Wednesday, July 10, 2013

Transgastric appendectomy. Would you have one?

A study in the British Journal of Surgery says that removing an inflamed appendix via the stomach is feasible and "promising." This is what is known as NOTES or natural orifice transluminal endoscopic surgery.

The paper (full text plus videos under "Supporting Information" tab) describes the first 15 cases done at the University of Heidelberg in Germany.

There is so much wrong with this paper and the concept in general that it is hard to know where to start.

During the year from April 2010 to April 2011, 111 patients were offered the chance to have this procedure done and only 15 agreed to do so. It appears that patients have a lot more common sense than some physicians think. The patients were carefully selected. Those with BMIs > 30 and with perforated appendicitis were excluded

The procedure was done by inserting an endoscope through the mouth and then through the stomach wall,  but if you read only the abstract, you would miss the fact that a separate trocar was inserted via the umbilicus to facilitate the operation. Therefore, it is not a pure NOTES procedure. The NOTES crowd would call this a "hybrid" procedure.

Several complications occurred. The first case had to be converted to an open appendectomy because of "severe inflammation." This was not explained in the paper but was revealed in the typically uncritical MedPage Today article about it.

Two patients developed postoperative pelvic abscesses requiring what they called "laparoscopic revision" which is their euphemism for second operations. A second operation is very uncommon in patients without perforated appendicitis.

In one patient, a technical problem necessitated ligation of the stump of the appendix through the umbilical port. Another patient had bleeding which had to be controlled by clips. For an obese patient (curious, as only patients with BMIs < 30 were said to have been included), the appendix had to be cut into two pieces because it would not fit through the opening in the gastric wall.

The median duration of the NOTES cases was 105 minutes with a range of 59 to 150 minutes. The average time for a standard three-port laparoscopic appendectomy is about 25 to 35 minutes which means that the NOTES takes three times as long.

The median hospital stay was 3 days with a range on 1 to 8 days. The usual length of stay for a standard laparoscopic appendectomy in the United States is < 24 hours.

The heavily edited videos are worth a look, especially the fourth one, which shows that it takes at least 10 snips of the tiny endoscopic scissors before the appendix is completely divided.

Because of the two patients in the series who developed abscesses, the authors advise caution for those with purulent appendicitis and suggest doing a standard laparoscopic appendectomy instead. The problem is that the surgeon would not know that a patient has purulent appendicitis until she has looked and made what would then have been an unnecessary hole in the stomach.

Most standard laparoscopic appendectomy scars are invisible anyway. If just one patient suffered a leak of the stomach wall closure which would cause sepsis and other major complications, that would strongly negate the minimal cosmetic gain from the trans-gastric operation.

The study ended two years ago but was just published. I always wonder about that. What took so long? Was it rejected by other journals? You would think the authors would want this sort of breakthrough brought to light as soon as possible. Have they done more cases since then? What were the outcomes?

After reading the paper and seeing the videos, is there a surgeon in the world who would want a trans-gastric appendectomy performed on herself or a loved one? An unscientific Twitter poll indicated they would decline. One surgeon said, "Not sure if I'd answer 'No' or 'Hell No,' and I do NOTES research."

Here's the bottom line. Unless you have promised your patient trouble, only the most ardent proponent of NOTES could call these results "promising".


Laurie Mann said...

It sounds like the sort of thing surgeons might joke about after having a few drinks. But actually doing it? HELL NO!

Skeptical Scalpel said...

It's a nice example of "Just because you can do something doesn't mean you should."

DD said...

Why create a potential problem where there is none (i.e. putting a hole in an intact organ--> the stomach)?

artiger said...

The nicest comment I can come up with is that it doesn't appear ready for prime time. Maybe it will in my lifetime, but I'm not volunteering, neither as surgeon nor patient.

Didn't we cover this one a few months ago?

Skeptical Scalpel said...

DD and Artiger, I agree. Artiger, very sharp eye. This post appeared on my Physician's Weekly blog 3 months ago.

gail said...

This makes absolutely no sense. Even as a lay person all I see is a much more complicated surgery than a simple appendectomy.

Skeptical Scalpel said...

I agree and all to avoid the smallest of scars.

Erin Smith - Online PhD UK said...

This does not sound promising at all. This sounds very stupid in fact. There is something to be said when only 15 out of 111 people decide to participate. Thank you for publishing this information so that more people can become aware of this.

Skeptical Scalpel said...

Erin, you are right -- 96 patients figured it out too.

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