Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis

BackgroundThe goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis.MethodsA multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016–2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles.Results100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm³; OR 5.31 [95% CI: 4.87–5.80]), followed by female sex (OR 1.55 [95% CI: 1.42–1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13–17 years with elevated WBC [1.1%] vs. females 3–4 years with normal WBC [15.8%]).ConclusionsContemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted.Level of EvidenceIII.     

Efficacy and safety of cold snare polypectomy for sessile serrated polyps ≥ 10 mm: A systematic review and meta-analysis

BackgroundCold snare polypectomy (CSP) is a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. However, the efficacy and safety of this technique remain undetermined.AimsWe aimed to comprehensively evaluate the efficacy and safety of CSP for SSPs ≥ 10 mm.MethodsPubMed, EMBASE, Web of Science and Cochrane Library were searched up to January 2021.ResultsA total of 10 studies consisting of 1727 SSPs (range, 10–40 mm) from 1021 patients were included. The overall rates of technical success, adverse events (AEs) and residual SSPs were 100%, 0.7% and 2.9%, respectively. Subgroup analysis showed that the rates of technical success and AEs were comparable between CSP and cold endoscopic mucosal resection (EMR) (99.9% vs. 100% and 1.3% vs. 0.5%, respectively), between the proximal and distal colon (100% vs. 99.9% and 0.3% vs. 0, respectively), and between polyps of 10–19 mm and ≥20 mm (99.8% vs. 100% and 0.9% vs. 0, respectively). However, subgroup analysis showed that the rate of residual SSPs was slightly lower in CSP compared with cold EMR (1.3% vs. 3.9%), as well as in polyps of 10–19 mm compared with those ≥20 mm (3.1% vs. 4.7%).ConclusionCSP was an effective and safe technique for removing SSPs ≥ 10 mm.     

Validation of the Modena bleeding score in endoscopic sinus surgery

IntroductionThe Modena bleeding score is a categorical rating scale that allows the assessment of the surgical field in relation to bleeding during endoscopic surgery. It has recently been presented and validated in the field of endoscopic ear surgery by the present authors. The Modena bleeding score provides five grades for rating the surgical field during endoscopic procedures (from grade 1 ? no bleeding to grade 5 ? bleeding that prevents every surgical procedure except those dedicated to bleeding control).ObjectiveThe aim of this study was to validate the Modena bleeding score in the setting of endoscopic sinus surgery.MethodsFifteen three-minute videos of endoscopic sinus surgery procedures (each containing three bleeding situations) were evaluated by 15 specialists, using the Modena bleeding score. Intra and inter-rater reliability were assessed, and the clinical validity of the Modena bleeding score was calculated using a referent standard.ResultsThe data analysis showed an intra-rater reliability ranging from 0.6336 to 0.861. The inter-rater reliability ranged from 0.676 to 0.844. The clinical validity was α = 0.70; confidence limits: 0.64 ? 0.75, corresponding to substantial agreement.ConclusionThe Modena bleeding score is an effective method to score bleeding during endoscopic sinus surgery. Its application in future research could facilitate the performance and efficacy assessment of surgical techniques, materials or devices aimed to bleeding control during endoscopic sinus surgery.     

A Pre-Protocol/Post-Protocol Quality Improvement Initiative Specific to One Hospital for Security of Pathologic Specimen

ObjectiveThe objective of this study was to reduce errors in a pathologic specimen with the help of a protocol systematizing the pathology specimen management process in the operating room.Materials and methodThis quasi-experimental study was carried out in the operating room unit of a research and training hospital. A protocol systematizing the process of specimen management in secure surgical pathology and prepared in light of the current literature was used as an intervention, and the effectiveness of the protocol was tested.ResultsIt was determined that the rate of adverse events decreased from .3226% (68 of 21,078) to .032% (6 of 18,706) after the protocol systematizing the surgical pathology specimen management process prepared by the researchers, and the protocol was found to be effective by 90% (P = .03).ConclusionBased on the data obtained in this study, we recommend the use of a pathologic specimen management protocol in the operating room.     

Future directions in managing aniridia-associated keratopathy

Congenital aniridia is a panocular disorder that is typically characterized by iris hypoplasia and aniridia-associated keratopathy (AAK). AAK results in the progressive loss of corneal transparency and thereby loss of vision. Currently, there is no approved therapy to delay or prevent its progression, and clinical management is challenging because of phenotypic variability and high risk of complications after interventions; however, new insights into the molecular pathogenesis of AAK may help improve its management. Here, we review the current understanding about the pathogenesis and management of AAK. We highlight the biological mechanisms involved in AAK development with the aim to develop future treatment options, including surgical, pharmacological, cell therapies, and gene therapies.     

Hirschsprung-associated inflammatory bowel disease: A multicenter study from the APSA Hirschsprung disease interest group

Background/PurposeA small number of Hirschsprung disease (HD) patients develop inflammatory bowel disease (IBD)-like symptoms after pullthrough surgery. The etiology and pathophysiology of Hirschsprung-associated IBD (HD-IBD) remains unknown. This study aims to further characterize HD-IBD, to identify potential risk factors and to evaluate response to treatment in a large group of patients.MethodsRetrospective study of patients diagnosed with IBD after pullthrough surgery between 2000 and 2021 at 17 institutions. Data regarding clinical presentation and course of HD and IBD were reviewed. Effectiveness of medical therapy for IBD was recorded using a Likert scale.ResultsThere were 55 patients (78% male). 50% (n = 28) had long segment disease. Hirschsprung-associated enterocolitis (HAEC) was reported in 68% (n = 36). Ten patients (18%) had Trisomy 21. IBD was diagnosed after age 5 in 63% (n = 34). IBD presentation consisted of colonic or small bowel inflammation resembling IBD in 69% (n = 38), unexplained or persistent fistula in 18% (n = 10) and unexplained HAEC >5 years old or unresponsive to standard treatment in 13% (n = 7). Biological agents were the most effective (80%) medications. A third of patients required a surgical procedure for IBD.ConclusionMore than half of the patients were diagnosed with HD-IBD after 5 years old. Long segment disease, HAEC after pull through operation and trisomy 21 may represent risk factors for this condition. Investigation for possible IBD should be considered in children with unexplained fistulae, HAEC beyond the age of 5 or unresponsive to standard therapy, and symptoms suggestive of IBD. Biological agents were the most effective medical treatment.Level of EvidenceLevel 4     

Surgical emergencies in pregnancy in the era of modern diagnostics and treatment

Pregnancy can be complicated with different surgical emergencies which may potentially endanger the mother as well as foetus. In the modern era of advanced diagnostics and treatments, neither of them in response to a surgical emergency in a pregnant woman should be delayed. Appropriate early intervention is essential to decrease the morbidity and mortality. Following article encompasses common surgical emergencies that can arise in a pregnant woman and tries to suggest the approach that may be taken to reduce the burden of morbidity and mortality.     

Place et modalités de l’irradiation postopératoire dans la prise en charge des métastases cérébrales

Metastases are the most common brain tumors. After surgery, stereotactic radiotherapy (SRT) of the resection cavity is the standard of care. Data from two randomized trials indicate that SRT to the surgical bed is an effective treatment in reducing local failure as compared with observation, while reducing the risk of cognitive deterioration and maintaining quality of life as compared with whole brain radiation therapy. Local control appears higher after hypofractionated SRT compared to single-fraction SRT. Several questions such as target volumes, the optimal regimen in particular for large tumor bed, strategies to reduce the risk of lepto-meningeal recurrence, and the treatment sequence still need to be answered.     

归脾丸加减对围绝经期功血患者免疫功能的影响

目的:探究归脾丸加减对围绝经期功血患者免疫功能、白细胞介素2(IL-2)、可溶性白细胞介素-2受体(sIL-2R)的影响。方法:选取2019年3月至2018年6月山东省济南市中西医结合医院收治的符合纳入条件的围绝经期功血患者118例作为研究对象,按照就诊顺序编号随机分为对照组和观察组,每组59例。对照组常规西医治疗,观察组加用归脾丸加减治疗,均治疗3个月。观察2组治疗前、完成治疗后T淋巴细胞亚群、IL-2、sIL-2R、凝血功能、子宫内膜厚度、激素水平、症状积分变化;完成治疗后统计治疗过程中的不良反应。结果:1)完成治疗后,2组CD3+、CD4+、CD4+/CD8+、IL-2较治疗前均显著升高,CD8+、sIL-2R则显著下降(P<0.05);完成治疗后观察组CD8+、sIL-2R显著低于于对照组,余均高于对照组(P<0.05)。2)完成治疗后2组凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、子宫内膜厚度较治疗前均显著下降(P<0.05),完成治疗后观察组以上指标均显著低于对照组(P<0.05)。3)完成治疗后2组黄体生成素(LH)、促排卵生成素(FSH)、雌二醇(E2)、孕酮(P)、血管内皮生长因子(VEGF)、碱性成纤维细胞生长因子(bFGF)较治疗前均显著下降(P<0.05),完成治疗后观察组以上指标均显著低于对照组(P<0.05)。4)完成治疗后2组月经周期、阴道出血量、阴道出血天数、神疲乏力积分较治疗前均显著下降(P<0.05),完成治疗后观察组以上指标均显著低于对照组(P<0.05)。5)完成治疗后观察组胃肠道反应、体质量增加、肝功能异常、乳房胀痛发生率均显著低于对照组,2组比较差异有统计学意义(P<0.05)。结论:归脾丸加减能提高围绝经期功血患者免疫功能,抑制IL-2、sIL-2R,改善凝血功能,从而改善症状,提高疗效。