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Laparoscopic Appendectomy Has Clear Advantages Over Conventional Procedure

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Duke Health News 919-660-1306

DURHAM, N.C. -- After analyzing a nationwide database of
more than 43,000 patients, Duke University Medical Center
researchers have determined that the minimally invasive
laparoscopic approach to removing infected appendices has
significant advantages over the traditional open surgical
approach.

The researchers found that patients who received
laparoscopic surgery were discharged from the hospital sooner,
were more likely to be discharged home as opposed to further
medical care, and had fewer complications while in the
hospital. Just as importantly, the researchers added, the
laparoscopic approach was as effective as the open approach in
the more serious cases where the appendix is either perforated
or where an abscess is present.

The results of the Duke analysis were published today (Dec.
22, 2003) in the January edition of the Annals of Surgery.

The appendix is a finger-like tube located at the juncture
of the large and small intestine. While its function is not
clearly understood, it can often become infected, leading to
appendicitis, a condition characterized by severe abdominal
pain. If not removed, the inflamed appendix can burst, spilling
bacteria-laden contents into the abdomen, which can lead to
life-threatening infections.

"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 lead author Ulrich Guller, M.D., M.H.S, who is currently
completing a surgical residency at the University of Basel,
Switzerland. He conducted the analysis during a surgical
research fellowship at Duke.

"This study provides compelling evidence that in terms of
length of stay in the hospital and routine discharge, the
laparoscopic approach is better than the open approach," Guller
continued. "However, we still need further studies to compare
other issues, such as quality of life, costs and long-term
complications."

During a laparoscopic procedure, surgeons operate through
small slits in the abdomen. They are guided by a tiny camera
that relays images within the abdomen to a television monitor.
Surgeons use an array of cutters, staplers and cauterization
instruments to perform the surgery.

Specifically, the researchers found that the median hospital
stay for patients who underwent laparoscopic appendectomies was
2.06 days, compared to 2.88 days for the open approach, a
statistically significant and clinically relevant difference,
Guller said. These patients were also more than three times
likely to be discharged home, instead of going to more
intensive treatment areas, nursing homes or home health
care.

Also, the researchers found that there was no significant
difference in complications between the laparoscopic and open
procedure in patients whose appendix was either perforated or
abscessed.

"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."

For their analysis, the researchers consulted the 1997
National Inpatient Sample (NIS), a database supported by the
Agency for Healthcare Research and Quality. It has discharge
information on approximately 20 percent of all patients
hospitalized during 1997 in all regions of the country.

From the NIS database, the Duke team found 43,757 patients
who underwent appendectomies for acute appendicitis. Of that
total, 17.4 percent of the patients underwent laparoscopic
appendectomies.

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

The researchers believe that these strengths in the data
compensate for the fact the NIS is retrospective and
administrative database.

"Our findings may have important implications for the health
system as a whole, since improving clinical outcomes can lead
to lower health care costs," Guller said. "While we have shown
that there are clear benefits for some endpoints for the
patients who underwent laparoscopic appendectomy, this is an
important first step towards evaluating all aspects of the
surgical approaches."

Guller's research was supported by the Swiss National
Foundation, Kresliga beider Basel, Freiwillige Akademische
Gesellschaft, and Fondazione Gustav e Ruth Jacob.

Other members of the Duke research team include Sheleika
Hervey, Harriett Purves, Lawrence Muhlbaier, Ph.D., Eric
Peterson, M.D., and Steve Eubanks, M.D.

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