Digital cholangioscope-assisted endoscopic direct-vision appendicitis therapy versus laparoscopic appendectomy for chronic appendicitis: a multicenter retrospective cohort study

Background and study aimsDirect visualization endoscopic retrograde appendicitis therapy (ERAT), an advanced technique building upon conventional ERAT, represents a novel endoscopic approach for managing acute uncomplicated appendicitis. This study aimed to assess clinical efficacy and safety of employing cholangioscope-guided endoscopic intervention as a therapeutic approach.Patients and methodsA retrospective analysis was conducted on 656 patients presenting with suspected acute appendicitis between February 2024 and November 2024. To minimize baseline differences, propensity score matching was applied, resulting in a final study population of 34 patients undergoing direct visualization ERAT and 68 patients treated with laparoscopic appendectomy (LA). Key outcome measures included technical and clinical success rates, operative time, time to postoperative pain resolution, length of hospital stay, recurrence rate, incidence of adverse events (AEs), and overall patient satisfaction.ResultsThe technical success rate was 97.06% (33/34) in the ERAT group and 100% in the LA group (P= 0.333), while clinical success was achieved in 94.12% (32/34) of ERAT cases compared with 100% in the LA cohort (P= 0.109). Notably, ERAT was associated with a significantly shorter operative time (37 vs 50 minutes;P< 0.001) and more rapid postoperative pain relief (P= 0.001), with a greater proportion of patients reporting complete symptom resolution within 2 days of the procedure. There were no significant differences between the two groups in terms of AEs, length of hospital stay, or patient satisfaction. During follow-up, a recurrence of appendicitis was observed in one ERAT patient (2.94%, 1/34).ConclusionsDirect visualization ERAT demonstrated high feasibility and effectiveness as a diagnostic and therapeutic modality for acute uncomplicated appendicitis, offering a promising alternative to conventional approaches.

BackgroundAn increasing number of studies have shown the merits of endoscopic retrograde appendicitis therapy (ERAT) in diagnosing and treating acute uncomplicated appendicitis. However, no related prospective controlled studies have been reported yet. Our aim is to assess the feasibility and safety of ERAT in the treatment of acute uncomplicated appendicitis.MethodsIn this open-label, randomized trial, participants were randomly allocated to the ERAT group, laparoscopic appendectomy (LA) group and open appendectomy (OA) group. The primary outcome was the clinical success rate of the treatment. Intention-to-treat analysis was used in the study.ResultsThe study comprised of 99 patients, with 33 participants in each group. The clinical success rate was 87.88% (29/33), 96.97% (32/33) and 100% (33/33) in the ERAT, LA and OA group, respectively. In the ERAT group, 4 patients failed ERAT due to difficult cannulation. In LA group, 1 patient failed because of abdominal adhesion. There were no significant differences among the three treatment groups regarding the clinical success rate (P = 0.123). The median duration of follow-up was 22 months. There were no significant differences (P = 0.693) among the three groups in terms of adverse events and the final crossover rate of ERAT to surgery was 21.21% (7/33).ConclusionERAT can serve as an alternative and efficient method to treat acute uncomplicated appendicitis.Trial registration The study is registered with the WHO Primary Registry-Chinese Clinical Trial Registry (ChiCTR1900025812).

Background The aim of this study was to validate the pros of laparoscopic appendectomy (LA) over open appendectomy (OA) and to compare various primary outcome measures in the management of acute and recurrent appendicitis.Study Design Prospective comparative study.Place and Duration Between June 2015 and October 2019 in JJ Hospital, Mumbai.Materials and Methods Total of 60 patients with acute and recurrent appendicitis were included in the study. Thirty patients underwent OA and 30 underwent LA. Both groups were comparable clinicopathologically and demographically. Various intraoperative and postoperative parameters were compared. Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. Mann–Whitney U test was used to compare continuous variables and chi-squared test was used to compare categorical variables.p-Value≤0.001 was considered to be statistically significant.Results The median age of patients undergoing OA and LA was 24.9 and 25.2 years (p = 0.221), respectively. Female: male ratio in OA and LA was 1.30 and 1.14, respectively (p = 0.795). Mean operative duration in LA and OA group was 47.17 ± 14.39 minutes and 36.9 ± 12.33 minutes (p = 0.001), respectively. Mean length of postoperative stay in LA and OA group was 3.69 ± 0.71 days and 5.28 ± 0.63 days (p = 0.000), respectively. Median visual analogue scale score in LA and OA group was 3.5 and 5 (p = 0.001), respectively. Mean time to return to normal activity in LA and OA group was 8.13 ± 1.33 days and 10.10 ± 2.20 days (p = 0.000), respectively. About 6.66% patients in LA group and 13.33% in OA group had postoperative wound infection (p = 0.652). Mean scar scale scoring done on 30th postoperative day was 4.23 in LA and 8.23 in OA (p = 0.000).Discussion and Conclusion LA is more promising than OA in the management of acute and recurrent appendicitis. LA offers lesser operative site pain in the postoperative period, shorter postoperative hospital stays, earlier recovery, and return to normal activities and cosmetically better scars on 30th day follow-up. No conversions or significant difference in wound related complications were seen in both groups. Prolonged intraoperative duration was the only drawback of LA.

Covered self-expandable metallic stents (CSEMS) are effective for managing malignant distal biliary obstruction (MDBO). However, migration is a significant problem, which requires prevention. The novel multi-hole fully CSEMS (MHSEMS), which features multiple small holes on the covered membrane, is expected to prevent migration. This study aimed to evaluate the efficacy and safety of MHSEMS for MDBO. This multicenter retrospective cohort study included 111 patients with MDBO who underwent MHSEMS placement between September 2022 and August 2023. The primary outcome was the recurrent biliary obstruction (RBO) rate. The secondary outcomes were adverse event (AE) rates, removability, technical and clinical success rates, and time to RBO. The technical success rate was 100%, and the clinical success rate was 94.6%. AEs occurred in 34.2% of patients, with RBO in 21.0% and non-RBO AEs in 17.1%. RBO included stent migration in 1.9%, stent occlusion in 11.7% (including ingrowth in 5.7%, biliary debris in 2.9%, hemobilia in 1.9%, and food impaction in 1.0%), and nonocclusion cholangitis (requiring biliary drainage) in 5.7%. Non-RBO AEs included post-endoscopic retrograde cholangiopancreatography pancreatitis in 11.7%, cholecystitis in 2.7%, and nonocclusion cholangitis in 2.7%. Stent removal was successful in 88.9% of attempts. The median time to RBO was 446 days. The placement of MHSEMS for MDBO was effective and feasible, demonstrating low migration rates, acceptable AEs, and removability.

BackgroundAppendectomy is one of the most common operations. Laparoscopic appendectomy (LA) is considered first-line treatment, but the use of LA for treatment of complicated appendicitis remains controversial. Here, we performed a retrospective analysis to compare clinical outcomes between patients treated with LA and those who underwent open appendectomy (OA).MethodsData for 179 patients who underwent an operation for the treatment of complicated appendicitis at our hospital between 2011 and 2017 were retrospectively analyzed. The selection included 89 patients who underwent a conventional appendectomy and 90 patients who were treated laparoscopically. Outcome measures such as mean operative time, blood loss, time until oral intake duration of hospital stay, and postoperative complications were analyzed. Logistic regression analysis was performed to determine the concurrent effects of the examined factors on the rate of postoperative complications.ResultsThe mean ages of patients in the OA and LA groups were 50.17 ± 22.77 and 50.13 ± 25.84 year. Mean operative times were longer in the LA group than OA (10.2.56 ± 44.4 versus 85.4 ± 43.11 min; p = 0.009). The duration of hospital stay was shorter for the LA group (9.61 ± 5.57 versus 12.19 ± 8.4; p = 0.016). There were no significant differences in return to consumption of oral intake between the LA and OA groups (2.03 ± 1.66 versus 2.48 ± 2.17; p = 0.123). Multivariable analysis found that the rate of postoperative complications was significantly reduced for the LA group, in comparison with the postoperative-complication rate of the OA group (16.7% versus 27%; odds ratio 0.376; 95% CI 0.153–0.923; p = 0.0327).ConclusionsThese results suggest that LA is a safe and efficient operative procedure that provides clinically beneficial advantages in comparison with OA. Thus, when possible, appendectomy for complicated appendicitis should be attempted using a laparoscopic approach.Trial registrationRetrospectively registered.

Objective: To analyse the efficacy and safety of endoscopic direct-vision appendicitis therapy (EDAT) in patients with acute appendicitis. Methods: The clinical data of patients diagnosed with acute appendicitis and underwent surgical treatment from May 2023 to July 2024 at Zhongda Hospital of Southeast University were analysed retrospectively. The patients were divided into EDAT group (41 cases) and laparoscopic appendectomy (LA) group (630 cases) according to the surgical methods. After 1∶2 propensity score matching (PSM) based on general baseline information, Alvarado score and underlying diseases, the perioperative period and prognosis indicators were compared between the 2 groups. The deadline for follow-up was October 30, 2024. Results: A total of 123 patients were included after PSM, 41 patients in EDAT group, including 21 males and 20 females, aged [M (Q1, Q3)] 55 (37, 61) years; and 82 patients in LA group, including 41 males and 41 females, aged 50 (35, 60) years. A total of 366(221, 492) days were followed up. The operative time [ (38.7±22.3) vs (54.8±16.2) min], postoperative intestinal function recovery time [(2.5±1.3) vs (21.8±5.0) h], duration of antibiotic use [2 (2, 2) vs 3 (3, 4) d] and hospitalisation days [2 (1, 2) vs 3(2, 4) d] in EDAT group were shorter than those in LA group; postoperative visual analogue scale (VAS) score at 6 hours [(3.2±1.3) vs (5.5±1.2) scores] was lower than that in LA group; the proportion of patients with intraoperative bleeding >20 ml [0 vs 61% (50/82)] and proportion of painkiller use [7.3% (3/41) vs 69.5% (57/82)] were lower than those of LA group (all P<0.001). The rate of postoperative recurrence in EDAT group was higher than that in LA group [4.9% (2/41) vs 0, P=0.035]. Conclusion: EDAT is effective and safe in treating patients with acute appendicitis, but patients are at risk of recurrence.

Laparoscopic appendectomy (LA) has been described in 1983, and its superiority over open appendectomy (OA) is still being debated. Currently, there is no agreement on the advantages of LA. Postoperative pain is reported to be lower along with a faster return to normal activities in LA. However, some studies do not support these findings. In our study, we aimed to compare the outcomes and cost effectiveness of LA and OA. Patients were prospectively randomized into LA (31 patients) and OA (32 patients) groups. Demographic data, pre- and postoperative C-reactive protein (CRP) levels, white blood cell (WBC) count, duration of surgery and hospitalization, complications, and pain scores (VAS) were recorded. Cost was calculated for both groups. Return to normal activities was evaluated by phone calls at the first and second week and 1 month after surgery. There was a significant postoperative decrease in WBC count in the LA group (p<0.01). There were no differences between LA and OA groups in terms of postoperative CRP levels (p>0.05). The rates of wound infection and abscess were similar (p>0.05), while post-operative pain and time to return to normal activities were higher in the OA group (p<0.01). There was a positive correlation between BMI and operative time in the LA group (p<0.01), while BMI and operative time did not show a correlation in the OA group (p>0,05). The average cost in the LA and OA groups were 1960.5±339.05 and 687.115±159.5 TL, respectively. LA is an effective method in the treatment of acute appendicitis due to less pain and faster recovery. LA can be the choice of treatment in acute appendicitis, with utilization of re-useable and cheaper vascular sealing devices.

To compare open appendectomy (OA) with laparoscopic appendectomy (LA) for length of the operation, complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. Prospective randomized clinical trial of patients with acute appendicitis. Tertiary care, urban teaching hospital. A population-based sample of patients (aged > or = 12 years; weight, > 49.7 kg) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis. Patients were prospectively randomized to either OA or LA during a 20-month period (from April 1, 1994, to December 31, 1995). Fifty-seven patients were initially enrolled in the study; 7 did not complete the study because of a protocol violation. All remaining patients completed the study, including postdischarge follow-up. Two (7.4%) of the 27 patients in the LA group required conversion to OA because of technical difficulties. One patient (in the OA group) underwent a second surgical procedure for drainage of a pelvic abscess. Three patients (in the LA group) required second surgical procedures. For analysis, no crossovers were allowed and all patients remained in their originally randomized group. Length of the operation, intraoperative and postoperative complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. Fifty patients (19 women and 31 men) were examined. Twenty-seven patients underwent LA, 2 requiring conversion to an OA. Twenty-three patients underwent an OA. Patient demographics were similar between groups. Statistical differences between the 2 groups were found for (1) length of the operation (median, 81.7 vs 66.8 minutes, LA vs OA groups: P < .002), (2) operating room charges (median, $3191 vs $1514, LA vs OA group; P < .001), and (3) total hospital charges (median, $5430 vs $3673, LA vs OA group; P < .001). No statistical differences between the 2 groups were found for (1) length of hospitalization (median, 1.1 vs 1.2 days, LA vs OA group), (2) pain control (mean, 4 vs 3.7 of 10 [0 indicates least pain; 10, most pain], LA vs OA group), (3) recovery time (time necessary before returning to work or school) (median, 14.0 days for both groups), and (4) complications (5 vs 1, LA vs OA group). Laparoscopic appendectomies and OAs are comparable for complications, postoperative pain control, length of hospitalization, and recovery time. Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges. Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis.

Benign choledochojejunal anastomotic stricture (CJS) is a complication of pancreaticoduodenectomy and choledochojejunostomy. Typically managed with endoscopic balloon dilatation, CJS has a high recurrence rate. Covered metallic stent (CMS) placement is a potential alternative; however, a comprehensive evaluation is lacking. The aim of this study was to evaluate the treatment outcomes of CMS placement in patients with CJS. We retrospectively analyzed patients who underwent balloon dilation via endoscopic retrograde cholangiopancreatography using a double-balloon endoscope for CJS between October 2010 and October 2023. The study outcomes included technical and clinical success rates, adverse event rates, choledochojejunal anastomotic stricture recurrence rates, and time to recurrence for balloon dilation and CMS treatment for CJS. There were 43 patients, 55 procedures (40 balloon dilation and 15 CMS placement). The technical and clinical success rates were 100% for both treatments. Recurrence of CJS was observed in 35% (14/40) of the patients in the balloon dilation group. The recurrence rate was significantly higher in the balloon dilation group than in the CMS group (35% vs. 0%, p = 0.006). The time to CJS recurrence was significantly shorter in the balloon dilation group than in the covered metallic stent group (NR vs. NR, p = 0.03). Placement of CMS for treating patients with CJS was demonstrated to be an effective and safe method with a lower recurrence rate than balloon dilation.

Endoscopic-ultrasound-guided gastrojejunostomy (EUS-GJ) can be a new alternative for patients with malignant afferent loop syndrome (MALS). However, a fully covered self-expandable metal stent (FCSEMS) has not been well investigated in this setting. This is a multicenter retrospective cohort study. Consecutive patients that underwent EUS-GJ using a FCSEMS for MALS between April 2017 and November 2022 were enrolled. Primary outcomes were technical and clinical success rates. Secondary outcomes were adverse events, recurrent symptoms, and overall survival. Twelve patients (median age: 67.5 years (interquartile range: 58-74.8); 50% male) were included. The most common primary disease and type of previous surgery were pancreatic cancer (67%) and pancreatoduodenectomy (75%), respectively. Technical success and clinical success were achieved in all patients. Procedure-related adverse events occurred in one patient (8%) with mild peritonitis. During a median follow-up of 96.5 days, one patient (8%) had recurrent symptoms due to the EUS-GJ stent dysfunction; including biliary events unrelated to the EUS-GJ stent, five patients (42%) had recurrent events. The median overall survival was 137 days. Nine patients (75%) died due to disease progression. EUS-GJ with a FCSEMS seems safe and effective for MALS with high technical and clinical success rates and an acceptable recurrence rate.

ABSTRACTBackground and Objectives:Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided choledochoduodenostomy (EUS-CD) are alternate therapies to endoscopic retrograde cholangiopancreatography with stent placement for biliary decompression. The primary outcome of this study is to compare the technical and clinical success of PTBD to EUS-CD in patients with distal biliary obstruction. Secondary outcomes were adverse events (AEs), need for reintervention, and survival.Methods:A multicenter retrospective cohort study from three different centers was performed. Cox regression was used to compare time to reintervention and survival and logistic regression to compare technical and clinical success and AE rates. Subgroup analysis was performed in patients with malignant biliary obstruction (MBO).Results:A total of 86 patients (58 PTBD and 28 EUS-CD) were included. The two groups were similar with respect to age, gender, and cause of biliary obstruction, with malignancy being the most common etiology (80.2%). EUS-CD utilized lumen-apposing metal stents in 15 patients and self-expandable metal biliary stents in 13 patients. Technical success was similar been EUS-CD (100%) and PTBD (96.6%; P = 0.3). EUS-CD was associated with higher clinical success compared to PTBD (84.6% vs. 62.1%; P = 0.04). There was a trend toward lower rates of AEs with EUS-CD 14.3% versus PTBD 29.3%, odds ratio: 0.40 (95% confidence interval [CI]: 0.12–1.33, P = 0.14). The need for reintervention was significantly lower among patients who underwent EUS-CD (10.7%) compared to PTBD (77.6%) (hazard ratio: 0.07, 95% CI: 0.02–0.24; P < 0.001). A sensitivity analysis of only patients with MBO demonstrated similar rate of reintervention between the groups in individuals who survived 50 days or less after the biliary decompression. However, reintervention rates were lower for EUS-CD in those with longer survival.Conclusion:EUS-CD is a technically and clinically highly successful procedure with a trend toward lower AEs compared to PTBD. EUS-CD minimizes the need for reintervention, which may enhance end-of-life quality in patients with MBO and expected survival longer than 50 days.

Background: Appendectomy is one of the most common surgical emergencies worldwide and is performed using either an open or a laparoscopic approach. Although minimally invasive surgeries are replacing open surgical procedures, laparoscopic appendectomy (LA) has not yet been established as the gold standard procedure compared to open appendectomy (OA). This study aimed to compare the outcomes of LA and OA in 100 cases and evaluate the feasibility, safety, and efficacy of LA as the preferred method for treating acute appendicitis. Methods: This study was a prospective comparative analysis of 100 patients with acute appendicitis who underwent LA or OA. This study was conducted at a tertiary care hospital (CMH Chattogram) between January 2021 and April 2023. Patients were divided into two groups: laparoscopic (n=50) and open (n=50) appendectomy. Both groups were compared for operative time, length of hospital stay, postoperative pain, complication rate, time to return to normal activity, and cosmetic outcome. Results: The mean operative time was significantly longer in the LA group (43 minutes) compared to the OA group (36.4 minutes) (p&lt;0.001). However, the LA group had significantly less postoperative pain with a mean VAS score of 2.04 at 48 hours postoperatively compared to 5.7 in the OA group(p&lt;0.001). LA group had a shorter length of hospital stay compared to the OA group (3.12 days versus 6.48 days, p&lt;0.001) and a faster time to return to normal activities (7.68 days versus 16.58 days, p&lt;0.001). the LA group had less surgical site infection compared to the open group, with 2 out of 50 compared to 8 in the open group (p&lt;0.46). The cosmetic outcome was measured with the scar scale where the LA group had a significantly better-looking scar with a score of 4.28 versus the score of 8.86 (p&lt;0.001) in the case of the OA group. Conclusions: While the longer operative time of LA was a drawback, its benefits in terms of the better visual field of vision during operation and improved patient outcomes make it the more favorable option for appendectomy.

LARGE-SCALE, MULTICENTER, RETROSPECTIVE STUDY ON NEPHROTOXICITY ASSOCIATED WITH EMPIRIC, BROAD-SPECTRUM ANTIBIOTICS IN CRITICALLY ILL PATIENTS

Background Endoscopic retrograde appendicitis therapy (ERAT) is a new and minimally invasive technique for the treatment of acute appendicitis. This study aimed to assess the efficacy and clinical outcomes of ERAT versus laparoscopic appendectomy for patients with uncomplicated acute appendicitis. Methods We adopted propensity score matching (1:1) to compare ERAT and laparoscopic appendectomy in patients with uncomplicated acute appendicitis between April 2017 and March 2020. We reviewed 2880 patients with suspected acute appendicitis, of whom 422 patients with uncomplicated acute appendicitis met the matching criteria (ERAT 79; laparoscopic appendectomy 343), yielding 78 pairs of patients. Results The rate of curative treatment within 1 year after ERAT was 92.1 % (95 % confidence interval [CI] 83.8 % to 96.3 %). The percentage of patients recording visual analog scale values of ≤ 3 for pain at 6 hours after treatment was 94.7 % (95 %CI 87.2 % to 97.9 %) in the ERAT group, which was significantly higher than that in the laparoscopic appendectomy group (83.3 %; 95 %CI 73.5 % to 90.0 %). Median procedure time and median hospital length of stay were significantly lower in the ERAT group compared with the laparoscopic appendectomy group. At 1 year, the median recurrence time was 50 days (interquartile range 25–127) in the ERAT group. The overall adverse event rate was 24.4 % (95 %CI 14.8 % to 33.9 %) in the laparoscopic appendectomy group and 18.4 % (95 %CI 9.7 % to 27.1 %) in the ERAT group, with no significant difference between the two groups. Conclusion ERAT was a technically feasible method of treating uncomplicated acute appendicitis compared with laparoscopic appendectomy.

Purpose: Laparoscopic appendectomy (LA) has become a gold standard for children even in complicated appendicitis. The purpose of this study was to compare the postoperative surgical site infection rates between laparoscopic and open appendectomy (OA) group in pediatric complicated appendicitis. Methods: A total of 1,158 pediatric patients (age ≤15 years) underwent operation for appendicitis over a period of 8 years. Among these patients, 274 patients (23.7%) were diagnosed with complicated appendicitis by radiologic, operative and pathologic findings, and their clinical outcomes were retrospectively analyzed. Results: Of the 274 patients with complicated appendicitis, 108 patients underwent LA and 166 patients underwent OA. Patients in the LA group returned to oral intake earlier (1.9 days vs. 2.7 days; p＜0.01) and had a shorter hospital stay (5.0 days vs. 6.3 days; p＜0.01). However, rate of postoperative intra-abdominal infection (organ/space surgical site infection) was higher in the LA group (LA 15/108 [13.9%] vs. OA 12/166 [7.2%]; p＜0.01). Readmission rate was also higher in the LA group (LA 9/108 [8.3%] vs. OA 3/166 [1.8%]; p＜0.01). Conclusion: The minimally invasive laparoscopic technique has more advantages compared to the open procedure in terms of hospital stay and early recovery. However, intra-abdominal infection and readmission rates were higher in the laparoscopy group. Further studies should be performed to evaluate high rate of organ/space surgical infection rate of laparoscopic procedure in pediatric complicated appendicitis.