Hyperbilirubinemia as a predictive factor in acute appendicitis

Purpose

Our aim was to establish the role of hyperbilirubinemia as a predictive parameter for the prediction of either acute, or gangrenous/perforated appendicitis as well as to compare other parameters in a similar role.

Methods

Medical files of the patients who underwent appendectomies between September 2013 and September 2014 were evaluated. Age, gender, preoperative white blood cell count (WBC), neutrophil count (NEU), neutrophil percentage (NEU%), C-reactive protein (CRP), total/direct/indirect bilirubin levels, and the postoperative histopathological findings were recorded. The Fisher’s exact, Pearson’s χ ², ANOVA, and Kruskal–Wallis tests while logistic regression for multivariate analysis was performed. p < 0.05 was accepted as statistically significant.

Results

The study group of 162 patients consisted of 97 (60 %) men and 65 (40 %) women with a median age of 36 (18–90). Histopathological examinations revealed normal appendix in 21 (13 %) patients, non-complicated acute appendicitis in 100 (62 %), and appendiceal gangrene/perforation in 41 (25 %) patients. WBC, NEU, NEU%, and CRP levels were significantly higher in cases of acute and gangrenous/perforated appendicitis (p < 0.01). Total and direct bilirubin levels were also significantly elevated in patients with acute and gangrenous/perforated appendicitis (p < 0.01). According to multivariate analysis, elevated CRP levels were associated with 14 times, elevated total bilirubin levels were associated with five times, and elevated direct bilirubin levels were associated with 36 times greater risk for appendiceal gangrene/perforation (p < 0.01, p < 0.05, p < 0.01, respectively).

Conclusions

Hyperbilirubinemia, especially with elevated direct bilirubin levels, may be considered as an important marker for the prediction of appendiceal gangrene/perforation.

     

The influence of age on the severity of peritonitis

Objective

To evaluate the influence of age on the evolution and severity of peritonitis.

Design

A chart review.

Setting

An adult university hospital.

Patients

One hundred and twenty-two patients with acute appendicitis and 100 patients with acute colonic diverticulitis requiring operation or percutaneous drainage.

Main Outcome Measures

Patient age and sex, presence of perforation or gangrene (appendicitis), extent of peritonitis (diverticulitis); duration of symptoms prior to admission; admission leukocyte count; duration of hospitalization before surgery; length of hospital stay; and death rate.

Results

Patients with acute appendicitis who were aged 65 years or older were three times more likely than younger patients to have a gangrenous or perforated appendix (odds ratio 3.1, 95% confidence interval 1.1 to 8.4, p < 0.05); older patients with perforated diverticulitis were three times more likely than younger patients to have generalized peritonitis than localized (pericolic or pelvic) peritonitis (odds ratio 2.9, 95% confidence interval 1.2 to 7.5, p < 0.05).

Conclusion

These findings are consistent with the hypothesis that the biologic features of peritonitis differ in the elderly, who are more likely to present with an advanced or severe process than young patients.     

Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis

Background

Clinical evaluation alone is still considered adequate by many clinicians who treat patients with appendicitis. The impact of computed tomography (CT) on clinical outcomes remains unclear, and there is no consensus regarding the appropriate use of CT in these patients. We sought to evaluate the impact of abdominal CT on the clinical outcomes of patients presenting with suspected appendicitis.

Methods

We conducted a systematic review of the literature to identify studies that examined clinical outcomes related to the use of abdominal CT in the diagnosis of acute appendicitis. Inclusion criteria were studies of adult patients with suspected appendicitis that evaluated the impact of abdominal CT on negative appendectomy rates, perforation rates or time to surgery. Two independent investigators reviewed all titles and abstracts and extracted data from 28 full-text articles. Statistical analysis was conducted using Review Manager 5.0.10 software.

Results

The negative appendectomy rate was 8.7% when using CT compared with 16.7% when using clinical evaluation alone (p < 0.001). There was also a significantly lower negative appendectomy rate during the CT era compared with the pre-CT era (10.0% v. 21.5%, p < 0.001). Time to surgery was evaluated in 10 of the 28 studies, 5 of which demonstrated a significant increase in the time to surgery with the use of CT. Appendiceal perforation rates were unchanged by the use of CT (23.4% in the CT group v. 16.7% in the clinical evaluation group, p = 0.15). Similarly, the perforation rate during the CT era was not significantly different than that during the pre-CT era (20.0% v. 19.6%, p = 0.74).

Conclusion

This meta-analysis supports the hypothesis that the use of preoperative abdominal CT is associated with lower negative appendectomy rates. The use of CT in the absence of an expedited imaging protocol may delay surgery, but this delay is not associated with increased appendiceal perforation rates. Routine CT in all patients presenting with suspected appendicitis could reduce the rate of unnecessary surgery without increasing morbidity.     

Association between the appendix and the fecalith in adults

Background

We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix.

Methods

We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith.

Results

During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10–76) years. The fecalith rate was 13%–16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma.

Conclusion

Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.     

Increased use of pre-operative imaging and laparoscopy has no impact on clinical outcomes in patients undergoing appendicectomy

INTRODUCTION

The aim of this study was to review changes in the management of acute appendicitis in a ten-year period at a large university teaching hospital in London.

METHODS

This was a retrospective cohort study reviewing the medical records of patients who underwent an appendicectomy over a period of 12 months either in 1999 or 2009. Data collected included use of radiological investigations (ultrasonography, computed tomography [CT]), technique of appendicectomy (open [OA] or laparoscopic [LA]), operative time, histopathology and post-operative complications. Univariate and multivariate analysis was performed to assess the influence of variables on the incidence of negative appendicectomy, appendiceal perforation and post-operative complications.

RESULTS

All of the patients operated on in 1999 (n=109) had OA. Of the patients operated on in 2009 (n=164), 67 had OA, 91 had LA and 6 had LA converted to OA.None of the patients in 1999 had CT whereas in 2009 26% of patients had CT (sensitivity 94.7%, specificity 75.0%). This increased use of pre-operative imaging had no effect on negative appendicectomy (25.7% vs 12.8%, p=0.445), perforation (30.0% vs 21.3%, p=0.308) or complication rates (9.2% vs 10.4%). The complication rate was also similar regardless of whether patients had OA or LA (11.9% vs 9.9%). Multivariate analysis revealed that age was the only predictor of negative appendicectomy (p=0.029) or perforation (p=0.014).

CONCLUSIONS

This study shows that significant increase in the use of pre-operative imaging and laparoscopy in the management of patients with acute appendicitis failed to reduce negative appendicectomy, perforation and complications rates. The patient''s age was the only predictor of negative appendicectomy and perforation.     

Role of the faecolith in modern-day appendicitis

Introduction

The prevailing view on appendicitis is that the main aetiology is obstruction owing to faecoliths in adults and lymphoid hyperplasia in children. Faecoliths on imaging studies are believed to correlate well with appendicitis.

Methods

A retrospective chart review was conducted of 1,014 emergency appendicectomy patients between 2001 and 2011. Faecolith prevalence in adult and paediatric appendicectomy specimens with and without perforation was studied. The sensitivity and positive predictive value (PPV) of computed tomography (CT) for identifying faecoliths in the pathology specimen were examined.

Results

Overall, faecoliths were found in 18.1% (178/986) of appendicitis specimens and 28.6% (8/28) of negative appendicectomies. Faecolith prevalence for positive cases was 29.9% (79/264) in paediatric patients and 13.7% (99/722) in adults (p<0.05). Faecolith prevalence was 39.4% in perforated appendicitis but only 14.6% in non-perforated appendicitis (p<0.05). In adults, faecolith prevalence was 27.5% in perforated appendicitis and 12.0% in non-perforated appendicitis (p<0.05) while in paediatric patients, it was 56.1% in perforated appendicitis and 22.7% in non-perforated appendicitis (p=0.00). Sensitivity and PPV of preoperative CT in identifying faecoliths on pathology were 53.1% (86/162) and 44.8% (86/192) respectively.

Conclusions

Faecolith prevalence is too low to consider the faecolith the most common cause of non-perforated appendicitis. Faecoliths are more prevalent in paediatric appendicitis than in adult appendicitis. Preoperative CT is an unreliable predictor of faecoliths in pathology specimens.     

‘To have … or not to have’. Should Computed Tomography and Ultrasonography be Implemented as a Routine Work-Up for Patients with Suspected Acute Appendicitis in a Regional Hospital?

INTRODUCTION

Appendicitis is a common diagnosis, but is by no means a simple one to establish. This retrospective study investigated the value of medical imaging (ultrasonography and/or computed tomography [CT]) for patients with suspected appendicitis. Negative appendicectomy rate and appendiceal perforation with or without medical imaging were used as end points for this investigation.

PATIENTS AND METHODS

This study retrospectively reviewed all patients admitted in one district general hospital with suspected acute appendicitis. The patient cohort was identified from the Unit Registry and an International Classification of Diseases-based Review of medical records. The medical records were analysed, and the outcome of patients were followed up.

RESULTS

Between 12 January 2004 to 27 May 2005, 168 patients'' medical records were audited. The negative appendicitis rate was 6.7% and appendiceal perforation rate was 3.2%. Among them, only 20 in-patients (12%) had medical imaging (ultrasonography and/or CT scan) after clinical assessment for suspected acute appendicitis. Medical imaging had a 70% prediction rate for acute appendicitis, 20% false-negative rate, and 10% false-positive rate. Overall, the prediction rate for appendicitis by clinical assessment supplemented by laboratory tests and medical imaging at clinician''s discretion was 93.2%.

CONCLUSIONS

Despite studies advocating routine use of medical imaging for patients with suspected acute appendicitis, this study showed that the clinical evaluation is still paramount to the management of patients with suspected acute appendicitis before considering medical imaging.     

Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients

Objective

To compare the efficacy of laparoscopic appendectomy (LA) and open appendectomy (OA) in the treatment of acute appendicitis.

Design

A prospective randomized trial.

Setting

A university teaching hospital.

Patients

Eighty-one patients with a diagnosis of acute appendicitis were prospectively randomized to undergo either LA or OA. The two groups were matched for age and sex.

Interventions

LA or OA.

Main Outcome Measures

Number of days in hospital and time to full recovery.

Results

The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA (p < 0.001). The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group (p < 0.001). The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group (p < 0.001). The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA (p < 0.001). Three patients in the LA group had intra-abdominal abscesses (p > 0.25). No significant difference in wound infection rates was demonstrated (p > 0.05). Similarly, pain scores at 7 and 28 days showed no significant difference (p > 0.05).

Conclusions

With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities. LA takes longer to perform and was associated with three intra-abdominal abscesses. In cases of simple acute appendicitis the hospital stay for LA is significantly shorter.     

A Comparison of Laparoscopic and Open Appendectomy

Background and Objectives:

To compare laparoscopic appendectomy with traditional open appendectomy.

Methods:

Seventy-one patients requiring operative intervention for suspected acute appendicitis were prospectively compared. Thirty-seven patients underwent laparoscopic appendectomy, and 34 had open appendectomy through a right lower quadrant incision. Length of surgery, postoperative morbidity and length of postoperative stay (LOS) were recorded. Both groups were similar with regard to age, gender, height, weight, fever, leukocytosis, and incidence of normal vs. gangrenous or perforated appendix.

Results:

Mean LOS was significantly shorter for patients with acute suppurative appendicitis who underwent laparoscopic appendectomy (2.5 days vs. 4.0 days, p<0.01). Mean LOS was no different when patients classified as having gangrenous or perforated appendicitis were included in the analysis (3.7 days vs. 4.1 days, P=0.11). The laparoscopy group had significantly longer surgery times (72 min vs. 58 min, p<0.001). There was no significant difference in the incidence of postoperative morbidity.

Conclusions:

Laparoscopic appendectomy reduces LOS as compared with the traditional open technique in patients with acute suppurative appendicitis. The longer operative time for the laparoscopic approach in our study is likely related to the learning curve associated with the procedure and did not increase morbidity.     

Endoloop versus endostapler closure of the appendiceal stump in pediatric laparoscopic appendectomy

Background

There is little information available to inform choice of technique for appendiceal stump control in pediatric laparoscopic appendectomy (LA). We compared complications (stump leak, intra-abdominal abscess formation [IAA], surgical site infection [SSI]) in children undergoing LA for perforated (PA) and nonperforated appendicitis (NPA) by technique of appendiceal stump control.

Methods

All children who underwent LA for confirmed acute appendicitis between 2006 and 2009 were reviewed. Choice of stump control (endoloop [EL] or endostapler [ES]) was determined by surgeon preference. Interactions between stump closure techniques and other potential confounders (intra-abdominal drain, irrigation, different antibiotic regimens) were explored using a logistic regression model.

Results

Of 242 patients undergoing LA, 57 (23.6%) had PA. In the PA group the appendiceal stump was closed with EL in 47 (82.5%) patients, while in the NPA group EL was used in 161 (87%) patients. Among PA patients, IAA was more common in the ES than the EL group (5 of 10 [50%] v. 6 of 47 [12.7%]). There was no significant difference in rates of SSI. Among NPA patients, there were no differences in rates of IAA or SSI. There were no stump leaks in either group. Logistic regression analysis confirmed the predictive effect of ES use on IAA formation in PA (adjusted odds ratio 7.09; 95% confidence interval 1.08–46.13; p = 0.042).

Conclusion

Our data suggest that in most cases of PA, the appendiceal stump can be safely controlled with EL. Within the PA group, the higher rates of IAA seen in ES patients may be attributable to the quality of the appendiceal stump rather than the technique of closure.     

Hyperbilirubinemia in Appendicitis: A New Predictor of Perforation

This study examines the relationship between hyperbilirubinemia and appendicitis. It was hypothesized that an association exists between the presence of appendiceal perforation and hyperbilirubinemia. Patients with liver function tests on admission and pathologically confirmed appendicitis were included in the study. Age, duration of symptoms, temperature, white blood cell counts, systemic inflammatory response score, and bilirubin levels were independent variables in a logistic regression analysis assessing factors predicting the presence or absence of appendiceal gangrene/perforation. Elevated total bilirubin levels (>1 mg/dl) were found in 59 (38%) of 157 patients. Patients with gangrene/perforation were significantly (p = 0.004) more likely to have hyperbilirubinemia than those with acute suppurative appendicitis. No statistical differences were observed for any of the other variables. On logistic regression the only significant relationship between the presence or absence of appendiceal gangrene and perforation was the presence of hyperbilirubinemia (p = 0.031, 95% confidence interval 1.11–7.6). The odds of appendiceal perforation are three times higher (odds ratio 2.96) for patients with hyperbilirubinemia compared to those with normal bilirubin levels. Hyperbilirubinemia is frequently associated with appendicitis. Elevated bilirubin levels have a predictive potential for the diagnosis of appendiceal perforation. Poster of Distinction presented at the 47th annual meeting of the Society for Surgery of the Alimentary Tract held in Los Angeles, CA on 22 May 2006.     

The diagnostic value of white cell count,C-reactive protein and bilirubin in acute appendicitis and its complications

Introduction

Inflammatory markers such as white cell count (WCC) and C-reactive protein (CRP) and, more recently, bilirubin have been used as adjuncts in the diagnosis of appendicitis. The aim of this study was to determine the diagnostic accuracy of the above markers in acute and perforated appendicitis as well as their value in excluding the condition.

Methods

A retrospective analysis of 1,169 appendicectomies was performed. Patients were grouped according to histological examination of appendicectomy specimens (normal appendix = NA, acute appendicitis = AA, perforated appendicitis = PA) and preoperative laboratory test results were correlated. Receiver operating characteristic (ROC) curve area analysis (area under the curve [AUC]) was performed to examine diagnostic accuracy.

Results

ROC analysis of all laboratory variables showed that no independent variable was diagnostic for AA. Good diagnostic accuracy was seen for AA when all variables were combined (WCC/CRP/bilirubin combined AUC: 0.8173). In PA, the median CRP level was significantly higher than that of AA (158mg/l vs 30mg, p<0.0001). CRP also showed the highest sensitivity (100%) and negative predictive value (100%) for PA. CRP had the highest diagnostic accuracy in PA (AUC: 0.9322) and this was increased when it was combined with WCC (AUC: 0.9388). Bilirubin added no diagnostic value in PA. Normal levels of WCC, CRP and bilirubin could not rule out appendicitis.

Conclusions

CRP provides the highest diagnostic accuracy for PA. Bilirubin did not provide any discriminatory value for AA and its complications. Normal inflammatory markers cannot exclude appendicitis, which remains a clinical diagnosis.     

A Clinicopathological Review of 324 Appendices Removed for Acute Appendicitis in Durban,South Africa: A Retrospective Analysis

INTRODUCTION

Acute appendicitis remains a common surgical condition and the importance of specific elements in the clinical diagnosis remain controversial. A variety of neoplastic and inflammatory conditions mimic acute appendicitis. The purpose of this study was to determine the presenting pattern of acute appendicitis and to review the pathological diagnosis.

PATIENTS AND METHODS

This is a retrospective analysis of 324 patients who had appendicectomy for acute appendicitis at Prince Mshiyeni Memorial Hospital (Natal, South Africa) during the period January 2002 to December 2004. Patient demographics, clinical features, white cell count, operative findings, outcome and histology results were recorded on a special patient proforma.

RESULTS

A total of 371 patients underwent appendicectomy during this period and 324 (M:F, 3.6:1) were available for analysis. The majority of our patients were in the second decade (43.1%) with only 29.3% presenting within 24 h of onset of symptoms. The most common symptoms were abdominal pain (100%), vomiting (57.4%) and anorexia (49.0%). Generalised and localised abdominal tenderness were present in 62.0% and 19.4% of patients, respectively. Pyrexia was noted in 41.0%. Localised and generalised peritonitis were present in 26.4% and 14.0%, respectively. The most common incisions were lower midline laparotomy (47.2%) and gridiron (37.3%). The negative appendicectomy rate was 17.0%. Acute appendiceal inflammation and gangrenous appendicitis was present in 36.1% and 9.6%, respectively. The perforation rate was 34.0% and there was a direct correlation with delayed presentation. There were no patients with carcinoid tumour or adenocarcinoma. Parasites and other associated conditions were seen in 8.6% of cases. Postoperative complications included: wound sepsis (25.3%), prolonged ileus (6.2%), peritonitis (4.6%) and chest infection (3.4%). Four patients died (1.2%) all from the perforated group.

CONCLUSIONS

Our patients present late with advanced disease and complications. All surgeons should bear in mind the possibility of parasitic infestations mimicking acute appendicitis and the presence of significant unusual histological findings in our setting justifies routine histopathological examination of appendices.     

The impact of an acute care surgery clinical care pathway for suspected appendicitis on the use of CT in the emergency department

Background

The natural evolution of an acute care surgery (ACS) service is to develop disease-specific care pathways aimed at quality improvement. Our primary goal was to evaluate the implementation of an ACS pathway dedicated to suspected appendicitis on patient flow and the use of computed tomography (CT) in the emergency department (ED).

Methods

All adults within a large health care system (3 hospitals) with suspected appendicitis were analyzed during our study period, which included 3 time periods: pre-and postimplementation of the disease-specific pathway and at 12-month follow-up.

Results

Of the 1168 consultations for appendicitis that took place during our study period, 349 occurred preimplementation, 392 occurred postimplementation, and 427 were follow-up visits. In all, 877 (75%) patients were admitted to the ACS service. Overall, 83% of patients underwent surgery within 6 hours. The mean wait time from CT request to obtaining the CT scan decreased with pathway implementation at all sites (197 v. 143 min, p < 0.001). This improvement was sustained at 12-month follow-up (131 min, p < 0.001). The pathway increased the number of CTs completed in under 2 hours from 3% to 42% (p < 0.001). No decrease in the total number of CTs or the pattern of ultrasonography was noted (p = 0.42). Wait times from ED triage to surgery were shortened (665 min preimplementation, 633 min postimplementation, 631 min at the 12-month follow-up, p = 0.040).

Conclusion

A clinical care pathway dedicated to suspected appendicitis can decrease times to both CT scan and surgical intervention.     

Appendiceal diverticulum associated with chronic appendicitis

INTRODUCTION

Appendiceal diverticulosis is a rare entity, with a global incidence between 0.004% and 2.1% of all appendectomies. It has been related with an elevated risk of perforation in comparison to acute appendicitis, as well as an increased risk for synchronic appendicular cancer in 48% of the cases, and colonic cancer in 43%. The incidence of chronic appendicitis has been reported in 1.5% of all appendicitis cases.

PRESENTATION OF CASE

We present a 73-year-old female, with no relevant familial history, who presented due to a four-month-long oppressive, moderate pain in the lower right abdominal quadrant without irradiation or any other accompanying symptoms.

DISCUSSION

The documented incidence of appendiceal diverticula and chronic appendicitis by themselves is low; therefore the presence of both entities at the same time is extremely rare.

CONCLUSION

We present a case in which both diagnoses concurred in the same patient. The relevance of this case relies on the importance of the adequate knowledge of these pathologies, so we can approach them correctly. Although it does not represent an absolute surgical emergency, appendectomy represents the first therapeutic option.     

County Versus Private Hospitals: Access of Care, Management and Outcomes for Patients with Appendicitis

Background and Objectives:

Race/ethnicity and socioeconomic status may affect healthcare access (higher appendiceal perforation [AP] rates), management (lower laparoscopic appendectomy [LA] rates), and outcomes in patients with appendicitis. This study determines if disparities exist between county and private hospitals.

Methods:

A review of patients ≥18 years treated for appendicitis from 1998 through 2007 was performed. Data from a county hospital were compared to data from 12 private hospitals. Study outcomes included length of hospitalization (LOH), and rates of AP, LA, and abscess drainage. Predictor variables collected included age, sex, race/ethnicity, per-capita income, and hospital type.

Results:

For this study, 16,512 patients were identified (county=1,293, private=15,219). On univariate analysis, patients at the county hospital had lower mean per-capita incomes ($13,412 vs. $17,584, P<.0001), similar AP rates at presentation (26% vs. 24%, P=.10), and lower abscess drainage (0.2% vs. 2.1%, P<.0001). However, multivariate analysis demonstrated a higher AP (OR 1.4, CI 1.2–1.6) and LA rate (OR 1.9, CI 1.7–2.2), a lower abscess drainage rate (0.07, 95%CI 0.02–0.27), and longer LOH (parameter estimate = 0.4, P<.0001) at the county hospital. Within the county hospital cohort, LOH and rates of AP, LA, and abscess drainage were similar across all races/ethnicities and income levels.

Conclusions:

When compared to private hospital patients, adults with appendicitis treated at a county hospital were of lower socioeconomic background, had higher AP rates and longer LOH, but were more likely to undergo LA and less likely to require abscess drainage. Since racial and socioeconomic disparities were no longer apparent once within the county hospital cohort, these differences may be due to differences in access to healthcare.     

How to prevent cut-out and cut-through in biaxial proximal femoral nails: is there anything beyond lag screw positioning and tip–apex distance?

Purpose

Hip perforation is a major complication in proximal femoral nailing. For biaxial nails, knowledge of their biomechanics is limited. Besides re-evaluation of accepted risk factors like the tip–apex distance (TAD), we analysed the influence of anti-rotational pin length.

Methods

We compared 22 hip perforation cases to 50 randomly chosen controls. TAD, lag-screw position, angle between lag-screw and femoral neck axis, lag-screw gliding capacity, displacement and anti-rotational pin length were investigated.

Results

Hip perforation was associated with a higher angle of deviation between lag-screw and femoral neck axis (p = 0.001), a lower telescoping capacity of the lag screw (p = 0.02), and higher TAD (p = 0.048). If the anti-rotational pin exceeded a line connecting the tip of the nail and the lag screw (NS line), hip perforation incidence was increased (p = 0.009). Inadequate pin length resulted in an odds ratio of 10.8 for hip perforation (p = 0.001).

Conclusions

In biaxial nails anti-rotational element positioning is underestimated, however, crucial.     

Leucocyte count and oral temperature are a useful guide to selecting women with right iliac fossa pain for diagnostic laparoscopy

INTRODUCTION

In women, negative appendicectomy rates can be as high as 34%. A 5-fold reduction is possible with diagnostic laparoscopy. A selective policy is favoured as indiscriminate use may increase postoperative morbidity. Scoring systems are helpful but not used widely du to their complexity. The value of leucocyte count and temperature in selecting women with right iliac fossa pain for diagnostic laparoscopy is investigated.

PATIENTS AND METHODS

Over a 12-month period, admission leucocyte count and temperature data were obtained from women undergoing appendicectomy. Cohorts were sub-categorised by age (< 20, 21–40 and > 40 years) and the proportion of negative (normal appendix) and positive (inflamed, gangrenous or perforated appendix) appendicectomies compared.

RESULTS

In 100 women, 11% had leucocyte counts and temperature ≥ 11 × 10⁹/l and 38°C, respectively; all had appendicitis. In 50%, leucocyte counts and temperature were ≥ 11 × 10⁹/l and < 38°C; negative appendicectomies occurred in 13.8% < 20 years, 10% > 40 years (P < 0.01) and 27.3% aged 21–40 years (P = 0.086). In 39%, the negative appendicectomy rate was ≥ 36.8% when leucocyte count and temperature were < 11 × 10⁹/l and 38°C (P = 0.1).

CONCLUSION

Diagnostic laparoscopy should be considered in all women when leucocyte counts and temperature are ≥ 11 × 10⁹/l and 38°C and for females aged 21–40 years when these values are ≥ 11 × 10⁹/l and < 38°C.     

Gangrenous appendicitis: No longer complicated

Background

Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections.