratnam.
North Middlesex University Hospital, Sterling Way, London, United Kingdom.
Introduction
Appendicectomy is the most common surgical
procedure in the world. Traditional open surgical
techniques are steadily being replaced by laparoscopic
approaches because of improved morbidity profiles.
LA is increasingly performed in hospitals outside
specialist centres.
• Performance analysis to assess safety and identify
areas for improvement is vital for a newly introduced
technique in any hospital.
•Controversial areas include whether operation length
is shortened and real costs reduced by using the more
expensive Endo-GIA stapling devise (€230.7 ) vs the
cheaper Endo-loop ligature ( €28.85 )[1, 2, 3,4].
•Debate surrounds whether reduced time from
admission to LA shortens post-operative inpatient
hospital stay. [5, 6]
Aims
• To evaluate safety and outcomes during the ‘advent’
of LA in a London District General teaching hospital.
Results
•No deaths
•Insufficient power to detect significant differences in
Endo–GIA vs. endoloop post-operative complication
rates.
•Endo-GIA vs. endoloop no significant difference in
duration of surgical procedure.
Methods
• Retrospective cohort study.
• All LAs performed between March 2007 and
January 2012 were identified through theatre log
books and hospital electronic informatics system.
• Information gathered from patient records:
Admission chronology and biochemistry,
Intra-operative subjective grade of appendiceal
inflammation (no inflammation (0), inflammation
(1), perforation (2))
Post-operative complications and LOS.
Time spent intubated as a surrogate for duration of
operation
•Exclusion criteria: open appendicectomy, interval LA
and incomplete data.
•Primary outcome measures: mortality, post-operative
complications
•Secondary outcome data: post-op LOS, time spent
intubated, duration of operation
•Statistical Analysis performed with SPSS Statistics
20.0 package
• To identify pre & peri-operative variables which
impact on LA outcomes and cost of inpatient stay.
Appendicectomies
711
45
Results: Post-operative Length of Stay (LoS)
• Mean Post-operative LoS; 76.7 h. (95% CI 66.0 h to 87.4
hrs)
• When ‘inflamed appendix’ was identified by operator at
operation, the use of Endo-GIA was associated with a
reduction in Post-operative LoS from 59.7 hours to 35
hours.
Endo-loop:
n=36, Mean LoS = 59.7 h ±39.5
Endo-GIA:
n=8, Mean LoS = 35.0 h ± 20.0
24.7 h r± 9.57 reduction in post-operative LoS.
P < 0.05 (Mann-Whitney U Test)
•Reduction of Post-operative LoS of 24.7 h (± 9.57 h).
• Cost of 24 hours in a surgical bed in our hospital is £240.
•No difference when ‘no appendicitis’ and ‘perforated
appendicitis’ groups were included in Endo-GIA vs. Endoloop Post-operative LoS analysis was performed.
NMUH LAs by year
40
35
• To examine whether use of Endo-loop versus EndoGIA techniques influenced length of operative
procedure (time spent intubated).
• To consider whether use of Endo-loop versus EndoGIA techniques influenced Post-operative Length of
Stay.
References
1.
Delibegovic S, Matovic E. Hem-o-lok clips in securing off the base of the appendix during laparoscopic appendectomy. Surg Endosc. 2009; 23(12): 2851-2854.
2.
Gomes CA, Nunes TA, Soares C Jr, Gomes CC. The appendiceal stump closure during laparoscopy: historical, surgical and future perspecitves. Surg Laparosc Endosc
Percutan Tech. 2012; 22(1): 1-4.
3.
Ates M, Dirican A, Ince V, Ara C, Isik B, Yilmaz S. Comparison of intracorporeal knot-tying suture (polyglactin) and endoclips in laparoscopic appendiceal stump
closure: a prospective randomized study. Surg Laparosc Endosc Percutan Tech. 2012; 22(3): 226-231.
4.
Delibegovic S. The use of a single Hem-o-lok clip in securing the base of the appendix during laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2012
Jan; 22(1): 85-87.
5.
Nagpal K, Udqiri N, Sharma N, Curras E, Cosgrove JM, Farkas DT. Delaying an appendectomy: is it safe? Am Surg. 2012 Aug; 78(8): 897-900.
6.
Busch M, Gutzwiller FS, Aelig S, Kuettel R, Metzger U, Zingg U. In-hospital delay increases the risk of perforation in adults with appendicitis. World J Surg. 2011;
35(7): 1626-1633.
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Laparoscopic
107
Open
604
Discussion
25
20
15
10
Endo-GIA
18
Endoloop
69
Converted to
Open
20
5
0
2008
2009
LA
•
•
•
•
•
n = 107
15% of total number of Appendectomies
63.6% female
Mean age 28.4
Age Range 9-70yrs
2010
2011
2012
*2012 to January
31st only.
• Study limited in retrospective design.
• Representative of the work load at a typical UK DGH.
• Local perspectives on international LA issues.
• Demonstrates largely successful increasing
implementation of LA .
• No evidence of decreased duration of operation nor
decreased rates of complications using Endo-GIA.
• However, use of Endo-GIA is supported in patients with
confirmed uncomplicated appendicitis as is associated with
shorter post-operative length of stay thereby improving
patient experience and reducing hospital costs.