1. Evidence Based Medicine R3 林雅慧 Clerks 翁瑄、楊畯棋 指導老師 : 駱至誠 醫師

2. Clinical 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 of laparascopic approach outweigh the traditional approach?

3. Background 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)

4. Background 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

5. Background 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

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8. Ask A child with appendicitis P Laparascopic appendectomy I Open appendectomy C Prognosis and complications O

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10. Acquire Database: PubMed Keywords: laparoscopic appendectomy, open appendectomy

16. The Evidence Pyramid Randomized controlled double blind studies Randomized controlled studies Cohort studies Case control studies Case series Case reports Animal research Ideas, editorials, opinions In vitro (test tube) research Meta-analysis

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18. 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

19. Oxford Centre for EBM Levels of Evidence

20. 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.

21. PR (prospective randomized) 7 PNR (prospective nonrandomized) 4 R (indicates retrospective) 12 From 1992 to 2004, 23 cases, and 6477 patients, (43% laparoscopic, 57% open)

22. RESULTS: wound infection Meta-analysis of all studies showed a significantly reduced incidence of wound infection 1.5% in LA and 5% in OA, odds ratio of 0.45, CI of 0.27 to 0.75

23. 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

24. RESULTS: operative time Operative time was not significantly longer in the laparoscopic group. (weighted mean difference, 5.84; 95% CI, -o.95 to 12.63). Operative time was not significantly longer in the laparoscopic group. (weighted mean difference, 5.84; 95% CI, -o.95 to 12.63).

25. 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).

26. Discussion 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.

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28. Conclusion 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.

29. 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.

30. Thank you for your attention!