Elsevier

Journal of Surgical Research

Volume 275, July 2022, Pages 103-108
Journal of Surgical Research

Acute Care Surgery
Safety of Laparoscopic Appendectomy in the Setting of Coagulopathy: An ACS-NSQIP Study

https://doi.org/10.1016/j.jss.2022.01.029Get rights and content

Abstract

Introduction

Patients with coagulopathy requiring emergent appendectomy constitute a challenging patient population. It is unclear whether laparoscopic appendectomy (LA) is as safe as open appendectomy (OA) in these patients.

Methods

We queried the ACS-NSQIP database for adults with coagulopathy undergoing emergent appendectomy from 2014 to 2017. Demographic characteristics and operative outcomes were compared between the two groups. Propensity weighting for LA versus OA was estimated using augmented inverse probability of treatment weights (AIPW).

Results

A total of 137,429 patients were included, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, LA was the most common approach (89%). After AIPW, there was no difference in the adjusted risk of either postoperative transfusion or 30-day reoperation between OA and LA. LA was associated with reduced operative time (56 versus 75 min), length of stay (3.5 versus 7.0 d), and surgical site infection rate (6% versus 13%) compared to OA.

Conclusions

Patients with coagulopathy represent a significant proportion of those undergoing an appendectomy. The majority of patients with coagulopathy who require appendectomy undergo LA, and this approach appears to be safe with regard to transfusion requirement and reoperation.

Section snippets

Background

The operative management of coagulopathic patients with appendicitis is challenging. Coagulopathy in these patients is most commonly due to the use of antithrombotic agents, but it can also be due to the endotoxin-mediated activation of the extrinsic coagulation pathway caused by the septic process itself.1 The number of patients on antithrombotic therapy (anticoagulants and/or antiplatelet therapy) is rising worldwide as the population ages and the prevalence of cardiovascular disorders

Study design

We queried the ACS-NSQIP Participant Use Data Files from 2014 to 2017. The study met the requirements for our institutional review board exemption status and for the informed consent requirement to be waived due to the deidentified nature of the data. We included all adult patients who underwent emergent appendectomy. ACS-NSQIP defines an emergent procedure as the primary procedure performed during the hospital admission and is designated by the surgeon and/or anesthesiologist as emergent.

Results

A total of 137,429 patients who underwent appendectomy were identified, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, 54.3% had elevated INR, 9.7% with prolonged PTT, 26.3% with decreased platelet count, and 34.2% had a bleeding disorder as defined above. These parameters were not mutually exclusive, and some patients met multiple criteria for coagulopathy. The mean age was 51 ± 20, and 4279 (61%) were male. The most common American Society of Anesthesiology class was III (

Discussion

Our data demonstrate that 89% of patients with coagulopathy who undergo emergent appendectomy (5% of all patients undergoing appendectomy) do so via a laparoscopic approach. LA in this patient group appears to be safe with regard to transfusion requirement and reoperation.

The surgical care of patients with coagulopathy is challenging. Comparative data to guide the management of these patients are limited, although there are several published studies reporting surgical outcomes in patients with

Author Contributions

Ya Zhou: Literature search, study design, manuscript writing. Vida Rastegar: Study design, statistical analysis, manuscript writing. Thomas E. Read: Critical revision of the manuscript. Mazen R. Al-Mansour: Study concept and design, manuscript writing, critical revision.

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