Komplike Olmayan Akut Apandisitte Uygulanan Laparoskopik Apendektomilerde Güdük Kapatma Yöntemlerinin Karşılaştırılması: Retrospektif Bir Kohort Çalışması

Amaç: Daha kısa hastanede kalış süresi ve daha erken çalışmaya dönüş süresi sunan laparoskopik apendektomi, daha az postoperatif ağrı ve daha iyi kozmesis ile dünya çapında kabul gördü ve ilk laparoskopik apendektomi bildiriminden on yıllar sonra kılavuzlarda standart tedavi olarak yerini aldı. Bu çalışmada güdük kapatma yöntemleri ile postoperatif enfeksiyon komplikasyonları arasındaki ilişki incelenmiştir. Gereç ve Yöntem: Komplike olmayan akut apandisit nedeniyle 10 yıllık bir süre içinde bir üniversite hastanesinde gerçekleştirilen laparoskopik apendektomi olguları retrospektif olarak incelendi. Stapler, polimer klips ve intrakorporeal düğüm dahil olmak üzere üç güdük kapatma yöntemi karşılaştırıldı. Bulgular: Nihai analize toplam 391 olgu dahil edildi. Stapler, polimerik klips ve intrakorporeal düğüm sırasıyla 191 (%48,8), 52 (%13,3) ve 148 (%37,9) hastada güdük kapatılması için kullanıldı. Apendiks çapı stapler grubunda daha büyük, intrakorporeal düğüm grubunda daha küçük bulundu. Diğer preoperatif özellikler gruplar arasında benzerdi. İki intraabdominal apse dahil olmak üzere 9 (%2,3) cerrahi alan enfeksiyonu görüldü. Dokuz cerrahi alan enfeksiyonundan 8’i görece risk oranı 8.699 bulunan stapler grubunda gözlendi. Cerrahi alan enfeksiyonu olan olgularda postoperatif lökosit azalması daha az sıklıkta, lökosit azalması ise kantitatif olarak daha az bulundu veya hiç olmadı. Sonuç: Polimerik klipsler ve intrakorporeal düğümler, komplike olmayan akut apandisit olgularında zımba kullanımına tercih edilmesini önerdiğimiz güdük kapatma yöntemleridir. Peroperatif lökosit sayısının seyri, postoperatif cerrahi alan enfeksiyonlarını öngörmede değerli olabilir.

Comparison of Stump Closure Methods in Laparoscopic Appendectomies Performed for Uncomplicated Acute Appendicitis: A Retrospective Cohort Study

Objectives: Laparoscopic appendectomy offering shorter hospital stay and time to work, less postoperative pain and better cosmesis gained worldwide acceptance and took its place as the standard treatment in the guidelines decades after the first report of laparoscopic appendectomy. In the present study, relationship between stump closure methods and postoperative infectious complications were analyzed. Materials and Methods: Laparoscopic appendectomy cases performed for non-complicated acute appendicitis at a university hospital in a ten-year period were analyzed retrospectively. Three stump closure methods including stapler, polymer clip and intracorporeal knot were compared. Results: Totally 391 cases were included in the final analysis. Stapler, polymeric clip and intracorporeal knot were used for closure of the stump in 191 (48.8%), 52 (13.3%) and 148 (37.9%) patients, respectively. Appendix diameter was found larger in the stapler group and smaller in the intracorporeal knot group. Other preoperative characteristics were similar among the groups. Nine (2.3%) surgical site infections including 2 intraabdominal abscesses were observed. Eight of 9 surgical site infections were observed in the stapler group with odds ratio of 8,699. Postoperative leucocyte decrease was found to be less frequent and leucocyte decrease was quantitatively less or absent in cases with surgical site infections. Conclusion: Polymeric clips and intracorporeal knots are the stump closure methods we recommend being preferred over stapler use in cases of uncomplicated acute appendicitis. The course of the peroperative leukocyte count may be valuable in predicting postoperative surgical site infections.

PDF

___

1. Wagner M, Tubre DJ, Asensio JA. Evolution and Current Trends in the Management of Acute Appendicitis. Surg Clin North Am. 2018;98:1005- 1023.
2. Di Saverio S, Birindelli A, Kelly MD, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg. 2016;11:34.
3. Semm K. Endoscopic appendectomy. Endoscopy. 1983;15:59-64.
4. Ukai T, Shikata S, Takeda H, et al. Evidence of surgical outcomes fluctuates over time: results from a cumulative meta-analysis of laparoscopic versus open appendectomy for acute appendicitis. BMC Gastroenterol. 2016;16:37.
5. Surgical Site Infection (SSI) Event: Center for Disease Control. 2010.http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent. pdf?agree=yes&next=Accept. Updated January 2021. Accessed January 10, 2021.
6. Masoomi H, Nguyen NT, Dolich MO, et al. Laparoscopic appendectomy trends and outcomes in the United States: data from the Nationwide Inpatient Sample (NIS), 2004-2011. Am Surg. 2014;80:1074-1077.
7. Gorenoi V, Dintsios CM, Schönermark MP, et al. Laparoscopic vs. open appendectomy: systematic review of medical efficacy and health economic analysis. GMS Health Technol Assess. 2007;2:Doc22.
8. Athanasiou C, Lockwood S, Markides GA. Systematic Review and Meta- Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature. World J Surg. 2017;41:3083-3099.
9. Strzałka M, Matyja M, Rembiasz K. Comparison of the results of laparoscopic appendectomies with application of different techniques for closure of the appendicular stump. World J Emerg Surg. 2016;11:4.
10. Knight SR, Ibrahim A, Makaram N, et al. The use of polymeric clips in securing the appendiceal stump during laparoscopic appendicectomy: a systematic review. Eur J Trauma Emerg Surg. 2019;45:665-670.
11. Delibegović S, Mehmedović Z. The Influence of the Appendiceal Base Diameter on Appendix Stump Closure in Laparoscopic Appendectomy. World J Surg. 2016;40:2342-2347.
12. Zhang P, Zhang Q, Zhao H, et al. Factors affecting the length of hospital stay after laparoscopic appendectomy: A single center study. PLoS One. 2020;15:e0243575.
13. Sajid MS, Rimple J, Cheek E, et al. Use of endo-GIA versus endo-loop for securing the appendicular stump in laparoscopic appendicectomy: a systematic review. Surg Laparosc Endosc Percutan Tech. 2009;19:11-5.
14. Graham CW, Komidar L, Perger L. Comparison of Polymeric Clips and Endoscopic Staplers for Laparoscopic Appendectomy. J Laparoendosc Adv Surg Tech A. 2019;29:240-242.
15. Al-Temimi MH, Berglin MA, Kim EG, et al. Endostapler versus Hem-O-Lok clip to secure the appendiceal stump and mesoappendix during laparoscopic appendectomy. Am J Surg. 2017;214:1143-1148.
16. Mannu GS, Sudul MK, Bettencourt-Silva JH, et al. Closure methods of the appendix stump for complications during laparoscopic appendectomy. Cochrane Database Syst Rev. 2017;11:006437.
17. Dickinson CM, Coppersmith NA, Luks FI. Early Predictors of Abscess Development after Perforated Pediatric Appendicitis. Surg Infect (Larchmt). 2017;18:886-889.
18. Sohn M, Hoffmann M, Pohlen U, et al. [Stump closure in laparoscopic appendectomy. Influence of endoloop or linear stapler on patient outcome]. Chirurg. 2014;85:46-50.
19. Delibegović S, Mehmedovic Z. The influence of the different forms of appendix base closure on patient outcome in laparoscopic appendectomy: a randomized trial. Surg Endosc. 2018;32:2295-2299.
20. Zorzetti N, Lauro A, Vaccari S, et al. A systematic review on the cost evaluation of two different laparoscopic surgical techniques among 996 appendectomies from a single center. Updates Surg. 2020;72:1167-1174.
21. Parikh PP, Tashiro J, Wagenaar AE, et al. Looped suture versus stapler device in pediatric laparoscopic appendectomy: a comparative outcomes and intraoperative cost analysis. J Pediatr Surg. 2018;53:616-619.
22. Escolino M, Becmeur F, Saxena A, et al. Endoloop versus endostapler: what is the best option for appendiceal stump closure in children with complicated appendicitis? Results of a multicentric international survey. Surg Endosc. 2018;32:3570-3575.