Appendiceal abscess: immediate operation or percutaneous drainage?

Conflicting evidence exists regarding the optimal treatment for abscess complicating acute appendicitis. The objective of this study is to compare immediate appendectomy (IMM APP) versus expectant management (EXP MAN) including percutaneous drainage with or without interval appendectomy to treat periappendiceal abscess. One hundred four patients with acute appendicitis complicated by periappendiceal abscess were identified. We compared 36 patients who underwent IMM APP with 68 patients who underwent EXP MAN. Outcome measures included morbidity and length of hospital stay. The groups were similar with regard to age (30.6 +/- 12.3 vs. 34.8 +/- 13.5 years), gender (61% vs. 62% males), admission WBC count (17.5 +/- 5.1 x 10(3) vs. 17.0 +/- 4.8 x 10(3) cells/dL), and admission temperature (37.9 +/- 1.2 vs. 37.8 +/- 0.9 degrees F). IMM APP patients had a higher rate of complications than EXP MAN patients at initial hospitalization (58% vs. 15%, P < 0.001) and for all hospitalizations (67% vs. 24%, P < 0.001). The IMM APP group also had a longer initial (14.8 +/- 16.1 vs. 9.0 +/- 4.8 days, P = 0.01) and overall hospital stay (15.3 +/- 16.2 vs. 10.7 +/- 5.4 days, P = 0.04). We conclude that percutaneous drainage and interval appendectomy is preferable to immediate appendectomy for treatment of appendiceal abscess because it leads to a lower complication rate and a shorter hospital stay.     

Aspiration or extirpation in cerebral abscess surgery?

The author carried out CT investigation of 11 patients who recovered after cerebral abscess operation. The finding established in all cases was a hypodensic area of various extensions, which, in 4 patients, made the impression of pseudocysts. Large pathologic lesions were found mainly in the patients in whom healing was complicated by relapse. Surprisingly, rather extensive pathologic changes in the patients were found which were cured by so-called minimalized surgical intervention. The author imputes these changes to the remaining granulation tissue of the abscess capsula, which worsens conditions for healing. Aspiration is suitable mainly in cases in which the abscess is not — or only slightly encapsulated. Preoperation CT scans cannot establish exactly the presence and eventual thickness of the capsula. The establishment relationship of the kind and extent of operation to the extent of later cerebral tissue changes in CT findings requires further observation and verification in a larger group of patients.     

Splenic abscess: an easily overlooked disease?

Splenic abscess is an uncommon but potentially life-threatening disease. Recent advances in radiology have affected the diagnosis and management of this disease entity. The purpose of this study was to review our experience in managing these patients. We retrospectively reviewed the medical records of 51 patients with splenic abscess as seen in a tertiary medical center between 1998 and 2003. We analyzed the demographics, clinical manifestations, etiology, predisposing factors, diagnostic modalities, bacteriologic profile, treatment, and outcome of these patients. The mean age was 59.9 +/- 14.2 years (ranging from 21-89 years). The male:female ratio was 29:22. Common symptoms included fever (82%), abdominal pain (71%), and nausea and vomiting (46%). The majority of these patients (83%) had leukocytosis. Thirty-six patients had associated parenchymal liver diseases and 26 patients had diabetes mellitus. Abdominal sonogram or computed tomography was performed to establish the diagnosis. Most cultures from the abscess cavities grew gram-negative enteric bacilli. Patients were treated with antimicrobial therapy only (n = 33), additional percutaneous drainage with a pigtail catheter (n = 11), or splenectomy (n = 7), and the survival rates were 48 per cent, 45 per cent, and 100 per cent, respectively. Splenic abscess should be considered in a patient with fever, left upper abdominal pain, and leukocytosis. Splenectomy appears to have better treatment outcome than percutaneous drainage or intravenous antibiotics alone.     

Does use of intraoperative irrigation with open or laparoscopic appendectomy reduce post-operative intra-abdominal abscess?

To date, no study shows a decrease in postoperative abscess with the use of irrigation during appendectomy. Postoperative abscess rate for laparoscopic and open appendectomy is 3.3 and 2.6 per cent. The purpose of this study is to determine if irrigation at appendectomy decreases the postoperative intra-abdominal abscess rate. Retrospective chart review of 176 consecutive appendectomies, open (39%) and laparoscopic (61%), at a university affiliated tertiary care facility from July 2007 to November 2008 for use of intraoperative irrigation was performed. Patients under age 18 were excluded. There were no differences between the irrigation groups in regards to age, sex, or weight. Perforation was observed in 28 per cent (50/176), of which 86 per cent (43/50) of patients received intraoperative irrigation. Eleven patients (9.6%) with irrigation developed postoperative abscess compared with two (3.3%) patients without irrigation (P = 0.22). Our results do not show decrease in postoperative intra-abdominal abscess with use of intraoperative irrigation. Thirteen patients developed postoperative abscess: 11 with irrigation, two without irrigation. Ten of 13 patients who developed abscess were perforated; nine with irrigation and one without. These results suggest routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided.     

Paraesophageal hernias: operation or observation?

OBJECTIVE: To examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias. SUMMARY BACKGROUND DATA: The management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery. METHODS: A Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted life-years (QALYs). RESULTS: Analysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery. CONCLUSIONS: If ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.     

Should an infected Nuss bar be removed?

Background

The Nuss procedure is a minimally invasive procedure for correction of pectus excavatum. It involves insertion of a substernal metal bar. A feared complication of any implanted device is infection, which often necessitates removal. The purpose of this report is to describe the authors' experience with infectious complications after the Nuss procedure.

Methods

From February 2000 to July 2002, 102 patients underwent the Nuss procedure in 2 pediatric surgical centers. In a retrospective way, the files of those patients in whom a postoperative infection developed were studied.

Results

Seven patients suffered postoperative infectious complications. Only one bar needed to be removed.

Conclusion

The authors' experience indicates that there is no need for immediate removal of an infected Nuss bar. Most of these infections can be managed conservatively. However, early antibiotic treatment is warranted to ensure salvage of the bar.     

Does routine nasogastric tube placement after an operation for perforated appendicitis make a difference?

BACKGROUND: Divergent opinions exist regarding the routine use of nasogastric (NG) tubes in the postoperative management of patients undergoing abdominal surgery. Empiric use of an NG tube after abdominal surgery is presumed to prevent abdominal distension, vomiting, and ileus, which may complicate the postoperative course. To investigate the validity of this assumption, we compared the postoperative course of patients who underwent appendectomy for perforated appendicitis who subsequently either had or did not have an NG tube placed postoperatively. METHODS: A retrospective chart review of all children operated for perforated appendicitis between 1999 and 2004 was performed. Patients with prolonged hospitalizations were excluded to eliminate bias created by patients with multiple operations and opportunities for NG placement. The use of an NG tube, time to first and to full oral feeds, length of hospitalization, and complications were compared between groups. RESULTS: Patients with NG tubes left in place (N = 105) were compared with those who did not receive an NG tube (N = 54) following appendectomy for perforated appendicitis. Mean time to first oral intake was 3.8 d in those with NG tubes compared with 2.2 d in those without NG tubes (P < 0.001). Similarly, mean time to full feeds was 4.9 d when an NG tube was left compared with 3.4 d in those without tubes (P < 0.001). Mean length of stay was 6.0 d in those with NG tubes compared to 5.6 d in those without (P = 0.002). CONCLUSIONS: The use of NG decompression after an operation for perforated appendicitis does not appear to improve the postoperative course and we recommend that it is not routinely used in this patient population.     

The stenosed Brescia-Cimino fistula: operation or intervention?

INTRODUCTION: Stenosis of the vein close to the arteriovenous anastomosis is the most frequent cause for late failure of Brescia-Cimino fistulae (BCF). Although since decades proximal re-anastomosis has been regarded as the surgical standard treatment, success rates can hardly be deducted from the literature. Considering the increasing activities of interventional radiologists surgical position finding seems necessary. METHODS: Over three years 30 anastomotic BCF stenoses were treated in 28 patients. In 15 patients the stenosis had caused fistula thrombosis. In all cases the fistula vein was re-anastomosed to the proximal radial artery. All patients could be followed up (average 12 months). Each fistula functioning after 24 hours was classified as procedural success. For calculation of patency rates (life table analysis), however, usability of the needling segment of the access was assessed. RESULTS: Procedural success rate was 100%. One fistula thrombosed on the second postoperative day after a successful dialysis session due to an overlooked proximal stenosis of its feeding radial artery. In five fistulae stenoses developed after 4 to 13 months. In only one fistula this was a true re-stenosis of the newly created anastomosis (0.03 per patient-year). Two of the stenoses occurred in the needling segment of the access vein and within its central venous outflow, respectively. Overall re-intervention rate was 0.3 per patient-year, and primary (secondary) patency was 80% (95%) at one year and 67% (87%) at two years. CONCLUSION: In BCF proximal re-anastomosis is a simple and effective therapeutic option for anastomotic venous stenosis. Re-intervention rates are low and procedural success rates as well as primary and secondary patency rates at least equal those of interventional radiology.     

Does seminal fluid viscosity influence sperm chromatin integrity?

A retrospective study was undertaken to investigate whether viscosity alters sperm chromatin integrity. Semen samples were obtained from 269 men attending the infertility clinic. The viscosity was measured quantitatively by needle and syringe method and the viscosity ratio was calculated against distilled water. The chromatin integrity was evaluated by in vitro decondensation test using 1% SDS and 6 mM EDTA. According to the viscosity ratios the samples were divided into 2 groups: I, normal (ratio < 9, n = 239): and II, abnormal (ratio > 9, n = 30) viscosity. Chromatin integrity was significantly lower in the group with higher viscosity. Significant decrease in sperm count and motility were seen in group II as compared to group I. Thus, hyperviscosity of seminal fluid alters the sperm chromatin integrity.