Does delay in appendectomy affect surgical site infection in children with appendicitis?

Purpose

The purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy.

Methods

Pediatric patients undergoing appendectomy in 2010–2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI.

Results

1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p = 0.51; SA patients, p = 0.91; CA patients, p = 0.44) or with increased time from admission to operation (all patients, p = 0.997; SA patients, p = 0.69; CA patients, p = 0.96). However, greater length of symptoms was associated with an increased risk of SSI (p < 0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p < 0.0001).

Conclusion

We found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.     

Early hospital readmission in the trauma population: Are the risk factors different?

Introduction

Hospital readmission rates will soon impact Medicare reimbursements. While risk factors for readmission have been described for medical and elective surgical patients, little is known about their predictive value specifically in trauma patients.

Patients and methods

We retrospectively identified all admissions after trauma resuscitation to our urban level 1 trauma centre from 1/1/2004 to 8/31/2010. All patients discharged alive were included. Data collected included demographics, Injury Severity Score (ISS), and length of stay (LOS). We analyzed these index admissions for the development of complications that have previously been shown to be associated with readmission. Readmissions that occurred within 30 days of index admission were identified. Univariable and multivariable analyses were performed. p < 0.05 was considered significant.

Results

We identified 10,306 index admissions, with 447 (4.3%) early (within 30 days) readmissions. Mean ISS was 11.1 (SD 10.4). On multivariable analysis, African-American race (OR 1.3, p = 0.009), pre-existing chronic obstructive pulmonary disease (COPD) (OR 1.5, p = 0.02), and diabetes mellitus (OR 1.8, p < 0.001) were associated with readmission, along with higher ISS (OR 1.01, p < 0.001), ICU admission (OR 2.1, p < 0.001), and increased LOS (OR 1.01, p < 0.001). Among many in-hospital complications examined, only the development of surgical site infection (SSI) (OR 1.9, p = 0.02) was associated with increased risk of readmission.

Conclusions

Trauma patients have a low risk of readmission. In contrast to elective surgical patients, the only modifiable risk factor for readmission in our trauma population was SSI. Other risk factors may present clinicians with opportunities for targeted interventions, such as proactive follow up or early phone contact. With future changes to health care policy, clinicians may have even greater motivation to prevent readmission.     

Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy

Background/Purpose

Single-incision laparoscopic appendectomy has been associated with improved cosmetic benefits, and decreased postoperative pain. Less is known about costs and other outcomes. Our aim was to evaluate the costs and outcomes between transumbilical laparoscopic-assisted appendectomy (TULAA) and multiport laparoscopic appendectomy (MLA).

Methods

IRB-approved retrospective review (September 2010–July 2013) of institutional medical records identified 372 pediatric patients undergoing laparoscopic appendectomy. Outcomes included costs, LOS and readmission. Costs were fully loaded operating costs from the hospital’s cost accounting database. Generalized linear regression was used to assess costs of MLA and TULAA. A subgroup analysis was performed using only patients with non-perforated appendicitis.

Results

There were 132 patients (35.5%) that underwent TULAA while 240 patients (65.5%) underwent MLA. Compared to MLA, TULAA was associated with decreased operative time (0.6 vs. 1.0 h, p < 0.0001), used in comparable proportions of interval appendectomies, but was performed less often for perforated appendicitis (9.8% vs. 22.9%, p = 0.002). Readmission and postoperative complications were similar between both groups. In the setting of non-perforated appendicitis, TULAA was associated with lower costs of $1378 relative to MLA (p = 0.009).

Conclusions

In non-perforated appendicitis, TULAA is associated with lower costs and comparable rates of readmission and postoperative complications.     

Evaluation of soluble CD14 subtype (presepsin) in burn sepsis

Background

Diagnosing sepsis is difficult in burn patients because of the inflammatory mediators that alter postburn metabolic profile. Here, we compare a new marker presepsin with procalcitonin (PCT), c-reactive protein (CRP) and white blood cell (WBC) in diagnosis and follow up of sepsis in burn patients.

Methods

Patients admitted to burn center of our institute were prospectively investigated. Presepsin, PCT, CRP and WBC levels were measured at admission and every 6 h for first day and daily thereafter. At all timing samples, patients were classified as sepsis or non-sepsis according to the current American Burn Association Consensus Criteria (ABA) 2007.

Result

37 adult patients were evaluated. A total data of 611 time points were supplied. Sepsis time points differ significantly from non-sepsis in presepsin (p < 0.0001), PCT (p = 0.0012) and CRP (p < 0.0001) levels. Non-surviving patient results differ significantly from survivors in presepsin (p < 0.0001), PCT (p = 0.0210) and CRP (p = 0.0008). AUC-ROC % values for diagnosing sepsis were 83.4% for presepsin, 84.7% for PCT, 81.9% for CRP and 50.8% for WBC. Sepsis patients had significantly different presepsin, CRP and WBC but not PCT levels on their first day of sepsis compared to previous days.

Conclusion

Plasma presepsin levels have comparable performance in burn sepsis.     

Standardization of operative equipment reduces cost

Background

We hypothesize that standardizing operative equipment, and reducing variability can safely achieve cost reduction.

Methods

We retrospectively measured supply costs, operative time, intra-operative complications, and length of stay in a cohort of 145 patients at a children's hospital who underwent a laparoscopic appendectomy. A standardized preference card for laparoscopic appendectomy was developed and implemented. Data were prospectively collected on 101 consecutive patients and compared to the retrospective cohort using multiple linear regression. A survey assessing the perception of surgeons, nurses and scrub technologists of the impact of standardization on patient safety, patient care, OR efficiency, and cost was conducted.Wilcoxon rank sum test was used to evaluate associations between clinical role and years of experience with the total level of agreement on the survey.

Results

A 20% average reduction was achieved in supply cost per case, with no significant change in operative time (p = 0.14), total time in OR (p = 0.15), or length of stay (p = 0.60). No intra-operative complications were identified in either group. Survey participants agreed that standardization improves cost and safety. Nurses tended to have greater agreement that standardization improved efficiency and patient care compared to other roles (p = 0.06).

Conclusions

Standardization of operative equipment can result in a significant cost reduction without impacting quality or delivery of care. Based on average case number per year, a total annual cost savings of > $41,000 could be realized. Survey participants agree that standardization improves cost and patient safety, yet perceptions regarding the impact on efficiency and patient care varied by occupation.     

Evaluation of the spontaneous breathing trial in burn intensive care patients

Background

The extubation failure rate in our burn patients is 30%.

Objective

To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients.

Methods

A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24 h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT.

Results

Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter (p = 0.04) in the patients who passed a SBT and those who failed extubation were significantly older (p = 0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation (p = 0.0001) and ITU length of stay (p = 0.001).

Conclusions

The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.     

Impact of Smoking and Smoking Cessation on Outcomes in Bladder Cancer Patients Treated with Radical Cystectomy

Background

Cigarette smoking is the best-established risk factor for urothelial carcinoma development.

Objective

To elucidate the association of pretreatment smoking status, cumulative exposure, and time since smoking cessation on outcomes of patients with urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC).

Design, setting, and participants

We retrospectively collected clinicopathologic and smoking variables, including smoking status, number of cigarettes per day (CPD), duration in years, and time since smoking cessation, for 1506 patients treated with RC for UCB. Lifetime cumulative smoking exposure was categorized as light short-term (≤20 CPD for ≤20 yr), light long-term (≤20 CPD for >20 yr), heavy short-term (>20 CPD for ≤20 yr), and heavy long-term (>20 CPD for >20 yr).

Intervention

RC and bilateral lymph node (LN) dissection without neoadjuvant chemotherapy.

Outcome measurements and statistical analysis

Logistic regression and competing risk analyses assessed the association of smoking with disease recurrence, cancer-specific mortality, and overall mortality.

Results and limitations

There was no difference in clinicopathologic factors between patients who had never smoked (20%), former smokers (46%), and current smokers (34%). Smoking status was associated with the cumulative incidence of disease recurrence (p = 0.004) and cancer-specific mortality (p = 0.016) in univariable analyses and with disease recurrence in multivariable analysis (p = 0.02); current smokers had the highest cumulative incidences. Among ever smokers, cumulative smoking exposure was associated with advanced tumor stages (p < 0.001), LN metastasis (p = 0.002), disease recurrence (p < 0.001), cancer-specific mortality (p = 0.001), and overall mortality (p = 0.037) in multivariable analyses that adjusted for standard characteristics; heavy long-term smokers had the worst outcomes, followed by light long-term, heavy short-term, and light short-term smokers. Smoking cessation ≥10 yr mitigated the risk of disease recurrence (hazard ratio [HR]: 0.44; p < 0.001), cancer-specific mortality (HR: 0.42; p < 0.001), and overall mortality (HR: 0.69; p = 0.012) in multivariable analyses. The study is limited by its retrospective nature.

Conclusions

Smoking is associated with worse prognosis after RC for UCB. This association seems to be dose-dependent, and its effects are mitigated by >10 yr smoking cessation. Health care practitioners should counsel smokers regarding the detrimental effects of smoking and the benefits of smoking cessation on UCB etiology and prognosis.     

Adverse Events of Intravesical Botulinum Toxin A Injections for Idiopathic Detrusor Overactivity: Risk Factors and Influence on Treatment Outcome

Background

Intravesical injection of botulinum toxin type A (BoNTA) provides effective treatment for detrusor overactivity and overactive bladder (OAB). However, the high rates of treatment-related adverse events (AEs) prevent its more widespread use.

Objective

To investigate the risk factors of increasing AEs after BoNTA injection for idiopathic detrusor overactivity (IDO).

Design, setting, and participants

This study included a total of 217 patients receiving their first intravesical BoNTA injection for refractory IDO in a tertiary university hospital from 2004 to 2009.

Measurements

AE incidence was analyzed according to gender, age, comorbidities, prostate condition in men, OAB subtype, BoNTA dose, injection site, and baseline urodynamic parameters. Successful outcome was determined based on patient perception of improvement of bladder condition at 3 mo.

Results and limitations

Successful outcomes were reported by 144 (66.3%) patients. By multivariable analysis, male gender (p = 0.013) and baseline postvoid residual (PVR) ≥100 ml (p = 0.003) were independent predictors of acute urinary retention (AUR). Baseline PVR ≥100 ml (p = 0.007) and receiving >100 U BoNTA (p = 0.029) were predictors of straining to void. The incidence of large PVR after treatment was associated with comorbidity (p = 0.011). Urinary tract infection occurred more frequently in women (p = 0.003) and in men with retaining prostate (p = 0.008). No AUR developed after bladder base/trigonal injection. Nevertheless, the occurrence of AUR or large PVR did not affect therapeutic outcome. This study is limited by nonconsecutive enrollment of patients.

Conclusions

Male gender, baseline PVR ≥100 ml, comorbidity, and BoNTA dose >100 U are risk factors for increasing incidence of AEs after intravesical BoNTA injection for IDO.     

Disease Control Outcomes from Analysis of Pooled Individual Patient Data from Five Comparative Randomised Clinical Trials of Degarelix Versus Luteinising Hormone-releasing Hormone Agonists

Background

Studies comparing the gonadotropin-releasing hormone antagonist, degarelix, with luteinising hormone-releasing hormone (LHRH) agonists indicate differences in outcomes.

Objective

To assess differences in efficacy and safety outcomes in a pooled analysis of trials comparing degarelix with LHRH agonists.

Design, setting, and participants

Data were pooled from five prospective, phase 3 or 3b randomised trials (n = 1925) of degarelix and leuprolide or goserelin in men requiring androgen deprivation therapy for the treatment of prostate cancer. Patients received either 3 mo (n = 467) or 12 mo (n = 1458) of treatment.

Intervention

Men were randomised to receive degarelix (n = 1266), leuprolide (n = 201), or goserelin (n = 458).

Outcome measurements and statistical analysis

Unadjusted Kaplan-Meier analyses were supported by the Cox proportional hazards model, adjusted for disease-related baseline factors, to estimate hazard ratios (HRs) of efficacy and safety outcomes. The Fisher exact test compared crude incidences of adverse events.

Results and limitations

Prostate-specific antigen (PSA) progression-free survival (PFS) was improved in the degarelix group (HR: 0.71; p = 0.017). For patients with baseline PSA levels >20 ng/ml, the HR for PSA PFS was 0.74 (p = 0.052). Overall survival (OS) was higher in the degarelix group (HR: 0.47; p = 0.023). OS was particularly improved with degarelix in patients with baseline testosterone levels >2 ng/ml (HR: 0.36; p = 0.006). In terms of disease-related adverse events, there were, overall, fewer joint-related signs and symptoms, musculoskeletal events, and urinary tract events in the degarelix group.

Conclusions

These data indicate clinical benefits with degarelix, including a significant improvement in PSA PFS and OS, as well as reduced incidence of joint, musculoskeletal, and urinary tract adverse events, compared with LHRH agonists.     

Standardization and improvement of care for pediatric patients with perforated appendicitis

Background/purpose

Reduction of treatment variation and application of evidenced based care are increasingly important in the current care environment. Utilizing formal quality improvement methods, an evidenced based guideline was implemented at our institution.

Methods

A guideline was established regarding timing of surgery (immediate vs interval appendectomy) and duration of antibiotics. Twelve months of baseline data were collected prior to implementation. The guideline dictates immediate appendectomy (IA) and postoperative antibiotic therapy until discharge (regular diet, clinically improved, normal complete blood count (CBC)). Data was collected prospectively during hospitalization and at 30 days postdischarge. Control charts document adherence to the overall guideline, IA, antibiotic guideline, and readmission for complications.

Results

Guideline implementation resulted in an increase in IA (79% vs 94%), decrease in the use of IV antibiotics post discharge (25% to 4%), no change in overall LOS, no change in postoperative abscess formation, and slight decrease in 30 day readmission. Charges were decreased.

Conclusion

Implementation of an evidenced based guideline resulted in significant practice change for managing perforated appendicitis. The changes suggest more efficient care without compromising patient outcome. Utilization of quality improvement methods allows for implementing and tracking the change as well as creating a platform for future improvement.     

Long-term Cancer-specific Outcomes of TaG1 Urothelial Carcinoma of the Bladder

Background

Few studies have investigated the natural history of TaG1 urothelial carcinoma of the bladder (UCB).

Objective

To assess the long-term outcomes of patients with TaG1 UCB and the impact of immediate postoperative instillation of chemotherapy (IPIC).

Design, setting, and participants

A retrospective analysis of 1447 patients with TaG1 UCB treated between 1996 and 2007 at eight centers. Median follow-up was 67.2 mo (interquartile range: 67.9). Patients were stratified into three European Association of Urology (EAU) guidelines risk categories; high-risk patients (n = 11) were excluded.

Intervention

Transurethral resection of the bladder with or without IPIC.

Outcome measurements and statistical analysis

Univariable and multivariable Cox regression models addressed factors associated with disease recurrence, disease progression, death of disease, and any-cause death.

Results and limitations

Of the 1436 patients, 601 (41.9%) and 835 (58.1%) were assigned to low- and intermediate-risk categories, respectively. The actuarial estimate of 5-yr recurrence-free survival was 56% (standard error: ±1). Advancing age (p = 0.04), tumor >3 cm (p = 0.001), multiple tumors (p < 0.001), and recurrent tumors (p < 0.001) were independently associated with increased risk of disease recurrence, whereas IPIC was associated with decreased risk (p = 0.001). The actuarial estimate of 5-yr progression-free survival was 95% ± 1. Advancing age (p < 0.001) and multiple tumors (p = 0.01) were independent risk factors for disease progression. Five-year cancer-specific survival was 98% ± 1. Advancing age (p = 0.001) and previous recurrence (p = 0.04) were associated with increased risk, whereas female gender (p = 0.02) was associated with decreased risk of cancer-specific mortality. Compared with low-risk patients, intermediate-risk patients were at significantly higher risk of disease recurrence, disease progression, and cancer-specific mortality (all p < 0.01). Limitations include the retrospective design of the study and the lack of a central pathology review.

Conclusions

TaG1 UCB patients experience heterogeneous risks of disease recurrence. We validated the EAU guidelines risk stratification in TaG1 UCB patients. IPIC was associated with a reduced risk of disease recurrence in patients with low- and intermediate-risk TaG1 UCB.     

Tracheotomy after laryngotracheopasty: Risk factors over 10 years

Background

Subglottic stenosis (SGS) is the most common congenital and/or acquired laryngotracheal anomaly requiring tracheotomy in infants. We sought to determine factors associated with a greater likelihood of tracheotomy in symptomatic infants with SGS who underwent laryngotracheoplasty (LTP).

Methods

Retrospective case series with chart review of patients undergoing single-stage LTP for SGS over a 10-year period (2001–2010) in a tertiary-care pediatric hospital.

Results

Twenty-two children (15 boys, 7 girls), with a mean gestational age of 32.5 weeks, underwent LTP with and without interpositional grafting, at a median age of 89 days. Ten patients (43%) required postoperative tracheotomy. Of patients weighing < 2.5 kg, 7 of 8 eventually required tracheotomy, while none weighing > 5 kg needed tracheotomy (p = 0.003). The average length of stay for patients with a tracheotomy was 125 days, while those without tracheotomy required only 58 days (p = 0.011). The grade of SGS (p = 0.809), gender (p = 0.968), age at surgery (p = 0.178), and gestational age (p = 0.117) were not significantly associated with the need for tracheotomy. Weight at surgery was significantly correlated with the likelihood of needing tracheotomy (p = 0.003).

Conclusions

Patients who weighed less than 2.5 kg at the time of LTP procedures were more likely to require a postoperative tracheotomy. Children who required tracheotomy had longer lengths of hospital stay.     

Features Associated with Recurrence Beyond 5 Years After Nephrectomy and Nephron-Sparing Surgery for Renal Cell Carcinoma: Development and Internal Validation of a Risk Model (PRELANE score) to Predict Late Recurrence Based on a Large Multicenter Database (CORONA/SATURN Project)

Background

Approximately 10–20% of recurrences in patients treated with nephrectomy for renal cell carcinoma (RCC) develop beyond 5 yr after surgery (late recurrence).

Objective

To determine features associated with late recurrence.

Design, setting, and participants

A total of 5009 patients from a multicenter database comprising 13 107 RCC patients treated surgically had a minimum recurrence-free survival of 60 mo (median follow-up [FU]: 105 mo [range: 78–135]); at last FU, 4699 were disease free (median FU: 103 mo [range: 78–134]), and 310 patients (6.2%) experienced disease recurrence (median FU: 120 mo [range: 93–149]).

Interventions

Patients underwent radical nephrectomy or nephron-sparing surgery.

Outcome measurements and statistical analysis

Multivariable regression analyses identified features associated with late recurrence. Cox regression analyses evaluated the association of features with cancer-specific mortality (CSM).

Results and limitations

Lymphovascular invasion (LVI) (odds ratio [OR]: 3.07; p < 0.001), Fuhrman grade 3–4 (OR: 1.60; p = 0.001), and pT stage >pT1 (OR: 2.28; p < 0.001) were significantly associated with late recurrence. Based on accordant regression coefficients, these parameters were weighted with point values (LVI: 2 points; Fuhrman grade 3–4: 1 point, pT stage >1: 2 points), and a risk score was developed for the prediction of late recurrences. The calculated values (0 points: late recurrence risk 3.1%; 1–3 points: 8.4%; 4–5 points: 22.1%) resulted in a good-, intermediate- and poor-prognosis group (area under the curve value for the model: 70%; 95% confidence interval, 67–73). Multivariable Cox regression analysis showed LVI (HR: 2.75; p < 0.001), pT stage (HR: 1.24; p < 0.001), Fuhrman grade (HR: 2.40; p < 0.001), age (HR: 1.01; p < 0.001), and gender (HR: 0.71; p = 0.027) to influence CSM significantly. Limitations are based on the multicenter and retrospective study design.

Conclusions

LVI, Fuhrman grade 3/4, and a tumor stage >pT1 are independent predictors of late recurrence after at least 5 yr from surgery in patients with RCC. We developed a risk score that allows for prognostic stratification and individualized aftercare of patients with regard to counseling, follow-up scheduling, and clinical trial design.     

Robotic Versus Laparoscopic Partial Nephrectomy: A Systematic Review and Meta-Analysis

Context

Centres worldwide have been performing partial nephrectomies laparoscopically for greater than a decade. With the increasing use of robotics, many centres have reported their early experiences using it for nephron-sparing surgery.

Objective

To review published literature comparing robotic partial nephrectomy (RPN) with laparoscopic partial nephrectomy (LPN).

Evidence acquisition

An online systematic review of the literature according to Cochrane guidelines was conducted from 2000 to 2012 including studies comparing RPN and LPN. All studies comparing RPN with LPN were included. The outcome measures were the patient demographics, tumour size, operating time, warm ischaemic time, blood loss, transfusion rates, length of hospital stay, conversion rates, and complications. A meta-analysis of the results was conducted. For continuous data, a Mantel-Haenszel chi-square test was used; for dichotomous data, an inverse variance was used. Each was expressed as a risk ratio with a 95% confidence interval p < 0.05 considered significant.

Evidence synthesis

A total of 717 patients were included, 313 patients in the robotic group and 404 patients in the laparoscopic group (seven studies). There was no significant difference between the two groups in any of the demographic parameters except for age (age: p = 0.006; sex: p = 0.54; laterality: p = 0.05; tumour size: p = 0.62, tumour location: p = 57; or confirmed malignant final pathology: p = 0.79). There was no difference between the two groups regarding operative times (p = 0.58), estimated blood loss (p = 0.76), or conversion rates (p = 0.84). The RPN group had significantly less warm ischaemic time than the LPN group (p = 0.0008). There was no difference regarding postoperative length of hospital stay (p = 0.37), complications (p = 0.86), or positive margins (p = 0.93).

Conclusions

In early experience, RPN appears to be a feasible and safe alternative to its laparoscopic counterpart with decreased warm ischaemia times noted.     

Incidence and outcomes of unexpected pathology findings after appendectomy

Purpose

Pathologic evaluation of the appendix after appendectomy is routine and can identify unexpected findings. We evaluated our experience in children undergoing appendectomy to review the clinical course of patients with unexpected appendiceal pathology.

Methods

After IRB approval, a retrospective review was conducted on patients who underwent appendectomy from January 1, 1995 to March 1, 2011. Patient demographics, diagnosis, pathological findings, disease outcomes, and treatment were collected only on patients with abnormal pathology.

Results

3602 patients underwent appendectomy. 113 patients had normal appendices, and 86 patients had unexpected findings, including carcinoid tumor (n = 9), pinworm (n = 34), granuloma (n = 14), eosinophilic infiltrates (n = 18), and other (n = 11). All cases of carcinoid tumor were completely resected, with no recurrence or need for reoperation. Of the 34 patients with pinworm infestation, 41.2% underwent antimicrobial therapy, and none had post-operative symptoms. One patient (7%) with an appendiceal granuloma developed Crohn’s disease. Three patients (16.7%) with eosinophilia developed symptomatic intestinal eosinophilia.

Conclusions

Pediatric appendiceal carcinoid is an incidental finding; in this series, none required further intervention. Appendiceal granulomas are not commonly associated with developing Crohn’s disease in the short term. Routine antibiotics for the treatment of pinworms are adequate. Patients with appendiceal eosinophilia may develop symptomatic intestinal eosinophilia.     

The Impact of Solitary and Multiple Positive Surgical Margins on Hard Clinical End Points in 1712 Adjuvant Treatment–Naive pT2–4 N0 Radical Prostatectomy Patients

Background

Positive surgical margins (PSMs) increase the risk of biochemical recurrence (BCR) after radical prostatectomy (RP), but their impact on hard clinical end points is a topic of ongoing discussion.

Objective

To evaluate the influence of solitary PSMs (sPSMs) and multiple PSMs (mPSMs) on important clinical end points.

Design, setting, and participants

Data from 1712 patients from the Centre Hospitalier Universitaire de Québec with pT2–4 N0 prostate cancer (PCa) and undetectable prostate-specific antigen after RP were analyzed.

Intervention

RP without neoadjuvant or adjuvant treatment.

Outcome measurements and statistical analysis

Kaplan-Meier analysis estimated survival functions, and Cox proportional hazards models addressed predictors of clinical end points.

Results and limitations

Median follow-up was 74.9 mo. A total of 1121 patients (65.5%) were margin-negative, 281 patients (16.4%) had sPSMs, and 310 patients (18.1%) had mPSMs. A total of 280 patients (16.4%) experienced BCR, and 197 patients (11.5%) were treated with salvage radiotherapy (SRT). Sixty-eight patients (4.0%) received definitive androgen deprivation therapy, 19 patients (1.1%) developed metastatic disease, and 15 patients (0.9%) had castration-resistant PCa (CRPC). Thirteen patients (0.8%) died from PCa, and 194 patients (11.3%) died from other causes. Ten-year Kaplan-Meier estimates for BCR-free survival were 82% for margin-negative patients, 72% for patients with sPSMs, and 59% for patients with mPSMs (p < 0.0001). Time to metastatic disease, CRPC, PCa-specific mortality (PCSM), or all-cause mortality did not differ significantly among the three groups (p = 0.991, p = 0.988, p = 0.889, and p = 0.218, respectively). On multivariable analysis, sPSMs and mPSMs were associated with BCR (hazard ratio [HR]: 1.711; p = 0.001 and HR: 2.075; p < 0.0001), but sPSMs and mPSMs could not predict metastatic disease (p = 0.705 and p = 0.242), CRPC (p = 0.705 and p = 0.224), PCSM (p = 0.972 and p = 0.260), or all-cause death (p = 0.102 and p = 0.067). The major limitation was the retrospective design.

Conclusions

In a cohort of patients who received early SRT in 70% of cases upon BCR, sPSMs and mPSMs predicted BCR but not long-term clinical end points. Adjuvant radiotherapy for margin-positive patients might not be justified, as only a minority of patients progressed to end points other than BCR. PCSM was exceeded 15-fold by competing risk mortality.     

Predictive Factors for Ipsilateral Recurrence After Nephron-sparing Surgery in Renal Cell Carcinoma

Background

Ipsilateral recurrence after nephron-sparing surgery (NSS) is rare, and little is known about its specific determinants.

Objective

To determine clinical or pathologic features associated with ipsilateral recurrence after NSS performed for renal cell carcinoma (RCC).

Design, setting, and participants

We analysed 809 NSS procedures performed at eight academic institutions for sporadic RCCs retrospectively.

Measurements

Age, gender, indication, tumour bilaterality, tumour size, tumour location, TNM stage, Fuhrman grade, histologic subtype, and presence of positive surgical margins (PSMs) were assessed as predictors for recurrence in univariate and multivariate analysis by using a Cox proportional hazards regression model.

Results and limitations

Among 809 NSS procedures with a median follow-up of 27 (1–252) mo, 26 ipsilateral recurrences (3.2%) occurred at a median time of 27 (14.5–38.2) mo. In univariate analysis, the following variables were significantly associated with recurrence: pT3a stage (p = 0.0489), imperative indication (p < 0.01), tumour bilaterality (p < 0.01), tumour size >4 cm (p < 0.01), Fuhrman grade III or IV (p = 0.0185), and PSM (p < 0.01). In multivariate analysis, tumour bilaterality, tumour size >4 cm, and presence of PSM remained independent predictive factors for RCC ipsilateral recurrence. Hazard ratios (HR) were 6.31, 4.57, and 11.5 for tumour bilaterality, tumour size >4 cm, and PSM status, respectively. The main limitations of this study included its retrospective nature and a short follow-up.

Conclusions

RCC ipsilateral recurrence risk after NSS is significantly associated with tumour size >4 cm, tumour bilaterality (synchronous or asynchronous), and PSM. Careful follow-up should be advised in patients presenting with such characteristics.     

Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail

Objective

Our study aimed to determine whether the displacement and morphology of a fragment in femur fracture with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association/32-B/32-C (AO/OTA/32-B/32-C) classification affect the outcomes following closed reduction and internal fixation with an interlocking nail.

Design

This was a retrospective study.

Setting

The study was conducted at a Level III trauma centre.

Patients

A total of 50 consecutive patients presenting femoral shaft fracture with AO/OTA-type 32-B/32-C were included in the present study.

Interventions

Patients were divided into two groups according to the displacement of the fragments. In the large displacement group, patients were further subgrouped according to whether a reversed morphology of the fragment was present.

Outcomes measurement

The radiographic union score of femur (RUSF), the mean union time and the re-operation rate were assessed.

Results

The union rate of small- and large-gap groups at 12 months postoperatively was 75.9% and 21.1%, respectively (p = 0.000). The mean union time of those union cases in these two groups was 7.8 and 13.0 months, respectively (p = 0.000). The union rate of the non-reversed and reversed groups at 12 months postoperatively was 30% and 11.1%, respectively (p = 0.179). The mean RUSF at 12 months in the non-reversed and reversed groups was 8.8 and 8.3, respectively (p = 0.590). However, we found that patients presenting a reversed fragment had an increased risk of more than one re-operation (p = 0.030).

Conclusions

A fragmentary displacement of >1 cm in AO/OTA-type 32-B/32-C femoral shaft fracture after nailing affected bone healing. Among the large-gap group patients, an unreduced reverse fragment presented a negative prognostic factor for re-operation.

Level of evidence

Prognostic level III.     

The primary determinants of radiation use during fixation of proximal femur fractures

Objectives

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

Design

Retrospective cohort study.

Setting

Level I trauma centre.

Cohort

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

Main outcome measures

Fluoroscopy time, dose-area-product (DAP).

Results

Longer fluoroscopy time was correlated with higher body mass index (p = 0.04), subtrochanteric fracture (p < 0.001), attending surgeon (p = 0.001), and implant type (p < 0.001). Increased DAP was associated with higher body mass index (p < 0.001), subtrochanteric fracture (p = 0.002), attending surgeon (p = 0.003), lateral body position (p < 0.001), and implant type (p = 0.05).

Conclusion

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.     

Postoperative antibiotics are not associated with decreased wound complications among patients undergoing appendectomy for complicated appendicitis

Background

The objective of this study was to determine the role of postoperative antibiotics in reducing complications in patients undergoing appendectomy for complicated appendicitis.

Methods

We performed a 5-year retrospective cohort study of adult patients who underwent appendectomy for acute appendicitis. Patients with complicated appendicitis (perforated or gangrenous) were analyzed on the basis of whether they received postoperative antibiotics. Main outcome measures were wound complications, length of stay (LOS), and readmission to hospital.

Results

Of 410 patients with complicated appendicitis, postoperative antibiotics were administered to 274 patients (66.8%). On univariate and multivariate analyses, postoperative antibiotics were not associated with decreased wound complications or readmission, but independently predicted an increased LOS (P = .01).

Conclusions

Among patients with complicated appendicitis, postoperative antibiotics were not associated with a decrease in wound complications but did result in an increased hospital LOS.