Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Abstract

Introduction Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. Material and methods We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). Results Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41–0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11–0.96), p = 0.045] complications could be detected when using energy devices. Conclusions Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

Enhancing Outcomes Through Preoperative Risk Evaluation in Colorectal Cancer Surgery

“…Some studies have found that laparoscopic surgery minimally impacts human immune function and injury, making postoperative incision infections less likely [113,114]. Therefore, the choice of surgical method is particularly crucial, with a preference for laparoscopic surgery when possible [115,116]. Research indicates that in a single-center randomized controlled trial, the postoperative incision infection rate for patients undergoing laparoscopic surgery for colorectal cancer was 4.9% (47/961), signi cantly lower than the open surgery group (9.6%, 95/986) [117,118,119,120].…”

Focus on identifying and closing knowledge gaps in acute appendicitis

“…They also catalog their experience in applying this approach to achieve two specific goals: (1) identifying knowledge gaps regarding the optimal treatment for appendicitis as a hypothesis-generating launchpad for future interventional RCTs, and (2) describing the gap between evidence-based practice guidelines [6] and "real world" selective application as a lens through which to assess the variability in surgical outcomes. Tackling some of the controversies in current care of the patient with acute appendicitis, the ESTES SnapAppy collaborative explores technical aspects of surgical management (including the use of staplers and energy devices at key portions of the operation), operating surgeon experience, mentorship and graded trainee autonomy, and contemporary surgical outcomes following appendectomy across Europe, North America and the Middle East, particularly in the context of an evolving COVID pandemic [7][8][9][10].…”