Hybrid transgastric appendectomy no better than laparoscopic appendectomy

Last Updated: 2017-05-08

By Will Boggs MD

NEW YORK (Reuters Health) - Hybrid transgastric appendectomy, while feasible, offers no advantages over laparoscopic appendectomy, researchers from Germany report.

"The main message is that transgastric surgery is possible,” Dr. Georg Kaehler from University Medical Center Manheim and the University of Heidelberg told Reuters Health by email.

The problem, he said, is that “the medical industry doesn’t trust in this and doesn’t invest in new devices for flexible endoscopic surgery,” without which the operation can’t be perfected.

Natural orifice translumenal endoscopic surgery (NOTES) has been touted as the next operative frontier, although it has emerged slowly from the experimental stage to clinical case reports and occasional case studies.

Dr. Kaehler's team investigated the feasibility and safety of the novel hybrid transgastric appendectomy (TGA) in their pilot study of 65 patients (30 who underwent TGA and 35 who underwent laparoscopic appendectomy).

There were no intraoperative complications with TGA, the median duration of which was 94.5 minutes, compared with 69 minutes for laparoscopic appendectomy. One TGA and one laparoscopic appendectomy required conversion to open operation.

Three TGA patients and two laparoscopic appendectomy patients experienced postoperative complications, according to the April 23rd Surgery online report.

Postoperative pain and quality of life scores did not differ significantly between TGA and laparoscopic appendectomy.

Satisfaction rates were similar after TGA (90%) and laparoscopic appendectomy (100%).

“The hybrid transgastric appendectomy is a feasible operative technique,” the researchers conclude. “Compared with laparoscopic appendectomy, it can achieve clinically acceptable results. However, this technique remains experimental until the appropriate tools and platforms are developed to aid surgeons with the complicated procedures.”

“In our study, we offered the transgastric route to all eligible patients, but just 10% agreed with the new (experimental) method,” Dr. Kaehler said. “From my experience, especially old and multimorbid patients have a benefit from the avoidance of transabdominal incisions. Less pain means better recovery.”

He added, “Meanwhile, we performed another pure NOTES study with transgastric oophorectomy together with a transvaginal trocar.” The results have been submitted for publication.

Dr. P. Marco Fisichella from Harvard Medical School, Brigham and Women's Hospital, and the Boston VA Healthcare System told Reuters Health by email, "No matter how genial an innovation might be, an innovation could be ‘not relevant.’ In addition, this specific innovation could be performed only in specialized centers denying the vast majority of the patient the benefits of potential advantages.”

“Furthermore, the cost of this innovation might not be offset by the advantages in clinical outcomes and could burden our healthcare system,” he said. “Lastly, these cases are usually done in quaternary academic centers and would be done by experts, thus denying trainees with the opportunity to foster their skills.”

Dr. Fisichella concluded, “With this I don't mean that all innovations should be discounted in favor of the status quo. On the contrary, all innovations should be rigorously ethically and scientifically evaluated, and the results of the study should be incorporated in clinical practice for the advantage of the patients, so that by scientific selection the best method becomes the standard of care.”

SOURCE: http://bit.ly/2qJNvy2

Surgery 2017.