Appendiceal stump closure by metal endoclip in the management of complicated acute appendicitis
© Gomes et al.; licensee BioMed Central Ltd. 2013
Received: 24 March 2013
Accepted: 3 September 2013
Published: 18 September 2013
Closure of appendicular stump has been performed in different ways; however, the use of the metal endoclip in complicated grades of acute appendicitis, has not been evaluated yet in a prospective way.
To establish the effectiveness of appendiceal stump closure by metal endoclip for complicated appendicitis.
From January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix, which may lead to abscess formation and degrees of peritonitis. The outcomes viability, operative time, infection complication, operative complications, and conversion rate were chosen to evaluate the procedure.
The appendiceal stump closure by metal endoclip was used in 90% of cases. The presence of appendix base necrosis was the most important factor involved in failure of the procedure. Laparoscopic knot (1.5%), laparoscopic endo-suture (3.8%) and video assisted laparotomy (4.7%) were the alternatives used in difficult cases. The mean operative time was (67.54 ± 28.13 minutes). The wound and intra-abdominal infection rates were 2.54% and 5.08%, respectively. There were no operative complications and the conversion rate was 0.85%.
The appendiceal stump closure by metal endoclip, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with appendix base necrosis it should be avoided in favor of other alternatives.
Appendicular stump closure is an important step during appendectomy as its inappropriate management can lead to serious post-operative complications. The development of life-threatening problems such as stercoral fistulas, postoperative peritonitis, and sepsis is feared and unwanted. In 1985, Engstrom and Fenyo  showed that the tactical modification of appendiceal stump closure, with a single endoligature replacing the invaginating suture, is a safe and effective approach. The modification adjusted very well with demonstrated benefits such as simplicity and decreased operation time and anatomic deformities at the cecum. Nowadays, it has become the procedure of choice during a laparoscopic appendectomy .
Appendiceal stump has been secured by different ways during laparoscopic appendectomy, including the use of mechanical endo-stapler [2–4], endo ligature (endo-loop®) [5–7], metal endoclips [8–11], bipolar endocoagulation , polymeric endoclips [13, 14], and intracorporeal suture . All these alternatives have advantages and disadvantages during the different clinical stages of the acute appendicitis, and none of them have been assessed by any prospective randomized (and experimental) studies .
In addition, the appendiceal stump treatment by metal endoclips in complicated acute appendicitis has not been evaluated yet by any prospective clinical research. Therefore, the objective of this study was to verify the safety and effectiveness of appendicular stump closure by metal endoclips, in complicated stages of acute appendicitis.
From January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male.
The study was approved by the Ethics and Research Commission at the Monte Sinai Hospital in Juiz de Fora – Minas Gerais – Brazil, and all patients signed up an informed consent term. Three senior surgeons who are titled by the Brazilian Society of Laparoscopic Surgery participated in it.
Laparoscopic grading system of acute appendicitis according to macroscopic inflamatory findings
Normal looking appendix
Hiperemia e oedema of appendix
Grau 3 A
Grau 3 B
Appendicular base necrosis
Grau 4 A
Grau 4 B
Operative time that lasts from skin incision to skin suture was measured in terms of minutes. Surgical site infection was defined by clinical signs of edema, redness around the wound, or purulent discharge until the 30th postoperative day. The diagnosis of intra-abdominal infections was suspected by clinical signs and demonstrated by ecography, computed tomography, or laparoscopy. Operative complications were defined as bleeding, iatrogenic injury, small bowel obstruction, endoclip escape, or enteric leak.
The viability of appendiceal stump secured by metal endoclips, operative time, infection complication, operative complication, and conversion rate were the outcomes chosen to study the effectiveness of the procedure. Statistical Package for Social Sciences (SPSS) 13.0 version for Windows was used as data bases.
Viability of appendiceal stump closure by metal endoclips according to laparoscopic grading system of acute appendicitis (n = 131)
Alternatives of appendiceal stump closure in complicated grades of acute appendicitis (n = 131)
Apendiceal stump closure
Laparoscopic grading system
( n ) *
Mean operating time spent during laparoscopic appendectomy for complicated grades of acute appendicitis compared with four other similar studies (n = 118)
Mean operating time spent during laparoscopic appendectomy for complicated grades of acute appendicitis from four similar studies (n = 118)
Mean operating time in complicated laparoscopic appendectomy
Study or subgroup
Katsuno et al., 2009 ( 17 )
Lin et al., 2006 ( 18 )
So et al., 2002 ( 19 )
Khalili et al., 1999 ( 20 )
μ Gomes et al., 2012
Conversion and postoperative infection rates, among patients operated on for complicated grades of acute appendicitis which the appendiceal stump was closured by metal endoclip (n = 118)
Conversion and postoperative infection rates among patients operated on with complicated appendicitis which the appendiceal stump was closured by metal endoclip (n = 118)
The treatment of appendiceal stump by metal endoclip was evaluated with the help of four clinical studies [8–11]. Two of these prospectives studied the treatment’s effectiveness in non complicated forms of appendicitis, and despite the small size of sample used; they recommended its use [8, 10]. Another study enrolled 233 patients retrospectively, from 2005 to 2010 ; however, its methodology failed to include non complicated and complicated forms of the disease. Moreover, it omitted the percentages among them and did not comment on any grading system. Thus, the comparison of the results of this research is hampered. The study of Gomes & Nunes  included non complicated and complicated forms of acute appendicitis, like the previous one; however, the survey was not designed with this objective and, therefore, the results are observable.
Thus, this series stands out from the others, as it evaluated the effectiveness of the procedure only in complicated grades of acute appendicitis. The research has shown that the treatment of appendiceal stump by metal endoclip was feasible in 90% of cases. In nine out 12 (84%) patients, the presence of appendiceal base necrosis (grade 3B), represented the most important aspect of procedure failure and other alternatives were required. In remaining three patients, the endoclip could be positioned in a healthy segment of the cecum wall. Therefore, the presence of local or diffuse peritonitis was not a disincentive event for the procedure (Tabela-1).
The mean operative time of 67.4 ± 28.1 minutes was the lowest when compared with the four other studies [18–21], but is similar to that reported by So et al.  in which all patients were operated by trained surgeons. The patients with abscess had longer operative time, which may explain the presence of more advanced cecum-appendiceal inflammatory processes and more a difficulty operation (Table 3).
Infection complications (wound and intra-abdominal) are two parameters traditionally used to validate the safe and effectiveness of laparoscopy in the management of acute appendicitis . Similarly, we can evaluate the appendiceal stump closure with metal endoclips with them. A point that should be highlighted is that the diagnosis of surgical site infection would more accurately require positive organism culture confirmation rather than just a clinical diagnosis, as used in this series and in others. A meta-analysis that compiled 11 studies has shown that from the 2175 operated patients with complicated acute appendicitis, 92 (4.2%) had infection related to the wound . Therefore, the frequency of 2.54%, observed in this series, was low and is in agreement with the literature (Table 4).
The frequency of intra-abdominal infection in the same study was 5.9% (1059 patients/63 events) . The copious irrigation of the abdominal cavity with saline solution 0.9% is cited as a possible cause of its development, proposing a judicious local irrigation, accompanied by aspiration and the application of gauze . Katkhouda et al.  have reduced its frequency from 2.4% to 0.4%, with the implementation of a laparoscopic surgery service and some simple per-operative care such as exposure of the appendicular base; concern with fragments, gaps and the appendicolith; inspection, irrigation and aspiration of the bottom of the peritoneal cavity; and the use of endobags. The frequency of intra-abdominal infection of 5.08% was similar and moreover, of the six patients with intra-abdominal collection, four of them were treated exclusively with antibiotics and the other two by means of percutaneous drainage guided by abdominal ultrasound (Table 4). No patient required reoperation, and all of them had uneventful recovery. In this context, the treatment of the appendiceal stump using metal clips qualifies as a safe and effective alternative.
The need of laparotomy is variable in its frequency and can reach 10 to 39.7% [25, 26]. Among the assigned factors are adhesions, localized perforation, diffuse peritonitis, appendix base necrosis, retrocecal position, bleeding, and inability to identify the organ, appendicular tumor, and iatrogenic lesions . In this series of 118 studied patients, laparotomy was necessary in only one (0.85%) with abscess. This low conversion rate can be explained, because in nine out 12 (84%) patients with appendiceal base necrosis, the management of appendiceal stump by metal endoclip was not possible and they could not be included in the analysis. Anyway, the appendiceal base necrosis was the most important factor responsible for procedure failure during treatment of complicated appendicitis. The use of mechanical stapler can circumvent the problem; however, because of its cost, it was not used in this series.
There were no complications related to the endoclip during its release or the fragmentation of cecum-appendicular tissue when it is placed during operation. The fact of not performing its twisting can, at least partly, explain the difference with another study published recently .
Therefore, despite being a nonrandomized study without considering the body mass index and the cost of the procedure, it draws attention to an approach, independent of the diagnosis of complicated or non-complicated acute appendicitis. It is the choice of treatment of appendiceal stump in our Service and not just mere philosophical question. Moreover, it reserves the use of endo stapler for patients with disease located in appenciceal base and appendix with large diameter. In conclusion, the appendiceal stump closure by metal endoclips, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with necrosis and large appendiceal base, the use of metal endoclips should be avoided in favor of other alternatives.
Carlos Augusto Gomes: MD. PhD. Associate Professor, Surgery Department, Hospital Universitário (HU), Universidade Federal de Juiz de Fora (UFJF) and Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA) – Brasil. TCBC (Membro Titular do Colégio Brasileiro de Cirurgiões)
The authors would like to thank MD. Sandra Marcia Carvalho Ribeiro Costa for her considerable help in the histological assessment of the removed appendix.
The place where the manuscript was produced: Surgery and Internal Medicine Unit of Monte Sinai Hospital, Juiz de Fora, Minas Gerais, Brazil.
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