ORIGINAL ARTICLE Long-term Follow-up for Adhesive Small Bowel Obstruction After Open Versus Laparoscopic Surgery for Suspected Appendicitis Karolin Isaksson, MD,∗ Agneta Montgomery, MD, PhD,† Ann-Cathrin Moberg, MD, PhD,† Roland Andersson, MD, PhD,∗ and Bobby Tingstedt, MD, PhD∗ A diagnostic laparoscopy is safe and offers the possibility to detect Objective: The aim of the present study was to compare the frequency of read- pathological conditions mimicking appendicitis, especially important missions due to small bowel obstruction (SBO) after open versus laparoscopic in fertile women, and also rendering the option to leave a normal ap- surgery performed for suspected acute appendicitis. pendix in place.11 Background: Appendicitis is a common disease, with a lifetime risk of ap- Postoperative adhesions are quite common, especially not only proximately 7%. Appendectomy is the treatment of choice for most patients. after surgery of the lower part of the abdomen such as gynecological Postoperative adhesions are common after abdominal surgery, including ap- and colorectal surgery but also after appendectomy. Late complica- pendectomy. tions due to intra-abdominal adhesions include chronic abdominal Materials and Methods: Consecutive patients, 16 years or older, operated pain, small bowel obstruction (SBO), and female infertility. These on because of suspected appendicitis at 2 university hospitals between 1992 chronic conditions can result in a major impairment for the patient, a and 2007 were included. The prime approach was open at one hospital and challenge to treat, and represent a major cost for society. In Sweden, laparoscopic at the other hospital. Open and laparoscopic procedures were costs related to admissions due to abdominal adhesions are estimated compared retrospectively, reviewing the patients’ charts until the middle of to about €40 million to €60 million per year.12 Abdominal adhesions 2012. Hospitalization for SBO after index surgery was registered. are the most common cause of SBO requiring surgical intervention. Results: A total of 2333 patients in the open group and 2372 patients in The lifetime risk of postoperative bowel obstruction after abdominal the laparoscopic group were included. The frequency of hospitalization for surgery with a frequency of up to 25% after some procedures has been SBO was low in both groups, although a difference between the groups was reported. The incidence of bowel obstruction after appendectomy has identified (1.0% in the open group and 0.4% in the laparoscopic group) (P = historically been reported to be between 0.7% and 10.7%.13–18 0.015). Type and grade of surgical trauma seem to play an important Conclusions: Hospitalization due to SBO, between open and laparoscopic role in adhesion formation. There are documented advantages of la- procedures, in patients operated on because of suspected appendicitis demon- paroscopic procedures in general, as compared with open surgery, in strated a significant difference, favoring the laparoscopic approach. The fre- reducing postoperative adhesion formation by minimizing the trauma quency of SBO after the index surgery was, though, low in both groups. to the peritoneal surface.19 The aim of this study was to determine Keywords: adhesive, appendicitis, long term follow-up, open versus laparo- the incidence of SBO after open and laparoscopic operations in pa- scopic, small bowel obstruction tients with suspected appendicitis in a large cohort of adult patients subjected to a long-term follow-up. (Ann Surg 2014;259:1173–1177) PATIENTS AND MATERIALS ppendicitis is a common condition, with a calculated cumu- Data from patients, 16 years or older, operated on for suspected 1,2 A lated lifetime risk of 7% to 8%. Surgery is the treatment appendicitis between 1992 until the end of 2007 at the University of choice for the majority of patients. The incidence of appendec- Hospitals in Lund and Malmo¨ (since 2011 merged to form 1 university tomy is around 100 of 100,000 inhabitants per year in the Western hospital: Skane˚ University Hospital) were retrospectively collected. 3 world. Open appendectomy has been the criterion standard until the The hospitals are closely localized in the southern region of Sweden. 4 laparoscopic technique was introduced by Semm in early 1980s. During this time period, the preferred operation technique in Lund was Several studies have described advantages of using the laparoscopic the open approach whereas laparoscopic operation was the procedure technique, including diagnostic possibilities, faster recovery with of choice in Malmo.¨ shortened hospital stay, decreased postoperative pain, and a lower The open group (OG) consisted of all consecutive patients op- 5–7 incidence of wound infections. Others have demonstrated dis- erated on by open technique in Lund, and the laparoscopic group advantages such as a possible higher risk of postoperative intra- (LG) consisted of all consecutive patients operated on in Malmo.¨ 6,8,9 abdominal abscess formation, whereas others have not demon- The patients were identified by the ICD (International Classification 10 strated any difference between open and laparoscopic procedures. of Diseases) codes. For open appendectomy, the codes 4510 (ICD-9 until 1996) and JEA 00 (ICD-10 after 1996) were used; for the la- paroscopic operations, the codes 4511, 4042 (ICD-9), and JEA 01, ∗ From the Department of Surgery, Skane˚ University Hospital, Lund, Sweden; and JAH 01 (ICD-10) were used. The LG included 3 possible pathways †Department of Surgery, Skane˚ University Hospital, Malmo,¨ Sweden. Disclosure: This study was partly supported by grants from Eric and Angelica for patients with clinically suspected appendicitis: an appendectomy Sparre Foundation, although the funding source had no influence on the study completed laparoscopically, a conversion to open appendectomy, or at all. None of the authors have any conflicts of interest. a diagnostic/explorative laparoscopy leaving a macroscopically nor- Reprints: Karolin Isaksson, MD, Department of Surgery, Skane˚ University Hospital, mal appendix in place. The curriculum was to perform an initial S-221 85 Lund, Sweden. E-mail: [email protected]. laparoscopy for diagnostic purposes. The appendix was left in place Copyright C 2013 by Lippincott Williams & Wilkins ISSN: 0003-4932/13/25906-1173 when diagnosed as macroscopically normal. When appendicitis was DOI: 10.1097/SLA.0000000000000322 diagnosed at laparoscopy, the surgeons having an accreditation for r Annals of Surgery Volume 259, Number 6, June 2014 www.annalsofsurgery.com | 1173 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. r Isaksson et al Annals of Surgery Volume 259, Number 6, June 2014 laparoscopic appendectomy went on with a laparoscopic procedure of risk factors for SBO. Statistical calculations were performed with and converted in case of technical difficulties. The surgeons not hav- SPSS version 19.0, IBM Corp., Armonk, NY, USA. A 2-sided P < ing the accreditation for laparoscopic appendectomy converted to 0.05 was considered statistically significant. open appendectomy after the diagnostic laparoscopy. This strategy resulted in a high conversion rate, although the number of conver- RESULTS sions diminished over time as the educational program proceeded. In A total of 4705 patients, 2333 in the OG and 2372 in the LG, the OG, an appendectomy was performed for all patients, including were included. The excluded patients are shown in Figure 1. There when finding macroscopically normal appendices. were 994 female patients (43%) and 1339 male patients in the OG Patients were analyzed both on the intention-to-treat basis and (P < 0.001) and 1250 female patients (53%) and 1122 male patients per protocol. In the per protocol analysis, the converted operations in in the LG (P = 0.009). The difference in sex between the groups was the LG were excluded to study the laparoscopic versus open technique statistically significant (P < 0.001). The mean age was 35 (SD = 16) per se. years in the OG and 36 (SD = 16) years in the LG (P = 0.072). The mean follow-up time was 161 (SD = 53) months in the OG and 133 Exclusion Criteria (SD = 49) months in the LG (P < 0.001). • If the appendectomy was performed as a part in a more extensive In the LG, the distribution of surgical intervention was 1401 surgical procedure (en passant, eg, colorectal resection) or when laparoscopic appendectomies (59%), 595 converted to open appen- the operation was extended because of an advanced appendicitis dectomy (25%), and 376 diagnostic laparoscopies (16%). A total of (eg, ileocecal resection). 34 patients were hospitalized for SBO, most likely related to the index • When the appendectomy was accompanied with another concurrent surgery: 24 patients (1.0%) in the OG and 10 patients (0.4%) in the LG intra-abdominal surgical procedure (eg, oophorectomy, Meckel di- (P = 0.015). Readmissions are depicted in Table 1. Outcomes of SBO verticulum). regarding patient factors are outlined in univariate and multivariate • In patients with carcinoma of the appendix (not carcinoids that did analyses in Table 2. Open appendectomy and older age are indepen- not lead to further surgical treatment). dent risk factors for SBO in the multivariate analysis. Altogether 7 • In patients readmitted for SBO having information of conflicting patients in the OG and 2 patients in the LG had more than 1 readmis- surgery to the lower part of the abdomen, presence of adhesions at sion, resulting