The role of basic blood parameters in determining the viability of intestinal tissue in incarcerated hernias

OBJECTIVE

Abdominal hernia repair is a common surgery, with incarcerated hernias accounting for 15% of all cases. In these cases, early diagnosis of intestinal ischaemia and necrosis is crucial to prevent mortality and morbidity. Biomarkers that can predict ischaemic or necrotic status are of vital importance. The aim of this study was to reveal the roles of basic blood parameters in determining ischaemic or necrotic status.

METHODS

Patients were divided into three groups. Group I included 24 patients with normal bowels, Group II included 31 patients with intestinal ischaemia without necrosis, and Group III included 10 patients who underwent bowel resection for necrosis. Patients' demographic characteristics and blood parameters were retrospectively analysed.

RESULTS

A total of 65 patients were operated for incarcerated abdominal hernias. There was no significant difference between the groups in terms of age, sex, comorbidity or complications (P > .05). Group III had the longest length of hospital stay (P < .001). There were significant differences between the groups in terms of serum white blood cell (WBC), neutrophil, lymphocyte (LYM), neutrophil-lymphocyte ratio (NLR), urea, creatinine, total bilirubin, indirect bilirubin, lipase, C-reactive protein (CRP) and lymphocyte-to-C-reactive protein (CRP) ratio (LCR) values (P < .05).

CONCLUSION

Blood parameters combining with clinical symptoms and radiological examination may contribute to predicting intestinal resection. Preoperative WBC, neutrophil, NLR, urea, creatinine and total bilirubin levels can contribute to predict the onset of intestinal ischaemia. Serum creatinine, total bilirubin, indirect bilirubin, phosphorus, lactate dehydrogenase (LDH) and lipase levels can contribute to deciding on bowel resection.

Efficacy of Preoperative Imaging Features and Blood Tests in Predicting the Increased Risk of Conversion in Laparoscopic Appendectomy Surgery

Background

In this study, we identified preoperative risk factors, including imaging features and blood tests, to predict conversion from laparoscopic appendectomy to open appendectomy. Thus, we aimed to prevent patients from being exposed to the risks of laparoscopy by choosing patients for whom proceeding directly to an open surgery as an initial approach was appropriate.

Patients and methods

The cohort of 632 patients who underwent laparoscopic appendectomy due to acute appendicitis in our center between January 2017 and March 2021 were analyzed, and 521 of these patients comprised the study population. Baseline characteristics, medical history, preoperative laboratory tests, imaging features, and postoperative pathologic findings of all patients according to groups who underwent laparoscopic appendectomy or conversion to open appendectomy were examined.

Results

Among 521 patients, the appendectomy procedure was completed laparoscopically in 498 (95.6%) patients, and conversion to open appendectomy was occurred in 23 (4.4%) patients. 223 (42.8%) patients were female, and 298 (57.2%) patients were male. The mean age of all patients was 35.17±12.61 years (range, 16-80 years). Preoperative ultrasonography feature associated with a higher rate of conversion was free fluid collection (p=0.001). The levels of C-reactive protein, neutrophil, and neutrophil/lymphocyte ratio on admission were found to be significantly higher in the conversion group compared to the laparoscopy group (p=0.001, p=0.027, p=0.02, respectively). 

Conclusions

Free fluid collection detected by ultrasonography, and elevation of C-reactive protein, neutrophil, and neutrophil/lymphocyte ratio may be useful in the prediction of a high risk of conversion appendectomy. Despite the unquestionable advantages of laparoscopic surgery, there are still substantial conversion rates. Within this framework, our study will help the surgeons to choose the most appropriate surgical methods for patients by evaluating them individually, and to inform them of the possibility of conversion to the open approach, and other risks before surgery. 

Idiopathic granulomatous mastitis associated with erythema nodosum may indicate a worse prognosis

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory breast disease of unknown etiology, and erythema nodosum (EN) is a rare extramammary manifestation of this entity characterized by reddish, tender nodules of the lower legs. We aimed to investigate whether the association of IGM with EN has a role as a prognostic indicator. There are few case reports, and only 1 original article including 12 IGM patients with EN has been reported.

METHODS

We present 43 women with IGM coexisting with EN and 43 with a diagnosis of IGM only, who were randomly selected from 610 patients for a control group. To the best of our knowledge, this paper comprises the first comparative study of the coexistence of IGM and EN to be reported in the literature.

RESULTS

Our findings show that the association of IGM with EN indicates a more aggressive disease course. White blood cells, erythrocyte sedimentation rate, and C-reactive protein were significantly higher in the EN-positive group (P < .05). Arthralgia, breast feeding, fistula distribution and recurrence distributions were significantly higher in the EN-positive group (P < .05).

CONCLUSION

Since fistula distribution and recurrence rates were higher in EN-positive group, association of IGM with EN may be an indictor of a worse prognosis. The present study highlights the importance of dermatological care. All physicians should not neglect questioning breast complaints in patients with EN since EN may be caused by IGM.

A novel therapy for granulomatous lobular mastitis: Local heat therapy

Granulomatous lobular mastitis (GLM) is a chronic inflammatory breast condition that is characterized by granulomatous inflammation. GLM remains a refractory disease due to its failure to respond to routine anti-inflammatory therapies and its high recurrence rate. Thus, the present study aimed to investigate the application of local heat therapy in GLM as a potential therapeutic strategy. The results revealed that the application of local heat therapy was associated with a shortened remission time for GLM, while the remission and recurrence rates were similar to those of existing therapies. The median first remission time following local heat therapy was significantly decreased compared with that following corticosteroid therapy (5.30 months vs. 11.27 months; P<0.05). The remission rates were not significantly different between the local heat therapy (76.9%), extensive excision (90.4%) and the corticosteroid therapy (85.7%) groups (P>0.05). In addition, the recurrence rates were not statistically different between the groups (local heat therapy, 8.3%; extensive excision, 10%; and corticosteroid therapy, 10%; P>0.05). The local heat therapy showed mild adverse effects and shortened healing times compared to the other therapies; however, further confirmation is required.

Clinicopathological evaluation of idiopathic granulomatous mastitis patients: A retrospective analysis from a tertiary care hospital in Turkey

Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory disease of the breast with unknown etiology that is characterized by granuloma formation. We analyzed the clinical, radiological, and therapeutic approaches; the recurrence rate of the disease; and the pathological findings diagnosed with mastitis in a retrospective study. We evaluated a total of 77 patients subjected to core needle or excisional biopsy with preliminary diagnosis of mastitis between January 2017-December 2019 who diagnosed with IGM, nonspecific mastitis/abscess, or periductal mastitis/plasma cell mastitis as a result of their pathological assessment. The mean age was 39.24 ± 10.6. Though 65 patients were diagnosed with IGM (84.4%), other diagnoses were reported as nonspecific mastitis/abscess (n = 9), periductal mastitis (n = 2) and plasma cell mastitis (n = 1). Recurrence occurred in 30 (39%) patients during follow-up. In patients without IGM, the number of 5-year postpartum mastitis diagnoses was significantly higher (p = 0.0008) while number of 2-year postpartum mastitis diagnoses was lower (p = 0.255) compared to those in IGM patients. The rates of axillary lymphadenopathy, bacterial culture, parity, and menopausal status were not different in patients without IGM. Linear correlation analysis did not reveal a significant relationship between radiological preliminary diagnosis and pathological diagnosis with BI-RADS classification. A detailed assessment, accompanied with clinical, radiological, and pathological findings, should be performed to achieve an accurate diagnosis and effective patient management in IGM. Furthermore, IGM should always be considered in the differential diagnosis of mastitis among breast masses.

One-stage sex reassignment surgery at the delayed presentation in a patient with partial androgen insensitivity syndrome: A case report

Introduction and importance

The partial androgen insensitivity syndrome (PAIS) is a rare genetic disorder, which needs to be diagnosed early and provided suitable treatment. One-stage sex reassignment surgery can be considered as one of the treatment options for PAIS patients.

Case presentation

A 44-year-old patient with PAIS was admitted to our hospital. After getting a consultation, the patient decided to choose the one-stage sex reassignment surgery to be reassigned to be a female. The surgery consisted of breast augmentation and genital surgery. After 8 months of follow-up, the patient's breast had a desired shape and volume. The clitoris was in normal size with normal sensation, and the neovagina was 8 cm in depth with a smooth mucosal surface. We also observed that the minor labia were symmetric. The patient reported achieving orgasms with sex toys.

Clinical discussion

The one-stage sex reassignment surgery for the PAIS patient is safe and reduces treatment time for patients. It could also bring many benefits to the patients, such as reducing the incision, preventing gonadoblastoma and giving a sense of the patient's female gender which helps the patient feel confident and improve her quality of life. Thus, the one-stage surgery should be indicated for the patient at middle-aged who shouldn't be delayed anymore to have normal female breast and external genitalia.

Conclusion

The one-stage sex reassignment surgery was performed safely and successfully on the delayed presentation of the PAIS patient. This could be an effective and appropriate approach to treat late-diagnosed PAIS patients.

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One-stage sex reassignment surgery for a patient with partial androgen insensitivity syndrome

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A 44-year-old patient at the delayed presentation of the disorder

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We observed good treatment outcomes with a 8-moth follow-up

Aspiration versus peritoneal lavage in appendicitis: a meta-analysis

BACKGROUND

Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis.

METHODS

According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate.

RESULTS

Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%).

CONCLUSIONS

This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.

Epidemiology of neuroendocrine tumors of the appendix in the USA: a population-based national study (2014-2019)

Background

The appendix is the third most common place for neuroendocrine tumors (NETs) along the digestive tract and NETs are the most common neoplasms of the appendix. However, there are limited population-based data on the epidemiology of this disease. Using a large database, we sought to describe the epidemiology and risk association of NETs of the appendix.

Method

We queried a multi-institutional database (Explorys Inc., Cleveland, OH, USA), comprising 360 hospitals in the United States (US), for patients with a diagnosis of NETs of the appendix from 2014-2019.

Results

Of the 30,324,050 individuals in the database, 2020 patients had an appendiceal NET diagnosis (0.007%). The most common presenting symptoms included abdominal pain, nausea, vomiting and diarrhea. Patients with appendiceal NETs were more likely to be female (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.24-1.49), Caucasian (OR 2.71, 95%CI 2.40-3.07), with a history of smoking (OR 1.82, 95%CI 1.65-2.01), family history of primary gastrointestinal malignancy (OR 7.26, 95%CI 6.31-8.33), diagnosis of multiple endocrine tumor type 1 (OR 52.31, 95%CI 23.15-118.23), or neurofibromatosis type 1 (OR 16.37, 95%CI 7.24-37.01).

Conclusions

In a population-based study in the US, using the Explorys database, we found the overall prevalence of NETs of the appendix to be 7 per 100,000 persons. The incidence in the year January 2019-January 2020 was 0.4 per 100,000 individuals. These rates are higher than previously reported and may be more accurate, given the more comprehensive nature of the Explorys database.

Epidemiologic Trends of and Factors Associated With Overall Survival for Patients With Gastroenteropancreatic Neuroendocrine Tumors in the United States

IMPORTANCE

Although the incidence and prevalence of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) have been thought to have increased during the past decades, updated epidemiologic and survival data are lacking.

OBJECTIVES

To conduct an epidemiologic and survival analysis of the largest cohort of patients with GEP-NETs using the latest data and to establish a novel nomogram to predict the survival probability of individual patients with GEP-NETs.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, 43 751 patients with GEP-NETs diagnosed from January 1, 1975, to December 31, 2015, were identified from the Surveillance, Epidemiology, and End Results Program. Associated data were used for epidemiologic and survival analysis, as well as the establishment and validation of a nomogram to predict the survival probability of individual patients with GEP-NETs. The study cutoff date was December 31, 2018. Statistical analysis was performed from February 1 to April 30, 2020.

MAIN OUTCOMES AND MEASURES

Incidence, factors associated with overall survival, and a nomogram model for patients with GEP-NETs.

RESULTS

A total of 43 751 patients received a diagnosis of GEP-NETs from 1975 to 2015 (22 398 women [51.2%], 31 976 White patients [73.1%], 7097 Black patients [16.2%], 3207 Asian and Pacific Islander patients [7.3%], 270 American Indian and Alaska Native patients [0.6%], and 4546 patients of unknown race [10.4%]; mean [SD] age at diagnosis, 58 [15] years). The age-adjusted incidence rate of GEP-NETs increased 6.4-fold from 1975 to 2015 (annual percentage change [APC], 4.98; 95% CI, 4.75-5.20; P < .001). Furthermore, among site groups, the incidence of GEP-NETs in the rectum increased most significantly (APC, 6.43; 95% CI, 5.65-7.23; P < .001). As for stage and grade, the incidence increased the most in localized GEP-NETs (APC, 6.53; 95% CI, 6.08-6.97; P < .001) and G1 GEP-NETs (APC, 18.93; 95% CI, 17.44-20.43; P < .001). During the study period, the mean age at diagnosis for localized disease increased by 9.0 years (95% CI, 3.3-14.7 years; P = .002), which remained unchanged for regional and distant cases. On multivariable analyses, age, sex, marital status, and tumor size, grade, stage, and site were significantly associated with overall survival for patients with GEP-NETs (eg, patients with distant vs localized disease: hazard ratio, 10.32; 95% CI, 8.56-12.43; G4 vs G1 GEP-NET: hazard ratio, 6.37; 95% CI, 5.39-7.53). Furthermore, a nomogram comprising age, size, grade, stage, and site was established to predict the 3-year and 5-year survival probability, with the concordance indexes of 0.893 (95% CI, 0.883-0.903) for the internal validations and 0.880 (95% CI, 0.866-0.894) for the external validations. The receiver operating characteristic curve demonstrated that the nomogram exhibited better discrimination power than TNM classification (area under the curve for 3-year overall survival, 0.908 vs 0.795; for 5-year overall survival, 0.893 vs 0.791).

CONCLUSIONS AND RELEVANCE

In this study, the incidence and prevalence of GEP-NETs have continued to increase over 40 years, especially among patients with rectal GEP-NETs. In addition, this study suggests that a nomogram with 5 prognostic parameters may accurately quantify the risk of death among patients with GEP-NETs, indicating that it has satisfactory clinical practicality.

Pneumatosis intestinalis and porto-mesenteric venous gas: a multicenter study

BACKGROUND

Estimating the prognosis of patients with pneumatosis intestinalis (PI) and porto-mesenteric venous gas (PMVG) can be challenging. The purpose of this study was to refine prognostication to improve decision making in daily clinical routine.

METHODS

A total of 290 patients with confirmed PI were included in the final analysis. The presence of PMVG and mortality (90d follow-up) were evaluated with regard to the influence of possible risk factors. Furthermore, a linear estimation model was devised combining significant parameters to calculate accuracies for predicting death in patients undergoing surgery by means of a defined operation point (ROC-analysis).

RESULTS

Overall, 90d mortality was 55.2% (160/290). In patients with PI only, mortality was 46.5% (78/168) and increased significantly to 67.2% (82/122) in combination with PMVG (median survival: PI: 58d vs. PI and PMVG: 41d; p < 0.001). In the entire patient group, 53.5% (155/290) were treated surgically with a 90d mortality of 58.8% (91/155) in this latter group, while 90d mortality was 51.1% (69/135) in patients treated conservatively. In the patients who survived > 90d treated conservatively (24.9% of the entire collective; 72/290) PMVG/PI was defined as "benign"/reversible. PMVG, COPD, sepsis and a low platelet count were found to correlate with a worse prognosis helping to identify patients who might not profit from surgery, in this context our calculation model reaches accuracies of 97% specificity, 20% sensitivity, 90% PPV and 45% NPV.

CONCLUSION

Although PI is associated with high morbidity and mortality, "benign causes" are common. However, in concomitant PMVG, mortality rates increase significantly. Our mathematical model could serve as a decision support tool to identify patients who are least likely to benefit from surgery, and to potentially reduce overtreatment in this subset of patients.

Diverticular Disease of the Appendix Is Associated with Complicated Appendicitis

INTRODUCTION

Diverticular disease of the vermiform appendix (DDA) has an incidence of 0.004 to 2.1% in appendicectomy specimens. DDA is variably associated with perforation and malignancy. We report a single-center experience of DDA. The primary aim is to validate the association of DDA with complicated appendicitis or malignancy, and the secondary aim is to validate systemic inflammatory response syndrome (SIRS) criteria and quick Sepsis-related Organ Failure Assessment (qSOFA) scores.

METHODS

The histopathology reports of 2,305 appendicectomy specimens from January 2011 to December 2015 were reviewed. Acute appendicitis was found in 2,164 (93.9%) specimens. Histology of the remaining 141 (6.1%) patients revealed: normal appendix (n = 110), DDA (n = 22), endometriosis of appendix (n = 6), and an absent appendix (n = 3). Patient demographics, clinical profile, operative data, and perioperative outcomes of DDA patients are studied. Modified Alvarado score, Andersson score, SIRS criteria, and qSOFA scores were retrospectively calculated.

RESULTS

The incidence of DDA was 0.95%. Ten patients (45.5%) had diverticulitis. The mean age of DDA patients was 39.5 years (range 23-87), with male preponderance (n = 12, 54.5%). The median Modified Alvarado score was 8 (range 4-9), and the median Andersson score was 5 (range 2-8). Fourteen patients (63.6%) had SIRS, and none had a high qSOFA score. Eight patients (36.4%) had complicated appendicitis (perforation [n = 2] or abscess [n = 6]). Eleven (50%) patients underwent laparoscopic appendicectomy. There were three 30-day readmissions and no mortality.

CONCLUSION

DDA is a distinct clinical pathology associated with complicated appendicitis.

Treatment Results of Intralesional Steroid Injection and Topical Steroid Administration in Pregnant Women with Idiopathic Granulomatous Mastitis

Objective

Idiopathic granulomatous mastitis (IGM) is an inflammatory and chronic benign breast disease that has proven difficult to diagnose and treat. Since most treatment modalities cannot be used in pregnant patients, the choice of treatment is more difficult and the need for surgery is more pressing. In this first and innovative study, we assess the results of local corticosteroid therapy of IGM in pregnant women.

Materials and Methods

Pregnant women with IGM were evaluated between June 2017 and May 2019. The six pregnant women were treated using intralesional steroid injections and topical steroid administration. The treatment response was evaluated, both clinically and radiologically, at the end of 2 weeks and once more at the end of 1 month.

Results

The median patient age was 26 years. The mean duration of complaints was 4.3 months. The median number of children was 2, and the mean breastfeeding time was 41 months. The predominant complaints at onset were a breast mass or local pain and inflammation in four (66.7%) patients and a breast mass with pain and without signs of local skin inflammation in two (33.3%) patients. Diagnosis was made using a tru-cut biopsy in two patients, and with an incisional biopsy in four patients who had abscess drainage and fistulation to the skin. Five (83.3%) patients achieved a complete response, and one (16.7%) patient responded only partially after the first course of treatment. A second course of treatment was given to the patient with partial response. All patients achieved complete response at the end of the second course of treatment. The mean follow-up time was 19.5 months. During the follow-up period, one patient experienced a recurrence at 4 months after giving birth, and she then received a third course of treatment. Topical and systemic side effects of the corticosteroids were not observed in any patient.

Conclusion

While the state of pregnancy generally precludes the use of most drugs, the use of local corticosteroid in the treatment of IGM is effective in terms of treatment response, treatment duration, need for surgery, and reduced recurrence and side effects.

Clinical Characteristics and Treatment Outcomes Among Patients With Gastrointestinal Phytobezoars: A Single-Institution Retrospective Cohort Study in Korea

Purpose: To describe our experience with phytobezoars, evaluate risk factors on treatment, and analyze whether previous gastric surgery affects treatment outcomes.

Methods: Medical records of 51 patients with phytobezoars between 2000 and 2019 were retrospectively evaluated. We compared endoscopic and surgical treatment groups and evaluated risk factors using multivariate logistic regression analysis. And we compared patients with and without previous gastric surgery in the surgical treatment group.

Results: The median patient age was 62.9 (range: 27–89) years. The endoscopic and surgical treatment groups included 26 (51%) and 25 (49%) patients, respectively. Patients aged ≥65 years, diabetes, and small intestinal phytobezoars were more frequent in the surgical treatment group. Previous gastric surgery (n = 16, 31.4%) was the most common predisposing risk factor, but without a significant difference between the groups. Enterotomy was performed for 20 patients (80%), segmental resection was performed for five patients (20%). Five patients (20%) had postoperative complications; there was one death. There were no significant differences in age, preoperative diagnosis, operation method, operative time, or postoperative stay between patients with and without previous gastric surgery, but postoperative complications were significantly more common in patients with previous gastric surgery.

Conclusions: Phytobezoar should be suspected early in patients with previous gastric surgery or a specific food intake history. Early diagnosis and treatment are important for avoiding surgical intervention and complications, especially in elderly patients. Surgery is required in most patients with small intestinal phytobezoars, safe removal can be achieved mainly via enterotomy.

Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia

BACKGROUND

Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis.

METHODS

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

METHODS

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer's perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

RESULTS

LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient.

CONCLUSIONS

LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer's perspective in the Colombian health system.

Conditional CT Strategy-An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT

(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.

Intestinal Obstruction Secondary to Multiple Gastrointestinal phytobezoars, A Rare presentation

Introduction

Intestinal obstruction considered to be one of the most common surgical presentation. Adhesions secondary to previous operations, hernias, neoplasms, inflammatory bowel disease, intussusception, or volvulus are the usual causes of intestinal obstruction but bezoar can presents in 0.4-4%. Bezoar can be trapped in different locations throughout the gastrointestinal tract and it can be solitary or multiple lesions.

Case presentation

This is a 37-year-old male, known case of diabetes mellitus, Presented to the Emergency Department complaining of generalized abdominal pain for 2 days duration. Associated with abdominal distention, fever, nausea, vomiting and obstipation. There was a history of persimmon intake. Unremarkable past surgical history. On examination, He was tachycardic, other vital signs were within normal. Abdominal examination showed abdominal distention and Sluggish bowel sound. Abdominal X-ray revealed multiple air-fluid levels. An abdominal CT scan with IV contrast revealed an intra-luminal mass in the ileum and intra-gastric mass with suspicious of bezoars. He underwent exploratory laparotomy, gastrostomy to remove intra-gastric bezoar, and enterotomy to remove the ileal bezoar.

Clinical discussion

Intestinal obstruction is considered to be the most common complication of this entity; other possible complications include gastric ulcer, gastritis, and gastric perforation. Due to limitations of endoscopy and barium enema in the diagnosis of bezoar, Abdominal CT-scan is considered to be the gold standard in the diagnosis. The management of phytobezoar can be either conservative or surgical, depends on the lesion size and location.

Conclusion

Although intestinal obstruction secondary to bezoar is rare, multiple levels of gastrointestinal obstruction should raise the suspicion of bezoar.

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Bezoar can be trapped in different locations throughout the gastrointestinal tract and it can be solitary or multiple lesions.

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The predisposing risk factors for bezoar formation include previous gastric surgery, gastroparesis, peptic ulcer disease, or psychiatric illness.

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Abdominal CT-scan considered the gold standard in the diagnosis for bezoar.

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The management of phytobezoar can either be conservative or surgical depends on the lesion size and location.

Acute pancreatitis and small bowel obstruction caused by a migratory gastric bezoar after dissolution therapy: A case report

BACKGROUND

Bezoars are conglomerates of indigestible foreign material that can be found in the gastrointestinal tract. Gastric ulcer, gastrointestinal perforation, and intestinal obstruction are the main complications. Acute pancreatitis secondary to bezoar is rare. Here, we present a rare case of a migratory gastric bezoar complicated by acute pancreatitis and small bowel obstruction after dissolution therapy.

CASE SUMMARY

A-65-year-old woman underwent gastroscopy because of epigastric pain, which revealed a huge bezoar and a gastric ulcer 10 d prior. The patient was discharged with a prescription of drinking 1 L Coca-Cola daily for 6 d, without repeat gastroscopy. However, she suddenly developed epigastric pain, nausea and vomiting for 3 d. Abdominal computed tomography (CT) revealed mild inflammation of the pancreas. Magnetic resonance cholangiopancreatography showed no abnormalities in the pancreatic duct or common bile duct. The nasogastric tube still showed drainage of more than 1.6 L of dark fluid each day after symptomatic treatment. Abdominal CT re-examination suggested intestinal obstruction. Esophagogastroduodenoscopy revealed a huge yellowish hard mass in the jejunal lumen, and we used the basket and net to fragment the bezoar. She was discharged with a good outcome.

CONCLUSION

Endoscopic therapy is the first choice for gastric bezoars. When mechanical disintegration cannot be achieved, timing of repeat endoscopy is important during Coca-Cola dissolution therapy.

Comparing the Accuracy of Ohmann and Alvarado Scoring Systems in Detection of Acute Appendicitis; a Cross-Sectional Study

Introduction:

Alvarado Scoring System (ASS) and Ohmann Scoring System (OSS) are two scoring systems for diagnosing acute appendicitis (AA). This study was designed to compare the diagnostic accuracy of the two mentioned scores in detection of acute abdominal cases at risk for AA.

Methods:

In this prospective cross-sectional study, patients admitted to the emergency departments of two academic hospitals in Qom, Iran, with right lower quadrant (RLQ) abdominal pain suspected to AA were evaluated. All cases were scored using ASS and OSS, and screening performance characteristics of the two scores were calculated and reported considering the pathologic findings as a gold standard.

Results:

174 patients with a preliminary AA diagnosis and the mean age of 38.1 ± 10.63 years (11- 73) were included in this study (62.07% male). At the optimal cutoff point of ≥7 for the ASS, the sensitivity and the specificity were 46.43% (95% CI: 37.97%-55.07%), 97.05% (95% CI: 84.67%-92.93%), respectively. At the optimal cutoff point of ≥11 for the OSS, the sensitivity and the specificity were 74.29% (95% CI: 66.22%-81.29%), and 55.88% (95% CI: 37.89% - 72.82%), respectively.

Conclusion:

Based on the finding of this study, the ASS ≥ 7 was more accurate than the OSS ≥ 11 for detection of AA. But it should be considered that the overall accuracy of Alvarado and Ohmann scores in this regard were fair (0.83) and poor (0.67), respectively.

An update on granulomatous mastitis: a rare and complex condition

Granulomatous mastitis is a rare inflammatory condition of the breast affecting women of child-bearing age. The disease is characterised by chronic and relapsing inflammation, resulting in scarring and discharging sinuses. Granulomatous mastitis is considered to be idiopathic and the pathogenesis is poorly understood. An amplified immune response has been proposed as a likely cause and there is evidence linking Corynebacterium to some cases of granulomatous mastitis. The presentation is similar to bacterial mastitis or abscess and antibiotics are commonly commenced empirically. The cornerstone of diagnosis is histopathological evaluation on core biopsy; an index of suspicion based on demographic assessment can avoid delays in diagnosis. Management is difficult and there is no consensus on best treatment. Various treatment regimens are described, with high relapse rates relating to the nature of the condition. Watchful waiting is appropriate for mild presentations and steroids are the mainstay of treatment for more severe cases. This article reviews the emerging evidence on granulomatous mastitis and describes an updated approach to management.

Priorities in peritonitis

PURPOSE OF REVIEW

Timely and adequate management are the key priorities in the care of peritonitis. This review focuses on the cornerstones of the medical support: source control and antiinfective therapies.

RECENT FINDINGS

Peritonitis from community-acquired or healthcare-associated origins remains a frequent cause of admission to the ICU. Each minute counts for initiating the proper management. Late diagnosis and delayed medical care are associated to dramatically increased mortality rates. The diagnosis of peritonitis can be difficult in these ICU cases. The signs of organ failures are more relevant than biological surrogates. A delayed source control and a late anti-infective therapy are of critical importance. The quality of source control and medical management are other key elements of the prognosis. The conventional rules applied for sepsis are applicable for peritonitis, including hemodynamic support and anti-infective therapy. Growing proportions of multidrug resistant pathogens are reported from surgical samples, mainly related to Gram-negative bacteria. The increasing complexity in the care of these critically ill patients is a strong incentive for a multidisciplinary approach.

SUMMARY

Early clinical diagnosis, timely and adequate source control and antiinfective therapy are the essential pillars of the management of peritonitis in ICU patients.

Idiopathic granulomatous mastitis: challenges of treatment in iranian women

BACKGROUND AND OBJECTIVE

As a chronic inflammatory disease of an unknown origin, the treatment of granulomatous mastitis has always been controversial. According to some researchers, surgical treatment and certain medications, especially steroids, are more effective in treating the disease. This study aimed at evaluating the results of treatment in a group of patients with granulomatous mastitis.

MATERIALS AND METHODS

This longitudinal cohort study evaluated the treatment outcomes of 87 patients with pathology-confirmed granulomatous mastitis referred to the surgical clinic of Central Hospital in Sari, Iran. Demographic, clinical, and pathological information, treatment methods and results, and the recurrence rate were analyzed.

FINDINGS

A total of 87 female patients with granulomatous mastitis aged 22-52 years with a mean age of 34 years were evaluated. All patients had palpable masses; the breast masses were painful in 48.3% of patients, and 55.2% of patients suffered from erythema and inflammation, and8% had fistulas and ulcers at the inflammation site. The patients were followed-up for an average duration of 26 months (8-48 months) after treatment and recovery. The overall recurrence rate was 24.1%, and the recurrence rate was 29.4% in patients underwent surgery, 34.8% in patients received high-dose prednisolone, and 17% in those received low-dose prednisolone together with drainage (p < 0.001).

CONCLUSIONS

According to the results, the low-dose prednisolone plus drainage was more effective with a lower recurrence rate than only surgical excision or high-dose prednisolone. In fact, the use of minimally invasive methods such as drainage plus low-dose steroids is a more effective method with fewer side effects than the other two methods.

Tertiary peritonitis: A disease that should not be ignored

Intra-abdominal infections can be classified into uncomplicated or complicated (peritonitis). Peritonitis is divided into primary, secondary, and tertiary. Tertiary peritonitis is the less common but the most severe among peritonitis stratifications, being defined as a recurrent intra-abdominal infection that occurs 48 h after a well-succeeded control of a secondary peritonitis. This disease has a complex pathogenesis that is closely related to the capacity of the peritoneal cavity to activate immunological processes. Patients who progress to persistent peritonitis are at an increased risk of developing several infectious complications such as sepsis and multiple organ failure syndrome. Moreover, tertiary peritonitis remains an important cause of hospital death mainly among patients with associated risk factors. The microbiological profile of organisms causing tertiary peritonitis is often different from that observed in other types of peritonitis. In addition, there is a high prevalence of multidrug-resistant pathogens causing this condition, and an appropriate and successful clinical management depends on an early diagnosis, which can be made easier with the use of clinical scores presenting a good prediction value during the intensive care unit admission. Complementarily, immediate therapy should be performed to control the infectious focus and to prevent new recurrences. In this sense, the treatment is based on initial antimicrobial therapy and well-performed peritoneal drainage.

Patients with idiopathic granulomatous mastitis accompanied by erythema nodosum

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare, chronic inflammatory disease of the breast. The aetiology is unknown. Erythema nodosum (EN) is a rare skin disease associated with IGM. EN is a disease in which the aetiologic factors include infection, malignancy, autoimmune diseases, and pregnancy.

OBJECTIVE

The objective of this study was to evaluate the incidence and coexistence of EN with IGM and the approach to treatment.

METHODS

Patients who were admitted to the General Surgery and Dermatology Department of our hospital and diagnosed with EN and IGM were evaluated. Demographic data, symptoms, examination findings, number of birth, smoking, diagnosis and treatment methods, recurrence, and follow-up periods of the patients were evaluated.

RESULTS

EN was seen in six of the patients admitted to the clinic for IGM. Four patients with EN had pregnancy and all had arthritis. Two patients were not pregnant. Oral methylprednisolone treatment was started in patients whose IGM diagnosis was verified pathologically.

CONCLUSION

IGM may be associated with extramammary symptoms such as EN, arthralgia, and episcleritis. These extramammary findings suggest that IGM may be an autoimmune disease. For this reason, breast examination and history of IGM of the breast should be questioned in female patients admitted to different clinics with EN. This way, delays in the diagnosis and treatment of IGM can be prevented.

Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction The COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. Method All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. Results  Fifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). Conclusions COVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

Clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the adult population: Part 1

In the adult population, foreign bodies may be accidentally or intentionally ingested or even inserted into a body cavity. The majority of accidentally ingested foreign bodies pass through the alimentary tract without any complications and rarely require intervention. Accidentally ingested foreign bodies are usually fish bones, bones of other animals, and dentures. Oesophageal food impaction is the commonest cause of oesophageal foreign bodies in the Western hemisphere. Intentionally ingested foreign bodies may be organic or inorganic, and often require intervention; these patients have either underlying psychological or mental disease or are involved in illegal activities such as body packing, which involves trafficking narcotics. Imaging plays a crucial role in not only identifying the type, number and location of the foreign body but also in excluding any complications. In this comprehensive pictorial review, we provide an overview of the spectrum of foreign bodies ingested in adults, emphasising the role of various imaging modalities, their limitations and common foreign body mimickers on imaging.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials

AIMS

The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters.

RESULTS

Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD -0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD -2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection.

CONCLUSION

Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

BACKGROUND

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA).

METHODS

The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality.

RESULTS

182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications.

CONCLUSIONS

Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Acute complex appendicitis during the COVID-19 epidemic: A single-institution retrospective analysis based on real-world data

Objectives

To investigate the influence of Coronavirus Disease 2019 on incidence of acute complex appendicitis and management of acute appendicitis.

Methods

Patients undergoing acute appendicitis surgery in a single center during the COVID-19 epidemic from January to September 2020 and patients from January to September 2019 were taken as the epidemic group and control group respectively. The clinical characteristics and surgical pathological information were compared between the two groups. The primary outcome measure was complex appendicitis.

Results

A total of 235 patients were included in the study, containing 106 in the epidemic group and 129 in the control group. The patients in the epidemic group had a significantly longer interval from the onset of symptoms to registration (37.92 h vs 24.57 h, P = 0.028), from registration to admission (18.69 h vs 8.04 h, P < 0.001), and from admission to surgery (7.23 h vs 6.52 h, P = 0.016). The epidemic group had a higher incidence of suppurative appendicitis (86.8% vs 76.0%, P = 0.036) and a higher incidence of complex appendicitis (35.8% vs 19.4%, P = 0.005).

Conclusion

Higher incidence of acute complex appendicitis seemed to occur during COVID-19 outbreak.

Idiopathic Granulomatous Mastitis: Etiology, Clinical Manifestation, Diagnosis and Treatment

Idiopathic granulomatous mastitis (IGM) is a rare form of chronic inflammatory breast disease. Although it is a benign breast lesion, it may be sometimes difficult to distinguish from breast cancer. The cause of IGM is unknown, but may be associated with autoimmunity, abnormal hormone levels and infection. While the clinical manifestations of IGM involve various manifestations of inflammation, the diagnosis is principally established by histopathology, characterized by non-caseating granulomas and microabscess formation centered on the breast lobules. Therapeutic options for IGM range from observation to various medical treatments, such as steroids, immunosuppressants, and antibiotics, to surgical intervention, particularly if secondarily infected. Given that the controversy on etiology and treatment choices, we accomplished the present review through reviewing IGM-related literature published in 'Pubmed' and 'Web of science' databases during 1997 to 2020, aiming to provide the basis for rational clinical diagnosis and treatment.

Risk of emergency surgery for complicated appendicitis: Japanese nationwide study

AIM

Appendicitis is divided into two categories: complicated appendicitis (CA) and uncomplicated appendicitis (UA). In pediatric patients with CA, the use of interval appendectomy (IA), which is non-operative management followed by elective surgery, has decreased the number of postoperative complications. Before discussing the merit of IA for adult patients, we need to clarify whether the frequency and seriousness of the complication rate after emergency surgery is higher for CA than for UA.

METHODS

This retrospective cohort study included adult patients who underwent appendectomy and who were registered in the National Clinical Database (NCD) from 2014 to 2016. Patients with CA who underwent emergency appendectomy comprised the CA group. Patients with UA comprised the UA group. Patients with chronic or recurrent appendicitis who underwent elective appendectomy comprised the elective appendectomy (EA) group. Primary outcomes were all morbidity, serious morbidity, and mortality within 30 days after appendectomy.

RESULTS

We included 109 256 patients in the study: 14 798 CA, 86 876 UA, and 7582 EA patients. Compared with the UA group, the rates of all morbidity, serious morbidity, and mortality were significantly higher in the CA group. All morbidity, serious morbidity, and mortality rates were significantly lower in the EA group than in the other two groups.

CONCLUSIONS

We confirmed that emergency surgery for CA places the patient at relatively higher risk. We also showed that the risk associated with EA is significantly lower than that for the other methods.

Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue

BACKGROUND

Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi.

METHODS

We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality.

RESULTS

We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation.

CONCLUSIONS

Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Appendectomy as Teaching Operation: No Compromise in Safety-An Audit of 17,106 Patients

OBJECTIVE

In a surgical career, teaching of surgical procedures plays a central role. In this study we want to evaluate the influence of teaching in appendectomies on the in-hospital outcome.

DESIGN AND SETTING

Retrospectively, 26,436 cases from the national quality measurement database (AQC) between the years 2009 and 2017 were evaluated using the diagnosis and the procedure codes. Included were all cases with appendicitis (International Classification of Diseases diagnostic codes K35-K37), surgical treatment (appendectomy), and a documented teaching status of the procedure. Variables were sought in bivariate and multivariate analyses. The occurrence of any complication was the primary outcome, whereas in-hospital mortality was the secondary outcome.

PARTICIPANTS

A total of 17,106 patients with a mean age of 37 ± 19 years remained for final analysis. A total of 6267 operations (37%), were conducted as teaching-operations. Seventy-four percent of all teaching procedures were performed by residents.

RESULTS

We found no statistical association between teaching operations and complication rates or mortality. However, the teaching group showed longer duration of surgery (+ 11%).

CONCLUSIONS

There was no influence of the training status of the appendectomy procedure on complication rates and in-hospital mortality. However, there was a prolonged duration of surgery. Despite these statistically significant differences, a comparable clinical outcome was observed in all patients, thus justifying the benefits of resident training.

Acute Appendicitis in Childhood and Adulthood

BACKGROUND

Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of unclear abdominal conditions.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Cochrane Library databases.

RESULTS

In addition to the medical history, physical examination and laboratory tests, abdominal ultrasonography should be performed to establish the diagnosis (and sometimes computed tomography [CT] or magnetic resonance imaging [MRI], if ultrasonography is insufficient). Before any treatment is provided, appendicitis is classified as either uncomplicated or complicated. In both types of appendicitis, the decision to treat surgically or conservatively must be based on the overall clinical picture and the patient's risk factors. Appendectomy is the treatment of choice for acute appendicitis in all age groups. In Germany, appendectomy is mainly performed laparoscopically in patients with low morbidity. Uncomplicated appendicitis can, alternatively, be treated conservatively under certain circumstances. A meta-analysis of five randomized, controlled trials has revealed that ca. 37% of adult patients treated conservatively undergo appendectomy within one year. Complicated appendicitis is a serious disease; it can also potentially be treated conservatively (with antibiotics, with or without placement of a drain) as an alternative to surgical treatment.

CONCLUSION

Conservative treatment is being performed more frequently, but the current state of the evidence does not justify a change of the standard therapy from surgery to conservative treatment.

Revisiting Amyand's Hernia: A 20-Year Systematic Review

PURPOSE

Protrusion of the appendix within an inguinal hernia is termed an Amyand's hernia. A systematic review of case reports and case series of Amyand's hernia was performed, with emphasis on surgical decision-making.

METHODS

The English literature (2000-2019) was reviewed, using PubMed and Embase, combining the terms "hernia", "inguinal", "appendix", "appendicitis" and "Amyand". Overall, 231 studies were included, describing 442 patients.

RESULTS

Mean age of patients was 34 ± 32 years (adults 57.5%, children 42.5%). 91% were males, while a left-sided Amyand's hernia was observed in 9.5%. Of 156 elective hernia repairs, 38.5% underwent appendectomy and 61.5% simple reduction of the appendix. 88% of the adult patients had a mesh repair, without complications. Of 281 acute cases, hernial complications (76%) and acute appendicitis (12%) were the most common preoperative surgical indications. Appendectomy was performed in 79%, more extensive operations in 8% and simple reduction in 13% of cases. A mesh was used in 19% of adult patients following any type of resection and in 81% following reduction of the appendix. Among acute cases, mortality was 1.8% and morbidity 9.2%. Surgical site infections were observed in 3.6%, all of which in patients without mesh implantation.

CONCLUSION

In elective Amyand's hernia cases, appendectomy may be considered in certain patients, provided faecal spillage is avoided, to prevent mesh infection. In cases of appendicitis, prosthetic mesh may be used, if the surgical field is relatively clean, whereas endogenous tissue repairs are preferred in cases of heavy contamination.

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

Background

In 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.

Methods

All 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.

Results

There 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).

Discussion

The 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.

Acute abdominal disease with nonspecific symptoms in the elderly: A case series

Acute stomach disease in elderly patients often lacks characteristic clinical manifestations. Presentations may differ from those in younger patients and are often complicated by concomitant diseases, delayed presentation, and misdiagnosis. Incorrect diagnosis and treatment can lead to medical-related death claims. We investigated eight cases of elderly fatality due to acute abdominal diseases in forensic autopsy cases. Although most fatalities were unwitnessed, possibly due to the characteristics of elderly individuals, recent social backgrounds, and involvement with health care, some cases of possible misdiagnosis suggested that physicians should carefully consider atypical clinical manifestations and the characteristics of elderly individuals when the managing abdominal symptoms, particularly in primary health care. Our investigation of these forensic autopsy cases indicated the particular importance of peritoneal adhesions as an unexpected cause of acute abdomen in the elderly due to strangulation ileus, even among those with no history of abdominal surgery or trauma. Diagnosis of acute stomach symptoms can be difficult in elderly patients. Pathophysiological examination and autopsy analyses can thus contribute to early-stage diagnosis and prevention of acute stomach symptoms in elderly patient populations.

Platelet indices in patients with acute appendicitis: a systematic review with meta-analysis

Correlation between blood inflammatory parameters and acute appendicitis (AA) remains controversial. This meta-analysis aims to evaluate whether platelet (PLT) indices including mean platelet volume (MPV), PLT count, and platelet distribution width (PDW) are associated with AA. Pubmed, Embase, and Cochrane Library databases were searched for observational studies published from inception through April 2020 by two independent investigators. Studies reporting associations between platelet indices and AA were selected for inclusion. Standardized mean difference (SMD) and 95% confidence interval (CI) were estimated for continuous outcomes using a DerSimonian-Laird random-effects model. Of 842 records identified, 17 studies with a total of 6793 subjects met our inclusion criteria. Meta-analysis indicated that compared with those in healthy controls, significant decrease in MPV levels was observed in subjects with AA (SMD - 0.34; 95% CI - 0.56 to - 0.12; P = 0.003). Subgroup analyses represented a significant reduction of MPV levels in patients aged ≥ 30 years and non-complicated/non-perforated AA. Due to the small number of studies and patients included in each subgroup, these subgroup analyses need to be interpreted with caution. However, none of the levels of PLT (SMD - 0.13; 95% CI - 0.28-0.012; P = 0.071) or PDW (SMD 0.30; 95% CI - 0.22-0.83; P = 0.257) was seen decrease or increase in subjects with AA. This meta-analysis indicates a significant decrease in MPV levels in patients with AA, which makes MPV have the potential of serving as a biomarker for AA. The associations of other PLT indices with AA need to be further examined.

Comparison of acute appendicitis before and within lockdown period in COVID-19 era: A retrospective study from rural Nepal

Introduction

The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic.

Methods

A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis.

Results

There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008].

Conclusion

During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.

Quarantine and Appendicitis: A Macro-Area Experience

PURPOSE

Appendicitis is the most frequent urgency in pediatric age; the aim of this study was to investigate the association of quarantine for severe acute respiratory syndrome coronavirus 2 pandemic and the incidence of pediatric appendicitis in a specific macro area.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis in the period March-April since 2014. This specific quarantine period was divided into two phases as indicated by National government. Patient data, demographics, characteristics and outcomes were studied and evaluated comparing patients treated during quarantine especially phase 1 vs. phase 2 (March-April 2020).

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 155 patients were studied; focusing on the final outcome, it is possible to show a decreased amount of appendicitis during phase 1 and a progressive increase during phase 2; respect to previous years, there was a statistical increase in severity of appendicitis during quarantine (gangrenous vs. phlegmonous appendicitis).

CONCLUSION

During this specific quarantine there was a reduction in appendicitis and a progressive increase during phase 2. These results offer new perspective among disease incidences during lockdown.

Acute appendicitis: a case report of hyperinfection with Enterobius vermicularis

Acute appendicitis is one of the most common causes of abdominal emergent surgical disease worldwide. Enterobius vermicularis, a human intestinal parasite, is reported to be associated with acute appendicitis. We report a case of an 8-year-old girl who was admitted to the emergency unit with complaints of severe abdominal pain and was diagnosed with acute appendicitis. Microscopic pathological examination showed lymphoid follicles with prominent germinal centers and mantle zones within the appendix wall. Cross-sections of multiple female and male Enterobius vermicularis worms and a few longitudinal sections of E.vermicularis were seen. E. vermicularis is one of the most common human parasitic infections, so the possibility of infection of the appendix with E. vermicularis should be considered in the differential diagnosis of agents of appendicitis.

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis in children: a systematic review and meta-analysis

AIM

To evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children.

METHODS

A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters.

RESULTS

Four RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) - 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes.

CONCLUSIONS

SPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.

Risk factors, endoscopic findings, and treatments in upper gastrointestinal bezoars: multi-center experience in Iran

AIM

The current study aimed to investigate the risk factors, endoscopic findings, and treatments of upper gastrointestinal bezoars.

BACKGROUND

Bezoars are compact masses formed by the accumulation of dietary fiber, undigested food, hair, or medications. The majority of bezoars are asymptomatic, but they may cause serious symptoms or even life-threatening events such as bleeding, obstruction, or perforation.

METHODS

This retrospective study was conducted in three gastroenterology clinics between January 2016 and December 2019. Bezoars were detected in 109 of 15,830 endoscopy records (0.68%).

RESULTS

A total of 103 patients (52.4% male) were enrolled in this study. Mean patient age was 60.5±11.3 years. The most frequent risk factors were history of gastric surgery (25.2%), diabetes mellitus (21.3%), hypothyroidism (15.5%), trichophagia (5.8%), and anxiety disorders (2.9%), respectively. The most common endoscopic findings were peptic ulcers (34.9%), erosive gastritis/duodenitis (12.6%), and reflux esophagitis (10.6%). While bezoars were most commonly observed in the stomach (84.4%), the majority of them were phytobezoars (92.2%). The mean number of endoscopic interventions for each patient was 1.5 (range, 1-4). Endoscopy was successful in removing bezoars in 85.4%.

CONCLUSION

The synergistic effect of multiple factors for a long time, such as gastrointestinal surgery, diabetes mellitus or psychiatric disorders, may lead to bezoar formation. These risk factors should be avoided or treated in order to prevent bezoar formation and subsequent life-threatening complications.

Development and Validation of a Nomogram for Preoperative Prediction of Localization of Neonatal Gastrointestinal Perforation

Background: Information regarding the localization of gastrointestinal perforation is crucial for the following surgical procedure. This study was to determine the key indicators and develop a prediction model for the localization in neonates with gastrointestinal perforation. Methods: A nomogram to predict the location of neonatal gastrointestinal perforation was developed using a cohort of patients who underwent surgery between July 2009 and May 2021. Baseline variables were analyzed using logistics regression and nomogram developed using significant predictors. The predictive performance of the nomogram was assessed by the concordance index (C-index), calibration curve, and area under the receiver operating characteristic (ROC) curve (AUC). The nomogram was further validated in an integrated external cohort. Results: We investigated the data of 201 patients, of which 65 (32.3%) were confirmed with upper gastrointestinal perforation by surgery. Multivariate logistic regression analysis identified the following as independent predictors: preterm [OR: 5.014 (1.492-18.922)], time of onset [OR: 0.705 (0.582-0.829)], preoperative hemoglobin [OR:1.017 (1.001-1.033)], bloody stool: No [OR: 4.860 (1.270-23.588)], shock [OR: 5.790 (1.683-22.455)] and sepsis: No [OR 3.044 (1.124-8.581)]. Furthermore, the nomogram was effective in predicting the perforation site, with an AUC of 0.876 [95% confidence interval (CI): 0.830-0.923]. Internal validation showed that the average AUC was 0.861. Additionally, the model achieved satisfactory discrimination (AUC, 0.900; 95% CI, 0.826-0.974) and calibration (Hosmer-Lemeshow test, P = 0.4802) in external validation. Conclusions: The nomogram based on the six factors revealed good discrimination and calibration, suggesting good clinical utility. The nomogram could help surgeons predict the location of gastrointestinal perforation before surgery to make a surgical plan.

Same-day discharge after appendectomy for acute appendicitis: a systematic review and meta-analysis

PURPOSE

Patients presenting with acute appendicitis are usually hospitalized for a few days for appendectomy and postoperative recovery. Shortening length of stay may reduce costs and improve patient satisfaction. The purpose of this study was to assess the safety of same-day discharge after appendectomy for acute appendicitis.

METHODS

A systematic review was performed according to PRISMA guidelines. A literature search of EMBASE, Ovid MEDLINE, Web of Science, Cochrane Central, and Google Scholar was conducted from inception to April 14, 2020. Two reviewers independently screened the literature and selected studies that addressed discharge on the same calendar day as the appendectomy. Risk of bias was assessed with the ROBINS-I tool. Main outcomes were hospital readmission, complications, and unplanned hospital visits in the postoperative course. A random effects model was used to pool risk ratios for the main outcomes.

RESULTS

Of the 1912 articles screened, 17 comparative studies and 8 non-comparative studies met the inclusion criteria. Most only included laparoscopic procedure for uncomplicated appendicitis. Most studies were considered at moderate or serious risk of bias. In meta-analysis, same-day discharge (vs. overnight hospitalization) was not associated with increased rates of readmission, complication, and unplanned hospital visits. Non-comparative studies demonstrated low rates of readmission, complications, and unplanned hospital visits after same-day discharge.

CONCLUSION

This study suggests that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients.

TRIAL REGISTRATION

PROSPERO registration no. CRD42018115948.

Gastric bezoar

Gastric bezoar is an accumulation of indigestible masses in stomach. Depending on the composites of these masses, descriptive names are given like tricobezoar if the mass contains hair. Most of the patients have psychological issues that result in their desire to eat hair which predispose them to have gastric tricobezoar. Unfortunately, the presentation is usually very late with signs of gastric outlet obstruction which include abdominal pain, distension, nausea and vomiting. There are typical findings seen in abdominal radiograph like large intraluminal filling defect with mottled translucency and ultrasound finding of shadowing intra-luminal masses. The treatment of such cases includes laproscopic trial to remove the bezoar and if not successful to proceed for gastrostomy.

Appendectomy: prognostic factors in the brazilian unified health system

INTRODUCTION

Acute appendicitis (AA) is the most common cause of surgical acute abdomen. Postoperative complications in emergency care are reflections of the surgical procedure and pre- and postoperative factors.

OBJECTIVE

Define prognostic factors for patients who underwent appendectomy, comparing them with the literature.

METHODS

Descriptive observational study with a cross-sectional design based on data from the emergency/urgency appendectomy records between September 2018 and April 2019. Variables of interest were considered based on intrinsic patient data, clinical status, and perioperative management factors. Primary outcomes considered: postoperative complications from hospital admission discharge and prolonged hospital stay for > 2 days. Secondary outcome: death. The results were evaluated by Fisher's exact test (p <0.05).

RESULTS

We identified 48 patients undergoing an appendectomy. Young adults accounted for 68.7%. From the total, 58.3% were males, 6 (12.5%) had hospitalization> 2 days, 4 (8.3%) had complications and no deaths. Among the variables, the stage of AA, the time of complaint up until seeking care, and advanced age were correlated with worse prognosis during hospitalization (p <0.05). The emergence of immediate postoperative complications was correlated with longer hospital stay (p <0.05).

DISCUSSION

The descriptive data of the sample converge with the epidemiological profile of patients with AA in the literature, corroborating the applicability of conventional guidelines. The results strengthen the hypothesis that the patient's flow with abdominal manifestations is complicated from the first contact with SUS to the resolution of the condition.

CONCLUSION

Knowledge of the epidemiological profile and perioperative predictors that are most related to complications favor the appropriate management of patients.