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Steyaert H, Hendrice C, Lereau L, Hayem C, Ghoneimi AE, Valla JS. Laparoscopic Appendectomy in Children: Sense or Nonsense? Acta Chir Belg 2020. [DOI: 10.1080/00015458.1999.12098461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- H. Steyaert
- Paediatric Surgery, Fondation Lenval pour Enfants, Nice, France
| | - C. Hendrice
- Paediatric Anaesthesiology, Fondation Lenval pour Enfants, Nice, France
| | - L. Lereau
- Paediatric Anaesthesiology, Fondation Lenval pour Enfants, Nice, France
| | - C. Hayem
- Paediatric Anaesthesiology, Fondation Lenval pour Enfants, Nice, France
| | - A. El Ghoneimi
- Paediatric Surgery, Fondation Lenval pour Enfants, Nice, France
| | - J. S. Valla
- Paediatric Surgery, Fondation Lenval pour Enfants, Nice, France
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Jaschinski T, Mosch CG, Eikermann M, Neugebauer EAM, Sauerland S. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2018; 11:CD001546. [PMID: 30484855 PMCID: PMC6517145 DOI: 10.1002/14651858.cd001546.pub4] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010. OBJECTIVES To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence. MAIN RESULTS We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies. AUTHORS' CONCLUSIONS Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.
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Affiliation(s)
- Thomas Jaschinski
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (Building 38)CologneGermany51109
| | - Christoph G Mosch
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (Building 38)CologneGermany51109
| | - Michaela Eikermann
- Medical advisory service of social health insurance (MDS)Department of Evidence‐based medicineTheodor‐Althoff‐Straße 47EssenNorth Rhine WestphaliaGermany51109
| | - Edmund AM Neugebauer
- Brandenburg Medical School Theodor Fontane 3Fehrbelliner Str 38NeuruppinBrandenburgGermany16816
| | - Stefan Sauerland
- Institute for Quality and Efficiency in Health Care (IQWiG)Department of Non‐Drug InterventionsIm Mediapark 8CologneGermany50670
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Harji D, Marshall H, Gordon K, Crow H, Hiley V, Burke D, Griffiths B, Moriarty C, Twiddy M, O'Dwyer JL, Verjee A, Brown J, Sagar P. Feasibility of a multicentre, randomised controlled trial of laparoscopic versus open colorectal surgery in the acute setting: the LaCeS feasibility trial protocol. BMJ Open 2018; 8:e018618. [PMID: 29472259 PMCID: PMC5879497 DOI: 10.1136/bmjopen-2017-018618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Acute colorectal surgery forms a significant proportion of emergency admissions within the National Health Service. There is limited evidence to suggest minimally invasive surgery may be associated with improved clinical outcomes in this cohort of patients. Consequently, there is a need to assess the clinical effectiveness and cost-effectiveness of laparoscopic surgery in the acute colorectal setting. However,emergency colorectal surgical trials have previously been difficult to conduct due to issues surrounding recruitment and equipoise. The LaCeS (randomised controlled trial of Laparoscopic versus open Colorectal Surgery in the acute setting) feasibility trial will determine the feasibility of conducting a definitive, phase III trial of laparoscopic versus open acute colorectal resection. METHODS AND ANALYSIS The LaCeS feasibility trial is a prospective, multicentre, single-blinded, parallel group, pragmatic randomised controlled feasibility trial. Patients will be randomised on a 1:1 basis to receive eitherlaparoscopic or open surgery. The trial aims to recruit at least 66 patients from five acute general surgical units across the UK. Patients over the age of 18 with a diagnosis of acute colorectal pathology requiring resection on clinical and radiological/endoscopic investigations, with a National Confidential Enquiry into Patient Outcome and Death classification of urgent will be considered eligible for participation. The primary outcome is recruitment. Secondary outcomes include assessing the safety profile of laparoscopic surgery using intraoperative and postoperative complication rates, conversion rates and patient-safety indicators as surrogate markers. Clinical and patient-reported outcomes will also be reported. The trial will contain an embedded qualitative study to assess clinician and patient acceptability of trial processes. ETHICS AND DISSEMINATION The LaCeS feasibility trial is approved by the Yorkshire and The Humber, Bradford Leeds Research Ethics Committee (REC reference: 15/ YH/0542). The results from the trial will be presented at national and international colorectal conferences and will be submitted for publication to peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN15681041; Pre-results.
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Affiliation(s)
- Deena Harji
- Newcastle Centre for Bowel Disease, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Helen Marshall
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Katie Gordon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Hannah Crow
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Victoria Hiley
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Dermot Burke
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| | - Ben Griffiths
- Newcastle Centre for Bowel Disease, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Catherine Moriarty
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Azmina Verjee
- Patient and Public Representative, Association of Coloprocotology of Great Britain and Ireland, London, UK
| | - Julia Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Peter Sagar
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
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Sadat-Safavi SA, Nasiri S, Shojaiefard A, Jafari M, Abdehgah AG, Notash AY, Soroush A. Comparison the effect of stump closure by endoclips versus endoloop on the duration of surgery and complications in patients under laparoscopic appendectomy: A randomized clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:87. [PMID: 28163733 PMCID: PMC5244687 DOI: 10.4103/1735-1995.192503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/13/2015] [Accepted: 06/23/2016] [Indexed: 12/15/2022]
Abstract
Background: Laparoscopic appendectomy is a well-described surgical technique. However, concerns still exist regarding whether the closure of the appendiceal stump should be done with a clip, an endoloop, or other techniques. In this study, the effect of stump closure on duration of surgery and complications by endoclips was compared with endoloop in patients under laparoscopic appendectomy. The study was carried out as a prospective randomized clinical trial between 2013 and 2015 in Shariati Hospital of Tehran. Materials and Methods: Seventy-six patients under laparoscopic appendectomy were enrolled and randomly assigned to receive either endoclips or endoloop for stump closure. The results in terms of the operating time, length of hospital stay, and the complications were compared and analyzed between two groups. After collecting the essential data by using a checklist and examination of patients, the data were analyzed with SPSS. Results: The mean age was 23.13 ± 5.07 years and 44.7% of the patients were male. Moreover, in this study, it was seen that the mean duration of surgery was 23.2 min versus 21.5 min in endoloop and endoclips groups, respectively (P = 0.021). There was no difference between hospital stay among two groups (P > 0.05). Furthermore, the complications were same in two groups (P > 0.05). Conclusion: The effect of stump closure with endoloop versus endoclips is not different for complications, but the duration of surgery was shorter in endoclips method. Both methods could be used based on the opinion of the surgeon without expecting a statistically significant difference in the results.
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Affiliation(s)
- Seyed Abas Sadat-Safavi
- Research Center for Improvement of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirzad Nasiri
- Research Center for Improvement of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Shojaiefard
- Research Center for Improvement of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Jafari
- Research Center for Improvement of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Ghorbani Abdehgah
- Research Center for Improvement of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Aidin Yghoobi Notash
- Research Center for Improvement of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Soroush
- Research Center for Improvement of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Özdemir O, Metin Y, Metin NO, Küpeli A, Kalcan S, Taşçı F. Contribution of diffusion-weighted MR imaging in follow-up of inflammatory appendiceal mass: Preliminary results and review of the literature. Eur J Radiol Open 2016; 3:207-15. [PMID: 27570803 PMCID: PMC4990663 DOI: 10.1016/j.ejro.2016.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 08/09/2016] [Indexed: 12/29/2022] Open
Abstract
Objective We aimed to search the contribution of diffusion-weighted imaging (DWI) in follow-up of patients with acute appendicitis associated inflammatory appendiceal mass (IAM). DWI was used as a monitoring imaging method to assess the response of medical treatment. Materials and methods 19 patients (mean age, 37+–13.1; age range, 19–69; M/F: 10/9), presented with clinical, laboratory and computed tomography (CT) findings suggestive of IAM were enrolled prospectively in this study. CT and DWI images were evaluated by two radiologists in consensus. b values 0, 500 and 1000 s/mm2 were used, and DWI images were analysed both qualitatively and quantitatively. Laboratory parameters were C-reactive protein value and white blood cell count. During follow-up changes in the diameter of IMA and laboratory parameters were correlated with ADC values. Conservative treatment with interval appendectomy and a total conservative approach without surgery were the treatment options during follow-up. Results We found statistically significant correlation between the ADC values, maximum IAM diameter and laboratory parameters. During follow-up five surgical procedures were performed: one patient underwent surgery for cecal adenocarcinoma and four underwent interval appendectomy. One patient developed acute relapse of IAM at the sixth month of follow-up. Conclusion DWI may be used with a significant success for follow-up of patients with IAM. As a monitoring imaging method, DWI may also aid in determining of most appropriate timing for interval appendectomy as well as may help in diagnosing alternative diagnoses (e.g. malignancy and inflammatory bowel disease) that can mimic IAM.
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Affiliation(s)
- Oğuzhan Özdemir
- Recep Tayyip Erdoğan University, Faculty of Medicine, Department of Radiology, 53100, Rize, Turkey
| | - Yavuz Metin
- Recep Tayyip Erdoğan University, Faculty of Medicine, Department of Radiology, 53100, Rize, Turkey
| | - Nurgül Orhan Metin
- Recep Tayyip Erdoğan University, Faculty of Medicine, Department of Radiology, 53100, Rize, Turkey
| | - Ali Küpeli
- Muş State Hospital, Department of Radiology, 49000, Muş, Turkey
| | - Süleyman Kalcan
- Recep Tayyip Erdoğan University, Faculty of Medicine, Department of General Surgery, 53100, Rize, Turkey
| | - Filiz Taşçı
- Recep Tayyip Erdoğan University, Faculty of Medicine, Department of Radiology, 53100, Rize, Turkey
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Voellinger DC, Jordan WD. Video-Assisted Vein Harvest: A Single Institution's Experience of 103 Peripheral Bypass Cases. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449803200605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traditional harvesting of the greater saphenous vein (GSV) has meant a long, continuous incision with the potential for increased morbidity, pain, and hospital stay. The authors have used a minimally invasive video-assisted technique in an attempt to reduce these complications. In this report, they retrospectively analyze a series of 103 cases of videoassisted saphenous vein harvests for vascular bypass procedures. All patients from September 1994 to May 1997 who underwent video-assisted saphenous vein harvest were reviewed for vein harvest time, hospital length of stay, surgical complications, graft patency, and clinical outcome. Operative technique used limited incisions, video-assisted dissection, and two different subcutaneous retractors-endoplastic (Type I) (Snowden Pencer, Tucker, GA) and endosaphenous (Type II) (Ethicon Endosurgery, Cincinnati, OH). Ninety-six patients underwent 103 operations for lower and upper extremity vascular disease. For all patients, the average time of vein removal was 0.74 cm vein/minute operative time, for procedures with the Type I retractor 0.63 cm vein/minute, for procedures with the Type II retractor 1.07 cm vein/minute (p≤0.0001). Postoperative length of stay (LOS) averaged 7.7 days (median 5 days) for all patients and was longer between patients with rest pain (6.4 days) and tissue loss (10.1 days) vs claudicants (4.4 days) (p<0.05), between patients with tibioperoneal anastomoses (10.0 days) vs patients with popliteal anastomoses (6.0 days) (p<0.05), and between Type I patients (8.3 days) and Type II patients (6.9 days) (p=0.03). Nine wound complications occurred (8.7%), two of which (1.9%) were directly related to the video-assisted technique. Cumulative graft patency was 84% ±9% after 18 months. According to the International Society for Cardiovascular Surgery reporting standards for lower extremity occlusive disease, patient outcome averaged +2.03 for all patients, and was improved between patients with claudication (+2.82) vs patients with rest pain (+1.50) (p<0.05) and between Type II patients (+2.36) vs Type I patients (+1.64) (p=0.01). Video-assisted saphenous vein harvest can be accomplished with low morbidity and provides a satisfactory conduit. The patients had a short postoperative LOS, a satisfactory wound complication rate, and a good operative outcome. The Type II saphenous vein retractor decreased operative time, shortened hospital LOS, and improved outcome.
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Affiliation(s)
| | - William D. Jordan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Evaluation of scoring systems in predicting acute appendicitis in children. Surgery 2016; 160:1599-1604. [PMID: 27528209 DOI: 10.1016/j.surg.2016.06.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/20/2016] [Accepted: 06/18/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis can be difficult to diagnose, especially in children. Appendicitis scoring systems have been developed as a diagnostic tool to improve the decision-making process in patients with suspected acute appendicitis. This study evaluates the Appendicitis Inflammatory Response score, Alvarado score, and Pediatric Appendicitis Score in children suspected of acute appendicitis. METHODS Data were collected retrospectively. All children younger than 18 years suspected of acute appendicitis who presented to the emergency department between January 2006 and June 2014 were included in this study. Variables were registered to evaluate 3 different appendicitis scoring systems. The diagnostic performance of the 3 scores was analyzed using the area under the receiver-operating curve and by calculating the diagnostic performances at different cut-off points. RESULTS The present study included 747 consecutive children. There were 399 boys (53%) and 348 girls (47%) with a mean age of 11 years (range, 1-17 years). In total, 269 children (36%) were diagnosed with acute appendicitis. The area under the receiver-operating curve of the Appendicitis Inflammatory Response score was 0.90, the Alvarado score was 0.87, and the Pediatric Appendicitis Score was 0.82 (P < .05, respectively). The specificity and positive predictive value of the Appendicitis Inflammatory Response score were better at predicting an acute appendicitis than that of the Alvarado score and Pediatric Appendicitis Score. In children with a low-risk acute appendicitis, false negative rates of 14% for the Appendicitis Inflammatory Response, 7% for the Alvarado, and 18% for the Pediatric Appendicitis Score were measured. CONCLUSION In this study, the Appendicitis Inflammatory Response score had the highest discriminating power and outperformed the Alvarado score and Pediatric Appendicitis Score in predicting acute appendicitis in children. Excluding acute appendicitis safely in children with the scoring systems still remains uncertain.
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Schuh S, Chan K, Langer JC, Kulik D, Preto-Zamperlini M, Aswad NA, Man C, Mohanta A, Stephens D, Doria AS. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med 2015; 22:406-14. [PMID: 25808065 DOI: 10.1111/acem.12631] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. METHODS This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. RESULTS Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. CONCLUSIONS The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US or surgical consultation in most study patients.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
- Department of Pediatrics; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Kevin Chan
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | - Jacob C. Langer
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Dina Kulik
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | | | - Nadine Al Aswad
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Carina Man
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Arun Mohanta
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Derek Stephens
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Andrea S. Doria
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
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Gaitán HG, Reveiz L, Farquhar C, Elias VM. Laparoscopy for the management of acute lower abdominal pain in women of childbearing age. Cochrane Database Syst Rev 2014; 2014:CD007683. [PMID: 24848893 PMCID: PMC10843248 DOI: 10.1002/14651858.cd007683.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an updated version of the original review, published in Issue 1, 2011, of The Cochrane Library. Acute lower abdominal pain is common, and making a diagnosis is particularly challenging in premenopausal women, as ovulation and menstruation symptoms overlap with symptoms of appendicitis, early pregnancy complications and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications. OBJECTIVES To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age. SEARCH METHODS The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINAHL were searched (October 2013). The International Clinical Trials Registry Platform (ICTRP) was also searched. No new studies were included in this updated version. SELECTION CRITERIA Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis were included. Trials were included if they evaluated laparoscopy with open appendicectomy, or laparoscopy with a wait and see strategy. Study selection was carried out by two review authors independently. DATA COLLECTION AND ANALYSIS Data from studies that met the inclusion criteria were independently extracted by two review authors and the risk of bias assessed. We used standard methodological procedures as expected by The Cochrane Collaboration. A summary of findings table was prepared using GRADE criteria. MAIN RESULTS A total of 12 studies including 1020 participants were incorporated into the review. These studies had low to moderate risk of bias, mainly because allocation concealment or methods of sequence generation were not adequately reported. In addition, it was not clear whether follow-up was similar for the treatment groups. The index test was incorporated as a reference standard in the laparoscopy group, and differential verification or partial verification bias may have occurred in most RCTs. Overall the quality of the evidence was low to moderate for most outcomes, as per the GRADE approach.Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (seven RCTs, 561 participants; odds ratio (OR) 4.10, 95% confidence interval (CI) 2.50 to 6.71; I(2) = 18%), but no evidence was found of reduced rates for any adverse events (eight RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) = 0%). A meta-analysis of seven studies found a significant difference favouring the laparoscopic procedure in the rate of removal of normal appendix (seven RCTs, 475 participants; OR 0.13, 95% CI 0.07 to 0.24; I(2) = 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. A significant difference favoured laparoscopy in terms of rate of specific diagnoses (four RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) = 79%), but no evidence suggested a difference in rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) = 0%). AUTHORS' CONCLUSIONS We found that laparoscopy in women with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis led to a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared with open appendicectomy only. Hospital stays were shorter. No evidence showed an increase in adverse events when any of these strategies were used.
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Affiliation(s)
- Hernando G Gaitán
- National University of ColombiaDepartment of Obstetrics & Gynecology and Clinical Research Institute, Faculty of MedicineCarrera 30 No. 45‐03BogotaColombia
| | - Ludovic Reveiz
- Free time independent Cochrane reviewer7838 Heatherton LanePotomacUSA20854
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
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Harji DP, Griffiths B, Burke D, Sagar PM. Systematic review of emergency laparoscopic colorectal resection. Br J Surg 2013; 101:e126-33. [PMID: 24285040 DOI: 10.1002/bjs.9348] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND Laparoscopic surgery (LS) has become standard practice for a range of elective general surgical operations. Its role in emergency general surgery is gaining momentum. This study aimed to assess the outcomes of LS compared with open surgery (OS) for colorectal resections in the emergency setting. METHODS A systematic review was performed of studies reporting outcomes of laparoscopic colorectal resections in the acute or emergency setting in patients aged over 18 years, between January 1966 and January 2013. RESULTS Twenty-two studies were included, providing outcomes for 5557 patients: 932 laparoscopic and 4625 open emergency resections. Median (range) operating time was 184 (63-444) min for LS versus 148 (61-231) min for OS. Median (range) length of stay was 10 (3-23) and 15 (6-33) days in the LS and OS groups respectively. The overall median (range) complication rate was 27.8 (0-33.3) and 48.3 (9-72) per cent respectively. There were insufficient data to detect differences in reoperation and readmission rates. CONCLUSION Emergency laparoscopic colorectal resection, where technically feasible, has better short-term outcomes than open resection.
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Affiliation(s)
- D P Harji
- John Goligher Department of Colorectal Surgery, St James's University Hospital, Leeds, LS9 7TF, UK
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12
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Gomes CA, Junior CS, de Peixoto RO, Netto JMB, Gomes CC, Gomes FC. Appendiceal stump closure by metal endoclip in the management of complicated acute appendicitis. World J Emerg Surg 2013; 8:35. [PMID: 24047531 PMCID: PMC3874646 DOI: 10.1186/1749-7922-8-35] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 09/03/2013] [Indexed: 02/07/2023] Open
Abstract
Background Closure of appendicular stump has been performed in different ways; however, the use of the metal endoclip in complicated grades of acute appendicitis, has not been evaluated yet in a prospective way. Objective To establish the effectiveness of appendiceal stump closure by metal endoclip for complicated appendicitis. Method From January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix, which may lead to abscess formation and degrees of peritonitis. The outcomes viability, operative time, infection complication, operative complications, and conversion rate were chosen to evaluate the procedure. Results The appendiceal stump closure by metal endoclip was used in 90% of cases. The presence of appendix base necrosis was the most important factor involved in failure of the procedure. Laparoscopic knot (1.5%), laparoscopic endo-suture (3.8%) and video assisted laparotomy (4.7%) were the alternatives used in difficult cases. The mean operative time was (67.54 ± 28.13 minutes). The wound and intra-abdominal infection rates were 2.54% and 5.08%, respectively. There were no operative complications and the conversion rate was 0.85%. Conclusion The appendiceal stump closure by metal endoclip, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with appendix base necrosis it should be avoided in favor of other alternatives.
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Affiliation(s)
- Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário (HU), Universidade Federal de Juiz de Fora (UFJF) - Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA) -Brasil, Bairro Bom Pastor, Minas Gerais, Brasil.
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Tannoury J, Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013; 19:3942-3950. [PMID: 23840138 PMCID: PMC3703180 DOI: 10.3748/wjg.v19.i25.3942] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 03/22/2013] [Accepted: 04/28/2013] [Indexed: 02/06/2023] Open
Abstract
At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn’s disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.
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The appendiceal stump closure during laparoscopy: historical, surgical, and future perspectives. Surg Laparosc Endosc Percutan Tech 2012; 22:1-4. [PMID: 22318050 DOI: 10.1097/sle.0b013e31823fbf15] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During a laparoscopic appendectomy, the closure of the appendiceal stump is an important step because of postoperative complications from its inappropriate management. The development of life-threatening events such as stercoral fistulas, postoperative peritonitis, and sepsis is feared and unwanted. The tactical modification of the appendiceal stump closure with a single endoligature, replacing the invaginating suture, adjusted very well to laparoscopic appendectomy, and nowadays is the procedure of choice, whenever possible. Among the alternatives that do not make use of an invaginating suture, studies advocate the use of an endostapler, endoligature (endo-loop), metal clips, bipolar endocoagulation, and polymeric clips. All alternatives have advantages and disadvantages against the different clinical stages of acute appendicitis, and it should be noted that the different forms of appendiceal stump closure have never been assessed in prospective randomized studies. Knowledge about and appropriate use of all of them are important for a safe and more cost-effective procedure.
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Fingerhut A. Conversion From Open to Laparoscopic Treatment of Peritonitis: “Reversed Conversion” Revisited. Surg Innov 2011; 18:5-7. [DOI: 10.1177/1553350611400760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Abe Fingerhut
- University of Athens , Hippocratio Hopsital, Athens,
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Gaitán HG, Reveiz L, Farquhar C. Laparoscopy for the management of acute lower abdominal pain in women of childbearing age. Cochrane Database Syst Rev 2011:CD007683. [PMID: 21249692 DOI: 10.1002/14651858.cd007683.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute lower abdominal pain is common and making a diagnosis is particularly challenging in premenopausal woman as ovulation and menstruation symptoms overlap with the symptoms of appendicitis and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications. OBJECTIVES To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age. SEARCH STRATEGY The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINHAL were searched (to April 2010). SELECTION CRITERIA Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, nonspecific lower abdominal pain or suspected appendicitis were included. DATA COLLECTION AND ANALYSIS Data from studies that met the inclusion criteria were independently extracted by two authors and the risk of bias assessed. MAIN RESULTS Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (7 RCTs, 561 participants; OR 4.10, 95% CI 2.50 to 6.71; I(2) 18%) but there was no evidence of reduced rate for any adverse event (8 RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. There was a significant difference favouring laparoscopy in the rate of specific diagnoses (4 RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) 79%) but there was no evidence of a difference in the rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) 0%). AUTHORS' CONCLUSIONS The advantages of laparoscopy in women with nonspecific abdominal pain and suspected appendicitis include a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared to open appendicectomy only. Hospital stays were shorter. There was no evidence of an increase in adverse events with any of the strategies.
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Affiliation(s)
- Hernando G Gaitán
- Universidad Nacional de Colombia, Calle 119a # 18-14 (502), Bogota, Colombia
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Abstract
BACKGROUND Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery. OBJECTIVES To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery. SEARCH STRATEGY We searched the Cochrane Library, MEDLINE, EMBASE, LILACS, CNKI, SciSearch, study registries, and the congress proceedings of endoscopic surgical societies. SELECTION CRITERIA We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis. MAIN RESULTS We included 67 studies, of which 56 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.43; CI 0.34 to 0.54), but the incidence of intraabdominal abscesses was increased (OR 1.87; CI 1.19 to 2.93). The duration of surgery was 10 minutes (CI 6 to 15) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (CI 5 to 11 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.7 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Seven studies on children were included, but the results do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01). AUTHORS' CONCLUSIONS In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.
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Affiliation(s)
- Stefan Sauerland
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care, Dillenburger Str. 27, Cologne, Germany, 51105
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Nakhamiyayev V, Galldin L, Chiarello M, Lumba A, Gorecki PJ. Laparoscopic appendectomy is the preferred approach for appendicitis: a retrospective review of two practice patterns. Surg Endosc 2010; 24:859-64. [PMID: 19730948 DOI: 10.1007/s00464-009-0678-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 07/27/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aimed to compare the results of laparoscopic appendectomy (LA) and open appendectomy (OA). METHODS A retrospective analysis of 264 patients who underwent appendectomy (155 LA and 109 OA) over an 8-year period was performed. The variables analyzed included patient data (white blood cell count [WBC], duration of symptoms, American Society of Anesthesiology [ASA] score), operating data (length of the procedure and pathology), postoperative data (postoperative complications and length of hospital stay), and total costs. RESULTS Patient demographic data (age and sex), preoperative WBC, duration of symptoms, and pathology all were similar in the two study groups. Six cases were converted to OA and included in the LA group data. There was no statistical difference in the average operative time between the LA (mean, 55.7 + or - 22.3 min; range, 20-128 min) and OA (mean, 58.9 + or - 23.7 min; range, 29-135 min) groups (95% confidence interval [CI] -8.8-2.43; p = 0.26). The overall incidence of minor and major complications was significantly less in the LA group (3.2%, five incidents) than in the OA group (17.4%, 19 incidents; p = 0.0043). The median length of hospital stay (LOS) was significantly shorter in the laparoscopic group (median, 2 days; range, 1-8 days) than in the open group (median, 3 days; range, 1-11 days; p < 0.001). The mean total cost was $5,663 in the laparoscopic group and $6,031 in the open group (non-significant difference of -$368; 95% CI, -$926-$190; p = 0.19). CONCLUSION The findings show that LA is associated with fewer complications and similar total costs compared with OA. Therefore, LA can be recommended as a preferred approach to appendectomy.
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Affiliation(s)
- Vadim Nakhamiyayev
- Department of Surgery, New York Methodist Hospital, 506 Sixth Street, Brooklyn, NY 11215, USA
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Owais AE, Wilson TR, Sethi N, Aldoori MI. Whose appendicectomy?--Do laparoscopic appendicectomies impair SHO training? Ann R Coll Surg Engl 2009; 90:577-80. [PMID: 18831867 DOI: 10.1308/003588408x318200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Open appendicectomy is an ideal procedure for junior surgical trainees to develop operative skills. However, in recent years, we have noticed a decline in the number of appendicectomies performed by basic surgical trainees and a shift towards increasing use of laparoscopic appendicectomy. The aim of this study was to determine whether the growing popularity of laparoscopic appendicectomy is having a detrimental impact on the training experience of SHOs. PATIENTS AND METHODS We undertook a retrospective review of all cases of appendicectomies performed in one district hospital over a 7-year period (August 1999 to August 2006.) A standard performa was used to extract data from the original case notes of these patients relating to the operating surgeon and technique. RESULTS Data were obtained for 857 appendicectomies. Between February 2002 and July 2003, there was a significant decline in the proportion of appendicectomies performed by SHOs from 78.7% to 29.3% (P < 0.001). Either side of this decline there were no significant changes in the proportion of SHO appendicectomies. The number of appendicectomies performed laparoscopically only began to rise after February 2004, with a year-on-year increase. The number of appendicectomies performed by SHOs remained stable during this time. No laparoscopic appendicectomy was performed by an SHO. CONCLUSIONS We found no evidence that the popularisation of laparoscopic appendicectomy has contributed to the decline of appendicectomies performed by SHOs. Nevertheless, with the continual rise in popularity of this procedure, it is important to balance training opportunities for both junior and higher surgical trainees.
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Affiliation(s)
- Anwar E Owais
- Department of General Surgery, Huddersfield Royal Infirmary, Huddersfield, UK
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Goldman RD, Carter S, Stephens D, Antoon R, Mounstephen W, Langer JC. Prospective validation of the pediatric appendicitis score. J Pediatr 2008; 153:278-82. [PMID: 18534219 DOI: 10.1016/j.jpeds.2008.01.033] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2005] [Revised: 10/05/2007] [Accepted: 01/24/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To prospectively validate the Pediatric Appendicitis Score (PAS), developed on a cohort of children with abdominal pain suggestive of appendicitis, in unselected children with abdominal pain who present to the emergency department. STUDY DESIGN Over a 19-month period, we prospectively recruited children 1 to 17 years old who came to our tertiary pediatric emergency department, with a chief complaint of abdominal pain of duration less than 7 days. PAS components included fever >38 degrees C, anorexia, nausea/vomiting, cough/percussion/hopping tenderness (2 points), right-lower-quadrant tenderness (2 points), migration of pain, leukocytosis >10 000 cells/mm(3), and polymorphonuclear neutrophilia > 7500 cells/mm(3). A follow-up call was made to verify final outcome. Sensitivity, specificity, and the receiver operating characteristic curve of the PAS with respect to diagnosis of appendicitis were calculated. RESULTS We collected data on 849 children. 123 (14.5%) had pathologic study-proven appendicitis. Mean (median, range) score for children with appendicitis and without appendicitis was 7.0 (7, 2-10) and 1.9 (1, 0-9), respectively. If a cutoff PAS of <or=2 was used to discharge patients without further investigation, only 3 (2.4%) with appendicitis would be sent home. If a PAS of >or=7 was used to take children to the operating room without further investigation, only 29 (4%) would not have appendicitis. For the PAS the area under the receiver operator curve was 0.95. CONCLUSIONS The PAS is useful, because a value <or=2 (found in 73% of children without appendicitis) has high validity for ruling out appendicitis, and a score >or=7 (found in 61% of children with appendicitis) has a high validity for predicting the presence of appendicitis. Children with PAS of 3 to 6 (37% with appendicitis and 23% without appendicitis in this study) should undergo further investigation such as observation, ultrasonography, or computed tomography.
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Affiliation(s)
- Ran D Goldman
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Pediatric Research in Emergency Therapeutics Program, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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Yau KK, Siu WT, Tang CN, Yang GPC, Li MKW. Laparoscopic versus open appendectomy for complicated appendicitis. J Am Coll Surg 2007; 205:60-5. [PMID: 17617333 DOI: 10.1016/j.jamcollsurg.2007.03.017] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Revised: 10/10/2006] [Accepted: 03/01/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis; various reports demonstrated its merits in assisting diagnosis, reducing postoperative pain, analgesic requirement, and incidence of wound infection. The role of laparoscopy in management of complicated appendicitis, ie, gangrenous, perforated appendicitis and appendiceal abscess, remains undefined. Currently, the choice of operative approach is mostly at the surgeons' discretion. A retrospective study was conducted in our institution to review the feasibility, safety, and efficacy of laparoscopic appendectomy for patients with complicated appendicitis. STUDY DESIGN From January 1999 to January 2004, records of patients older than 14 years of age with diagnosis of appendicitis were retrieved from computer database for analysis. All patients underwent diagnostic laparoscopy to confirm diagnosis of complicated appendicitis, and patients subsequently underwent either laparoscopic or open appendectomies. Patients' demographics data and perioperative outcomes from the two groups were compared. RESULTS During the study period, 1,133 patients with acute appendicitis underwent operations in our institution. Two hundred forty-four patients (21.5%) with complicated appendicitis were identified by laparoscopy, of which 175 underwent laparoscopic appendectomy (LA) and 69 had open appendectomy (OA). Both groups of patients were comparable in demographics. Mean operative time was 55 minutes for LA group and 70 minutes for the OA group (p<0.001). Mean hospital stay was 5 days and 6 days for LA and OA group respectively (p<0.001). There was one conversion patient (0.6%) in the LA group who suffered from wound infection, and there were seven (10%) wound infections in the OA group (p=0.001). There were 10 cases (5.7%) of intraabdominal collection in the LA group and 3 (4.3%) in the OA group (p=0.473). There was no mortality in the current series. CONCLUSIONS Laparoscopic appendectomy for complicated appendicitis is feasible and safe. It is associated with a significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay when compared with patients who had open appendectomy.
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Affiliation(s)
- Kwok Kay Yau
- Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong
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Corfield L. Interval appendicectomy after appendiceal mass or abscess in adults: what is "best practice"? Surg Today 2007; 37:1-4. [PMID: 17186336 DOI: 10.1007/s00595-006-3334-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 05/09/2006] [Indexed: 12/11/2022]
Abstract
There is still much controversy surrounding whether interval appendicectomy is appropriate for adults with an appendiceal mass or abscess. The main debate centres on the recurrence rate, the complication rate of interval appendicectomy, and the potential for underlying malignancy. This review aims to assess current practice and to determine whether it is possible to define "best practice" for the asymptomatic patient who has had an appendiceal mass or abscess treated conservatively. I sent a postal questionnaire to 90 consultant general surgeons requesting information about their practice of interval appendicectomy. I also conducted a literature search confined to studies involving only adult patients. The 77.8% of questionnaires returned revealed that 53% of the surgeons perform routine interval appendicectomy, mainly because of concerns about recurrence. The preference was for open appendicectomy at 6 weeks to 3 months. The literature search revealed a recurrence rate of 10%-25%, with a complication rate of 23%. It was evident that the chances of missing malignancy are low and thorough investigation is better than interval appendicectomy in detecting colonic cancer. The practice of performing interval appendicectomy varies, with just over half of the surgeons surveyed performing this procedure routinely. The literature provides little evidence that interval appendicectomy is routinely indicated and would support the view that it is unnecessary in 75%-90% of cases. However, there is scope for further consideration of the use of laparoscopic interval appendicectomy and a randomised trial is needed to fully evaluate this issue.
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Affiliation(s)
- Lorraine Corfield
- Department of Surgery, University Hospital Lewisham, Lewisham High Street, London, SE13 6LH, UK
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Reiertsen O, Larsen S, Trondsen E, Edwin B, Faerden AE, Rosseland AR. Randomized controlled trial with sequential design of laparoscopic versus
conventional appendicectomy. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02694.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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McCall JL, Sharples K, Jadallah F. Systematic review of randomized controlled trials comparing laparoscopic with open appendicectomy. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02848.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Olmi S, Magnone S, Bertolini A, Croce E. Laparoscopic versus open appendectomy in acute appendicitis: a randomized prospective study. Surg Endosc 2005; 19:1193-5. [PMID: 16132334 DOI: 10.1007/s00464-004-2165-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2004] [Accepted: 04/07/2005] [Indexed: 12/23/2022]
Abstract
BACKGROUND Laparoscopic appendectomy is a safe and effective procedure, as both a diagnostic and therapeutic tool. It seems to be more effective than the corresponding open procedure. Aim of this study is to evaluate a group of patients randomly allocated either to laparoscopic appendectomy (LA) or to open appendectomy (OA). METHODS From January 1998 to December 2002, 252 consecutive and nonselected patients, 155 women and 97 men, were randomized either to LA or OA. Recorded data were operative time, postoperative length, of stay and complications. RESULTS Mean operative time was 45 min (range 30-120) for OA and 36 min (25-60) for LA, mean postoperative stay was 5.5 days (4-12) for OA and 3.4 days (2-8) for LA. Complication occurred in 20 patients (14.5%) for OA and in four patients (2.6%) for LA. CONCLUSION We believe that LA is effective in any kind of clinical situation, with low traumatic impact and best comfort for the patient.
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Affiliation(s)
- S Olmi
- Second Department of General Surgery, Centre for Minimally Invasive Surgery, Ospedale san Gerardo, Via Donizetti 106, Monza, MI, 20052, Italy
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Sato N, Kojika M, Yaegashi Y, Suzuki Y, Kitamura M, Endo S, Saito K. Mini-laparoscopic appendectomy using a needle loop retractor offers optimal cosmetic results. Surg Endosc 2004; 18:1578-81. [PMID: 15580448 DOI: 10.1007/s00464-003-8248-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2003] [Accepted: 02/05/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Do conventional laparoscopic appendectomy (LA) techniques provide truly satisfying results for patients and surgeons? We have devised a more advanced technique that improves cosmesis. METHODS A 2-mm scope is inserted at the umbilicus, and a 12-mm working trocar is inserted through a suprapubic incision placed below the line of pubic hair. A needle loop retractor (NLR) is inserted to hold the appendix in the lower right abdomen. In this NLR, a stainless steel wire is placed within a needle having a diameter of 2 mm. From the suprapubic trocar, a bipolar coagulator is inserted to transect the appendiceal mesentery. A series of 30 patients underwent this procedure. RESULTS There were no conversions to laparotomy and no intra- or postoperative complications. CONCLUSIONS Laparoscopic appendectomy using a 2-mm scope, suprapubic trocar, and an NLR yields optimal cosmetic results. For surgeons, the NLR allows the appendix to be held more firmly than then a 5- or 2-mm grasping forceps is used.
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Affiliation(s)
- N Sato
- Department of Critical Care Medicine, Iwate Medical University, School of Medicine, 19-1 Uchimaru, Morioka 020-8505, Japan.
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Sato N, Kojika M, Yaegashi Y, Suzuki Y, Kitamura M, Endo S, Saito K. Minilaparoscopic appendectomy using a needle loop retractor offers optimal cosmetic results. Surg Endosc 2004. [DOI: 10.1007/bf02637123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery. OBJECTIVES To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciSearch, the congress proceedings of endoscopic surgical societies. SELECTION CRITERIA We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis. MAIN RESULTS We included 54 studies, of which 45 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for LA. Pain on day 1 after surgery was reduced after LA by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Five studies on children were included, but the result do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01). REVIEWERS' CONCLUSIONS In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.
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Affiliation(s)
- S Sauerland
- Biochemical & Experimental Division, Medical Faculty, University of Cologne, Ostmerheimer Str. 200, Cologne, Germany, 51109
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Abstract
Laparoscopic appendectomy (LA) is one of the common procedures being carried out in general surgery. The technique of bipolar coagulation (BC) has been effectively employed in obstetric and gynecologic procedures but has not been used for intestines. We present the technique of LA using BC at our center. The technique consisted of identifying the appendix and coagulating the appendicular stump with bipolar coagulation until there were no bubbles at the cautery site, and a constriction ring formed at the site of coagulation. Sixty patients with acute or recurrent appendicitis underwent the procedure. The median duration of BC was 90 seconds. The median duration of surgery was 25 minutes, postoperative hospital stay was 3 days, and time to oral feeds was 12 hours. The technique of laparoscopic appendectomy by bipolar coagulation is very simple and economical. The duration of surgery is less than for the standard technique of laparoscopic appendectomy; no clip applicators, needle holders or knot pushers are required, and no foreign materials like ligatures or clips are needed.
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Geissler B, Neugebauer E, Angster R, Witte Dagger J. Qualitätsmanagement der postoperativen Schmerztherapie. Chirurg 2004; 75:687-93. [PMID: 15146277 DOI: 10.1007/s00104-003-0810-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND A main target of surgical treatment is to minimize postoperative pain. The aim of this study was to evaluate the benefit of quality management on postoperative pain and to improve pain therapy. METHODS In a prospective study, postoperative pain was recorded in a total of 700 patients in a general and visceral surgical ward in 2000, 2001, and 2002. Pain was measured on a ten-point visual analogue scale (0 no pain, 10 most severe pain). RESULTS Applying the principles of quality management (plan, do, check, act), we analyzed the reasons for high pain scores in detail. After study of the results in 2000, additional recommendations and guidelines for perioperative pain therapy were provided to all the physicians, and the mean visual analogue pain scores decreased by 15% in 2001 and more than 30% in 2002. At baseline, 12% of patients had pain above the threshold of 3 at rest and 5 in motion. These scores could be reduced to 6% and 3% in the two successive years, respectively. CONCLUSION A simple pain management system in a general surgical ward led to considerable improvement in postoperative pain scores as assessed by visual analogue scale.
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Affiliation(s)
- B Geissler
- Klinik für Allgemein- und Viszeralchirurgie, Klinikum Augsburg.
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Azzie G, Salloum A, Beasley S, Maoate K. The Complication Rate and Outcomes of Laparoscopic Appendicectomy in Children with Perforated Appendicitis. ACTA ACUST UNITED AC 2004. [DOI: 10.1089/109264104773513098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Stany MP, Winter WE, Dainty L, Lockrow E, Carlson JW. Laparoscopic Exposure in Obese High-Risk Patients With Mechanical Displacement of the Abdominal Wall. Obstet Gynecol 2004; 103:383-6. [PMID: 14754711 DOI: 10.1097/01.aog.0000110543.14290.35] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with morbid obesity or pulmonary disease are at a higher risk for complications during advanced laparoscopic procedures. Higher intraperitoneal carbon dioxide pressures required to elevate the pannus can negatively impact hemodynamic and respiratory parameters. CASES We describe a technique that uses a combination of a mechanical retractor and a Foley catheter inserted midway between the umbilicus and the pubic symphysis that assists in elevating the anterior abdominal wall. In 3 cases this technique allowed for a low-pressure pneumoperitoneum during advanced laparoscopic pelvic surgery, which resulted in improved hemodynamic parameters and pulmonary function in these high-risk patients. CONCLUSION The Foley Lap-Lift facilitated laparoscopy through mechanical abdominal wall elevation and allowed for a lower-pressure pneumoperitoneum. This technique is an addition to traditional operative laparoscopy in select high-risk patients.
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Affiliation(s)
- Michael P Stany
- Department of Obstetrics and Gynecology, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307, USA
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Sare M, Demirkiran AE, Tastekin N, Durmaz B. Effects of laparoscopic models on anaerobic bacterial growth with bacteroides fragilis in experimentally induced peritonitis. J Laparoendosc Adv Surg Tech A 2003; 13:175-9. [PMID: 12855099 DOI: 10.1089/109264203766207690] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous reports of recurrent intra-abdominal abcess formation after the laparoscopic treatment of perforated acute appendicitis led us to investigate the possible effects of gas insufflation on the spread of infection. We previously showed that Escherichia coli counts were significantly higher in a laparoscopy group that underwent carbon dioxide (CO2) insufflation than in control and laparotomy groups. The aim of this study is to investigate the effects of intra-abdominal CO2 and nitrous oxide (N2O) insufflation on anaerobic bacterial growth in a rat model. METHODS A standard strain of Bacteroides fragilis (ATCC 25285) was injected intraperitoneally (1 x 10(6) cfu/mL per kilogram) in 40 Wistar rats under sterile conditions. Forty rats with induced peritonitis were randomly divided into five groups: control, laparotomy, CO2 insufflation, N2O insufflation, and one group without pneumoperitoneum. Eight hours after the intraperitoneal injection of B. fragilis, peritoneal aspirates were obtained and inoculated onto Brucella agar. At the sixteenth hour of induced peritoneal infection (corresponding to hour 8 in the laparoscopy groups) all animals underwent laparotomy; peritoneal aspirates were obtained and inoculated into Brucella agar for bacterial counts. The colonies of B. fragilis were counted manually, and the results were expressed as the mean number of colony-forming units per milliliter. RESULTS No significant differences in microorganism counts were noted between the study groups before the procedure (p>.05 for all comparisons). We observed a significant increase in the number of bacteria (mean +/- SD) in the CO2 insufflation group between hour 8 and hour 16 of peritoneal contamination. CONCLUSION The results suggest that CO2 insufflation may promote the growth of intra-abdominal anaerobic bacteria. Such bacterial growth may lead to intra-abdominal abcess formation or cause localized peritonitis to develop into generalized peritonitis. We suggest that laparoscopy without pneumoperitoneum may be preferred in patients with peritonitis.
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Affiliation(s)
- Mustafa Sare
- Gazi University, Faculty of Medicine, Department of General Surgery, Besevler, Ankara, Turkey.
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Abstract
BACKGROUND/PURPOSE Morbidity in children treated with appendicitis results either from late diagnosis or negative appendectomy. A Prospective analysis of efficacy of Pediatric Appendicitis Score for early diagnosis of appendicitis in children was conducted. METHODS In the last 5 years, 1,170 children aged 4 to 15 years with abdominal pain suggestive of acute appendicitis were evaluated prospectively. Group 1 (734) were patients with appendicitis and group 2 (436) nonappendicitis. Multiple linear logistic regression analysis of all clinical and investigative parameters was performed for a model comprising 8 variables to form a diagnostic score. RESULTS Logistic regression analysis yielded a model comprising 8 variables, all statistically significant, P <.001. These variables in order of their diagnostic index were (1) cough/percussion/hopping tenderness in the right lower quadrant of the abdomen (0.96), (2) anorexia (0.88), (3) pyrexia (0.87), (4) nausea/emesis (0.86), (5) tenderness over the right iliac fossa (0.84), (6) leukocytosis (0.81), (7) polymorphonuclear neutrophilia (0.80) and (8) migration of pain (0.80). Each of these variables was assigned a score of 1, except for physical signs (1 and 5), which were scored 2 to obtain a total of 10. The Pediatric Appendicitis Score had a sensitivity of 1, specificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99. CONCLUSION Pediatric appendicitis score is a simple, relatively accurate diagnostic tool for accessing an acute abdomen and diagnosing appendicitis in children.
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Affiliation(s)
- Madan Samuel
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, England
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Abstract
BACKGROUND Laparoscopic surgery has been proposed to have diagnostic and therapeutic advantages over conventional surgery. OBJECTIVES To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery in the treatment of suspected acute appendicitis. SEARCH STRATEGY We searched for original articles and abstracts published until end of 2000. As main search tools we employed the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE and SciSearch. CCTR and MEDLINE searches were repeated until 10 October 2001, all other databases were searched 10 October 2000. We also handsearched the congress proceedings of endoscopic surgical societies. SELECTION CRITERIA We included clinical trials that assessed either: (1) Therapeutic effects of laparoscopic appendectomy (LA) versus open appendectomy (OA) in adults, (2) Therapeutic effects of LA versus OA in children, (3) Diagnostic effects of diagnostic laparoscopy (LAP) followed by LA or OA if necessary versus immediate OA, (4) Therapeutic effects of diagnostic laparoscopy (LAP) followed by OA if necessary versus immediate OA. We included only randomized studies and excluded those with unconcealed allocation. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed each study's eligibility and quality. One reviewer extracted the data, 10% of which were later cross-checked by a second reviewer. Abstract authors and authors of articles lacking important information on trial design or results were contacted. MAIN RESULTS We included 45 studies, of which 39 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were about half as likely (Peto OR 0.47; 95%-CI 0.36 to 0.62) after LA than after OA, but intraabdominal abscesses were increased nearly threefold after LA (Peto OR 2.77; 95%-CI 1.61 to 4.77). The duration of surgery was 14 minutes (95%-CI 10 to 19) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (95%-CI 3 to 13 mm) on a 100 mm VAS. Hospital stay was reduced by 0.7 days (95%-CI 0.4 to 1.0). Return to normal activity, work, and sport were 6 days (95%-CI 4 to 8), 3 days (1 to 5), and 7 days (3 to 12) earlier after LA than after OA. While the operation costs of LA were significantly higher than that of OA, the costs outside hospital were reduced. Strong heterogeneity was found for most outcomes, but not for wound infections and intraabdominal abscesses. In children, much less data were available, but the result do not seem to be much different when compared to adults. Pain which was measured blindly in two paediatric trials, was similar after LA and OA (-1 mm VAS; 95%-CI -8 to +7 mm). In trials on unselected patients, diagnostic laparoscopy led to large but variable reductions in the rate of negative appendectomies (RR 0.21; 95%-CI 0.13 to 0.33). In parallel, the rate of unestablished diagnoses was significantly decreased after laparoscopy (RR 0.34; 95%-CI 0.22 to 0.53). In fertile women, these effects were even more pronounced: rate of negative appendectomies: RR 0.19; 95%-CI 0.11 to 0.34; rate of patients without a final diagnosis established: RR 0.24; 95%-CI 0.15 to 0.38. REVIEWER'S CONCLUSIONS In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. In gangrenous or perforated cases, however, LA may possibly carry a higher risk of intraabdominal infections.
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Affiliation(s)
- S Sauerland
- Biochem. & Exptl. Dept., 2nd Dept. of Surgery, University of Cologne, Osterheimer Strasse 200, Cologne, Germany, D 51109.
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Satomi A, Tanimizu T, Takahashi S, Kawase H, Murai H, Yonekawa H, Takahashi H, Sakai M, Ikeda R, Hinoki A. One-Port Laparoscopy-Assisted Appendectomy in Children with Appendicitis: Experience with 100 Cases. ACTA ACUST UNITED AC 2001. [DOI: 10.1089/10926410152776351] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Akira Satomi
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Takemaru Tanimizu
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Shigeki Takahashi
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Hirokazu Kawase
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Hideaki Murai
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Hironobu Yonekawa
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Hiroshi Takahashi
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Masato Sakai
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Rie Ikeda
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Saitama Medical School, Saitama, Japan
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Wullstein C, Barkhausen S, Gross E. Results of laparoscopic vs. conventional appendectomy in complicated appendicitis. Dis Colon Rectum 2001; 44:1700-5. [PMID: 11711745 DOI: 10.1007/bf02234393] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although many trials show some advantages of laparoscopic appendectomy over open appendectomy, the value of laparoscopic appendectomy is still controversial. Specifically the question of whether there are benefits of laparoscopic appendectomy over open appendectomy in complicated appendicitis remains to be answered. METHODS Of 1,106 consecutive appendectomies (717 laparoscopic appendectomies, 330 open appendectomies, and 59 conversions) between 1989 and 1999, the results of 299 patients with complicated appendicitis (defined by perforation, abscess, or peritonitis) were analyzed retrospectively to compare the complications of laparoscopic appendectomy and conversion (intention-to-treat group) with those of open appendectomy. RESULTS Complicated appendicitis (n = 299) was treated by laparoscopic appendectomy in 171 patients, by open appendectomy in 82 patients, and by conversion in 46 patients. Laparoscopic appendectomy and conversion showed fewer abdominal wall complications than open appendectomy (13/217; 6 percent vs. 15/82; 18.3 percent; P < 0.003), which led to a decrease of the total complication rate in the intention-to-treat group (21/217; 9.7 percent vs. 19/82; 23.1 percent; P = 0.004). The rate of intra-abdominal abscess formation was nearly the same after laparoscopic appendectomy (4.1 percent) and open appendectomy (4.9 percent). The total complication rate was higher in complicated appendicitis than in acute appendicitis (P < 0.005) but was independent of the laparoscopic technique. The conversion rate was higher in complicated appendicitis than in acute appendicitis (21.2 vs. 2.3 percent; P < 0.001). CONCLUSION In comparison with open appendectomy, laparoscopic appendectomy (by itself and in an intention-to-treat view) leads to a significant reduction of early postoperative complications in complicated appendicitis and therefore should be considered as the procedure of choice.
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Affiliation(s)
- C Wullstein
- Chirurgische Klinik, Knappschaftskrankenhaus Bochum-Langendreer, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
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40
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Abstract
Infections are unusual following minimally invasive surgery but antibiotic prophylaxis is given in the same way as for the open surgery equivalents. Most prophylactic regimens have not been subjected to randomised placebo controlled trials. Antibiotic prophylaxis has been shown to be beneficial in transurethral resection of the prostate. In endoscopic retrograde cholangiopancreatography (ERCP) the incidence of bacteremia, but not cholangitis, is reduced by prophylaxis and some do not recommend its routine use. For arthroscopies and laparoscopies infection is too rare to warrant prophylaxis. There is a theoretical risk of infection in that endoscopes cannot withstand autoclaving so only high level disinfection can be used between patients. However, for most minimally invasive operations, the small wound size, reduced immune challenge and rapid recovery of the patient outweigh any disadvantages compared with open surgery.
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Affiliation(s)
- A P Wilson
- Department of Clinical Microbiology, University College London Hospitals, UK
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41
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Sare M, Demirkiran AE, Alibey E, Durmaz B. Effect of abdominal insufflation on bacterial growth in experimental peritonitis. J Laparoendosc Adv Surg Tech A 2001; 11:285-9. [PMID: 11642664 DOI: 10.1089/109264201317054573] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Perforated appendicitis can be treated laparoscopically, but this approach is associated with a higher rate of intra-abdominal abscess. Pneumoperitoneum impairs the clearance of bacteria from the peritoneal cavity in experimental models of peritonitis. The aim of this study was to investigate the effects of intra-abdominal gas insufflation on bacterial growth in a rat model. MATERIALS AND METHODS The effects of intraperitoneal insufflation with different gases and a gasless model on bacterial proliferation in a setting of Escherichia coli-induced experimental peritonitis were studied in a rat model. Saline (0.25 mL) was given intraperitoneally to six Wistar male rats as the sham group. Escherichia coli (1.5 x 10(9) cfu/mL per kilogram) was injected intraperitoneally into to 24 rats. Microorganism counts were taken after 8 hours, and rats were divided into three groups: group 1, CO2 insufflation; group 2, N2O insufflation; and group 3, no insufflation. Microorganism counts were repeated 8 hours after the procedure (at 16 hours postinjection). RESULTS The difference in microorganism counts between 8 and 16 hours were significant in the CO2 and N2O insufflation groups (P < 0.05) but not in the group without pneumoperitoneum. CONCLUSIONS Abdominal insufflation may promote intra-abdominal bacterial growth or decrease intra-abdominal bacterial clearance.
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Affiliation(s)
- M Sare
- Department of General Surgery, Gazi University, Faculty of Medicine, Ankara, Turkey.
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Pedersen AG, Petersen OB, Wara P, Rønning H, Qvist N, Laurberg S. Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg 2001; 88:200-5. [PMID: 11167866 DOI: 10.1046/j.1365-2168.2001.01652.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopy in patients with a clinical suspicion of acute appendicitis has not gained wide acceptance, and its use remains controversial. METHODS In a randomized controlled trial of laparoscopic versus open appendicectomy, 583 of 828 consecutive patients consented to participate. Three hundred and one patients were allocated to open appendicectomy and 282 patients to laparoscopy, 65 of whom required conversion to open appendicectomy. Length of stay in hospital was the primary endpoint, while operating time, postoperative morbidity, duration of convalescence and cosmesis were secondary endpoints. RESULTS Intention-to-treat analysis revealed an equally short hospital stay in the two groups (median 2 days). The median time to return to normal activity (7 versus 10 days) and work (10 versus 16 days) was significantly shorter following laparoscopy. Laparoscopy was associated with fewer wound infections (P < 0.03) and improved cosmesis (P < 0.001), but the operating time was longer (60 versus 40 min). Laparoscopy was associated with more intraperitoneal abscesses (5 versus 1 per cent) but, adjusted for a greater number of gangrenous or perforated appendices in this group, the difference failed to reach statistical significance. CONCLUSION Hospital stay was equally short, whereas laparoscopic appendicectomy was associated with fewer wound infections, faster recovery, earlier return to work and improved cosmesis.
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Affiliation(s)
- A G Pedersen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.
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Moberg AC, Montgomery A. Introducing diagnostic laparoscopy for patients with suspected acute appendicitis. Surg Endosc 2000; 14:942-7. [PMID: 11080408 DOI: 10.1007/s004640000225] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The diagnostic accuracy in patients with suspected acute appendicitis varies from 60% to 90% depending on age and gender. The aim of this study was to evaluate the use of diagnostic laparoscopy for diagnostic purposes in patients with suspected acute appendicitis to prevent unnecessary laparotomy and to leave a macroscopically normal appendix in place. METHODS For this study, 500 consecutive patients with suspected acute appendicitis admitted between January 1994 and October 1996 were included prospectively in a surgical training program set to provide diagnostic laparoscopy on a 24-h-a-day basis. Primary open operation was performed when no laparoscopically trained surgeon was available. Short-term outcome measurements were recorded, and a retrospective long-term follow-up evaluation was performed. RESULTS We succeeded in performing a diagnostic laparoscopy in 376 patients and a primary open operation in 124 patients. The overall appendicitis rate was 78%. A diagnostic laparoscopy alone was performed in 66 patients (56 of which were fertile women), with a median operating time of 36 min and a complication rate of 0%. The overall complication rate was 8.0%. During a median follow-up period of 19 months one patient returned on a later occasion with appendicitis. At completion of the study, 85% of the surgeons were skilled in diagnostic laparoscopy. CONCLUSIONS Substantial education effort is needed to introduce diagnostic laparoscopy on a 24-h-a-day basis. Diagnostic laparoscopy has a high rate of accuracy, short operating time, and low associated morbidity, and prevents unnecessary laparotomy. It is possible to leave a macroscopically normal-appearing appendix in place.
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Affiliation(s)
- A C Moberg
- Department of Surgery, Malmö University Hospital, S-205 02 Malmö, Sweden
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Lidar Z, Kuriansky J, Rosin D, Shabtai M, Ayalon A. Laparoscopic interval appendectomy for periappendicular abscess. Surg Endosc 2000; 14:764-6. [PMID: 10954826 DOI: 10.1007/s004640000188] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess. METHODS This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8-10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998. RESULTS Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections. CONCLUSION We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay.
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Affiliation(s)
- Z Lidar
- Department of General Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel
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Abstract
BACKGROUND For many years it has been claimed that observational studies find stronger treatment effects than randomized, controlled trials. We compared the results of observational studies with those of randomized, controlled trials. METHODS We searched the Abridged Index Medicus and Cochrane data bases to identify observational studies reported between 1985 and 1998 that compared two or more treatments or interventions for the same condition. We then searched the Medline and Cochrane data bases to identify all the randomized, controlled trials and observational studies comparing the same treatments for these conditions. For each treatment, the magnitudes of the effects in the various observational studies were combined by the Mantel-Haenszel or weighted analysis-of-variance procedure and then compared with the combined magnitude of the effects in the randomized, controlled trials that evaluated the same treatment. RESULTS There were 136 reports about 19 diverse treatments, such as calcium-channel-blocker therapy for coronary artery disease, appendectomy, and interventions for subfertility. In most cases, the estimates of the treatment effects from observational studies and randomized, controlled trials were similar. In only 2 of the 19 analyses of treatment effects did the combined magnitude of the effect in observational studies lie outside the 95 percent confidence interval for the combined magnitude in the randomized, controlled trials. CONCLUSIONS We found little evidence that estimates of treatment effects in observational studies reported after 1984 are either consistently larger than or qualitatively different from those obtained in randomized, controlled trials.
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Affiliation(s)
- K Benson
- Department of Family Medicine, University of Iowa College of Medicine, Iowa City 52242-1097, USA
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Casati A, Comotti L, Tommasino C, Leggieri C, Bignami E, Tarantino F, Torri G. Effects of pneumoperitoneum and reverse Trendelenburg position on cardiopulmonary function in morbidly obese patients receiving laparoscopic gastric banding. Eur J Anaesthesiol 2000. [DOI: 10.1097/00003643-200005000-00005] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kokoska ER, Murayama KM, Silen ML, Miller TA, Dillon PA, Weber TR. A state-wide evaluation of appendectomy in children. Am J Surg 1999; 178:537-40. [PMID: 10670867 DOI: 10.1016/s0002-9610(99)00219-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Traditional management of appendicitis in children involves open appendectomy (OA), an operation that is relatively inexpensive and carries few risks and complications. However, little information is available regarding the use, cost, and complication of laparoscopic appendectomy (LA) in children. METHODS Our initial aim was to determine if LA is frequently performed in children (<15 years). We then compared the surgical results of OA versus LA. In conjunction with the Missouri Department of Health, we evaluated 793 children treated for appendicitis throughout the state between January 1997 and June 1997. The authors were blinded to the patient, surgeon, and hospital; no children were excluded. RESULTS LA was infrequently performed in children with advanced disease. Overall, children undergoing LA were older and had a shorter hospitalization but no difference in hospital charge. When separated by child age, LA was associated with a shorter length of stay in all groups (0 to 5, 6 to 10, and 11 to 15 years) but only children in the 6 to 10 year range had a lower hospital charge when compared with patients undergoing OA. CONCLUSIONS LA is becoming a common surgical approach for older children with simple appendicitis. Furthermore, these data suggest that LA, independent of individual surgeon or medical center, is associated with a decreased length of hospitalization without a significant difference in hospital charge.
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Affiliation(s)
- E R Kokoska
- Department of Surgery, Saint Louis University Health Sciences Center and Cardinal Glennon Children's Hospital, Missouri, USA
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