Interval appendectomy after perforated appendicitis: what are the operative risks and luminal patency rates?

BackgroundThe need for interval appendectomy after nonoperative management of a perforated appendicitis is being questioned owing to recent studies that estimated recurrence rates as low as 5% because of obliteration of the appendiceal lumen. We review our experience with interval appendectomy in this subset of patients to determine the postoperative outcomes and luminal patency rates.MethodsA retrospective review was conducted of all children treated nonoperatively for a perforated appendicitis followed by elective interval appendectomy during the past 10 years. The data collected included initial hospitalization, convalescence period, perioperative course, and luminal patency rates.ResultsA total of 128 patients were identified, of whom 55% were male. Their mean ± SD age was 9.1 ± 4.2 years. The mean interval from the initial presentation to appendectomy was 65.9 ± 20.3 d. All but 2 of the patients underwent laparoscopic appendectomy with 3 conversions to open surgery. The mean operative time was 43.6 ± 19.2 min. The complication rate was 9%, including 1 postoperative abscess, 1 reoperation for bleeding, and 1 readmission for Clostridium difficile infection. Six patients had a superficial wound infection, and 2 patients underwent outpatient procedures for suture granuloma. No risk factors for complications were identified. Of the specimens, 16% had obliterated lumens.ConclusionsMajor postoperative morbidity for interval appendectomy after a perforated appendicitis is low and should not be a deterrent in offering interval appendectomy to this subset of patients.     

Staging of the axilla in breast cancer: accurate in vivo assessment using positron emission tomography with 2-(fluorine-18)-fluoro-2-deoxy-D-glucose.

OBJECTIVE: To evaluate the ability of positron emission tomography (PET) with 18F-fluoro-2-deoxy-D-glucose (18F-FDG) to determine noninvasively axillary lymph node status in patients with breast cancer. BACKGROUND: The presence of axillary lymph node metastasis is the most important prognostic factor in women with breast cancer. It signifies the presence of occult metastatic disease and indicates the need for adjuvant therapy. The only reliable way in which this important prognostic information may be obtained is by performing axillary dissection, which may be associated with significant complications and delay in discharge from the hospital. PET with 18F-FDG can visualize primary cancers in the breast and metastatic tumor deposits. METHODS: Fifty patients with untreated breast cancer had clinical examination of their axilla performed (graded as positive or negative), followed by PET of the axilla and midthorax. PET data were analyzed blindly and graded as positive or negative, depending on the presence or absence of axillary nodal metastases. Cytopathologic assessment of the axillary nodes was carried out within 1 week of PET, by fine-needle aspiration cytology in 5 patients and axillary dissection in 45; the excised specimens were examined by a single pathologist. RESULTS: The overall sensitivity of PET in 50 patients was 90% and the specificity was 97%. Clinical examination of the same patients had an overall sensitivity of 57% and a specificity of 90%. In the 24 patients with locally advanced breast cancer (T3, T4, TxN2), PET had a sensitivity of 93% and a specificity of 100%. In T1 tumors (seven patients), the sensitivity and specificity were 100%. PET had a high predictive value (>90%) and accuracy (94%) in staging the axilla. CONCLUSIONS: PET is a sensitive and specific method of staging the axilla in patients with breast cancer. It may obviate the need for axillary surgery in women with small primary tumors, define the women likely to benefit from axillary dissection, or allow radiotherapy to be substituted for surgery, particularly in post-menopausal women.     

Evaluation of long-term surgical site occurrences in ventral hernia repair: implications of preoperative site independent MRSA infection

Purpose

Previous work demonstrated that prior MRSA infection [MRSA(+)] is associated with 30-day surgical site infection (SSI) following ventral hernia repair (VHR). We aimed to determine the impact of MRSA(+) on long-term wound outcomes after VHR.

Participants

A retrospective cohort study was performed at a tertiary center between July 11, 2005, and May 18, 2012, of patients undergoing elective VHR with class I wounds. Patients with documented preoperative MRSA infection at any site (urinary, bloodstream, SSI, etc.) were considered MRSA(+). Primary outcome was 2-year surgical site occurrence (SSO), defined as SSI, cellulitis, necrosis, nonhealing wound, seroma, hematoma, dehiscence, or fistula. SSOs were subdivided into those that required procedural intervention (SSOPI) and those that did not.

Results

Among 632 patients, 46 % were female with average age 53 ± 13 years. There were 368 SSOs in 193 patients (31 %); an SSOPI occurred in 9.8 % (n = 62). The most common SSOs were cellulitis (91/632), seroma (91/632), and serous drainage (58/632). The rate of 2-year SSO was higher with MRSA(+) compared to those without (46 vs. 29 %, p = 0.023), attributed to increased soft tissue necrosis, purulent drainage, serous drainage, cellulitis, and fistula. In multivariable analysis, MRSA(+) was not associated with 2-year SSO (HR 1.5, 95 % CI 0.91–2.55, p = 0.113); factors associated with SSO included obesity, immunosuppression, mesh repair, and operative times.

Conclusions

This study is the first to evaluate long-term SSOs and SSOPIs after VHR, highlighting the importance of long-term follow-up. Though not independently associated with SSOs, MRSA(+) may be a marker of hernia complexity.

     

Effects of aerobic fitness on fat oxidation and body fatness

OBJECTIVE: This study investigated the contributions of physical fitness and body composition to 24-h fat oxidation in adults under sedentary conditions in a whole-room calorimeter. METHODS: The following measurements were studied in 109 adults (49 male/45 female) at least 36 h after a bout of exercise: 1) aerobic fitness level assessed by VO2max, 2) body composition determined by underwater weighing, 3) resting metabolic rate (RMR) after an overnight fast, and 4) 24-h energy expenditure (EE) and substrate oxidation determined in a whole-room calorimeter. While in the calorimeter, subjects were provided with a diet (15% protein, 30% fat, and 55% carbohydrate) estimated to produce energy balance on a sedentary day and of similar nutritional composition to their daily dietary intake. RESULTS: We found strong negative correlations between VO2max and % body fat in both male and female subjects, but no relationship between VO2max and 24-h EE under the sedentary conditions of this study. In male subjects, VO2max (mL O2 x kg(-1) fat-free mass x min(-1)) was negatively related to fat oxidation (r = -0.397, P < 0.005), and fat oxidation was more closely related to fat mass (r = 0.434, P < 0.0002) than to fat-free mass (r = 0.165, NS). In contrast, none of these relationships were significant in females. CONCLUSION: The results show that in male subjects under sedentary conditions, 24-h fat oxidation is positively related to body fat mass and negatively related to VO2max (the marker used here for level of physical fitness). This supports our hypothesis that regularly active males maintain lower body fat stores as the low contribution to daily fat oxidation from a lower body fat mass is counterbalanced by the high contribution to fat oxidation from daily physical activity. The lack of a relationship between VO2max and 24-h EE under the sedentary conditions of this study suggests that the major effects of physical activity on total daily EE and fat oxidation may occur during and relatively quickly after an exercise bout. Further, these data also suggest that cessation of regular exercise will likely be associated with a high risk of positive fat balance and weight gain.     

Management of postoperative infections after the minimally invasive pectus excavatum repair

Purpose

Pectus excavatum is frequently repaired using the minimally invasive placement of a substernal bar (Nuss procedure). Infectious complications after the Nuss procedure are potentially devastating. To date, the management of postoperative infectious complications has not been well described.

Methods

A retrospective review of all patients (N = 168) who underwent the Nuss procedure from January 1, 1997, to October 1, 2003, at our institution was performed. Six patients (4%) had postoperative infections, and their medical records were reviewed.

Results

Of the 6 patients, 5 underwent operative drainage for wound abscesses that developed 2 to 76 weeks postoperatively. The other patient developed cellulitis 12 months postoperatively and was treated effectively with antibiotics alone. Recurrent infections were treated in 3 of 6 patients, one of whom eventually required removal of the bar resulting in a mild, residual pectus excavatum defect. One of 6 patients has had the substernal bar removed electively. The remaining 4 continue to be without clinically apparent infection at this time and are over 1 year removed from their infection.

Conclusions

Although uncommon, infectious complications after the Nuss procedure require complex management strategies. Despite recurrent infection in some cases, most infectious complications occurring after the minimally invasive repair can be effectively treated without having to remove the substernal bar.     

Long-term outcome following stent reconstruction of the aortic bifurcation and the role of geometric determinants

We assessed the long-term patency of kissing stent reconstruction of the aortoiliac bifurcation and identified variables that may influence it. We retrospectively reviewed our experience with stent-reconstruction procedures of the aortoiliac bifurcation from January 1998 through June 2005. The impact of demographic variables, vascular risk factors, disease location and characteristics, stent material and design, and stenting configuration on stent patency was assessed using univariate and multivariate analysis. In particular, we evaluated the effect of geometric mismatch between the protruding segment of the stents and the distal aortic lumen. Sixty-six patients underwent aortobi-iliac stent reconstruction. Indications were bifurcation or bilateral proximal iliac disease in 52 patients and unilateral ostial disease requiring contralateral protection in 14 patients. Limited disease (TASC A and B) was present in 40 limbs in 19 patients; extensive/diffuse disease (TASC C and D) was present in 78 limbs in 47 patients. Complete occlusions were present in 37 limbs in 28 patients (bilateral in nine patients). Self-expanding stents were used in 56 procedures and balloon-expandable stents in 10. Crossing configuration was used in 43 procedures, while abutting configuration was used in 23 procedures. Technical success was achieved in 62 patients (94%), with all four failures due to inability to cross a chronically occluded limb. Three of these patients underwent aortomono-iliac stenting with a crossover femoral-femoral bypass graft, with the remaining one opting for no further interventions. Median combined follow-up was 37 +/- 27 months (range 0-102). Hemodynamically significant restenosis developed in nine patients (14%). The management of restenosis was endovascular in eight patients and was successful in all (balloon dilation in four, restenting in three, thrombolysis and stenting in one) and operative in one patient who developed aortic occlusion and underwent aortobifemoral grafting. Survival table analysis showed primary and assisted patency rates at 4 years of 81% and 94%, respectively. The mortality rate during follow-up was 19 (cardiac cause in eight, pulmonary cause in three, and malignancy in five). Univariate analysis showed radial mismatch (aortic lumen dead space around the protruding segment of the stents), female gender, prior occlusion, and residual stenosis to be significant predictors of restenosis. Multivariate logistic regression analysis showed radial mismatch to be the only significant determinant of restenosis, although the statistical power of the model was limited by the small number of restenoses. Stent reconstruction of the aortoiliac bifurcation for occlusive disease is effective and durable, even with complex aortoiliac disease and long segment occlusions. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency. Geometric variables related to individual aortic anatomy and disease pattern (patient-dependent) and stenting configuration (operator-dependent) may have an impact on long-term patency.     

Blood utilization in children managed non-operatively for blunt solid organ injury

BACKGROUND: Blood product utilization is an important issue in health care, given the frequent shortages in hospitals and the societal burden required to maintain the supply. Therefore, we retrospectively audited our blunt spleen/liver trauma experience to determine the percentage of cross-matched blood that was transfused to see whether more stringent typing criteria should be applied. METHODS: A retrospective analysis of a recent 7-year experience with nonoperative management in patients with blunt spleen or liver injury was performed. Demographics, packed red blood cells prepared by cross-match, and transfusions were measured. Unmatched, O-type blood given in the trauma bay was excluded. Patients undergoing laparotomy for solid organ injury were excluded. Data are expressed as mean +/- standard deviation. RESULTS: During the study period, 130 patients were nonoperatively managed for spleen and/or liver injury. Mean age was 8.7 +/- 4.6 years, and 62% were male. The mean grade of injury was 2.4 +/- 0.9. A total of 187 units of packed red blood cells was ordered in 60 patients. A total of 46.5 units was administered to 22 patients, revealing a 24.9% transfusion rate for the units ordered in 36.7% of the patients for whom it was ordered. When patients with other major injuries and those with ongoing bleeding requiring an operation or who clinically required blood on presentation were excluded, there were 80 patients. In this stable population, 104 units of PRBCs were ordered for 29 patients. A total of 18 units was then transfused in 5 patients, for a 17.3% transfusion rate for the units orders in 17.2% of the patients for whom it was ordered. None of the 5 patients received transfusion the day of admission. CONCLUSION: Hemodynamically stable patients with blunt spleen/liver injury triaged to conservative management should have their blood typed and be monitored closely for signs or laboratory values that would mandate a cross-match. According to our data, this strategy would safely improve utilization of blood bank resources.     

Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

Isoniazid-related hepatic failure in children: a survey of liver transplantation centers

BACKGROUND: Isoniazid (INH) therapy for tuberculosis carries a known risk for hepatoxicity, and leads to hepatic failure in a small subset of patients. This incidence has been described for adults, but is uncertain in children. Our aim was to estimate the incidence of pediatric referrals for INH-related liver failure, and to describe the characteristics and outcomes of these patients. METHODS: The 84 U.S. centers performing pediatric liver transplants between 1987 and 1997 were surveyed regarding patients with INH-induced liver failure. Additional transplant statistics were obtained from the United Network for Organ Sharing. Estimates of the number of children taking preventive INH were derived from a nationwide public health database. RESULTS: Twenty cases of INH-related liver failure were found during a 10-year period. Four patients (20%) recovered spontaneously; 10 (50%) underwent orthotopic liver transplantation (OLT), while six (30%) died awaiting OLT. Mean age at presentation was 9.8 years (range 1.3-17). Mean length of INH therapy was 3.3 months (range 0.5-9). Notably, five patients seen for symptoms of hepatitis were initially told not to stop treatment. INH-associated liver failure accounted for 0.2% (8 of 4679) of all pediatric OLTs, and 14% (8/56) of transplants for drug hepatoxicity. The estimated incidence of liver failure was up to 3.2/100,000 for children on prophylactic INH. CONCLUSIONS: While INH-associated liver failure in children is rare, discontinuation at the onset of symptoms does not assure recovery. This indicates a need for increased awareness of hepatotoxicity risk, expanded biochemical monitoring for children receiving INH, and prompt withdrawal in symptomatic patients.