No Statistics Without Clinical Evaluation
The authors conclude that laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate.
Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.
These conclusions are based on two meta-analyses (1, 2), including 599 and 637 pregnant patients, respectively, who underwent laparoscopic appendectomy. These meta-analyses are disproportionally dominated by a study which analyzed data from a patient registry in California (3). This retrospective study compared 454 patients undergoing laparoscopic surgery with 2679 patients undergoing open surgery for appendicitis between 1995 and 2002. According to the registry data for this period of time, a laparotomy was performed in 77% of all patients with suspected appendicitis, even in nonpregnant women. This is reflective of the operative techniques used at that time and cannot be applied to the year 2014, where only in exceptional cases an open appendectomy is performed.
In addition, the documentation quality of this database remains obscure. The outcome “fetal loss“ was defined by McGory (3) as ”spontaneous abortion“ or “intrauterine death“ or the procedure code for “dilation and curettage“. However, the term “intrauterine death“ also includes any conceptus after the 24th week of pregnancy and thus cannot be used as a synonym for miscarriage, as done by the authors. The outcome “early delivery“ was defined by McGory as the procedure codes “Caesarean section“ or “hysterectomy“. Are there no spontaneous preterm births in California? In this context, the authors even describe a preterm birth rate in the first trimester of 4.7%.
Meta-analyses are as good as the individual studies on which they are based. Conclusions drawn solely from such statistical data and without clinical evaluation are misleading the reader and cannot serve as a basis for the advice we give to our patients.
Prof. Dr. med. Richard Berger
Marienhaus Klinikum St. Elisabeth
der Universitäten Mainz und Maastricht
Klinik für Gynäkologie und Geburtshilfe, Neuwied
|1.||Walsh CA, Tang T, Walsh SR: Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg 2008; 6: 339–44. CrossRef MEDLINE|
|2.||Wilasrusmee C, Sukrat B, McEvoy M, Attia J, Thakkinstian A: Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg 2012; 99: 1470–8. CrossRef MEDLINE PubMed Central|
|3.||McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM: Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007; 205: 534–40. CrossRef MEDLINE|
|4.||Juhasz-Böss I, Solomayer E, Strik M, Raspé C: Abdominal surgery in pregnancy—an interdisciplinary challenge. Dtsch Arztebl Int 2014; 111: 465–72. VOLLTEXT|