Document

15.06.2016
Berühmte Würmer:
Appendix vermiformis - Caenorhabditis elegans
(≈20.000 Pubmed Artikel)
Operative Behandlung der akuten Appendizitis inkl. der komplizierten postoperativen Verläufe
AstraZeneca Focus
Update: Rund um die Appendix
09. Juni 2016
Dr.med.
Steffen Geuss
Klinik für Allgemein- und Viszeralchirurgie
The research conundrum of acute appendicitis, Soreide S, BJS, 2015.

Berühmte Würmer:
Appendix vermiformis - Caenorhabditis elegans
(≈20.000 Pubmed Artikel)
Themen
• Timing: Notfall‐OP oder doch nicht so dringend? • OP Technik: laparoskopisch vs. offen • Weiterentwicklungen (SILS, NOTES)
• Postoperative Komplikationen:
• Drainagen & intraop Spülung
• postoperative Antibiotika
• Behandlung intraabomineller Abszesse





meist retrospektive Arbeiten
keine Grundlagenforschung
marginaler Wissenszuwachs
kein Nobelpreis




Zell- /Entwicklungsbiologie
Grundlagenforschung
Massgebliche Fortschritte
3 Nobelpreise (2002, 2006, 2008)
The research conundrum of acute appendicitis, Soreide S, BJS, 2015.
• Appendektomie à froid
Short-term complications and long-term morbidity of lap and open appendicectomy in a national cohort. Andersson RE, BJS 2014
Laparoscopic versus open surgery for suspected appendicitis. Sauerland S, Cochrane Database Syst Review 2010.


Ist die Appendektomie eine
Notfall-OP?
Perforationsrate steigt mit Zeit
zwischen Schmerzbeginn und OP...
n=
Studien‐
typ
Ditillo MF
(USA 2006)
1081
retro‐
spektiv
Schnüriger B (CH 2014)
390
retro‐
spektiv
Saar S
(EST 2016)
266
prosp.
Kohorte
Jeon BG
4148
(S.Korea 2016)




prosp. Kohorte
Cut‐off
(SzBeginn ‐> OP)
Perforierte
Appendizitis
>48h
6% vs. 33%
Sz Beginn vor:
30h (nicht perf.) vs. 74h (perf.)
>24h
3% vs. 25%
„Perforations rates increased with
longer prehospital delays“
Schnüriger B et al, Introduction of a new policy of no nighttime appendectomies, World J Surg 2014.
Saar S et al, Delay between onset of symptoms and surgery in acute appendicitis increases perioperative Morbidity, World J Surg 2016.
Ditillo MF et al, Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006.
Jeon BG, Appendectomy: Should it be performed so quickly? Am Surg 2016
1
15.06.2016
... aber keine höhere Perforationsrate
bei längerer OP Wartezeit...
Drake FT (USA 2014)
n=
Studientyp
Cut‐off
(inhospital delay)
Perforierte Appendizitis
9048
Prospektive Kohorte
kontinuierlich

12‐24h


Nat Surg Res Coll
8858
(UK 2014)
Meta‐
analyse
(11 Studien)
Nat Surg Res 2510
Coll
(UK 2014)
Prospektive Kohorte
>48h
Jeon BG
(Korea 2016)
Prospektive Kohorte
>18h



4148
.. aber mehr post-op Komplikationen

Drake FT et al, Tim eto appendectomy and risk of perforation in acut eappendicitis, Jama Surg 2014.
The UK National Surgical Research Colaborative, Safety of short, in-hospital delays before surgery for acute appendicitis, Ann Surg 2014
Jeon BG et al, Appendectomy: Should it be performed so quickly? Am Surg 2016



n=
Studientyp
Cut‐off
Postoperative Komplikationen
Nat Surg
Res Coll
(UK 2014)
8858
Meta‐analyse (11 Studien)
12‐24h

Nat Surg
Res Coll
(UK 2014)
2510
Prospektive Kohorte
>48h

SSI: OR 2.24 Kompli: OR 1.71
Fair BA (USA 2015)
69926
Nationales
Register
>48h
 (OR 1.6)
Al‐Qurayshi
(USA 2016)
Nationales 265972
Register
>24h
 (OR 1.26)
The UK National Surgical Research Colaborative, Safety of short, in-hospital delays before surgery for acute appendicitis, Ann Surg 2014
Fair BA et al, The impact of operative timing on outcomes of appendicitis, Am J Surg 2015
Al-Qurayshi et al, Risk and outcomes of 24-h delayed and weekend appendectomies, J Surg Research 2016
„No Nighttime Appendectomies“
am Inselspital
Nacht‐Appendektomie
(23h00 – 8h00)
App Perforation
SSI
Spitalaufenthalt

2006 – 2009
(n=255)
2010 – 2011 (n=135)
45.9%
18.5%
20%
18.5%
2%
0%
3.9 d
3.4 d
Schnüriger B et al, Introduction of a new policy of no nighttime appendectomies, World J Surg 2014.
Lap Appendektomie: Zugang
Lap Appendektomie in 1 Minute
2
15.06.2016
Offene Appendektomie in 1 Minute
Offene Appendektomie: Zugang
Outcome: lap vs offene
Appendektomie
Lap App: internationaler Vergleich
• Schweiz: • 1992‐2008 Swedish National Register (n=169 896)
• 2004: 44% (4267 Ops)
• 2014: 92% (10421 Ops) • Laparoskopie
• Holland 2014: 80%
• USA:
• weniger Wundinfekte (OR 0.54)
• weniger postoperative Schmerzen
• 2004: 43% • 2011: 75%
• Laparoskopie
• Schweden:
• mehr intraop. Darmverletzungen (OR 1.3)
• mehr intraabdominelle Abszesse (OR 1.6) Cochrane 2010: OR 1.8
• 2004: 38% • 2014: 55%




Masoomi H et al, Laparoscopic appendectomy trends and outcomes in the United States: data from NIS, 2004-2011, Ann Surg 2014.
Van Rossem et al, Prospective nationwide outcome audit of surgery for suspected appendicitis, BJS 2016.
Sundbom M et al, Use of laparoscopy in GI surgery in Sweden 1998-2014: a nationwide study, Scand J Surg 2016.
Bundesamt für Statistik Schweiz, Medizinische Statistik der Krankenhäuser 2004 und 2014, www.bfs.ch.
Short-term complications and long-term morbidity of lap and open appendicectomy in a national cohort. Andersson RE, BJS 2014
Laparoscopic versus open surgery for suspected appendicitis. Sauerland S, Cochrane Database Syst Review 2010.


Von einer laparoskopischen Technik
profitieren auch...
Laparoskopische Appendektomie:
Historische Lernkurve ?
• Swiss Association of Lap & Thoracoscopic Surgery
• Patienten mit perforierter Appendizitis
• prospektive Datenbank 1995‐2006 (n=7446)
• Tiwari 2011, Galli 2013, Horvath 2016
• adipöse Patienten (BMI ≥30 kg/m2)
• Abnahme der Komplikationen:
• intraop
• Wundinfekte
• allgemeine
3,1 vs 0,7%
6,1 vs 1,9%
4,9 vs 3,5%
• Masoomi 2011, Mason 2012
intraoperative Komplikationen
• ältere Patienten (>60 J)
• Southgate 2012

Improving outcomes after lap appendectomy: a population-based, 12-yr trend analysis of 7446 pts. Brügger L, Ann Surg 2011.






Southgate E, Laparoscopic vs open appendectomy in older patients, Archi Surg 2012.
Masoomi H, Comparison of lap vs open app for acute nonperforated and perforated appendicitis in the obese population, Am J Surg 2011.
Tiwari MM, Comparison of outcomes of lap and open app in management of uncompl and comp appendicitis, Ann Surg 2011.
Galli R, Laparoscopic approach in perforated appendicitis: increased incidence of SSI? Surg Endosc 2013
Horvath P, Comparison of clinical outcome of laparoscopic versus open appendectomy for complicated app horvath, Surg Endosc 2016.
Mason RJ, Lap vs Open App in Obese Pts Outcomes Using the Am Coll of Surgeons Nati Surg Quality Improv Prog Database, J Am Coll Surg 2012.
3
15.06.2016
Single Incision Laparoscopic Surgery
(SILS)
Weiterentwicklung der
Operationstechniken
• SILS (LESS)
• NOTES
„Historische SILS“
SILS vs konventionelle lap Technik
• Allg. Komplikationen, SSI, LOS 
• „Hernie ombilicale et appendicectomie“
(Makar 2013, 7 RCT, n=1108) • 334 transumbilikale Appendektomien (Amar 1988)
• Wundinfekte
• „Lap app using a single umbilical puncture“ (Kim JH 2015, n=2587)
• 25 Fälle (Pelosi 1992)
• kompl. Appendizitis: Konversionsrate
• „One trocar appendectomy“ (Kang BM 2016, n=618)
• 55 Fälle (Esposito 2002)
• postop Schmerz
(RCT nach 75 pts gestoppt! Carter 2014)







Amar A, Hernie ombilicale et appendectomie, J Chir (Paris) 1988.
Pelosi MA, Laparoscopic appendectomy using a single umbilical puncture, J Reprod Med 1992,
Rispoli G, Esposito C, One trocar appendectomy, Surg Endosc 2002.
Natural Orifice
Transluminal Endoscopic Surgery
(Hybrid-)NOTES
Markar SR, Systematic review and meta-analysis of single-incision versus conventional multiport appendicectomy, BJS 2013.
Kim JH, Single-incision laparoscopic appendectomy versus conventional laparoscopic appendectomy, Experiences from 1208 cases, Ann Surg 2015.
Kang BM, iSngle-port laparoscopic surgery in acute appendicitis retrospective comparative analysis for 618 patients, 2016 Surg Endosc.
Carter JT, A prosp RCT of SILvs Conventional 3-Port Lap Appendectomy for Tx of Acute Appendicitis , J Am Coll Surg 2014.
(Hybrid-)NOTES Appendektomien
• transvaginal vs transgastrisch (n=181 vs 36)
• Komplikationen: • OP Dauer: 3% vs 11%
35min vs 96min
• transvaginal vs lap (n=18 vs 22)
• postop Opiatbedarf 
• körperliche Aktivität schneller
• Arbeitsunfähigkeit kürzer


Bulian DR, Analysis of the first 217 appendectomies of the german NOTES registry, AnnSurg 2016.
Roberts KE, Pure transvaginal appendectomy versus traditional lap appendectomy more procedure time but less length of hospital stay, BJS 2012.
4
15.06.2016
Postop Komplikationen
Postoperative Komplikationen
nicht perforiert
perforiert
5
10
Postop Ileus 3
15
Wundinfekt 0.5
3
1
4
<<1
<<1
Allg. Komplikationen
(Pneumonie, HWI, Niereninsuff, MI,TVT, LE)
Intraabomineller
Abszess
Stumpfinsuffizienz/‐
appendizitis



Komplikationsvermeidung (1):
postop Antibiotika
Margenthaler JA, Risk Factors for Adverse Outcomes After the Surgical Treatment of Appendicitis in Adults, AnnSurg 2003.pdf
Masoomi H, Comparison of lap ves open appendectomy for acute nonperf and perf appendicitis in the obese population, Am J Surg 2011
vanRossem CC, Duration of antibiotic treatment after appendicectomy for acute complicated appendicitis, BJS 2014.
Komplikationsvermeidung (2):
Drainagen und intraop Spülen?
• Wundinfekte / intraabdo Abszesse 
• NUR bei perforierter App u./o. eitriger Peritonitis
• Breitband AB
• Länge?
• Kein Unterschied zwischen 3d und 5d (vanRossem 2014)
• Kriterien: Leukozyten, Fieber, AZ ???
vanRossem CC, Duration of antibiotic treatment after appendicectomy for acute complicated appendicitis, BJS 2014.
Daskalakis K, The use of pre or post op antibiotics in surgery for appendicitis: a systematic review, Scand J Surg 2013.


Absaugen +/- peritoneale Spülung
bei perforierter App
Drainage bei komplizierter Appendizitis
• mehr Wundinfekte  mit Drainage (RR ≈1.7)
• Intra‐abdo Abszesse
mit Spülung (retrospektive Studien: Moore 2001, Akkoyun 2011, Hartwich 2013)
• Intra‐abdo Abszess 
• intra‐abdominelle Infekte Drainage ohne Effekt
mit Spülung (prospektiv randomisiert: StPeter 2012, Snow 2016)
• Hypothetische Power Calculation (α=80%, β=5%):
• 50% Reduktion intrabdomineller Infekte (10  5%)
• n=870


Abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis, Cheng Y, Cochrane Lib 2015.
Evidence-based Value of Prophylactic Drainage in Gastrointestinal Surgery Sys Rev and Meta-analyses. Petrowsky H, Ann Surg 2004
≈675ml





Does use of intraop irrigation w/ open or laparoscopic app reduce post-op intra-abdominal abscess? Moore CB, Am Surg 2011.
Advantages of abandoning abdo cavity irrigation and drainage in operations performed on children with perforated appendicitis. Akkoyun I, J Pediatr Surg 2012.
The effects of irrigation on outcomes in cases of perforated appendicitis in children, Hartwich JE, J Surg Res 2013.
Irrigation vs suction alone during lap appendectomy for perforated appendicitis: a prospective RT, St Peter SD, Ann Surg 2012.
Irrigation versus suction alone during laparoscopic appendectomy; A randomized controlled equivalence trial, SnowHA , Int J Surg 2016.
5
15.06.2016
Intraabomineller AbszessBehandlung
Perkutane Abszessdrainage
• Grösse >3‐5cm
• Antibiotika
• Kumar 2006: >6.5cm • Gasior 2013: >20cm2 (Kinder)
• Perkutane Drainage + Antibiotika
• Zugang: ventral/transgluteal
• Re‐operation
• Technik: CT (US)
• Dauer: klinisch (5‐7d)
• Erfolg: 70‐97%





Kumar RR, Factors affecting the successful manage. of intra-abdo abscesses wi/ ab & the need for percut drainage, Dis Colon Rectum 2006.
Robert B, Percutaneous transgluteal drainage of pelvic abscesses in interventional radiology: A safe alternative to surgery, J Visc Surg 2016.
To J, Image-guided drainage versus antibiotic-only treatment of pelvic abscesses: short-term and long-term outcomes, Fertil Steril 2014.
Brandt D, Percut CT scan-guided drainage vs. Ab-therapy alone for Hinchey II diverticulitis: a case-control study, Dis Colon Rect 2006
Gasior AC, To drain or not to drain: an analysis of abcess drains in the tx of app w abscess. Pediatr Surg Int 2013.
Appendektomie à froid
Appendektomie à froid
• Appendizitis Rezidivrisiko 5‐10%
nach konservativer Therapie
einer abszedierten Appendizitis
• Rezidiv meist innerhalb 6 Monate nach initialer Tx
• Rezidiv – prädiktive Indikatoren: (Castello GM 2014)
•
•
•
•



Appendicolith
Initiale Grösse der entzündlichen RF Symptompersistenz Langsame Rückbildung der entzündlichen RF (Bildgebung)
Interval routine appendectomy following conservative tx of acute app: Is it really needed? Sakorafas GH, W J Gastrointest Surg 2012
Nonsurgical Treatment of Appendiceal Abscess or Phlegmon - A Sys Review and Meta-analysis. Andersson RE, Ann Surg 2007
Predictors of recurrent app after non-op management of children w/perforated app presenting w/an app inflammatory mass.
Castello GM, Arch Dis Child 2014
Fazit
Appendektomie à froid
• Verzögerung der OP um 6‐12h: nicht wünschenswert, aber ohne Nachteil
• Laparoskopische OP Technik: Vorteile überwiegen
• Unerwartete Diagnosen nach Appendektomie à froid:
• 12% Neoplasien (11/89, 6 muzinöse TU, 5 Karzinoide, 1 Adeno‐CA) Wright GP, 2015
• 1,2% Malignome (32/2771) Andersson RE, 2007
• 0,7% benigne EK (17/2771) , v.a M. Crohn Andersson RE, 2007
• Fazit: Keine regelhafte Appendektomie à froid, aber Abklärung mittels • Bildgebung (CT) nach 2‐3 Monaten • +/‐ Koloskopie


• SILS/NOTES: innovativ, aber Fortschritt fraglich
• Drainage / Spülung bei perf. App:
Keine Evidenz
• Postop Antibiotika:
bei komp Appendizitis
• Perkut. Drainage intraabdo Abszesse: etablierte Methode • Appendektomie à froid: nach Abklärung
Nonsurgical Treatment of Appendiceal Abscess or Phlegmon - A Sys Review and Meta-analysis. Andersson RE, Ann Surg 2007
Is there truly an oncologic indication for interval appendectomy? Wright GP, Am J Surg 2015
6
15.06.2016
Lap App: internationaler Vergleich
Offene Fragen?
• Holland 2014: 80%
• Schweiz: • 2004: 44% (4267 Ops)
• 2014: 92% (10421 Ops) • USA:
• 2004: 43% • 2011: 75%
• Schweden:
• 2004: 38% • 2014: 55%
Masoomi H et al, Laparoscopic appendectomy trends and outcomes in the United States: data from NIS, 2004-2011, Ann Surg 2014.
Van Rossem et al, Prospective nationwide outcome audit of surgery for suspected appendicitis, BJS 2016.
Sundbom M et al, Use of laparoscopy in GI surgery in Sweden 1998-2014: a nationwide study, Scand J Surg 2016.
Bundesamt für Statistik Schweiz, Medizinische Statistik der Krankenhäuser 2004 und 2014, www.bfs.ch.




Postop Komplikationen:
Risikofaktoren
Drainage bei komplizierter Appendizitis
Systematic Review 2004
• Pathologie:
kompliziert > unkompliziert (OR 1.3)
• OP Technik:
offen > laparoskopisch (OR 3.4)
Systematic Review 2015
• Schmerzbeginn: >1d (OR1.5), >7d (OR 2.3)
Intraabdo infections
• Patientenalter: /Jahr (OR 1.02)
Wound infections

Tsipolis C, Factors influencing the course of acute appendicitis in adults and children, Langenb Arch Surg 2013.
Abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis, Cheng Y, Cochrane Lib 2015.
Evidence-based Value of Prophylactic Drainage in Gastrointestinal Surgery Sys Rev and Meta-analyses. Petrowsky H, Ann Surg 2004


Intraop Spülung bei perforierter App





Technik
Antibiotika
Spülmenge
Drainage
Moore CB (2011)
offen/lap
prä‐op
?
?
Akkoyun I (2012)
offen
post‐op
Dauer?
?
ja
Hartwich JE offen/lap
(2013)
post‐op
Dauer?
?
?
St Peter SD lap
(2012)
post‐op (7d) min. 500ml
Snow HA (2016)
post‐op (5d)
lap
... mittlerwerweile Trendumkehr ?
• 91.118 lap vs 97.496 offen (USA)
• Kinderchirurgie
675ml
(500‐950ml)
• Klinikpräferenz: laparoskopische Technik
• komplizierter Appendizitis
?
• post‐op Komplikationsrisiko (OR 1.11)
nein
Does use of intraop irrigation w/ open or laparoscopic app reduce post-op intra-abdominal abscess? Moore CB, Am Surg 2011.
Advantages of abandoning abdo cavity irrigation and drainage in operations performed on children with perforated appendicitis. Akkoyun I, J Pediatr Surg 2012.
The effects of irrigation on outcomes in cases of perforated appendicitis in children, Hartwich JE, J Surg Res 2013.
Irrigation vs suction alone during lap appendectomy for perforated appendicitis: a prospective RT, St Peter SD, Ann Surg 2012.
Irrigation versus suction alone during laparoscopic appendectomy; A randomized controlled equivalence trial, SnowHA , Int J Surg 2016.

Tashiro J, Hospital preference of laparoscopic versus open appendectomy: Effects on outcomes in simple and complicated appendicitis, J Ped Surg 2016.
7