Monday, January 12, 2004

Less Invasive Appendix Surgery Better For Patients
By Mike Upchurch

Duke researchers have found that a minimally invasive approach to appendectomies has clear advantages over the traditional open surgery. Patients undergoing laparoscopic removal of their infected appendixes had fewer complications and shorter hospital stays.

The Duke team, led by Dr. Ulrich Guller, analyzed a database of over 43,000 appendectomy procedures. They published their results in the January issue of the Annals of Surgery.

Dr. Ulrich Guller (courtesy Duke Medical Center)

“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 Guller, who is currently completing a surgical residency at the University of Basel, Switzerland. He conducted the analysis during a surgical research fellowship at Duke.

The laparoscopic procedure proved just as effective as open surgery even in high-risk cases when the infected appendix was already torn or an abscess was present.

"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."

During a laparoscopic appendectomy, a surgeon operates through several small incisions, or ports, in the patient’s abdomen. The narrow laparoscope, fitted with a tiny camera attached to a television monitor, is inserted through one of these ports. The surgeon then uses specially designed cutters, cauterizers, and other instruments via the other ports to conduct the surgery, watching his progress on the TV screen.

The Duke analysis revealed that laparoscopic patients were in the hospital for an average of 2.06 days, compared with 2.88 days for those undergoing open surgery. Patients undergoing the laparoscopic procedure were 3 times as likely to be discharged straight to their homes rather than to more intensive care facilities or home healthcare.

Dr. Guller and his colleagues gathered their data from the 1997 National Inpatient Sample (NIS), a database supported by the federal Agency for Healthcare Research and Quality. It has discharge information on approximately 20% of all patients hospitalized during 1997 in all regions of the country.

Of the nearly 44,000 patients who had undergone appendectomies for an infected appendix in the NIS sample, approximately 17% had the laparoscopic procedure.

“We have performed a quite powerful and sophisticated statistical analysis," said Ricardo Pietrobon, MD, 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. "