Invited commentary on “Werkgartner G et al lapa

Authors: Dirk R Bulian

Publish Date: 2014/12/14

Volume: 30, Issue: 4, Pages: 567-567

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Abstract

The authors discuss a very important and controversial topic Is laparoscopic appendectomy for complicated appendicitis in highrisk patients with an ASA score of 3 or 4 associated with a justifiable risk Compared to open appendectomy is the risk comparable or even less On the one hand the risk of postoperative complications in multimorbid patients is increased On the other hand the question is whether or not the laparoscopic technique further and unnecessarily increases that riskTo answer these questions the authors retrospectively analyzed the appendectomies from their institution over a course of 8 years and extracted those patients with both complicated appendicitis and ASA score of 3 or 4 These were then analyzed after having been divided into two groups namely open and laparoscopic procedures A conversion rate is not available Evaluated preoperative parameters were age gender and comorbidities Leucocyte count CRP ASA score and fever Documented intra and postoperative parameters were perforation procedural time hospital stay complications rated according to Clavien/Dindo as well as Leucocytecount and CRP on the first and third postoperative dayThe flaw in this analysis can be seen in the missing comparability of the two groups The choice of operative technique was left to the surgeons and was definitely influenced by the comorbidities As the authors state conventional appendectomy is the preferred method in their institution in case of severe cardiac or pulmonary comorbidities Thus it does not come as a surprise that these are overrepresented in the OA group Almost half of the OA patients 45  were rated as NYHA IV According to the authors this was a contraindication for laparoscopy Therefore half of the patients in the OA group would not have been operated upon laparoscopically which forbids comparison of the two groups Similar differences between the two groups appear for age and the fraction of the ASA 4 patients Furthermore a markedly higher amount of perforations appeared in the OA group As a conclusion the significant differences are certainly not based on a statistically randomized pattern but possibly entirely on differences in both populationsIn order to allow a separate influence of the operative technique on the complication rate a multivariate analysis is needed However for this statistical tool the case number is too low A multicenter trial is probably the most suitable method to extensively answer the proposed questions As the authors correctly remark a prospective randomized trial would be hard to realize for this topicHowever the authors’ analysis impressively shows that for complicated appendicitis the laparoscopic technique could be performed in ASA 3/4 patients excluding those with a NYHA IV score after subjective selection by the performing surgeon with an acceptable rate of complication in their institution However I find that the direct comparison with the open technique is limited for the reasons mentioned aboveA further interesting result of the study is that the rise in CRP value in case of a postoperative complication is not as high following a laparoscopic appendectomy as compared to an open procedure Thus a complication might take a more concealed course This deserves further evaluation in future trials

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