Surgical management of primary appendiceal malignancy

Aim Primary appendiceal neoplasms are rare, with carcinoid being more common than carcinoma. Preoperative diagnosis is infrequent. We report a series of 24 primary appendiceal neoplasms treated over a 5‐year period. Method All primary appendiceal neoplasms diagnosed in a university teaching hospital between April 2003 and June 2008 were identified from the prospective histopathology database. Patient records were reviewed for clinical, operative and pathological data. Results Fourteen carcinomas and 10 carcinoids were identified in the 5‐year period. The former presented at median age 55.8 years with median symptom duration of 35 days, compared with 48 years and 3 days, respectively, for carcinoids. An abdominal mass was commoner in carcinomas (8/14 vs 1/10). Six patients with carcinoma underwent appendicectomy followed by completion right‐hemicolectomy, two of whom had residual disease; seven underwent primary right‐hemicolectomy and one had abscess drainage. Five patients with appendiceal carcinoma died of the disease during a median follow‐up of 633 (256–1158) days. Six patients underwent appendicectomy for acute appendicitis, one had a primary right‐hemicolectomy for a caecal mass. Three had a subsequent right‐hemicolectomy for a high‐risk carcinoid. An appendiceal carcinoid was an incidental finding in three right‐hemicolectomy specimens removed for other indications. No metastases or deaths were recorded at median follow‐up 451 (51–975) days. Conclusion Appendiceal carcinomas follow a more protracted clinical course than carcinoids, which usually present as acute appendicitis. Caution is needed when diagnosing simple appendicitis in older patients with longer symptom duration, particularly if a mass is present. Patients with appendiceal carcinoma should be offered completion right‐hemicolectomy. Carcinoma has a poor prognosis.     

Single-incision laparoscopic cecectomy for low-grade appendiceal mucinous neoplasm after laparoscopic rectectomy

In this case report,we discuss single-incision laparoscopic cecectomy for low-grade appendiceal neoplasm after laparoscopic anterior resection for rectal cancer.The optimal surgical therapy for low-grade appendiceal neoplasm is controversial;currently,the options include appendectomy,cecectomy,right hemicolectomy,and open or laparoscopic surgery.Due to the risk of pseudomyxoma peritonei,complete resection without rupture is necessary.We have encountered 5 cases of lowgrade appendiceal neoplasm and all 5 patients had no lymph node metastasis.We chose the appendectomy or cecectomy without lymph node dissection if preoperative imaging studies did not suspect malignancy.In the present case,we performed cecectomy without lymph node dissection by single-incision laparoscopic surgery(SILS),which is reported to be a reduced port surgery associated with decreased invasiveness and patient stress compared with conventional laparoscopic surgery.We are confident that SILS is a feasible alternative to traditional surgical procedures for borderline tumors,such as low-grade appendiceal neoplasms.     

Nationwide overview of survival and management of appendiceal tumors in children

Introduction

There remains a paucity of literature on survival related to pediatric appendiceal tumors. The purpose of this study was to determine the incidence, surgical management, and survival outcomes of appendiceal tumors in pediatric patients.

Unusual presentation for primary appendiceal lymphoma: A case report

Primary appendiceal neoplasms are uncommon, being found in approximately 0.5%–1.0% of appendectomy specimens at pathologic evaluation. Primary appendiceal Burkitt’s lymphomas are rare occurring in 0.015% of all gastrointestinal lymphomas. Almost all reported cases of appendiceal lymphoma have proved to be non-Hodgkin lymphoma. The majority of appendiceal lymphomas are of B-cell. Patients were almost entirely males. Acute appendicitis is the most common clinical manifestation. This report describes a rare case of primary appendiceal lymphoma in a patient presented with hematuria and dull aching right lower abdominal and back pain.     

Treatment of appendiceal peritonitis in children by video laparoscopic conversion: conversion is not a one-way procedure]

PATIENTS AND METHODS: This method was used in 14 children, seven boys and seven girls, aged from 2.7 to 14 years, with acute appendicitis and peritonitis. RESULTS: Conversion to median laparotomy was necessary in order to perform adhesiolysis in two cases in which small bowel was observed. Postoperative complications occurred in four patients involving three wound infections and one mechanical intestinal obstruction. There was no intra-abdominal abscess. CONCLUSION: This procedure allows appendectomy by an open classical approach to be performed, and subsequently allows the treatment of the generalized peritonitis by video laparoscopy, usually without median laparotomy.     

Alternate methods for laparoscopic management of adnexal masses greater than 10 cm in diameter.

PURPOSE: We describe alternate laparoscopic methods for inspection and removal of large adnexal masses, and report our experience with 18 cases in which these methods were used. PATIENTS AND METHODS: Between April 1994 and January 2000, the first author performed operative laparoscopy on 18 patients, each of whom had at least one adnexal mass with maximum diameter greater than 10 cm. Mean patient age was 32 years (range 11 to 82). Seventeen of the 18 patients were premenopausal. All procedures were performed at one of two community hospitals in Seattle or at Yuan's General Hospital in Taiwan. Preoperative screening included pelvic exam, tumor markers, and ultrasound. RESULTS: One 82-year-old patient underwent planned laparoscopic bilateral oopherectomy. In the other 17 cases the operative goal was cystectomy or unilateral oopherectomy with conservation of reproductive function. Cystectomy was successfully performed in five of these cases (29.4%). The remaining 12 patients underwent either unilateral oopherectomy (10 cases, 58.8%), or unilateral salpingo oopherectomy (2 cases, 8.8%) due to the extent of their mass. Sixteen of the 18 cases in this series were successfully managed by a single laparoscopic surgery, one case required a second-look laparoscopy, and in one case a malignancy was found by histological analysis of permanent section, which required a second laparoscopy for staging and debulking. CONCLUSIONS: Large adnexal masses can be successfully managed with minimal hospital stay using laparoscopic techniques, when care is taken to avoid rupture and spillage of cyst contents, and thorough inspection of the mass and abdominal cavity is made possible. The probability of finding an unexpected malignancy is low. In those cases where a malignancy is found, appropriate cytoreductive staging surgery can be performed immediately.     

儿童腹腔镜脾切除的初步体会

目的:总结儿童腹腔镜脾切除的经验和特点。方法:回顾性分析21例小儿腹腔镜脾切除患者的临床资料。结果:顺利完成腹腔镜脾切除术18例,中转开腹3例。1例因巨大脾装入取物袋困难,采用下腹横切口取出,余均经腹壁戳孔在取物袋中夹碎后取出。术中除1例出血达300ml外,余均少于10ml。发现副脾2例。术中损伤胃壁1例,术后出血1例。所有患儿术后恢复好,平均2d进食,住院5～11d。随访1个月～3年,患者生长发育良好,无严重感染,贫血和血小板计数明显改善。结论:小儿腹腔镜脾切除术具有创伤小、康复快、住院时间短且腹壁美容的优点,是一种安全、有效的术式。     

Peritoneal drainage as primary management in necrotizing enterocolitis: a prospective study

Background-Purpose: The use of peritoneal drainage (PD) in neonates with necrotizing enterocolitis (NEC) is controversial. The authors began to perform it successfully in infants with pneumoperitoneum, and subsequently they extended its use to infants with peritonitis and advanced NEC before radiologic evidence of peritoneal free air. To analyze the efficacy of PD they began a prospective study. Methods: A prospective study was conducted in 6 neonatal intensive care units (NICU) in Spain: neonates with pneumoperitoneum or peritonitis and advanced NEC were all included, whatever the birth weight and gestational age (GA). Results: PD was performed in 47 infants, but 3 of them were excluded because pneumoperitoneum was caused by pathologies other than NEC. In a cohort of 44 infants, 86% improved after PD, and 64% survived after only PD. After PD, 54% of infants needed delayed surgery. Overall survival rate was 82%; 57% infants with birth weight under 1,000 g, and 95% in infants over 1,000 g at birth. The main cause of mortality was massive NEC in the tiniest babies. Only one infant had a short bowel syndrome. Conclusions: From the authors' point of view, PD is the first step in treating neonates with pneumoperitoneum or overwhelming NEC, regardless of birth weight and GA. Laparotomy, if it is necessary, always must be performed after clinical stability is achieved. Mortality rates remain higher in the tiniest babies because of massive NEC.     

儿童阑尾穿孔的腹腔镜阑尾切除术

目的 :探讨儿童阑尾穿孔腹膜炎行腹腔镜阑尾切除术的优缺点。方法 :分析 30例阑尾穿孔并腹膜炎手术治疗患儿的临床资料 ,其中 15例行LA为腹腔镜组 ,15例开腹阑尾切除术为对照组。比较两组病例的手术时间、术后引流时间、住院时间、术后并发切口感染及腹腔残余感染等情况。结果 :15例LA手术时间 30～ 75min ,平均 5 2min ,几乎无出血 ,术中冲洗并吸尽腹腔内脓液后留置腹腔引流 2～ 3d ;切口感染 1例 ,平均住院 7d。对照组 15例手术时间 4 5～ 110min ,平均 6 4min ,腹腔残余感染 3例 ,切口感染 2例 ,肠粘连 1例。结论 :阑尾穿孔并腹膜炎患儿行LA比常规开腹术恢复快 ,住院时间短 ,切口感染及腹腔残余感染发生率明显降低 ,且切口疤痕小 ,美容效果好。阑尾脓肿形成早期不是LA的禁忌证 ,但阑尾脓肿并广泛包裹者不宜行LA。     

New imaging strategies for laparoscopic management of cancer

The Information Age has brought to the medical and surgical community the tools of digital imaging and 3-dimensional (3-D) visualization. These tools provide new methods for diagnosis and treatment of cancer. Using 3-D reconstructions from computed tomography and magnetic resonance imaging scans of patient-specific anatomy, diagnosis from virtual endoscopy is supplementing or replacing invasive endoscopic procedures. These same images can be used for preoperative planning of complicated procedures. At the time of surgery, data fusion of the real-time video image and the preoperative digital image provides intraoperative stereotactic navigation. These augmentations can be used in many types of procedures, from open and minimally invasive surgery to catheter-based and energy-directed therapies. This is a US government work. There are no restrictions on its use.     

Perforation of missed double gallbladder after primary laparoscopic cholecystectomy: endoscopic and laparoscopic management

Gallbladder congenital duplication is a rare disease difficultly diagnosed preoperatively. Eight days after a laparoscopic cholecystectomy a 72-year-old man, complaining of abdominal pain and vomiting, presented to our emergency department. Ultrasound and computer tomography (CT) scans demonstrated a gallbladder-like structure with a 12-mm diameter stone and a subhepatic fluid collection. During an endoscopic retrograde cholangiopancreatography, a probably second gallbladder with a fistula of the posterior wall was filled with contrast. Laparoscopic exploration confirmed a missed gallbladder, which was successfully removed. Histologic diagnosis of cholecystolithiasis and chronic cholecystitis was made. The postoperative course was uneventful. Symptomatic double gallbladder should be considered also during the complicated postoperative course after the laparoscopic cholecystectomy and laparoscopic reoperation is feasible.     

The rationale of laparoscopic treatment in acute appendiceal disease

Notwithstanding its widely perceived advantages, laparoscopic appendectomy has not yet met with universal acceptance. The aim of the present work was to illustrate retrospectively the results of a case-control study of laparoscopic vs open appendectomy carried out at our institution. From Jan. 1993 to Dec. 1999 a total of 457 patients (M:F = 210:247; mean age 25.2 +/- 15 years) underwent emergency and/or urgent appendectomy. Among them, 254 (55.5%) were operated on laparoscopically, while 203 (44.5%) were treated by conventional surgery The choice of technique depended upon the availability or otherwise of a team expert in minimally invasive surgery. The laparoscopic technique conversion rate was 3.9% and was mainly due to the presence of dense intraabdominal adhesions. The major intraoperative complication rates were 0.39% and 0% in the laparoscopic and laparotomy groups, respectively (P = ns). Major postoperative complications occurred in 2 and 1%, respectively (P = ns). The postoperative mortality rates were 0.4% and 0.5% in the laparoscopy and laparotomy groups, respectively (P = ns). The reoperation rate was 1.1% in the laparoscopic group as against 0% in the open surgery group (P = ns). Minor postoperative complications were observed in 0.8% and 7.5% of patients in the laparoscopy and open surgery groups, respectively (P = 0.001) and consisted mainly of wound infections. Resumption of bowel function was significantly more rapid and the hospital stay significantly shorter in the laparoscopically treated patients. The greater diagnostic accuracy of laparoscopy allowed concurrent diseases to be diagnosed in 9% of laparoscopically treated patients with histologically proven appendicitis as against 1.5% of those treated by conventional surgery (P = 0.001). Similarly, among those patients with no evidence of gross and/or microscopic appendicitis, concurrent diseases were detected in 58.4% of the laparoscopic cases as against only 6% of the laparotomy cases (P = 0.0001). Despite the limitations of a retrospective investigation, on the basis of our experience we believe that laparoscopic appendectomy is as safe and effective as conventional surgery, presents a higher degree of diagnostic accuracy and makes for less trauma and a more rapid postoperative recovery. Such features make its use mandatory in female patients of child-bearing age referred for urgent abdominal and/or pelvic surgery.     

两种腔镜下阑尾残端处理方法的前瞻性对比研究

目的：探讨腹腔镜阑尾切除术中两种阑尾残端处理方法的临床价值。方法：将2009年6月至2012年6月224例阑尾炎患者随机分为两组,对照组采用传统方法施术,阑尾残端用双重3-0可吸收线单纯结扎后,不包埋;实验组采用改良缝合包埋法,阑尾残端用双重3-0可吸收线结扎后,＂＋＂交叉缝合包埋。结果：两组手术均顺利完成。手术时间、术后并发症、住院时间、住院费用两组差异无统计学意义,实验组术后腹痛明显轻于对照组。结论：通过改进腹腔镜阑尾切除术中阑尾残端的处理方法,阑尾残端的处理更符合浆膜化原则及微创理念,术后腹痛发生率更低,操作简单。     

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children

Purpose

The aim of the study was to evaluate outcomes after a minimally invasive approach to pediatric subcutaneous abscess management as a replacement for wide exposure, debridement, and repetitive packing.

Methods

A retrospective study was performed of all children who underwent incision and loop drainage for subcutaneous abscesses between January 2002 and October 2007 at our institution.

Technique

Two mini incisions, 4-5 mm each, were made on the abscess, as far apart as possible. Abscess was probed, and pus was drained. Abscess was irrigated with normal saline; a loop drain was passed through one incision, brought out through the other, and tied to itself. An absorbent dressing was applied over the loop and changed regularly.

Results

One hundred fifteen patients underwent drainage procedures as described; 5 patients had multiple abscesses. Mean values (range) are as follows: age, 4.25 years (19 days to 20.5 years); duration of symptoms, 7.8 days (1-42 days); length of hospital stay, 3 days (1-39 days); duration of procedure, 10.8 minutes (4-43 minutes); drain duration, 10.4 days (3-24 days); and number of postoperative visits, 1.8 (1-17). Bacterial culture data were available for 101 patients. Of these, 50% had methicillin-resistant Staphylococcus aureus, 26% had methicillin-sensitive Staphylococcus aureus, and 9% streptococcal species. Of the 115 patients, 5 had pilonidal abscesses, 1 required reoperation for persistent drainage, and 1 had a planned staged excision. Of the remaining 110 patients, 6 (5.5%) required reoperation—4 with loop drains and 2 with incision and packing with complete healing.

Conclusion

The use of loop drains proved safe and effective in the treatment of subcutaneous abscesses in children. Eliminating the need for repetitive and cumbersome wound packing simplifies postoperative wound care. Furthermore, there is an expected cost savings with this technique given the decreased need for wound care materials and professional postoperative home health services. We recommend this minimally invasive technique as the treatment of choice for subcutaneous abscesses in children and consider it the standard of care in our facility.