evidence based medicine r3 林雅慧 clerks 翁瑄、楊畯棋 指導老師 : 駱至誠 醫師

Evidence Based MedicineEvidence Based Medicine

R3 林雅慧 Clerks 翁瑄、楊畯棋

指導老師 : 駱至誠 醫師

Clinical ScenarioClinical Scenario

• A 7 year-old boy with appendicitis requires management via appendectomy

• The doctor has a choice between traditional versus laparascopic surgery

Question: Do the benefits oflaparascopic approach outweighthe traditional approach?

Background KnowledgeBackground Knowledge• In the pediatric population, appendectomy is one of

the most common emergency operations• Appendectomy is traditionally performed through a

RLQ muscle-splitting incision• Laparoscopic appendectomy is also popular among

pediatric surgeons for both simple and perforated appendicitis

• Studies that have compared the open surgical approach to laparoscopic appendectomy demonstrate differences in administrative factors (cost, resource utilization, length of stay) and clinical outcome measures (wound infection rate, intraabdominal abscess, analgesic requirements, return to full activity)

Background KnowledgeBackground Knowledge

Laparascopic Approach:• In nonperforated appendicitis, it appears to have

lower narcotic analgesic requirements, decreased wound morbidity, and improved cosmesis, but operative times and costs seem slightly higher when compared to the open procedure

• Length of hospital stay does not differ significantly• Used most often for obese patients

Background KnowledgeBackground Knowledge

Complications:• Principal determinant of complications is the severity

of the appendicitis.• Nonperforated appendicitis: 5-10%• Perforated appendicitis: 15-30%• most common complications are wound infections

(3-10%) and intra-abdominal abscesses• Perforation rates are consistently >80% in children

<5 yr of age

5 A’s5 A’s

AskAsk

AcquireAcquire

Database: PubMedKeywords: laparoscopic appendectomy, open

appendectomy

The Evidence PyramidThe Evidence Pyramid

Meta-analysis

Ann Surg. 2006 Jan;243(1):17-27.

Laparoscopic Versus Open Appendectomy in Children a meta-analysis.

Aziz O, Athanasiou T, Tekkis PP, Purkayastha S, Haddow J, Malinovski V, Paraskeva P, Darzi A.

Imperial College of Science, Technology and Medicine, Department of Surgical Oncology and Technology,

St. Mary's Hospital, London, UK.

Level: IA

Oxford Centre for EBM Levels of Oxford Centre for EBM Levels of EvidenceEvidence

Are the results valid?Are the results valid?

• Comparative studies published between 1992 and 2004 of laparoscopic versus open appendectomy in children were included. Endpoints were postoperative pyrexia, ileus, wound infection, intra-abdominal abscess formation, operative time, and postoperative hospital stay.

PR(prospective randomized)

7

PNR(prospective

nonrandomized)

4

R(indicates retrospective)

12From 1992 to 2004, 23 cases,

and 6477 patients, (43% laparoscopic, 57% open)

RESULTS: wound infection

Meta-analysis of all studies showed a significantly reduced incidence of wound infection1.5% in LA and 5% in OA, odds ratio of 0.45, CI of 0.27 to 0.75

Meta-analysis of all studies showed a significantly reduced incidence of wound infection1.5% in LA and 5% in OA, odds ratio of 0.45, CI of 0.27 to 0.75

RESULTS: intra-abdominal abscess

Intra-abdominal abscess was more common in laparoscopic surgery, although this wasn’t statistically significant. 3.8% in LA and 3.4% in OA, odds ratio of 1.11, CI of 0.73 to 0.1.71

Intra-abdominal abscess was more common in laparoscopic surgery, although this wasn’t statistically significant. 3.8% in LA and 3.4% in OA, odds ratio of 1.11, CI of 0.73 to 0.1.71

RESULTS: operative time

Operative time was not significantly longer in thelaparoscopic group. (weighted mean difference, 5.84; 95% CI, -o.95 to 12.63).

Operative time was not significantly longer in thelaparoscopic group. (weighted mean difference, 5.84; 95% CI, -o.95 to 12.63).

RESULTS: length of stay in hospital

The length of hospital stay had significantly shorter in LA versus OA with random effect.(weighted mean difference, -0.48; 95% CI, -0.65 to -0.31).

The length of hospital stay had significantly shorter in LA versus OA with random effect.(weighted mean difference, -0.48; 95% CI, -0.65 to -0.31).

DiscussionDiscussion• Why wound infection is reduced during LA?– OA directly delivered through the wound, there by

risking contamination.– Small size of individual port-site wounds during LA– Reduce handling of small and large bowel during the

procedure.• Incidence of intra-abdominal abscess with LA was

higher than OA– When only RCT were considered (OR=1.7, CI: 1.0-

2.87)– it should be treated with caution, it account for

significantly patient morbidity.

ConclusionConclusion• What improvements should be made?– This meta-analysis was unable to account for the

effect of severity of appendicitis , which may have altered our conclusion

– An additional factor must be accounted for in further research is the experience of the operating surgeon due to laparoscopy

• The results of this meta-analysis suggest that laparoscopic appendectomy in children reduces complications. However, we also see the need for further high-quality randomized trials.

To Answer our Question…

Question: Do the benefits of laparascopic approach outweigh the traditional approach?

Answer: Yes, laparascopic appendectomy in children outweighs open appendectomy in that it significantly reduces complication. Thus, it can be considered a primary choice of management.

Thank you for your attention!Thank you for your attention!