Is there a role for interval appendectomy in the management of acute appendicitis?

Interval appendectomy (IA) remains a controversial subject in surgery. To determine its effectiveness we reviewed our results with this approach. From January 1990 through December 1998 a total of 73 patients underwent appendectomy, five (7%) of which were interval in nature. These IA patients had a palpable abdominal mass or delayed presentation that led to CT scan. The decision to delay surgery was determined by two factors: 1) a CT scan that showed advanced inflammatory changes (phlegmon or abscess) associated with acute appendicitis and 2) a rapid response to conservative management. All patients received antibiotics-first intravenous and then oral. Repeat CT scans were performed before surgery and showed a virtual resolution of the inflammatory process. Appendectomy was delayed from 35 to 66 days from the time of diagnosis (average 51 days). There were no preoperative complications, the operations were uneventful, and there were no significant postoperative sequelae. IA appears to convert an unfavorable surgical situation potentially fraught with complications (fistula, abscess, wound infection) to one that is essentially elective in nature. It should be considered for the patient who is found to have an extensive periappendiceal inflammatory process, is clinically stable, and responds favorably to initial nonoperative management.     

Perforated appendicitis in children: is there a best treatment?

Purpose

This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors’ hospital.

Methods

This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital.

Results

The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management.

Conclusions

Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm³. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.     

Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

BackgroundIn early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period.MethodsAll presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison.ResultsThere was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) – a 0% negative appendicectomy rate (NAR).DiscussionThe 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.     

Biomarkers of acute kidney injury in different clinical settings: a time to change the paradigm?

Acute kidney injury (AKI) is diagnosed in 5% of all hospitalized patients and in up to 50% of all ICU patients. In the last years a dramatic rise in the prevalence of AKI has been observed with virtually no change in mortality, reaching up to 50-80% in all dialyzed ICU patients. AKI may progress to end-stage renal disease, and even subclinical episodes of AKI, which are common, may also progress to end-stage renal disease. The early detection of AKI may enable timely intervention and prevention of progression; however, in animal models and in human studies the 'window of therapeutic intervention' is narrow. Different urinary and serum proteins have been intensively investigated as possible biomarkers for the early diagnosis of AKI. There are promising candidate biomarkers with the ability to detect an early and graded increase in tubular epithelial cell injury and distinguish pre-renal disease from acute tubular necrosis. In this review, new emerging biomarkers of AKI are presented and described in some clinical settings, such as cardiac surgery, contrast-induced nephropathy, delayed graft function and ICU/emergency departments, where biomarkers are urgently needed to diagnose, make prognoses and differentiate.     

Is there a diminishing role for surgery for merkel cell carcinoma of the skin? A review of current management

Merkel cell carcinoma is a highly malignant skin tumour that must be managed in a multidisciplinary forum. Excisional biopsy of the primary is recommended and this should be followed by postoperative radiotherapy to the primary site, in-transit areas and the draining lymph nodes. The tumour is quite radiosensitive and radiation doses of the order of 50 Gy offer high levels of local control. Resection margins of 3 cm are not required provided postoperative radiotherapy is used. In the event of inoperable disease, patient refusal of surgery or a frail patient, radiotherapy should be used as the sole treatment modality, with high likelihood of achieving local control. Patients with involved nodes have a higher risk of distant disease. Traditionally, involved nodes have been managed with resection but, currently, there are protocols exploring the use of synchronous chemoradiotherapy as definitive treatment. Although adjuvant chemotherapy has been used in this setting to reduce the risk of distant seeding, the benefits at this stage have not been confirmed conclusively. The presence of distant disease carries a grave outlook and responses to chemotherapy occur frequently, but are usually shortlived.     

Do current clinical trials in cystic fibrosis match the priorities of patients and clinicans? A systematic review

There are many uncertainties regarding Cystic Fibrosis (CF) treatment. Recently, the first James Lind Alliance (JLA) Priority Setting Partnership (PSP) in CF was completed, bringing clinicians, patients and carers together to identify the Top 10 research priorities. Here we investigate how well the current clinical trials landscape reflects these priorities. Trials in CF were identified through searches of research databases (Pubmed, ANZCTR, EU clinical trials register, ClinicalTrials.gov and ISRCTN). Trials meeting inclusion criteria of registered intervention studies in CF published between 01.012016 and 11.09.2017 were matched to the Top 10 priorities. We identified 259 trials, with 193 fulfilling the inclusion criteria. Only 63 (33%) of these matched one or more of the JLA priorities showing that current clinical trials poorly reflect the JLA Top 10. By increasing awareness of the Top 10 priorities, it is hoped that this will fuel future research in areas important to the CF community.     

Non-operative management of early,acute appendicitis in children: Is it safe and effective?

Purpose

The purpose of this study was to determine if early, acute appendicitis in children can be safely and effectively managed with antibiotics alone.

Methods

A retrospective review was performed of children (< 18 yrs) treated non-operatively (NOM) for early, acute appendicitis since May 2012. These were compared to patients treated with appendectomy between January 2011 and October 2011 (OM). Inclusion criteria included: (a) symptoms < 48 h, (b) localized peritonitis, and (c) ultrasound findings consistent with early, acute appendicitis.

Results

Twelve patients (66% female, mean age 12.2,SD = 4.2 yrs) were treated non-operatively, while 12 (50% female, mean age 12.5,SD = 3.2 yrs) were treated operatively. Two NOM children (16.7%) required initial appendectomy. One patient developed recurrent appendicitis requiring appendectomy 7 months post-discharge. Four other NOM patients returned with symptoms but did not require admission or surgery. Two OM patients (8.3%) had hospital visits and admissions related to surgical site infections. Mean length of stay (LOS) for the first visit was 1.5 days (SD = 1.0d) (NOM) vs. 1.3 days (SD = 0.5d) (OM) (p = 0.61). Including first and subsequent admissions, mean LOS was 1.8 days (SD = 1.1d) (NOM) vs. 1.7 days (SD = 1.5d) (OM) (p = 0.97).

Conclusion

Early acute appendicitis in appropriately selected children can be successfully treated non-operatively. Randomized trials with longer follow-up are required.     

Fate of excluded popliteal artery aneurysms: should we change our current treatment?

Surgical repair of popliteal artery aneurysms is usually performed by vascular exclusion and femoro-popliteal bypass grafting via a medial route. The vascular exclusion of a popliteal artery aneurysm may, however, prove ineffective long-term. We report on a patient with a large popliteal artery aneurysm observed twelve years after conventional surgical treatment and discuss alternative surgical options to be considered for long-lasting effective popliteal artery aneurysm treatment.     

Lumbar discography: should we use prophylactic antibiotics? A study of 435 consecutive discograms and a systematic review of the literature

BACKGROUND: Lumbar discography can be used in the diagnostic work-up of degenerative spine disease. The most serious complication is discitis, believed to be due to penetration of the disc by a needle contaminated with skin flora. The use of prophylactic antibiotics has been advocated, although there is great concern regarding their efficacy and possible adverse effects on disc cells. METHODS: In the current study, the incidence of postdiscography discitis without the use of prophylactic antibiotics was studied in a consecutive patient group. Additionally, a systematic literature review was performed using strict criteria: 1). Discography was performed by means of a two-needle technique, 2). complications such as discitis were specifically looked for at follow-up, and 3). the exact numbers of patients and those lost to follow-up were reported. RESULTS: The clinical results of 200 patients with 100% follow-up for a minimum period of 3 months showed no case of discitis. In the literature review, 10 studies were selected. Nine studies without prophylactic antibiotics reported an overall incidence of 12 cases in 4891 patients (0.25%) or 12770 discs (0.094%). The only study with prophylactic antibiotics (127 patients) showed no case of discitis. CONCLUSIONS: Regarding the small number of patients in the only study in which antibiotics were used and the overall low incidence of postdiscography discitis, not enough evidence was found that prophylactic antibiotics can prevent discitis. It was concluded that in lumbar discography by means of a two-needle technique without prophylactic antibiotics, the risk of postdiscography discitis is minimal and there is not enough support from the literature to justify the routine use of prophylactic antibiotics.     

Efficacy of treatment in peri-pelvic Morel–Lavallee lesion: a systematic review of the literature

Background

Morel-Lavallee lesion (MLL) of the peri-pelvic region is less common and various treatments have been introduced to manage the lesion. No standard treatment is recommended. We performed a systematic review of literature to (1) identify the classification of peri-pelvic MLL; (2) review the treatments of the lesion and their complications; (3) define the optimal treatment of peri-pelvic MLL.

Methods

A systematic search was performed via PubMed, ISI Web of Knowledge, and Embase for English abstract articles from 1966 to 2012. We identified 21 articles detailing 153 patients with peri-pelvic MLL, most of which were level IV studies. The treatments and clinical results were reviewed.

Results

For peri-pelvic MLL patients, surgical intervention was better than conservative therapy. Sclerhodesis method is attended with good outcome in the symptomatic MLL patients without fractures. Patients with peri-pelvic fractures could be managed with local suction drainage or open debridement with dead space closure technique during fracture fixation. The delayed-diagnosis cases might be treated with mass resection when fibrosis capsule was obtained in magnetic resonance imaging.

Conclusions

Peri-pelvic MLL can be treated with various surgical methods depending on the formation of fibrosis capsule and associated injuries. Dead space closure technique is emphasized in the treatment of MLL. Higher quality of literature is required to prove this result in future research.     

When can I be proficient in laparoscopic surgery? A systematic review of the evidence

Purpose: The aim of this study was to quantify the learning curve in laparoscopic surgery. Methods: A systematic review of the evidence using a defined search strategy (PubMed, Medline, OVID, Embase, ERIC, Cochrane databases) was performed. Studies without statistical evaluation of the learning curve and opinion articles were excluded. The authors analysed 7 common laparoscopic procedures: cholecystectomy, fundoplication, colectomy, herniorrhaphy, splenectomy, appendicectomy, and pyloromyotomy. The [ldquo ]initial[rdquo ] and [ldquo ]late[rdquo ] stages of experience were compared with regards to the following outcome measures: operating time, conversion rate, complication rate, and length of stay in hospital. Results: A total of 3,641 articles were reviewed, of which, 37 (25,777 patients) fulfilled the entry criteria (5 in children). In all articles, the definition of proficiency was subjective, and the number of operations required to reach it was highly variable. There were improvements in all 4 outcome measures for cholecystectomy, fundoplication, colectomy, herniorrhaphy, and splenectomy between the [ldquo ]initial[rdquo ] and [ldquo ]late[rdquo ] experience. No data were available for the learning curves in appendicectomy or pyloromyotomy. Conclusions: The number of procedures required to reach proficiency in laparoscopic surgery has not been defined clearly. These findings are important for training, ethical and medico-legal issues. J Pediatr Surg 38:720-724. [copy ] 2003 Elsevier Inc. All rights reserved.     

Can intracellular Staphylococcus aureus in osteomyelitis be treated using current antibiotics? A systematic review and narrative synthesis

Approximately 40% of treatments of chronic and recurrent osteomyelitis fail in part due to bacterial persistence. Staphylococcus aureus, the predominant pathogen in human osteomyelitis, is known to persist by phenotypic adaptation as small-colony variants(SCVs) and by formation of intracellular reservoirs, including those in major bone cell types, reducing susceptibility to antibiotics.Intracellular infections with S. aureus are difficult to treat; however, there are no evidence-based clinical g...     

A 23-year review of the management of acute retention of urine: progressing or regressing?

A retrospective review of all patients in Oxford under the care of one consultant urologist (GJF) who presented on alternate years over a 23-year period with acute retention of urine was undertaken. Data were collected on the: (i) number of patients discharged from hospital with an in-dwelling catheter; (ii) duration of catheter drainage prior to surgery; and (iii) duration of postoperative stay. In all, 244 patients underwent prostatectomy. Over the 23-year period, there was a significant increase in the proportion of patients discharged prior to surgery (P < 0.001) as well as their median duration of catheterisation (P < 0.001): more than 50% were catheterised for more than 3 months in 1997. Conversely, post-operative hospital stay has decreased. Prolonged catheter drainage carries considerable morbidity, with 72% experiencing some complication. Most patients feel they lose dignity, 69% consider it uncomfortable and more than 50% complain of burning sensations, bladder spasms and a persistent desire to micturate. We recommend that patients should not be placed on routine waiting lists where they are liable to remain for an unacceptably long time. Targets should be set to admit them within a set period and theatre lists made available. We feel that six weeks is a realistic target.