老年急性阑尾炎行腹腔镜与开腹手术的对比分析

目的对比分析腹腔镜(LA)和开腹阑尾切除术(OA)治疗老年急性阑尾炎的手术效果。方法2003年1月至2006年1月行阑尾切除术治疗老年阑尾炎56例,其中LA27例,OA29例。比较2种术式的手术时间、下床活动时间、术后排气时间、疼痛评分、误诊率、止痛药使用率、切口感染率、置管引流率、残余脓肿发生率、住院时间和综合费用。结果LA组和OA组以上各指标(除手术时间和综合费用外)差异均有统计学意义(P<0.05)。结论对于老年急性阑尾炎,和OA相比,LA具有创伤小、恢复快、并发症少和平均住院时间短等优点,值得临床推广。     

Infección de sitio quirúrgico tras apendicectomía urgente: tasa global y tipo según la vía de abordaje (abierta/laparoscópica)

Objective

To compare the incidence and profile of surgical site infection (SSI) after laparoscopic (LA) or open (OA) appendicectomy.

Material and method

Observational and analytical study was conducted on patients older than 14 years-old with suspected acute appendicitis operated on within a 4-year period (2007-2010) at a third level hospital (n = 868). They were divided in two groups according to the type of appendicectomy (LA, study group, 135; OA, control group, 733). The primary endpoint was a surgical site infection (SSI), and to determine the overall rate and types (incisional/organ-space). The risk of SSI was stratified by: i) National Nosocomial Infection Surveillance (NNIS) index (low risk: 0E, 0 and 1; high risk: 2 and 3); ii) status on presentation (low risk: normal or phlegmonous; high risk: gangrenous or perforated). The statistical analysis was performed using the software SPSS. The main result and stratified analysis was determined with χ², and the risk parameters using OR and Mantel-Haenszel OR with 95%CI, accepting statistical significance with P < .05.

Results

Age, gender, ASA index and incidence of advanced cases were similar in both groups. The overall SSI rate was 13.4% (more than a half of them detected during follow-up after discharge). Type of SSI: OA, 13% (superficial 9%, deep 2%, organ-space 2%); AL, 14% (superficial 5%, deep 1%, organ-space 8%) (overall: not significant; distribution: P < .000). Stratified analysis showed that there is an association between incisional SSI/OA and organ-space SSI/LA, and is particularly stronger in those patients with high risk of postoperative SSI (high risk NNIS or gangrenous-perforated presentation).

Conclusion

OA and LA are associated with a higher rate of incisional and organ-space SSI respectively. This is particularly evident in patients with high risk of SSI.     

Laparoscopic apendicectomy vs open approach for the treatment of acute appendicitis

BackgroundThere is no international consensus on the approach of choice for performing appendectomy.AimsTo analyze and compare open and laparoscopic approaches in the surgical treatment of acute appendicitis.Material and MethodsA retrospective study was carried out on patients over 14-years-old operated on for suspected acute appendicitis between January 2007 and December 2009. Variables were: age, sex, body mass index, specialized surgeon or resident in training, progression duration, conversion rate, use of drains, abdominal cavity irrigation, macroscopic appearance of the appendix, onset time of anesthesia, ASA classification, postoperative hospital stay, resumption of intake of liquids, and complications. The patients were divided into two groups: laparoscopic approach (LA) and open approach (OA).ResultsA total of 533 patients were enrolled (290 LA and 243 OA). Onset time of anesthesia was 75 min (30-190 min) in LA vs 55 min (20-160 min) in OA (p<0,0001). Complications: intraabdominal abscesses in 17 LA cases vs 13 OA cases (p=0,79); surgical wound alterations in 16 LA cases vs 47 OA cases (p=0,0001); incisional hernias in 2 LA cases (1%) vs 10 OA cases (p=0,008). There were no statistically significant differences in postoperative hospital stay (3 days), resumption of intake of liquids (1 day) or readmission rate (8%).ConclusionsThere are fewer surgical wound alterations and incisional hernias with the laparoscopic approach, but there is higher cost, lengthier surgery duration, and a longer learning curve. Our results cannot provide a clear indication for one approach or the other, and therefore each case must be evaluated on an individual basis.     

Initial experience with laparoscopic appendectomy

As experience with laparoscopy increases, new applications in general surgery are being identified. Treatment of acute appendicitis through the laparoscope has been proposed. We present our initial experience with this new technique. Over a 12-month period, laparoscopic appendectomy was attempted in 29 patients. There were no intraoperative complications. Two cases required conversion to the open technique owing to gangrene at the appendiceal base. The average operating time was 64 minutes. Two of nine patients with perforated appendicitis developed a pelvic abscess, and one patient developed wound cellulitis. Pain medication requirements were minimal, bowel function returned rapidly, and half of the patients were discharged on postoperative day one or two and returned to normal activity within one week. Based on our initial experience, it appears that laparoscopic appendectomy is a safe and effective technique for managing acute appendicitis and offers advantages in terms of decreased pain, decreased hospital stay, and a rapid return to normal activities     

Laparoscopic treatment of perforated appendicitis

The use of laparoscopy has been established in improving perioperative and postoperative outcomes for patients with simple appendicitis. Laparoscopic appendectomy is associated with less wound pain, less wound infection, a shorter hospital stay, and faster overall recovery when compared to the open appendectomy for uncomplicated cases. In the past two decades, the use of laparoscopy for the treatment of perforated appendicitis to take the advantages of minimally invasiveness has increased. This article reviewed the prevalence, approaches, safety disclaimers, perioperative and postoperative outcomes of the laparoscopic appendectomy in the treatment of patients with perforated appendicitis. Special issues including the conversion, interval appendectomy, laparoscopic approach for elderly or obese patient are also discussed to define the role of laparoscopic treatment for patients with perforated appendicitis.     

Updated meta-analysis of randomized controlled trials comparing conventional excisional haemorrhoidectomy with LigaSure for haemorrhoids

BACKGROUND: To compare the surgical outcome of haemorrhoidectomy performed using LigaSure bipolar diathermy with conventional haemorrhoidectomy. METHODS: Only randomized and alternate allocated studies were included from the major electronic databases using the search terms "ligasure" and "haemorrhoids". Duration of operation, blood loss during operation, postoperative pain score, wound healing, in-hospital stay, time to return to normal activities and complications were assessed. RESULTS: The 11 trials contained a total of 1,046 patients; the largest study was based on 273 patients and two earlier studies were based on 34 patients. No significant gender mismatch between the groups was reported in any of the studies. The patients' ages were similar between groups in the studies, as was disease severity. All 11 studies reported a shorter duration of the operation when using LigaSure compared to the conventional technique (p<0.001). The postoperative pain score (p=0.001) and blood loss during operation (p=0.001) were significantly reduced. After LigaSure haemorrhoidectomy wound healing (p=0.004) and the return to normal activities (p=0.001) were significantly faster than after conventional haemorrhoidectomy. However, the overall incidence of complications reported was not significantly different (p=0.056). CONCLUSIONS: LigaSure is an effective instrument for haemorrhoidectomy which results in less blood loss, quicker wound healing and earlier return to work.     

Laparoscopic Appendectomy for Acute Appendicitis: Is This a Feasible Option for Developing Countries?

Background/Aim:

The role of laparoscopic appendectomy is still not well defined in the literature. This study was conducted to evaluate the feasibility of laparoscopic appendectomy at a university hospital in a developing country.

Patients and Methods:

Patients undergoing laparoscopic appendectomy (LA) from August 2002 to August 2006 were identified. For each case, a control was selected from patients undergoing open appendectomy (OA) during the same year by systematic sampling. The groups were compared in terms of duration of surgery, requirement of narcotic analgesia, length of hospital stay, postoperative complications and the overall cost for each patient.

Results:

A total of 68 patients underwent laparoscopic appendectomy during the study period. Median duration of surgery was 82 minutes in LA group and 70 minutes in OA group (P < 0.001). Forty-five patients in LA group and 64 in OA group required narcotic analgesia (P < 0.001). Median length of hospital stay (P = 0.672) and postoperative complications (P = 0.779) were comparable in both groups. Median cost of hospital stay was Pakistani Rupees (PKR) 47121/in LA group and PKR 39318/in OA group, the difference being significant (P = 0.001).

Conclusions:

Laparoscopic appendectomy is feasible in developing countries with similar postoperative outcome and less requirement of narcotic analgesia. The duration of surgery and overall cost were significantly higher and efforts should be made to develop expertise and reduce operative time with resultant decrease in cost. Development of standardized protocols for discharge of patients from the hospital after LA may further reduce the cost and benefit patients in developing countries.     

Experience with Laparoscopic Appendectomy —The Technique and Our Views of its Indications—

Abstract: Since June, 1991 a laparoscopic appendectomy (LA) was performed on eleven patients with suspected appendicitis which could not be confirmed by the conventional diagnostic methods. The patients included 7 males and 4 females, with a mean age of 27, 9, ranging from 16 to 46 years. No postoperative complications were encountered. The laparoscopic diagnoses included gangrenous appendicitis in 2, suppurative appendicitis in 2, catarrhal appendicitis in 4, salpingitis in 2 and an appendiceal mass in one patient (Case 7). Histopathological diagnoses were phlegmonous appendicitis in 3, mucinous cystadenoma in one and catarrhal appendicitis in 7 patients. Two cases of salpingitis and a case with ovarian bleeding were treated conservatively after incidental laparoscopic removal of the appendix. Case 7 was histopathologically diagnosed as having mucinous cystadenoma. The patients’postoperative hospital stay was from 5 to 8 days, with an average of 6.9 days. All patients had been given the permission to be discharged by the third POD but they stayed longer because of benefits given by the health insurance system very specific to Japan. LA in our clinic has so far been limited to selected patients in whom the diagnosis of appendicitis could not been confirmed and laparoscopic examination was indicated, mainly due to manpower problems involving surgeons, anesthetists and operating room nurses. However, LA provides not only benefits for patients but also several merits for surgeons including better exposure of the operating field in most cases when compared with an open appendectomy. We feel, therefore, that the indications for LA might be extended more widely, probably to most cases of appendicitis.     

Postoperative wound infections detected during hsopitalization and after discharge in a community hospital

Postoperative wound infections were evaluated in 1271 patients who had 1389 surgical procedures. There were 49 postoperative wound infections identified, of which 26 (53%) were discovered after discharge. Wound infections varied from 2.5% for clean wounds up to 13.3% for dirty wounds. Among the specialties, the infection rate ranged from no infection for otolaryngologists and urologists to 8.6% for general surgeons. With routine hospital surveillance, the overall infection rate was 1.8% or 2.2%, including readmissions for infection, but less than the actual rate of 3.8%. Persons who had three procedures had an infection rate of 27.3%; for two procedures, 8.1%; and for one procedure, 3.2%. Most postoperative wound infections detected after discharge were based on clinical grounds and not positive cultures. Rehospitalization was required for seven patients because of infection. This study demonstrates that postoperative wound infection surveillance must be continued after discharge.     

Stump appendicitis. A diagnostic dilemma

A case of stump appendicitis in a 41-year-old man is presented. Initial appendicectomy for suppurative appendicitis had been performed 14 months earlier. An ultrasound scan suggested the diagnosis of stump appendicitis despite the hindsight of previous appendicectomy. A literature review on the subject is provided. Stump appendicitis should be considered in the differential diagnosis of recurrent lower abdominal symptoms any time following initial appendicectomy. Knowledge of a difficult approach at initial surgery may raise the level of suspicion.     

腹腔镜及开腹手术治疗小儿复杂性阑尾炎268例

目的:对比分析腹腔镜和开腹阑尾切除术在治疗小儿复杂性阑尾炎中的疗效.方法:回顾性分析2000-01/2009-11小儿复杂性阑尾炎患者268例临床资料,其中腹腔镜阑尾切除术(LA)128例,开腹阑尾切除术(OA)140例,比较两组手术情况和疗效.结果:手术时间:LA组较OA组长(62.2 min±15.3 min vs 57.1 min±6.4 min,P<0.01);术后肛门排气时间:LA组较OA组短(26.8 h±7.6 h vs 42.9 h±8.3 h.P<0.001);术后住院时间:LA组较OA组短(5.2 d±2.3 d vs 9.5 d±2.6d,P<0.001);术后腹腔脓肿LA组1例,OA组9例(P=0.036);切口感染:LA组3例,OA组28例(P<0.001);肠梗阻:LA组2例,OA组5例(P=0.518).结论:LA较OA具有创伤小、恢复快、并发症少、住院时间短和美容效果好等优点,是治疗小儿复杂性阑尾炎一种安全有效的手术方式.     

Laparoscopic appendicectomy: diagnosis and resection of acute and perforated appendices

Laparoscopic appendicectomy for acute appendicitis has been promulgated in many European countries during the 1980s. The introduction of the microchip camera and visual assistance on a monitor has increased the appeal of laparoscopic appendiceal resection. It carries a unique appeal in that the extent of inflammation and the presence of other pathological conditions are readily identified. This approach does not prevent the surgeon proceeding to open surgery if appropriate, and will aid in defining the site of incision. Prospective analyses (McAnena et al, 1992; Attwood et al, 1992) have shown that this approach shortens hospital stay, decreases wound infection rates and provides excellent cosmetic results. It also hastens return to full activity. It requires experience and, as with cholecystectomy, the option of converting to an open procedure should not be considered a failure of the approach. Details of approaches to the inflamed appendix are described. Caution in the use of diathermy is needed (particularly at the base of the appendix), as it may cause necrosis of the caecum or dissolution of the ties at the appendix base. Control of the appendicular artery by clip ligation is preferable to diathermy.The training of surgical residents will be enhanced rather than diminished if, under close, experienced supervision, they are taught to perform appendicectomy laparoscopically, as the essentials of anatomic dissection of the appendix are perhaps better appreciated on a video screen than at open surgery through a small incision.     

Seasonal variations of acute appendicitis and nonspecific abdominal pain in Finland

AIM:To investigate whether seasonal changes had an effect on the incidence of acute appendicitis(AA)or nonspecific abdominal pain(NSAP).METHODS:We carried out a national register study of all patients with a hospital discharge diagnosis of AA and acute NSAP in Finland.Data were analyzed for the whole country and correlated to seasonal and weather parameters(temperature,humidity).Moreover,additional sub-analyses were performed for five geographically different area of Finland.RESULTS:The observation period spanned 21 years,with 186558 appendectomies,of which 137528(74%)cases were reported as AA.The incidence of AA declined for 32%over the study period.The average incidence of the NSAP was 34/10000 per year.The mean annual temperature,but not relative humidity,showed clear geographical variations.The incidence of AA decreased significantly during the cold months of the year.No correlation was detected between temperature and incidence of NSAP.Humidity had a statistically significant impact on NSAP.CONCLUSION:The incidence of acute appendicitis is declining in Finland.We detected a clear seasonality in the incidence of AA and NSAP.     

Minilaparotomy for aortoiliac occlusive disease: preliminary results

This prospective study was designed to establish the feasibility of minilaparotomy for aortobifemoral bypass, and its effect on intraoperative and postoperative variables. A minilaparotomy has potential benefits for the patient, including smaller size of the surgical wound, reduced risk of infection, shorter postoperative intubation, decreased postoperative pain, earlier discharge, and a smaller, aesthetically more acceptable postoperative scar. Moreover, reoperation is less hazardous, because the peritoneum is not completely dissected. From the beginning of June 1999 through the end of September 2001, we used a minilaparotomy in 33 patients with aortoiliac occlusive disease. Obesity and prior abdominal surgery were regarded as contraindications to the operation. One patient required conversion to a full laparotomy because of intraoperative bleeding. Another patient developed wound infection. There were no deaths. The technique has proved safe, effective, and aesthetically acceptable to the patient. To date, no study has compared a median laparotomy with a minimally invasive alternative for the surgical treatment of aortoiliac occlusive disease. Prospective randomized trials are needed to determine whether minilaparotomy is the superior technique for treatment of aorto-occlusive disease.     

Ropivacaine continuous wound infusion after mastectomy with immediate autologous breast reconstruction: A retrospective observational study

Continuous wound infusion usually provides postoperative analgesia as a multimodal analgesia with systemic opioid use. When continuous wound infusion of local anesthetics (LA) supports successful postoperative analgesia without systemic opioid use, the side effects of opioid can be reduced. Nevertheless, continuous wound infusion after mastectomy with immediate autologous breast reconstruction leads to concerns about wound healing. This study evaluated analgesic effects and wound healing conditions of continuous wound infusion of LA compared with opioid-based, intravenous patient-controlled analgesia (IV PCA) in mastectomy with immediate autologous breast reconstruction.This retrospective observational study included females, aged between 33 and 67 years, who underwent mastectomy with immediate autologous breast reconstruction. Sixty-five patients were enrolled. The eligible patients were placed into 2 groups for managing postoperative pain, one used continuous wound infusion with 0.5% ropivacaine (ON-Q, n = 32) and the other used a fentanyl-based IV PCA (IV PCA, n = 33). Using the electronic medical record system, the postoperative recovery profiles were examined over 5 days using a visual analogue scale (VAS), incidence of postoperative nausea and vomiting (PONV), incidence of sleep disturbance, frequency of rescue analgesic use, analgesia-related adverse events, length of hospital stay, and degree of patient satisfaction. The condition of the surgical wound was observed for 1 year after surgery.The primary endpoint was the intensity of pain at 6 hours after surgery. The VAS was comparable between the groups (P > .05). Although recovery profiles and the degree of patient satisfaction were similar between the groups, the incidence of PONV was significantly lower in the ON-Q group than in the IV PCA group on the day of surgery and postoperative day 1. No patients had severe wound complications. The satisfaction score of analgesia in the ON-Q group was comparable with that of the patients in the IV PCA group.This study demonstrates that single use of continuous wound infusion showed comparable analgesia with fentanyl-based IV PCA in patients who underwent mastectomy with immediate autologous breast reconstruction. Furthermore, the continuous infusion of LA directly on the surgical site did not significantly affect wound healing.     

老年急性阑尾炎的临床特征

[目的]探讨老年急性阑尾炎患者的临床特征。[方法]随机选取2011年1月～2013年1月在我院诊治并经最后手术确诊的老年急性阑尾炎患者58例,对其临床特点、治疗效果和术后并发症进行分析。[结果]患者以食欲减少、精神不振（100%）等症状为主要表现,其次为腹胀47例（81.03%）;有21例（36.20%）患者有典型的转移性右下腹痛,体温高于38.5℃者8例（13.79%）;手术治疗的痊愈率98.00%,无死亡患者;患者手术后的并发症共10例,占17.24%,其中切口感染8.62%,肺部感染3.45%,多器官的功能衰竭3.45%,患者的平均住院时间（12±2.36）d。[结论]老年急性阑尾炎常合并有其他基础疾病,病情往往复杂,易延误治疗,诊断成立后,如果无明确的手术禁忌证,建议尽早手术治疗,对提高患者的治愈率,降低患者的并发症及死亡发生率具有显著意义。     

Cytomegalovirus Appendicitis in a Patient with Acquired Immune Deficiency Syndrome

We report a homosexual patient with the acquired immune deficiency syndrome (AIDS) and histopathologic evidence for cytomegalovirus (CMV) appendicitis in a patient with no prior history of CMV infection. The patient presented with right lower quadrant pain and intermittent fevers. The diagnosis of appendicitis was difficult to make in this patient because of the presumptive diagnosis of tuberculosis ileitis and the frequent presentation of abdominal pain with fever in AIDS patients. Although CMV colitis is frequently seen in AIDS patients, the prevalence of CMV appendicitis is exceedingly rare. The problems related to making a diagnosis of CMV appendicitis and the therapeutic management of CMV infections are reviewed.     

Prospective randomized trial comparing stapled hemorrhoidopexy versus closed Ferguson hemorrhoidectomy

Background Ferguson hemorrhoidectomy is believed to result in less postoperative pain because of a closed wound. Stapled hemorrhoidopexy, without a perianal wound, should thus have lesser pain. We conducted a prospective randomized trial to compare stapled hemorrhoidopexy (SH) with Ferguson hemorrhoidectomy (FH). Methods Fifty patients with third-degree or early fourthdegree hemorrhoids who required surgery were recruited. Patients were prospectively randomized to receive either FH or SH. Data collected include operative time, hospital stay, fecal incontinence and pain scores, morbidity and complications. Results SH patients had less pain in the early postoperative period. There were no significant differences in hospital stay or major complications. One patient after SH required emergency reintervention for thrombosed hemorrhoids distal to the staple line. FH patients had more minor problems of bleeding, wound discharge and pruritus. Fecal incontinence was similar in the 2 groups but two of the three patients with daily incontinence to gas after SH claimed that their lifestyle was affected. Conclusions SH is safe to perform and results in less postoperative pain as well as less minor morbidity. Early reintervention and incontinence to gas compromising lifestyle occurred only after SH.     

Review of the pathological results of 2660 appendicectomy specimens

Purpose Appendicitis is the most commonly performed emergency abdominal surgery. The appendix can also be the site of a variety of neoplasms and unusual inflammatory conditions. A retrospective review was performed to determine the pathological diagnoses in appendicectomy specimens. Methods This study is a retrospective analysis of 2660 appendicectomies performed from 1997 to 2003. The reports were analyzed for the following parameters: age-related incidence of acute appendicitis, seasonal variation in presentation, perforation rate, rate of negative and incidental appendicectomy, and the incidence of other pathologies encountered. Results Of the 2660 appendicectomy specimens, acute appendicitis was seen in 1718 patients (64.58%), with a peak in patients in their second decade (35.09% of cases of acute appendicitis). The perforation rate was 13.9% and was significantly higher in patients aged 70 years or more (P < 0.001). The negative appendicectomy rate was 28.8%, and was significantly higher in female patients (P < 0.001) and in the 11–30 year age group (P < 0.001). Other pathologies include carcinoid (0.52%), adenocarcinoma (0.39%), and mucinous cystadenoma (0.60%). Conclusions The high rate of negative appendicectomy among female patients and the increased incidence of perforation in elderly patients reinforce the validity of the judicious use of laparoscopy in these populations. There are still a number of unusual histologies found in appendicectomy specimens supporting the continued use of routine histology.     

A case of stump appendicitis after appendectomy]

Stump appendicitis is an acute inflammation of the residual appendix and a rare complication after an appendectomy. Although the signs and symptoms do not differ from acute appendicitis, the diagnosis is often not considered because of the past surgical history. Only a small number of stump appendicitis cases have been reported, but there has been no report of stump appendicitis in Korea. Herein, we report a case of stump appendicitis. A 28-year-old female was admitted to our hospital due to right lower quadrant abdominal pain. Fifteen months ago, the patient had a laparoscopic appendectomy under the diagnosis of an acute appendicitis, but she subsequently suffered from intermittent abdominal pain and fever. Abdominal ultrasonography and CT scan showed an inflamed appendiceal stump. Laparoscopic stump appendectomy was done and the biopsy revealed stump appendicitis.