SAN DIEGO – Elderly patients who underwent a laparoscopic appendectomy had less minor morbidity, less overall morbidity, a lower rate of superficial surgical site infection, and a shorter length of hospital stay compared with their counterparts who underwent an open appendectomy, results from a study of national data demonstrated.
"Laparoscopic appendectomy is becoming the procedure of choice for appendicitis due to the lower rate of surgical site infection, lower length of hospital stay, and faster return to normal life," Dr. Ashkan Moazzez said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
Dr. Ashkan Moazzez
However, most of the current published studies on the topic are limited by having small sample sizes, comparing laparoscopy in elderly versus younger adults only, and having no analysis of 30-day outcomes, said Dr. Moazzez of the H. Claude Hudson Comprehensive Health Center, Los Angeles. At the same time, he continued, life expectancy in the United States has increased over the last few years, "and many people have projected that there will be an increased rate of appendicitis in the elderly."
Using the American College of Surgeons National Surgical Quality Improvement Program databases from 2005 to 2009, he and his associates identified 3,674 patients aged 65 and older who underwent a single laparoscopic or open appendectomy and had a discharge diagnosis of appendicitis.
To compare 30-day outcomes in the two groups, the researchers conducted statistical analysis in two cohorts: an aggregate cohort, which included all 3,674 patients, and a matched cohort, which included 2,060 patients: 1,030 from the laparoscopic appendectomy group and 1,030 from the open appendectomy group, determined by propensity score matching based on 25 preoperative risk factors. This was done because patients in the study "were not randomized to a particular treatment; that can introduce selection bias in the data, which can affect the outcomes," Dr. Moazzez explained.
In the aggregate cohort, the mean age of patients in the open appendectomy group was 74 years compared with 73 years in the laparoscopic group. The mean age of patients in the matched cohort was 74 years. Overall sex distribution was almost 1:1 and 88% of patients were white.
In the aggregate cohort, the rate of overall morbidity in the open group was 13.4% vs. 8.2% in the laparoscopic group, a difference that was statistically significant (P less than .001). This group of patients also had significantly higher rates of mortality (2% vs. 0.9%, P = .003), superficial surgical site infection (3.8% vs. 1.4%, P less than .001), and deep incisional surgical site infection (0.8% vs. 0.2%, P = .003), yet the rate of serious morbidity was statistically similar (6.7% vs. 5.2%, P = .08).
In the matched cohort, the rate of overall morbidity was also statistically significant (10.1%, P = .020), but the rate of mortality was not (1.5%, P = .313). "This shows that when elderly patients are matched based on their preoperative risk factors, laparoscopic surgery does not have a benefit over open surgery as far as mortality," Dr. Moazzez said.
Patients who underwent an open appendectomy in the matched cohort had significantly higher rates of superficial surgical site infection (3.8% vs. 1.4%, P = .001), but the rate of deep incisional surgical site infections did not reach statistical significance (0.8% vs. 0.3%, P = .131).
In the aggregate cohort, patients in the open group had a significantly longer hospital length of stay compared with their counterparts in the laparoscopic group (a mean of 4.7 vs. 2.9 days, P less than .001). The mean length of stay among patients in the laparoscopic group in the matched cohort was 3.6 days (P less than .001).
In a subgroup analysis, aggregate cohort patients with an American Society of Anesthesiologists physical classification of 3 or 4 had higher overall morbidity (19.4% vs. 11.9%, P less than .001) and mortality (3.9% vs. 1.8%, P = .009) rates in the open appendectomy group.
Dr. Moazzez said that he had no relevant financial disclosures.