Utility of immature granulocyte percentage in pediatric appendicitis

Background

Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis.

Materials and methods

We identified all patients with appendicitis from July 2012–June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis.

Results

A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P = 0.0063), C-reactive protein (CRP) (P < 0.0001), and IG% (P = 0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40–8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09–6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis.

Conclusions

IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.     

Risk of perforation increases with delay in recognition and surgery for acute appendicitis

Background

Appendicitis remains a common indication for urgent surgical intervention in the United States, and early appendectomy has long been advocated to mitigate the risk of appendiceal perforation. To better quantify the risk of perforation associated with delayed operative timing, this study examines the impact of length of inpatient stay preceding surgery on rates of perforated appendicitis in both adults and children.

Methods

This study was a cross-sectional analysis using the National Inpatient Sample and Kids’ Inpatient Database from 1988–2008. We selected patients with a discharge diagnosis of acute appendicitis (perforated or nonperforated) and receiving appendectomy within 7 d after admission. Patients electively admitted or receiving drainage procedures before appendectomy were excluded. We analyzed perforation rates as a function of both age and length of inpatient hospitalization before appendectomy.

Results

Of 683,590 patients with a discharge diagnosis of appendicitis, 30.3% were recorded as perforated. Over 80% of patients underwent appendectomy on the day of admission, approximately 18% of operations were performed on hospital days 2–4, and later operations accounted for <1% of cases. During appendectomy on the day of admission, the perforation rate was 28.8%; this increased to 33.3% for surgeries on hospital day 2 and 78.8% by hospital day 8 (P < 0.001). Adjusted for patient, procedure, and hospital characteristics, odds of perforation increased from 1.20 for adults and 1.08 for children on hospital day 2 to 4.76 for adults and 15.42 for children by hospital day 8 (P < 0.001).

Conclusions

Greater inpatient delay before appendectomy is associated with increased perforation rates for children and adults within this population-based study. These findings align with previous studies and with the conventional progressive pathophysiologic appendicitis model. Randomized prospective studies are needed to determine which patients benefit from nonoperative versus surgically aggressive management strategies for acute appendicitis.     

Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis

Background

Although many laparoscopic procedures are performed on an outpatient basis, patients who have undergone a laparoscopic appendectomy have typically stayed at least overnight. Recently, data in both the pediatric and adult literature suggest that same day discharge (SDD) for acute nonperforated appendicitis is safe and associated with high patient and parent satisfaction. We have recently begun attempting SDD for nonperforated appendicitis, and this study is an analysis of our initial experience.

Methods

A retrospective chart review of all patients who underwent laparoscopic appendectomy for nonperforated appendicitis at our institution from January 2012 to July 2013 was performed. Demographics, length of stay, hospital course, and outcomes were measured. Data are expressed as mean ± standard deviation. Comparative analysis was performed using a t-test.

Results

A total of 588 laparoscopic appendectomies for nonperforated appendicitis were performed over an 18-mo period. Approximately 28% (n = 128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n = 59) stayed overnight for medical reasons, 0.4% (n = 2) stayed for social reasons, 3.9% (n = 18) stayed because the operation ended late in the evening, and 82.8% (n = 381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, P = 0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P = 1.0), and complication rate (0.7% versus 2.6%, P = 0.3). Patients whose operation ended later in the day had a longer hospital stay. We observed a trend toward more SDDs, the further we got from the initiation of our protocol.

Conclusions

SDD is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. The two main barriers to SDD were time of day for the operation and provider habit, both of which improved as more practitioners felt comfortable with the concept. SDD requires extensive education within the hospital system, and we have initiated an aggressive prospective protocol to improve the results.     

Laparoscopy utilization and outcomes for appendicitis in small children

Purpose

To examine the trends in laparoscopic appendectomy (LA) utilization and outcomes for children 5 years or younger.

Methods

We studied 16,028 inpatient admissions for children 5 years of age or less undergoing an appendectomy for acute appendicitis in 2000, 2003, and 2006 using the Kids' Inpatient Database (KID). Laparoscopy frequency, hospital length of stay, and complications were reviewed.

Results

In 2000, 2003 and 2006 appendectomies were done laparoscopically 11.4%, 18.7% and 31.3% of the time, respectively. Children were more likely to undergo LA at a children's hospital (P < 0.001). LA complications were less likely overall (OR: 0.80, CI: 0.70–0.92, P = 0.002) and in perforated cases (OR: 0.78, CI: 0.67-0.91, P = 0.001). LA decreased hospital length of stay by 0.54 days for all patients and 0.70 days for perforated cases (P < 0.001).

Conclusions

Open appendectomy has historically been the standard in children 5 years of age and younger. Laparoscopic appendectomy has slowly gained acceptance for the treatment of appendicitis in smaller children. The use of laparoscopy has increased significantly at all facilities. Furthermore, laparoscopic appendectomy in this age group has a comparatively low complication rate and short hospital length of stay, and is safe in complicated perforated appendicitis cases.     

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

Minimizing unnecessary parenteral nutrition after appendectomy in children

Background

Consensus guidelines have indicated that postoperative parenteral nutrition (PN) might provide benefit when patients are expected to be nil per os (NPO) ≥7 d and when PN is administered ≥5 d. We hypothesized that most children receiving PN after appendectomy do not satisfy these criteria.

Methods

The medical records of the patients who had undergone appendectomy for perforated appendicitis from 2006–2011 were analyzed, and the proportion meeting the criteria for beneficial PN was determined. The clinical parameters independently associated with the criteria for beneficial PN (PN therapy ≥5 d, ileus ≥5 d, NPO ≥7 d) were identified using multiple regression analysis.

Results

A total of 1612 patients were treated for appendicitis. Of these, 587 met the inclusion criteria (age <16 y, perforated appendicitis, appendectomy within 24 h, no previous indication for PN). Of the 587 patients, 12.1% received PN; 43.8% of these received PN for ≥5 d. The predictors of PN duration of ≥5 d included preoperative symptoms for ≥3 d (P < 0.01) and initiation of PN by postoperative day 3 (P = 0.047). Preoperative symptoms for ≥3 d, imaging showing a discrete abscess or bowel obstruction, and operative findings of diffuse peritonitis predicted ileus of ≥5 d and NPO of ≥7 d (P < 0.01 for all). Major complications were more common in patients with ileus lasting ≥5 d.

Conclusions

Fewer than one-half of patients receiving PN in the present cohort met the consensus-based guidelines for postoperative PN. The preoperative symptom duration, preoperative imaging findings demonstrating abscess and/or bowel obstruction, and intraoperative findings of diffuse peritonitis might predict prolonged ileus and longer recovery periods for children undergoing surgery for perforated appendicitis.     

Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy

Background

Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP).

Methods

Multicenter study of all pyloromyotomies (May 2007–December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers.

Results

Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006–4.083]; P = 0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI − 0.096 to 3.365]; P = 0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P = 0.2) and grade of primary operator did not affect the rate of either complication.

Conclusions

This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.     

Clinical Significance of Surveillance Culture in Liver Transplant Recipients

Background

Routine microbiologic surveillance is a method of infection control, but its clinical significance in transplant recipients is not known. We analyzed microbiologic data to evaluate the influence of cultured microorganisms between the point of surveillance and infectious episodes in liver transplant recipients.

Methods

We performed surveillance culture for sputum and peritoneal fluid in liver transplant recipients from January 2009 to December 2011, at the time of transplantation (T1), 5 days (T2), and 10 days (T3) postoperatively.

Results

Of the 179 recipients, 32.9% had a positive sputum culture result and 37.4% had a positive peritoneal culture result during surveillance. In the culture surveillance of sputum, 37 organisms were isolated from 35 recipients at T1, and the most common organism was Staphylococcus aureus (n = 13). At T2, 45 organisms were isolated from 39 recipients, including Klebsiella pneumoniae (n = 10), S aureus (n = 8), and Acinetobacter baumannii (n = 6). At T3, 18 organisms were isolated from 15 patients, including Stenotrophomonas maltophilia (n = 5) and K pneumonia (n = 4). In the peritoneal fluid, 11 organisms were isolated from 10 recipients at T1, including Pseudomonas aeruginosa (n = 2) and Enterococcus species (n = 2). At T2, 39 organisms were isolated from 36 recipients, including coagulase-negative Staphylococcus species (CNS; n = 8) and Enterococcus species (n = 7). At T3, 54 organisms were isolated from 51 recipients, including CNS (n = 17) and Candida species (n = 8). Among the 59 patients with positive culture results for sputum surveillance, 16.9% developed pneumonia caused by the same organisms. Among the 67 patients with positive peritoneal fluid culture, 16.4% developed an intra-abdominal infection caused by the same organisms cultured. The recipients with positive surveillance culture had a higher risk of pneumonia (20.3% [12/59] vs 1.6% [2/120]; P < .001) and intra-abdominal infection (31.3% [21/67] vs 18.7% [21/112]; P = .05).

Conclusions

Periodic microbiologic surveillance may be useful in the prediction of post-transplantation pneumonia and intra-abdominal infection and could offer a potential target for empirical antimicrobial therapy in cases of infection.     

Empleo,eficacia y repercusión clínica del apoyo radiológico al diagnóstico de la apendicitis aguda

Objective

The aim of this study is to analyze the increasing need of radiological support in the diagnosis of acute appendicitis (AA), the clinical repercussions associated, and the parameters of diagnostic accuracy of ultrasound and computed tomography (CT) scan for AA.

Material and methods

Observational and analytical study. Cohort, patients operated on for suspected AA at a tertiary referral hospital. Pregnancy and <14 years were exclusion criteria. Study group: January 2010-December 2011 (n1 = 419). Control group: set of patients aged 18 to 65 years old operated between October 2001-September 2003 (n2 = 237). Variables analyzed in both groups: 1) percentage of radiological support for diagnosis of acute appendicitis; 2) sensitivity and positive predictive value (PPV) of ultrasound and CT scan; 3) rate of surgical explorations with negative result or with diagnosis other than acute appendicitis. Statistical analysis: SPSS software, χ² test, statistical significance accepted with P<.05, 95% confidence interval (95% CI) for the odds ratio (OR).

Results

Age, gender, percentage of atypical locations and gangrenous/perforated episodes were similar in both groups. The number of radiological examinations needed for diagnosis was significantly higher in the study group (78.8% vs. 30.4%, P<.0,000). Sensitivity was significantly superior for CT than for ultrasound scan (97% vs. 86%), but PPV was similar in both tests (92% vs. 94%). Surgical exploration percent values with diagnosis of acute appendicitis was significantly higher in the study group (94.5% vs. 88.6%; P<.006, OR 2.2; CI 95% 1.25-4).

Conclusions

CT and ultrasound scan are excellent diagnostic tools for acute appendicitis, and have contributed to a significant increase in surgical explorations with correct diagnosis.     

The effect of appendectomy in future tubal infertility and ectopic pregnancy: a systematic review and meta-analysis

Background

Ruptured appendicitis has been implicated in causing scarring, which can lead to infertility and/or ectopic pregnancy. To assess the degree of association and the quality of evidence supporting the relation among appendectomy, female fertility outcomes, and ectopic pregnancy.

Methods

We systematically searched multiple electronic databases from inception through May 2013 for randomized trials and observational studies. Reviewers working independently and in duplicate extracted the study characteristics, the quality of the included studies, and the outcomes of interest. Random effects meta-analysis was used to pool the odds ratio (OR) from the included studies.

Results

Our meta-analysis based on seven observational studies provided evidence that previous appendectomy is not associated with increased incidence of infertility in women (OR = 1.03, 0.86–1.24, P = 0.71). This finding was further augmented by several noncomparative cohorts that discussed the same issue and reported nearly the same conclusion; however, these studies pointed toward putative negative impact of surgery for complicated appendicitis on fertility. Our second meta-analysis revealed the effect of appendectomy on ectopic pregnancy was found to be significant based on a pooled estimate from four studies (OR = 1.78, 95% confidence interval = 1.46–2.16, P < 0.0001).

Conclusions

Appendectomy is significantly associated with an increased risk of ectopic pregnancy but not significantly associated with future infertility in women.     

Prospective validation of a surgical complications grading system in a cohort of 2114 patients

Background

We recently reported a grading system for surgical complications. This system proved to have a high sensitivity for recording minor but meaningful complications prolonging hospital stay in patients after colorectal surgery. We aimed to prospectively validate the complication grading system in a general surgery department over 1 year.

Methods

All surgical procedures and related complications were prospectively recorded between January 1st and December 31st, 2009. Surgical complications were graded on a severity scale of 1-5. The system classifies short-term outcome by grade emphasizing intensity of therapy required for treatment of the defined complication.

Results

During the study period, 2114 patients underwent surgery. Elective and oncological surgeries were performed in 1606 (76%) and 465 (22%) patients, respectively. There were 422 surgical complications in 304 (14%) patients (Grade 1/2: 203 [67%]; Grade 3/4: 90 [29%]; Grade 5: 11 [4%]).Median length of stay correlated significantly with complication severity: 2.3 d for no complication, 6.2 and 11.8 d for Grades 1/2 and 3/4, respectively (P < 0.001). Older age (OR 2.75, P < 0.001), comorbidities (OR 1.44, P = 0.02), American Society of Anesthesiology score >2 (OR 2.07, P < 0.001), contamination Grade (OR 1.85, P = 0.001), oncological (OR 2.82, P < 0.001), open (OR 1.22, P = 0.03), prolonged >120 min (OR 2.08, P < 0.001), and emergency surgery (OR 1.42, P = 0.02) independently predicted postoperative complications.

Conclusions

This system of grading surgical complications permits standardized reporting of surgical morbidity according to the severity of impact. Prospective validation of this system supports its use in a general surgery setting as a tool for surgical outcome assessment and quality assurance.     

Negative Prognostic Impact of Renal Replacement Therapy in Adult Living-donor Liver Transplant Recipients: Preoperative Recipient Condition and Donor Factors

Background

In deceased-donor liver transplantation settings, post-transplantation acute renal failure with the induction of renal replacement therapy (RRT) is known to have negative effects on graft and patient survivals. However, the impact of RRT in living-donor liver transplantation (LDLT) has not been well investigated. The aim of this study was to elucidate risk factors requiring RRT and prognostic factors after its induction.

Methods

Clinical data on the consecutive 113 adult patients who underwent LDLT from March 2002 to May 2013 were retrospectively reviewed. They were divided into 2 groups: RRT (n = 33) and Non-RRT (n = 80). The primary reasons for receiving RRT were hepatorenal syndrome (n = 17), sepsis (n = 12), and renal hypoperfusion (n = 4).

Results

Although there were no significant differences in age or sex, the Model for End-Stage Liver Disease (MELD) score was significantly higher in the RRT group than in the Non-RRT group (23 ± 13 vs 16 ± 7; P = .002). The graft-recipient weight ratio (GRWR) was significantly lower in the RRT group (0.86 ± 0.3 vs 0.99 ± 0.2; P = .025). The 1- and 5-year patient survival rates were significantly higher in the Non-RRT group than in the RRT group (respectively, 91.3% and 84.3% vs 42.9% and 25.5%; P < .001). In multivariate analysis, independent risk factors for receiving RRT were MELD score >20 (P = .044) and GRWR <0.7 (P = .039). In the RRT group, donor age >50 years (P = .042) and preoperative serum creatinine level >1.5 mg/dL (P = .049) were significant prognostic risk factors.

Conclusions

In adult LDLT patients, the induction of RRT after LDLT was a negative predictor of survival. In addition to the preoperative recipient's condition, donor factors including graft size and donor age influenced prognosis after the induction of RRT.     

Impact of Vitamin D,Bisphosphonate, and Combination Therapy on Bone Mineral Density in Kidney Transplant Patients

Background

Osteoporosis can develop and become aggravated in kidney transplant patients; however, the best preventive options for post-transplantation osteoporosis remain controversial.

Methods

We retrospectively analyzed cohort of 182 renal transplant recipients of mean age 46.7 ± 12.1 years including 47.3% women. Seventy-three patients received neither vitamin D nor bisphosphonate after transplantation (group 1). The other patients were classified into the following 3 groups: calcium plus vitamin D (group 2; n = 40); bisphosphonate (group 3; n = 18); and both regimens (group 4; n = 51). Bone mineral density (BMD) was evaluated by dual-energy X-ray absorptiometry at baseline and at 1 year after transplantation.

Results

At 1 year after transplantation, T-scores of the femoral neck and entire femur were significantly decreased in group 1 (−0.23 ± 0.65 [P = .004] and −0.21 ± 0.74 [P = .018], respectively), whereas the lumbar spine was significantly increased in group 4 (0.27 ± 0.79; P = .020). Post hoc analysis demonstrated that the delta T-score was significantly lower in group 1 than in group 4 (P = .009, 0.035, and 0.031 for lumbar spine, femoral neck, and entire femur, respectively). In a multivariate analysis adjusted by age, sex, body mass index, dialysis duration, diabetes, calcineurin inhibitors, estimated glomerular filtration rate, and persistent hyperparathyroidism, both group 2 and group 4 showed protective effects on BMD reduction (odds ratio [OR], 0.165; 95% confidence interval [CI] 0.032–0.845 [P = .031]; and OR, 0.169; 95% CI, 0.045–0.626 [P = .008]; respectively). However, group 3 did not show a protective effect (OR, 0.777; 95% CI, 0.198–3.054; P = .718), because their incidence of persistent hyperparathyroidism after transplantation was significantly higher (50.0%) than the other groups (P < .001). The incidence of bone fractures did not differ among the groups.

Conclusions

Combination therapy with vitamin D and bisphosphonate was the most effective regimen to improve BMD among kidney recipients.     

A diagnostic model for histologic damage in undescended testes based on testis rigidity measurement: an experimental study with a novel device

Background

We aimed to test whether testis rigidity (hardness) measured using a newly-designed device we previously introduced would offer more reliable assessment of histologic damage in undescended testes than conventional methods (consistency feel at palpation, volume measurement).

Materials and methods

Forty-five 18-d-old Lewis rats underwent surgical inhibition of descent of left testes and were followed to 40 (n = 16), 63 (n = 14), or 90 days (n = 15). Another 45 18-d-old Lewis rats were sham operated (left side) and followed likewise (n = 14, n = 15, and n = 16). At the designated time points, testes were exposed bilaterally, rigidity was measured, and consistency at palpation was scored; testes were removed and subjected to length, width, weight measurements, volume calculation, and histomorphometry (mean Johnsen score [MJS], mean tubular diameter [MTD], and mean capsule width [MCW]). Testes of experimental group were compared with ipsilateral testes of sham-operated rats.

Results

At all time points, undescended testes had decreased rigidity, MJS, and MTD, increased MCW, decreased volume and weight; contralateral testes remained unaffected. Rigidity was associated only with MJS and MTD, and most strongly with MJS (multiple stepwise linear regression, F = 694.44, P < 0.0005). MJS could be precisely predicted from rigidity: MJS = 0.699 × testis rigidity (F = 1358.82, P < 0.0005). This model showed good fit between predicted and actual MJS values (R² = 0.94), low error, nonsignificant bias, sensitivity 75% and specificity 90%. Model validation showed low prediction error and nonsignificant bias, indicating generalizability. Testis volume and palpation proved imprecise MJS predictors.

Conclusions

Testis rigidity is an effective predictor of histologic damage in rat undescended testes, with diagnostic value superior to testis palpation scoring and volume measurement.     

The role of clinical care pathways: an experience with distal pancreatectomy

Background

Previous studies have indicated that clinical pathways may shorten hospital length of stay (HLOS) among patients undergoing distal pancreatectomy (DP). Here, we evaluate an institutional standardized care pathway (SCP) for patients undergoing DP.

Materials and methods

A retrospective review of patients undergoing DP from November 2006 to November 2012 was completed. Patients treated before and after implementation of the SCP were compared. Multivariable linear regression was then performed to identify independent predictors of HLOS.

Results

There were no differences in patient characteristics between SCP (n = 50) and pre-SCP patients (n = 100). Laparoscopic technique (62% versus 13%, P < 0.001), splenectomy (52% versus 38%, P = 0.117), and concomitant major organ resection (24% versus 13%, P = 0.106) were more common among SCP patients. Overall, important complication rates were similar (24% versus 26%, P = 0.842). SCP patients resumed a normal diet earlier (4 versus 5 d, P = 0.025) and had shorter HLOS (6 versus 7 d, P = 0.026). There was no increase in 30-d resurgery or readmission. In univariate comparison, SCP, cancer diagnoses, intraductal papillary mucinous neoplasm diagnoses, neoadjuvant therapy, operative technique, major organ resection, and feeding tube placement were associated with HLOS; however, after multivariable adjustment, only laparoscopic technique (−33%, P = 0.001), concomitant major organ resection (+38%, P < 0.001), and feeding tube placement (+68%, P < 0.001) were independent predictors of HLOS.

Conclusions

Implementation of a clinical pathway did not improve HLOS at our institution. The increasing use of laparoscopy likely accounts for shorter HLOS in the SCP cohort. In the future, it will be important to identify clinical scenarios most likely to benefit from implementation of a clinical pathway.     

Neutrophil to lymphocyte ratio changes predict small hepatocellular carcinoma survival

Background

There is limited information available concerning the delta neutrophil to lymphocyte ratio (ΔNLR) in hepatocellular carcinoma (HCC). The present study was designed to evaluate the predictive value of dynamic change of NLR in patients who undergo curative resection for small HCC.

Methods

A retrospective cohort study was performed to analyze 189 patients with small HCC who underwent curative resection between February 2007 and March 2012. Patient data were retrieved from our prospectively maintained database. Patients were divided into two groups: group A (NLR increased, n = 80) and group B (NLR decreased, n = 109). Demographic and clinical data, overall survival (OS), and recurrence-free survival (RFS) were statistically compared and a multivariate analysis was used to identify prognostic factors.

Results

The 1, 3, and 5-y OS in group A was 92.7, 70.0, and 53.0%, respectively, and 96.2, 87.5, and 75.9%, respectively, for group B (P = 0.003); The corresponding 1, 3, and 5-y RFS was 58.7, 37.9, 21.8, and 81.2%, 58.5% and 53.8% for groups A and B, respectively (P <0.001). Multivariate analysis suggested that ΔNLR was an independent prognostic factor for both OS (P = 0.004, Hazard Ratio (HR) = 2.637, 95% confidence interval (CI) 1.356–5.128) and RFS (P <0.001, HR = 2.372, 95% CI 1.563–3.601).

Conclusions

Increased NLR, but not high preoperative NLR or postoperative NLR, helps to predict worse OS and RFS in patients with small HCC who underwent curative resection.     

The value of hyperbilirubinaemia in the diagnosis of acute appendicitis

INTRODUCTION

No reliably specific marker for acute appendicitis has been identified. Although recent studies have shown hyperbilirubinaemia to be a useful predictor of appendiceal perforation, they did not focus on the value of bilirubin as a marker for acute appendicitis. The aim of this study was to determine the value of hyperbilirubinaemia as a marker for acute appendicitis.

MATERIALS AND METHODS

A retrospective analysis of appendicectomies performed in two hospitals (n=472). Data collected included laboratory and histological results. Patients were grouped according to histology findings and comparisons were made between the groups.

RESULTS

The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (p<0.001). More patients with simple appendicitis had hyperbilirubinaemia on admission (30% vs 12%) and the odds of these patients having appendicitis were over three times higher (odds ratio: 3.25, p<0.001). Hyperbilirubinaemia had a specificity of 88% and a positive predictive value of 91% for acute appendicitis. Patients with appendicitis who had a perforated or gangrenous appendix had higher mean bilirubin levels (p=0.01) and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 70%. The specificities of white cell count and C-reactive protein were less than hyperbilirubinaemia for simple appendicitis (60% and 72%) and perforated or gangrenous appendicitis (19% and 36%).

CONCLUSIONS

Hyperbilirubinaemia is a valuable marker for acute appendicitis. Patients with hyperbilirubinaemia are also more likely to have appendiceal perforation or gangrene. Bilirubin should be included in the assessment of patients with suspected appendicitis.     

Effects of additional laparoscopic cholecystectomy on outcomes of laparoscopic gastrectomy in patients with gastric cancer based on a national administrative database

Background

Little information is available on the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes of patients with gastric cancer. The aim of this study is to investigate the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes in patients with gastric cancer using a national administrative database.

Methods

A total of 14,006 patients treated with laparoscopic gastrectomy for gastric cancer were referred to 744 hospitals in Japan between 2009 and 2011. Patients were divided into two groups, those who also underwent simultaneous laparoscopic cholecystectomy for gallbladder stones (n = 1484) and those who underwent laparoscopic gastrectomy alone (n = 12,522). Laparoscopy-related complications, in-hospital mortality, length of stay, and medical costs during hospitalization were compared in the patient groups.

Results

Multiple logistic regression analysis revealed that adding laparoscopic cholecystectomy did not affect laparoscopy-related complications (odds ratio, 1.02; 95% confidence interval [CI], 0.84–1.24; P = 0.788) or in-hospital mortality (odds ratio, 1.16; 95% CI, 0.49–2.76; P = 0.727). Multiple linear regression analysis also showed that adding laparoscopic cholecystectomy did not affect the length of stay (unstandardized coefficient, 0.37 d; 95% CI, −0.47 to 1.22 d; P = 0.389). However, adding laparoscopic cholecystectomy was associated with significantly increased medical costs during hospitalization (unstandardized coefficient, $1256.0 (95% CI, $806.2–$1705.9; P < 0.001).

Conclusions

This study demonstrated that adding laparoscopic cholecystectomy did not affect outcomes of patients undergoing laparoscopic gastrectomy for gastric cancer, although medical costs during hospitalization were significantly increased.     

Effect of alcohol in traumatic brain injury: is it really protective?

Background

Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI.

Methods

Version 7.2 of the National Trauma Data Bank (2007–2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications.

Results

A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1–2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1–2.8, P = 0.009) in patients with isolated severe TBI.

Conclusions

ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification.     

The role of remote ischemic preconditioning in organ protection after cardiac surgery: a meta-analysis

Background

Remote ischemic preconditioning (RIPC) appears to protect distant organs from ischemia–reperfusion injury. We undertook meta-analysis of clinical studies to evaluate the effects of RIPC on organ protection and clinical outcomes in patients undergoing cardiac surgery.

Methods

A review of evidence for cardiac, renal, and pulmonary protection after RIPC was performed. We also did meta-regressions on RIPC variables, such as duration of ischemia, cuff pressure, and timing of application of preconditioning. Secondary outcomes included length of hospital and intensive care unit stay, duration of mechanical ventilation, and mortality at 30 days.

Results

Randomized control trials (n = 25) were included in the study for quantitative analysis of cardiac (n = 16), renal (n = 6), and pulmonary (n = 3) protection. RIPC provided statistically significant cardiac protection (standardized mean difference [SMD], −0.77; 95% confidence interval [CI], −1.15, −0.39; Z = 3.98; P < 0.0001) and on subgroup analysis, the protective effect remained consistent for all types of cardiac surgical procedures. However, there was no evidence of renal protection (SMD, 0.74; 95% CI, 0.53, 1.02; Z = 1.81; P = 0.07) or pulmonary protection (SMD, −0.03; 95% CI, −0.56, 0.50; Z = 0.12; P = 0.91). There was no statistical difference in the short-term clinical outcomes between the RIPC and control groups.

Conclusions

RIPC provides cardiac protection, but there is no evidence of renal or pulmonary protection in patients undergoing cardiac surgery using cardiopulmonary bypass. Larger multicenter trials are required to define the role of RIPC in surgical practice.