根部穿孔性阑尾炎的腹腔镜治疗策略

目的:探讨腹腔镜阑尾切除术(laparoscopic appendectomy,LA)治疗根部穿孔性阑尾炎的可行性,并提出根部穿孔性阑尾炎的临床分型及处理方法。方法:总结2012年9月至2016年3月收治的124例行LA的根部穿孔性阑尾炎患者的临床资料。根据阑尾根部、回盲部能否充分显露及阑尾根部距盲肠壁完整段的长度,将根部穿孔性阑尾炎分为Ⅰ型(Ⅰa型、Ⅰb型、Ⅰc型)、Ⅱ型,其处理方式为:用可吸收结扎夹对系膜缘侧双重夹闭阑尾根部、间断缝合阑尾残端周围5 mm盲肠壁、距阑尾根部10 mm处用腔内切割吻合器闭合并切割阑尾周围盲肠壁组织及中转开腹。结果:124例患者均痊愈出院,包括Ⅰa型73例、Ⅰb型30例、Ⅰc型18例(早期3例中转开腹,后期15例行LA)、Ⅱ型3例。术后病理均证实根部穿孔性阑尾炎。放置腹腔乳胶引流管的患者,术后48~72 h行腹腔B超检查证实无积液后拔除。随访3~48个月,无粘连性肠梗阻、腹腔脓肿及阑尾残端漏发生。结论:LA治疗根部穿孔性阑尾炎是可行的,必须依据临床分型进行根部处理,腔内切割吻合器处理根部穿孔性阑尾炎具有一定的临床意义。     

小儿急性穿孔性阑尾炎抗生素的选用

急性阑尾炎是小儿外科常见的急腹症,而穿孔性阑尾炎是其中的重症,往往存在抗生素的过量使用。到目前为止,尚无小儿阑尾炎抗生素使用的统一标准,在目前的医疗环境下,尽可能在提高医疗质量的同时,分析致病菌谱的变化及耐药性的情况,以及与抗生素使用关系,有利于术后抗生素的正确使用,减少抗生素的滥用,并减少耐药菌株的产生。一、小儿穿孔性阑尾炎致病菌群变化小儿急性阑尾炎主要是内源性感染,致病菌多来自肠道内正常菌群,且绝大多数合并厌氧菌的感染,以往曾经对小儿穿孔性阑尾炎厌氧菌感染情况进行调查,需氧菌和厌氧菌混合感染率为77.5%[1],…     

Wound management in perforated appendicitis

Open wound management after perforated appendicitis was common practice but, recently, primary closure has been advocated to reduce costs and morbidity. Hospital records from 319 adults who underwent appendectomy from 1993 to 1996 were reviewed to identify surgical wound infections (SWIs) and examine risk factors. Information about age, length of stay (LOS), operative time, white blood cell count, and antibiotic administration were obtained. Perforation was either noted at operation or identified microscopically by the pathologist. If primary wound closure was performed, patients with acute appendicitis and perforation had a 4-fold higher readmission rate, a 5-fold increase in SWI, and twice the LOS compared with patients with acute appendicitis without perforation. Patients with grossly perforated acute appendicitis had no difference in LOS if the wound was treated open or closed primarily. No patient with microscopic perforation and primary wound closure developed SWI. Primary wound closure after acute appendicitis was safe in the absence of clinical perforation. In the presence of clinical appendiceal perforation the wound should be left open.     

Current practice patterns in the treatment of perforated appendicitis in children

BACKGROUND: The treatment of perforated appendicitis in children often involves a combination of surgical and medical therapy. The aim of this study was to document the degree of consensus in the current management of perforated appendicitis in children. STUDY DESIGN: A survey was sent to all practicing pediatric surgeons in North America in April 2000 who were members of the American Pediatric Surgical Association for 1999-2000. Survey questions pertained to preoperative, perioperative, and postoperative practice patterns, particularly those issues related to use of antibiotic therapy. RESULTS: Among eligible surgeons, 80.2% completed the survey. Although more than 80% of respondents practiced in an academic setting, only 17% of surgeons used a formal clinical practice guideline to direct care. Responses varied substantially in the duration of postoperative antibiotic therapy, the use of intravenous or oral agents or both, and the duration of hospitalization. A considerable number of patients are receiving a portion of their intravenous antibiotic therapy as outpatients. CONCLUSIONS: There is little apparent consensus in the many aspects of perioperative and postoperative care of perforated appendicitis in children across North America. Only a fraction of surgeons currently uses a formal clinical practice guideline for treatment of perforated appendicitis, although increased pressures to develop more cost-effective therapeutic strategies can encourage development of additional guidelines. Definitive evidence to inform development of such guidelines and enhance consensus is lacking. Further studies are needed across institutions to better inform clinical decisions in light of a changing practice environment and treatment alternatives.     

Management of perforated appendicitis in children--revisited

Of 522 children with acute appendicitis treated from 1978 to 1985, 170 had appendiceal perforation with peritonitis. The protocol for perforation included aggressive fluid resuscitation, preoperative triple antibiotic therapy, copious peritoneal lavage, avoidance of transperitoneal drains except those used for well-localized abscesses, delayed wound closure, and postoperative antibiotic therapy for seven to ten days. The minor complication rate was 22%; this included pleural effusion, wound infection, atelectasis, and prolonged ileus. The major complication rate was 3%; this included intra-abdominal abscess, gastrointestinal bleeding, wound dehiscence, pneumonia, and intestinal obstruction. Only four postoperative intra-abdominal abscesses occurred, in three patients. The mortality rate was zero. A comparison of this series with a similar group of 24 patients who underwent drainage showed the relative rate of abdominal abscess formation to be 1.8% (undrained) vs 12.5% (drained). We achieved our lowest rate of serious complications following surgery for pediatric perforated appendix with the use of aggressive fluid resuscitation, broad-spectrum antibiotic therapy, copious peritoneal irrigation, and delayed wound closure and without drainage.     

A specific technique for the treatment of acute perforated appendicitis

In no case of acute appendicitis accompanied by peritonitis, abscess formation, or gangrene, should operation be postponed in the hope that a more suitable period for operation may be arrived at. Supportive treatment can be equally well carried out, after the major focus of infection has been eliminated and after an opportunity has been given for evacuation of toxic material.By means of a transverse incision placed above the anterior superior spine, adequate exposure can be obtained without the risk of injuring the musculature or nerve supply of the abdominal wall.If prior to incision of the peritoneum the wound in the abdominal wall be properly prepared and bipped, ultimate infection of the wound can be avoided.In every case the appendix should be removed, or at least that part of it attached to the cecum, and the stump ligated. As a rule it is advisable to attempt to bury the stump.In all severe cases, particularly those in which gangrene is present or in which the patient's life appears to be in jeopardy, a technique whereby the abdominal wound is left unsutured and the whole area involved in the inflammatory process packed with liquid parafflned gauze to which bipp has been added, has in the author's hands appeared to be followed by a distinct lessening in the mortality rate. Later closure of such wounds should be accomplished after four to ten days by delayed primary, or by secondary, suture, with the return of the abdominal wall to normal.The technique described in this article has appeared to lessen the number of deaths, has cut, by at least one-third, the number of hospital days required for treatment and has eliminated the accidental development of fecal fistulae and of post-operative herniae.     

Peritoneal cultures and antibiotic treatment in patients with perforated appendicitis.

OBJECTIVE: To question the common practice of sending material for microbiological examination during appendicectomy for perforated appendixes. DESIGN: Uncontrolled retrospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 89 patients who had their perforated appendixes removed. INTERVENTIONS: Appendicectomy and antibiotic treatment. MAIN OUTCOME MEASURE: Whether a change in antibiotic regimen was required after bacteriological identification of bacteria isolated during the operation. RESULTS: In only 43 of the cultures (48%) taken during the operation were bacteria grown, and these were mainly Escherichia coli. In 65 patients (73%) there was no need to change the previously initiated antibiotic regimen, and in 23 (26%) it was changed purely on clinical grounds. In only one patient (1%) was the change the consequence of microbiological testing, as the organisms identified in 42 of the 43 cultures (98%) were sensitive to at least one of the antibiotics that had already been given. CONCLUSION: The practice of culturing samples taken from a ruptured appendix is redundant, because the antibiotic that has already been initiated is effective in most of the patients and the decision to modify the therapeutic regimen is dominated by clinical considerations.     

Three days cefoxitin in perforated appendicitis

This study was undertaken to assess the efficacy and safety of a 3-day course of treatment with Mefoxitin (cefoxitin sodium, MSD) in patients with perforated or ruptured appendicitis. A series of 235 patients undergoing surgery for perforated or ruptured appendicitis were treated with cefoxitin for 3 days. Twenty-four patients (10%) developed wound infection and 28 (12%) developed an intra-abdominal abscess postoperatively. No side effects were observed during the study. Compared with the results of our previous series, where a 5-day course of cefoxitin was used, the incidence of wound infection was similar. However the incidence of intra-abdominal abscesses in the present series was significantly higher (p less than 0.01). The results seem to indicate that a 3-day course of cefoxitin is as effective as a 5-day course in controlling the incidence of wound infection following surgery for perforated or ruptured appendicitis, whereas the 3-day course seems to be inferior to a 5-day course in controlling the incidence of intra-abdominal abscesses.     

Fertility following perforated appendicitis in girls

A study was undertaken to determine fertility status in a group of adult females who as children had been operated on for perforated appendicitis between 1957 to 1975. The 389 girls operated on for perforated appendicitis were reviewed. Their ages ranged from 10 months to 13 years at the time of appendicectomy. Of these girls, 276 were now 20 to 43 years old, and they were contacted by means of a mail questionnaire, and personal interview wherever necessary. It proved possible to contact 181 women; 102 of them were married and 79 were unmarried. Eight-four of the married women (82%) had one or more children. Nine unmarried women also had one or more children. Eighteen married women who have no children were studied in detail. Five women were on contraceptives, two desired pregnancy but had not conceived, and one patient was separated from her husband. Two patients had conceived and aborted, and two were married to infertile men. Of the remaining six patients who had been investigated for infertility, no demonstrable cause of infertility was found in three. Of the other three patients, one showed evidence of bilateral tubal occlusion secondary to pelvic inflammatory disease, one has had a right ectopic pregnancy followed by two abortions, and the third patient was found to have a pituitary adenoma. Our data show that perforated appendicitis before puberty has little if any role in the aetiology of tubal infertility.     

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p < 0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p < 0.05). The surgeon's experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.     

Clinical analysis of the predictive factors for recurrent appendicitis after initial nonoperative treatment of perforated appendicitis

BACKGROUND: The purpose of this study was to study the clinical symptoms, laboratory data, and the characteristics of computed tomography (CT) imaging of nonoperated perforated appendicitis for predicting the recurrence of appendicitis. METHODS: Thirty-five patients with nonoperated perforated appendicitis were retrospectively reviewed for this study. During a median follow-up period of 1155 days, 7 patients had to receive an appendectomy owing to recurrent appendicitis. Accordingly, the patients were divided into 2 groups: the recurrence and the nonrecurrence group. The clinical characteristics between these 2 groups were compared. RESULTS: Both of the 2 patients who had a past history of appendicitis suffered recurrent appendicitis (the recurrence versus the nonrecurrence group, P<.05). The only CT imaging relating to the recurrence of appendicitis is the presence of calcified appendicolith (the recurrence versus the nonrecurrence group, P<.001). CONCLUSIONS: It is most likely that appendicitis will recur if a calcified appendicolith on CT imaging or a past history of appendicitis is presented. Interval appendectomy may be reserved only for those patients who possess one of these risk factors of recurrent appendicitis.     

Laparoscopic appendectomy in children with perforated appendicitis

PURPOSE: There is persistent controversy regarding the optimal surgical therapy for children with appendicitis. We have recently adopted laparoscopic appendectomy in lieu of the open technique for children with perforated appendicitis. We hypothesized that laparoscopic appendectomy would be as effective as open appendectomy in preventing postoperative complications. MATERIALS AND METHODS: We reviewed the medical records of children admitted to our hospital over a 5-year period with the diagnosis of perforated appendicitis. Patients were divided into two groups based on the operative approach: laparoscopic vs. open appendectomy. Demographic data, duration of presenting symptoms, initial white blood cell (WBC) count, length of stay, and complications were abstracted. Data were compared using appropriate statistical analyses. RESULTS: There was no difference between the laparoscopic (n = 43) and open (n = 77) groups with respect to gender, duration of presenting symptoms, initial WBC, or length of stay. However, patients in the laparoscopic group had a significantly lower complication rate than those in the open group (6/43 vs. 23/77, P = 0.05). Infectious complications were no different between groups. Patients in the laparoscopic group tended to be older than patients in the open group (10.6 +/- 3.3 years vs. 8.5 +/- 4.1 years, P = 0.003). CONCLUSION: Laparoscopic appendectomy for children with perforated appendicitis has the same infectious complication rate and a lower overall complication rate than open appendectomy. A prospective study with standardized postoperative care would be needed to determine whether laparoscopic appendectomy for children with perforated appendicitis is the treatment of choice, but until then it remains an attractive alternative.     

并发肠梗阻的盆腔位阑尾穿孔诊治分析

目的 总结并发肠梗阻盆位穿孔性阑尾炎的诊治经验.方法 对2010年1月至2012年12月摩洛哥赛达特哈桑二世医院收治的31例合并肠梗阻的盆位穿孔性阑尾炎患者的临床资料进行回顾性分析.结果 患者入院后均行剖腹探查、阑尾切除、腹腔引流手术,其中机械性肠梗阻8例,麻痹性肠梗阻23例,盆腔脓肿15例;围手术期感染性休克6例,多系统器官功能衰竭(MSOF)4例;术后腹腔残余感染和早期炎性肠梗阻5例,肺部感染3例,伤口感染7例.31例中治愈30例,死亡1例.结论 盆位阑尾炎症状不典型,容易延误诊治;并发肠梗阻的盆位阑尾穿孔可导致休克、MSOF等严重后果,需及时手术;螺旋CT对盆位阑尾穿孔引起的肠梗阻诊断具有一定价值.     

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis

Background: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially in cases where surgeons are not limited by technical constraints. Methods: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July 1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy was performed using a three-trocar technique and the endoscopic stapler. Results: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669; p= ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom had perforated appendicitis. Conclusions: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis. Received: 3 April 1997/Accepted: 19 August 1997