Does Peer-Reviewed Publication Change theHabits of Surgeons?

Bruce Jones, DO, Erick Ratzer, MD, Jeffrey Clark, MD, Francine Zeren, MSN, William Haun, MD,Denver, Colorado

BACKGROUND: From April 1994 to December1995 a prospective randomized trial was con-ducted at our institution comparing outcomes oflaparoscopic and open appendectomy. It demon-strated no significant advantage to laparoscopicappendectomy. Our current study evaluateswhether surgeon’s habits at our hospital havebeen influenced by our previously publishedstudy.

METHODS: Charts were reviewed for patients whounderwent appendectomy from August 1998 toDecember 1998. In addition, a formal survey wasconducted of all staff surgeons to ascertain theirprocedure of choice for appendicitis, and thereasons for their preference.

RESULTS: Seventy-nine percent of the appendec-tomies were attempted laparoscopically. Themedian operative time was longer for laparo-scopic appendectomy, and median hospitalcharges were higher. Survey results showed thatmost staff surgeons prefer laparoscopic appen-dectomy.

CONCLUSIONS: Despite our own published papersupporting open appendectomy over laparo-scopic appendectomy, laparoscopic appendec-tomy has become the standard of care at ourinstitution for the treatment of appendicitis. AmJ Surg. 2000;180:566–569. © 2001 by ExcerptaMedica, Inc.

Since the first description of laparoscopic appendec-tomy (LA) by Semm1 in 1983, it has failed to achievethe same widespread acceptance that laparoscopic

cholecystectomy has achieved. The advantages of laparo-scopic cholecystectomy (less postoperative pain, morerapid recovery, and improved cosmesis) may not apply toLA, as open appendectomy (OA) is already associated withminimal morbidity and short hospital stay.

Numerous randomized studies have compared OA withLA.2–6 The conclusions of these studies vary, but thedifferences in outcomes between the procedures are mini-mal. Studies that report hospital charges4–6 conclude thatthe charges for LA are higher. A nationwide study of the

charges of the two procedures also concluded that theaverage hospital charges for LA are significantly higherthan OA.7

A prospective randomized controlled trial was conductedin our hospital, from April 1994 to December 1995, com-paring LA and OA.6 This trial, consisting of 50 patients,was published in Archives of Surgery, July 1997. It showedthat there was no significant difference in complications,postoperative pain, length of hospitalization, or recoverytime between the two procedures. Open appendectomy wasshown to result in shorter operating time and lower oper-ating room and hospital charges than LA. The conclusionsof this paper were that LA offered no advantage over OAfor routine appendicitis, and should be reserved for obesepatients or women of childbearing age, where diagnosticlaparoscopy would be helpful.

Our current study was designed to evaluate the preferenceof our surgeons and to see whether they have been influ-enced by our previous study. In addition, we evaluatedoutcomes and hospital charges of LA and OA to see ifthese have changed since our previous study.

METHODSA retrospective review was conducted of all appendecto-

mies done on adults (.18 years of age), from August 1998to December 1998, at Exempla Saint Joseph Hospital, alarge community teaching hospital. Charts were reviewedfor the 200 adult patients that underwent appendectomyfor presumed appendicitis. Those patients that had inci-dental appendectomy as part of another procedure, or re-quired a more extensive procedure (ie, cecectomy), even iffor appendicitis, were excluded. Utilization of LA and OAwas compared as well as operative time, length of stay,complication rates, and total hospital charges. Operativetime was determined from time of incision to end of oper-ation.

Length of stay was determined as time from end of oper-ation to time of discharge. Procedures were performed by25 staff surgeons and surgical residents. The choice ofprocedure was made by attending surgeons.

A written survey was conducted of the 25 attendingsurgeons, to ascertain their procedure of choice, and thereasons for their preference.

RESULTSOf the 200 appendectomies, 158 (79%) were attempted

laparoscopically. Of these, 19 were converted to openprocedures (12%), 12 through a McBurney’s incision and 7through a lower midline incision. Forty-two appendecto-mies were done open. Six of these were through a lowermidline incision.

An “intent to treat” analysis was done comparing allpatients in both groups (Table). There was no statistically

From the Department of Surgery, Exempla Saint Joseph Hos-pital, Denver, Colorado.

Requests for reprints should be addressed to William E. Haun,MD, 1601 E. 19th Avenue, Suite 4500, Denver, Colorado 80218.

Presented at the 52nd Annual Meeting of the SouthwesternSurgical Congress, Colorado Springs, Colorado, April 9–12,2000.

566 © 2001 by Excerpta Medica, Inc. 0002-9610/00/$–see front matterAll rights reserved. PII S0002-9610(00)00495-5

significant difference in age, gender, median length of stay,or complications. The pathologic results of the two groupswere similar. There were 3 normal appendixes in the OAgroup versus 15 in the LA group (P 5 0.77). Eight of theOA group had pathologic signs of perforation and 16 in theLA group did (P 5 0.114). Median operative time for LAwas 52 minutes versus 46 minutes for OA (P 5 0.003).Laparoscopic appendectomy resulted in a median cost of$9,773, compared with a median cost of $6,582 for OA (P,0.001).

A second analysis was performed that excluded conver-sions from the LA group to OA. The patients that had OAthrough a midline incision were retained in the analysiseven though they had longer length of stay. The resultswere similar, with the only significant differences being inthe hospital charges and operative time. Median cost in theLA group was $9,410 versus $6,582, in the OA group (P 50.001). Median operative times were 50 and 46 minutes forthe LA and OA groups, respectively (P 5 0.02). This moreconservative analysis eliminates increases in charges andoperative time from laparoscopic appendectomies con-verted to open and still shows an advantage in charges andoperative time in the OA group.

A written survey was conducted of staff surgeons thatperform appendectomy at our institution. The surveyasked what the surgeon’s procedure of choice was forappendicitis, the main reasons for their choice, andwhether they were aware of the previous study con-ducted at our institution. All 25 of the surgeons re-sponded. Eighteen of the surgeons reported that theyprefer LA, 4 prefer OA, and 3 said that the procedurewould vary depending on characteristics of the individ-ual patient. Of those who prefer LA the main reasongiven for preference was better visualization with LA (6surgeons), 3 stated that gender was important in theirdecision, and for 3, physical structure of the patient wasimportant. Eighteen of the 25 surgeons responded thatthey were aware of the previous study; 15 of the 18 thatprefer LA were aware of the previous study.

COMMENTSLaparoscopic appendectomy was initially introduced in

1983. The fact that this procedure remains controversial

after this long period of time is evidence that its advantagesover OA, if any, are minimal. Fallahzadeh8 has suggestedthat in order for LA to be accepted it should decreasehospital stay, speed return to normal activity, be costeffective, and have fewer complications. His retrospectivereview concluded that LA did not meet these criteria.

Several randomized controlled trials have been done inthe United States.2–6 Results of these studies have beenvaried, with some authors reporting no advantage withLA,4–6 and others reporting less pain and faster return tonormal activity.2,3 Three of these studies comparedcharges, two report higher hospital charges for LA,5,6 andone reported no significant difference.4 A national analysisof average total hospital charges for LA and OA for 1997showed significantly higher charges for LA.7 These resultsimply the advantages of LA are questionable, but the costis almost certainly higher, which is supported by our cur-rent and previous investigations.

Our previous prospective randomized study of 50 pa-tients6 showed a statistical difference in length of opera-tion, operating room charges, and total hospital charges.Length of operation, calculated as median total operatingroom time, was 81.7 versus 66.8 minutes in the LA versusOA group (P ,0.002). Operating room charges were$3,191 for LA and $1,514 for OA (P ,0.001), and totalhospital charges were $5,430 and $3,673 for the respectivegroups (P ,0.001). Length of hospital stay was 1.1 days inthe LA group and 1.2 days in the OA group (P 5 notsignificant). Pain control was evaluated 12 hours aftersurgery, and was rated on a scale of 0 (no pain) to 10 (mostpain). The mean pain scores were 4 in the LA group and3.7 in the OA group (P 5 not significant). Time of returnto work was identical in both groups (median 14 days).Complications were not significantly different (5 in the LAgroup versus 1 in the OA group).

The conclusions of this earlier study were that LA is a safeprocedure, may be beneficial in obese patients, and addsthe benefit of diagnostic laparoscopy when the diagnosis isin question. However, it does not offer any proven benefitsover OA for routine appendicitis. We also concluded thatLA resulted in higher hospital charges, higher operatingroom charges and longer operating room times than OA.

TABLEResults of Intent-to-Treat analysis

Laparoscopic OpenP

Value

Number 158 42Median age (years) 38 34 0.30

(range 18–85) (range 18–84)Gender (M/F) 70/88 23/19 0.23Median LOS (hours) 26 24 0.88

(range 3–227) (range 7–236)Median charges $9,773 $6,582 ,0.001

(range $5,905–28,836) (range $5,038–18,580)Median operative time (min) 52 46 0.003

(range 16–119) (range 19–83)Complications 13 3 0.81

LOS 5 length of stay.

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This current study was undertaken to evaluate how ourtreatment of appendicitis was affected by the initial trial,and to see if the conclusions of the first study were stillvalid given the experience with LA has increased. Oper-ating room charges were not assessed in our current review,but median hospital charges remain significantly higher forLA than OA ($9,773 versus $6,582, P ,0.001). Operatingroom times in our current study were measured from be-ginning of operation to its conclusion, and for this reasonare shorter than those reported in the previous study,where the time reported was total operating room time.Median operative time still remains significantly higher forLA when compared with OA (52 versus 46 minutes, P 50.003). Length of stay remains short for both procedures,and not significantly different; complication rates are alsosimilar.

Outcome has not significantly changed since the random-ized trial conducted at our hospital. LA remains a safeprocedure based on both studies, and the difference inoperative time, while statistically significant, may not haveclinical importance. The difference in hospital chargeshowever, is most certainly important, especially if surgeonsare going to take responsibility for cost containment.

It is apparent that the previous study did not affect theway that acute appendicitis is treated at our hospital.Seventy-nine percent of the appendectomies reviewed inthis study were done laparoscopically. The reasons for thisare elusive. Most of the staff surgeons that prefer LA wereaware of the previous study (15 of 18), so ignorance of thedata does not explain our results. The survey did notspecifically address whether or not the surgeons thoughtthe results of the study were valid; however, most hadparticipated in the study. Reasons given by our surgeons fortheir preference primarily involved the technical aspect ofthe procedure such as better visualization, patient gender,

and body habitus. Patient preference was not listed as animportant factor in their choice.

Although the reasons are not clear from this study, lapa-roscopic appendectomy has become the preferred methodfor treatment of appendicitis at our hospital despite noproven benefit over open appendectomy. Additionally, ourprevious study and most other published articles on thesubject have consistently shown longer operating times,higher hospital charges, and a trend toward higher com-plication rates in ruptured appendices. However, we canconclude that the data in the literature, and particularlyour own data, have not affected the habits of surgeons inour hospital for the treatment of acute appendicitis. Wepublish these results in an attempt to stimulate furtherdiscussions on the topic of peer-reviewed literature and itseffect on the habits of surgeons and other physicians.

REFERENCES1. Semm K. Endoscopic appendectomy. Endoscopy. 1983;15:59–64.2. Ortega AE, Hunter JG, Peters JH, et al. A prospective random-ized comparison of laparoscopic appendectomy with open appen-dectomy. Am J Surg. 1995;169:208–213.3. Frazee RC, Roberts JW, Symmonds RE, et al. A prospectiverandomized trial comparing open versus laparoscopic appendec-tomy. Ann Surg. 1994;219:725–731.4. Martin LC, Puente I, Sosa JL, et al. Open versus laparoscopicappendectomy: a prospective randomized comparison. Ann Surg.1995;222:256–262.5. Williams MD, Collins JN, Wright TF, Fenoglio ME. Laparo-scopic versus open appendectomy. South Med J. 1996;89:668–674.6. Minne L, Varner D, Burnell A, et al. Laparoscopic versus openappendectomy. Arch Surg. 1997;132:708–712.7. Mushinski M. Laparoscopic and open appendectomies—averagecharges, 1997. Stat Bull Metrop Insur Co. 1999;80:23–31.8. Fallahzadeh H. Should a laparoscopic appendectomy be done?Am Surg. 1998;64:231–233.

DISCUSSIONDr. John F. Eidt (Little Rock, AR): I think the authors

have used a rather broad brush to paint this topic, butthey’ve touched on some interesting questions. How doessurgical literature effect clinical practice? How long does ittake for new information to permeate the practice of sur-gery? Are we as surgeons, victims of our training, failing torecognize definitive information that should be incorpo-rated into our practices? Or, are we too enamored with newtechnology, too influenced by market forces and too eagerto keep up with our colleagues in the adoption of newtechniques?

In my opinion, surgery has always been based on evi-dence, despite the recent emphasis on so-called evidence-based medicine. The concept, however, of grading medicalliterature, and determining its impact on clinical practice,I think is quite useful. As you know, class one studies aretypically large, prospective, and usually randomized studieswith low risk for type one and type two errors. Class twostudies are smaller prospective studies, with an increasedrisk of type two errors, that are due chiefly to their smallersample size.

Definitive recommendations for treatment are usuallybased on the confluence of results from more than one class

one study. In their previously published work, the authorsconcluded that laparoscopic appendectomy was associatedwith longer operating times and increased operating roomand hospital charges. There was no apparent benefit withregard to postoperative pain, hospitalization times or re-covery times. In the current study, laparoscopic operatingtimes more closely approach the open counterparts, andthe difference was really only six minutes. I’m not surethat’s much of a relevant difference. In addition, they againuse the term “charges” as a substitute for costs, and it seemsto me the correlation between charges and cost is insuffi-ciently close to permit any meaningful conclusions fromcharge data.

There are, as you’ve seen, at least 5 other prospectivestudies of laparoscopic appendectomy and open appendec-tomy, and these are all essentially class two studies, rela-tively small studies that do have the potential for type twoerrors. And while it’s generally true that laparoscopic ap-pendectomy has been shown to be slightly more costly thanopen appendectomy, there’s considerable variation inother end points in these studies, including operating time,post operative pain, recovery time and post op complica-tions.

In my opinion, there’s really no available surgical litera-

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ture on which to base a grade A recommendation regardingthe definitive answer for the role of laparoscopic appen-dectomy. And in particular, it’s difficult to identify that subgroup of patients, who would benefit from laparoscopicappendectomy and in whom it would be cost effective.Laparoscopy is probably appropriate in cases where thediagnosis is in doubt.

I have 3 primary questions. As I understand your data, thepatients in the current study were selected by identifyingpatients who had undergone appendectomy. Were therepatients during the same time period who underwent lapa-roscopy for possible appendicitis and were found to have analternative diagnosis and in whom the appendix was notremoved? By eliminating patients who did not undergoappendectomy, you may significantly reduce the apparentbenefit of laparoscopy as a diagnostic tool.

Secondly, how does diagnostic laparoscopy reduce theneed for other diagnostic tests, such as CT and ultrasound?Were there fewer adjunctive tests performed in the lapa-roscopic appendectomy group that you looked at?

Finally, it also appears to me that perhaps the surgeons inyour hospital were affected by your previous data. Forexample, although it was not statistically different, therewas a larger proportion of female patients that were se-lected for laparoscopy in the data that you presented,which was exactly what was recommended by your previ-ous paper.

Since you really don’t have any data on surgeon prefer-ences before your previous publication, what would youestimate that the utilization of laparoscopic appendectomyshould be?

And do you think the pendulum is swinging back so that

the sort recent interest in laparoscopy is being toned downas time goes by?

CLOSINGDr. Bruce Jones: Did we review the number of laparo-

scopies that were done in our institution for diagnosis otherthan appendicitis and in those cases where the appendixwas not removed? We did not specifically look at that. Ithink, in most cases, where we take a patient to theoperating room for abdominal pain and have a negativediagnostic laparoscopy, the appendix is removed anyway.And those patients were reviewed in this case. But, I can’tsay if there were patients in whom the appendix wasn’tremoved, because we did not specifically look at diagnosticlaparoscopy by itself.

As far as whether tests were done in the laparoscopicversus the open group, that also was not specifically lookedat. That would be an interesting thing to check in a futurereview. But I know that CT scanning is used fairly liberallyat our institution, and so a number of both the open andlaparoscopic groups may have gotten CT scans.

I don’t know how to estimate how many appendectomiesshould be done laparoscopically at our institution. And thepoint is well taken that there were more females in thelaparoscopic group than the open group. But, my impres-sion from our study was that the procedure of choice wasmore dependent on the surgeon, than on the gender of thepatient. Most of the patients who were done open, weredone by the same 4 or 5 surgeons. And most of those thatwere done laparoscopic were done by the same 18 or 19surgeons. I wouldn’t be able to estimate exactly how manyshould be done laparoscopically.

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