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Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial

  • Mario E. Trejo-Ávila
  • Sujey Romero-Loera
  • Eduardo Cárdenas-Lailson
  • Miguel Blas-Franco
  • Roberto Delano-Alonso
  • Carlos Valenzuela-Salazar
  • Mucio Moreno-Portillo
Article

Abstract

Background

Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy.

Methods

In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate.

Results

From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate–severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772).

Conclusions

ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.

Keywords

Acute appendicitis Enhanced recovery after surgery Ambulatory surgery Laparoscopic appendectomy 

Notes

Acknowledgements

We would like to thank Violeta Díaz-Fermin MD, for helping us in collecting data.

Compliance with Ethical Standards

Disclosures

Mario E. Trejo-Ávila, Sujey Romero-Loera, Eduardo Cárdenas-Lailson, Miguel Blas-Franco, Roberto Delano-Alonso, Carlos Valenzuela-Salazar, and Mucio Moreno-Portillo have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Gorter RR, Eker HH, Gorter-Stam MA, Abis GS, Acharya A, Ankersmit M, Antoniou SA, Arolfo S, Babic B, Boni L, Bruntink M, van Dam DA, Defoort B, Deijen CL, DeLacy FB, Go PM, Harmsen AM, van den Helder RS, Iordache F, Ket JC, Muysoms FE, Ozmen MM, Papoulas M, Rhodes M, Straatman J, Tenhagen M, Turrado V, Vereczkei A, Vilallonga R, Deelder JD, Bonjer J (2016) Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc 30(11):4668–4690CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Scott A, Shekherdimian S, Rouch JD, Sacks GD, Dawes AJ, Lui WY, Bridges L, Heisler T, Crain SR, Cheung MKW, Aboulian A (2017) Same-day discharge in laparoscopic acute non-perforated appendectomy. J Am Coll Surg 224(1):43–48CrossRefPubMedGoogle Scholar
  3. 3.
    Trevino CM, Katchko KM, Verhaalen AL, Bruce ML, Webb TP (2015) Cost effectiveness of a fast-track protocol for urgent laparoscopic cholecystectomies and appendectomies. World J Surg 40(4):856–862CrossRefGoogle Scholar
  4. 4.
    Gilliam AD, Anand R, Horgan LF, Attwood SE (2008) Day case emergency laparoscopic appendectomy. Surg Endosc 22(2):483–486CrossRefPubMedGoogle Scholar
  5. 5.
    Frazee RC, Abernathy SW, Isbell CL, Isbell T, Regner JL, Smith RD (2016) Outpatient laparoscopic appendectomy: is it time to end the discussion? J Am Coll Surg 222(4):473–477CrossRefPubMedGoogle Scholar
  6. 6.
    Ingraham AM, Cohen ME, Bilimoria KY, Ko CY, Hall BL, Russell TR, Nathens AB (2010) Effect of delay of operation on outcomes in adults with acute appendicitis. Arch Surg 145(9):886–892CrossRefPubMedGoogle Scholar
  7. 7.
    Cross W, Chandru Kowdley G (2013) Laparoscopic appendectomy for acute appendicitis: a safe same-day surgery procedure? Am Surg 79(8):802–805PubMedGoogle Scholar
  8. 8.
    Akkoyun I (2013) Outpatient laparoscopic appendectomy in children: a single center experience with 92 cases. Surg Laparosc Endosc Percutan Tech 23(1):49–50CrossRefPubMedGoogle Scholar
  9. 9.
    Alkhoury F, Burnweit C, Malvezzi L, Knight C, Diana J, Pasaron R, Mora J, Nazarey P, Aserlind A, Stylianos S (2012) A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis. J Pediatr Surg 47(2):313–316CrossRefPubMedGoogle Scholar
  10. 10.
    Cash CL, Frazee RC, Abernathy SW, Childs EW, Davis ML, Hendricks JC, Smith RW (2012) A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis. J Am Coll Surg 215(1):101–105CrossRefPubMedGoogle Scholar
  11. 11.
    Jain A, Mercado PD, Grafton KP, Dorazio RA (1995) Outpatient laparoscopic appendectomy. Surg Endosc 9(4):424–425CrossRefPubMedGoogle Scholar
  12. 12.
    Grewal H, Sweat J, Vazquez D (2004) Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery. JSLS 8(2):151–154PubMedPubMedCentralGoogle Scholar
  13. 13.
    Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg 37(2):259–284CrossRefPubMedGoogle Scholar
  14. 14.
    Dubois L, Vogt KN, Davies W, Schlachta CM (2010) Impact of an outpatient appendectomy protocol on clinical outcomes and cost: a case-control study. J Am Coll Surg 211(6):731–737CrossRefPubMedGoogle Scholar
  15. 15.
    Lasso-Betancor CE, Ruiz-Hierro C, Vargas-Cruz V, Orti-Rodriguez RJ, Vazquez-Rueda F, Paredes-Esteban RM (2013) Implementation of “fast-track” treatment in paediatric complicated appendicitis. Cir Pediatr 26(2):63–68PubMedGoogle Scholar
  16. 16.
    Lefrancois M, Lefevre JH, Chafai N, Pitel S, Kerger L, Agostini J, Canard G, Tiret E (2014) Managemet of acute appendicitis in ambulatory surgery. is it possible? How to select patients? Ann Surg 261(6):1167–1172CrossRefGoogle Scholar
  17. 17.
    Kraft K, Mariette C, Sauvanet A, Balon JM, Douard R, Fabre A, Guidat A, Huten N, Johanet H, Laurent A, Muscari F, Pessaux P, Pierme JP, Piessen G, Raucoules-Aime M, Rault A, Vons C (2011) Indications for ambulatory gastrointestinal and endocrine surgery in adults. J Visc Surg 148(1):69–74CrossRefPubMedGoogle Scholar
  18. 18.
    Sauerland S, Jaschinski T, Neugebauer EA (2010) Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev.  https://doi.org/10.1002/14651858.CD001546 PubMedGoogle Scholar
  19. 19.
    Hamill JK, Rahiri JL, Gunaratna G, Hill AG (2016) Interventions to optimize recovery after laparoscopic appendectomy: a scoping review. Surg Endosc 31(6):2357–2365CrossRefPubMedGoogle Scholar
  20. 20.
    Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78(5):606–617CrossRefPubMedGoogle Scholar
  21. 21.
    Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery: a review. JAMA Surg 152(3):292–298CrossRefPubMedGoogle Scholar
  22. 22.
    Garulli G, Lucchi A, Berti P, Gabbianelli C, Siani LM (2016) “Ultra” E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial. Surg Endosc 31(4):1806–1813CrossRefPubMedGoogle Scholar
  23. 23.
    Kehlet H (2006) Surgical stress and postoperative outcome from here to where? Reg Anesth Pain Med 31:47–52PubMedGoogle Scholar
  24. 24.
    Mohsina S, Shanmugam D, Sureshkumar S, Kundra P, Mahalakshmy T, Kate V (2017) Adapted ERAS pathway vs. standard care in patients with perforated duodenal ulcer: a randomized controlled trial. J Gastrointest Surg.  https://doi.org/10.1007/s11605-017-3474-2 PubMedGoogle Scholar
  25. 25.
    Lohsiriwat V (2014) Enhanced recovery after surgery vs. conventional care in emergenc y colorectal surgery. World J Gastroenterol 20(38):13950–13955CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Gonenc M, Dural AC, Celik F, Akarsu C, Kocatas A, Kalayci MU, Dogan Y, Alis H (2014) Enhanced postoperative recovery pathways in emergency surgery: a randomized controlled clinical trial. Am J Surg 207(6):807–814CrossRefPubMedGoogle Scholar
  27. 27.
    Frazee R, Burlew CC, Regner J, McIntyre R, Peltz E, Cribari C, Dunn J, Butler L, Reckard P, Dissanaike S, Karimi K, Behnfield C, Melo N, Margulies D (2017) Outpatient laparoscopic appendectomy can be successfully performed for uncomplicated appendicitis: a Southwestern Surgical Congress Multicenter Trial. Am J Surg.  https://doi.org/10.1016/j.amjsurg.2017.08.029 Google Scholar
  28. 28.
    Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R, MacCormick AD, Arroll B, Hill AG (2013) Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg 100:482–489CrossRefPubMedGoogle Scholar
  29. 29.
    Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2:CD007635Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Mario E. Trejo-Ávila
    • 1
  • Sujey Romero-Loera
    • 1
  • Eduardo Cárdenas-Lailson
    • 1
  • Miguel Blas-Franco
    • 1
  • Roberto Delano-Alonso
    • 1
  • Carlos Valenzuela-Salazar
    • 1
  • Mucio Moreno-Portillo
    • 1
  1. 1.Department of General and Endoscopic SurgeryHospital General Dr. Manuel Gea GonzálezMexico CityMexico

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