Defining a Relationship Between Postoperative Antibiotic Use and Wound Complications in the Setting of an Uncomplicated Laparoscopic Appendectomy.

INTRODUCTION: Appendicitis is a very common diagnosis that surgeons manage daily. Some surgeons are still giving antibiotics to patients suffering from uncomplicated appendicitis in the postoperative setting, despite an abundance of evidence to support a single preoperative dose of antibiotics. In this paper, we will describe the management of post-operative antibiotics at our institutions following uncomplicated appendicitis with regard to the use of antibiotics in the post-operative setting. METHODS: A retrospective chart review was performed analyzing post-operative antibiotic use and postoperative complications in 179 patients undergoing laparoscopic appendectomy for uncomplicated appendicitis. We retrospectively examined the patients to change our future practices as we perform appendectomies routinely, and there is practice variation at our centers. Current Procedural Terminology (CPT) codes for 'laparoscopic appendectomy' were used to identify the patients within our inclusion criteria. Twenty-four patients were excluded from the analysis as they had complicated appendicitis or met other exclusion criteria. We only studied the patient with uncomplicated appendicitis, as those with complicated appendicitis have a different clinical course that involves post-operative antibiotic administration or prolonged antibiotic administration with or without drain placement. Both arms of the study were homogeneous regarding patient characteristics. An independent test of the development of wound infection for those patients receiving post-operative antibiotics versus those not receiving post-operative antibiotics was conducted using the SPC XL 2010 Microsoft Excel (Redmond, USA) add-in. A p-value of <0.05 was considered statistically significant. This included the odds ratio for the development of complications.  Results: There was no difference in the risk of infection rate in patients given post-operative antibiotics; however, given the odds ratio of 6.53, there is an association between an increased wound infection rate and patients who received post-operative antibiotics.  Discussion: An appendectomy is a standard surgical procedure for acute appendicitis. The guidelines for using pre-operative antibiotics in uncomplicated appendicitis are well established; however, there is no specific recommendation on whether to continue antibiotics post-operatively. However, there is significant provider variability on this topic. Antibiotic use post-operatively in clean-contaminated cases, such as uncomplicated acute appendicitis, has been associated with higher risks of surgical site infections.  Conclusion: The use of antibiotics post-operatively may not be indicated for uncomplicated laparoscopic appendectomy and may increase wound infections. A large-scale study including a larger population and extending it to other hospitals may increase statistical significance and help guide physician management.

Stage II Medullary Carcinoma of the Colon: A Surgery Case Report.

Medullary carcinoma (MC) is a rare subtype of colorectal cancer, which presents with poorly differentiated histology and is often confused with conventional adenocarcinoma of the colon. While this form of colorectal cancer is rare, it often does not meet the high-risk criteria to qualify for adjuvant chemotherapy even with a favorable prognosis. Diagnosis of MC is a proven difficulty because of the lack of immunohistochemical stains on pathology seen in adenocarcinoma of the colon. Unlike adenocarcinoma of the colon, distant metastasis is rare. Patients diagnosed with MC have one- and two-year survival rates of 93% and 74%, respectively. The patient was a 75-year-old female diagnosed with MC of the sigmoid colon and a large uterine fibroid. In this case report, we discuss the high-risk indications of colorectal cancer and the recommended treatment of patients with stage II MC of the colon.

A Rare Case of an Inguinal Hernia-Containing (Extraperitoneal) Ureter.

BACKGROUND Ureteroinguinal hernias are exceptionally rare and are seldom diagnosed in the preoperative setting. There are 2 classifications of this type of hernia: paraperitoneal and extraperitoneal. CASE REPORT We report a case of a 67-year-old man who presented with urinary symptoms and a reducible right inguinal hernia. A computed tomography (CT) scan of the abdomen and pelvis suggested an ureteroinguinal hernia. Further diagnostics and treatment via cystoscopy, retrograde pyelogram, and right ureteral stent placement were performed, confirming the diagnosis and providing relief of the obstructive uropathy. The patient underwent an attempted elective transabdominal preperitoneal repair that was converted to an open Lichtenstein repair. Intraoperatively, an extraperitoneal ureteroinguinal hernia was identified. The patient did well postoperatively, and the stent was removed 1 month later. CONCLUSIONS Only 20% of the ureteroinguinal hernias described in the literature are extraperitoneal. In our case presentation, we demonstrated successful identification and treatment of an extraperitoneal ureteroinguinal hernia. The diagnosis was made using a combination of the clinical presentation, CT of the abdomen and pelvis, and cystoscopy with retrograde pyelogram. The extraperitoneal classification was an intraoperative diagnosis. The treatment consisted of a temporizing ureter stent and definitive management with an open Lichtenstein repair. We recommend obtaining a CT scan when a patient presents with a combination of urinary symptoms and an inguinal hernia because this process was invaluable in our preoperative diagnosis. Stent placement at the time of diagnosis permitted an elective repair and aided in the identification of the ureter during the hernia repair.

Internal hernia through the foramen of Winslow.

Foramen of Winslow hernias are one of the most uncommon types of internal hernias that a surgeon will encounter. They are often initially indolent with vague symptoms that present over an extended period of time. Unfortunately, these hernias are not often diagnosed prior to requiring emergent operative intervention. This case report describes a patient who had a long history of vague abdominal pain and radiographic evidence of a foramen of Winslow hernia 4 years prior to presenting with acute obstructive symptoms. This raises the question: Should foramen of Winslow hernias, if diagnosed early, be repaired on an elective basis?

Rare Reported Left Hepatic Subcapsular Biloma and Management.

Subcapsular bilomas are a rare complication of laparoscopic cholecystectomy and an even more rare occurrence to occur spontaneously. We present a case of left sided subcapsular biloma following a laparoscopic cholecystectomy. The location of the biloma was unrelated to our area of dissection. The operation was without difficult dissection or pressurization of the biliary tree. In addition, we present percutaneous drainage alone, without ERCP as adequate management in subcapsular bilomas.

Enfermedad diverticular del colon en pacientes jóvenes. Nuestra experiencia / Diverticular colon illness in young patients. Our experience

Se analizan restrospectivamente 7 pacientes menores de 45 años, con enfermedad diverticular complicada atendidos en el servicio de Cirugía General del Hospital Pirovano durante el período comprendido entre 1995 y 1997. El diagnóstico se realizó de acuerdo al cuadro clínico, el hallazgo intraoperatorio y estudios imagenológicos (colon por enema, tomografía computada). Cinco casos fueron intervenidos quirúrgicamente, 4 en la urgencia y el restante en forma programada. Las cirugías realizadas fueron: operación de Hartmann (3 casos), procedimiento de Lahey en uno y hemicolectomía izquierda en el programado. Los 2 casos tratados clínicamente respondieron al mismo. No se halló mortalidad, 2 pacientes presentaron absceso de la pared abdominal los cuales fueron resueltos con azúcar. Se evalúa junto con la revisión bibliográfica, el diagnóstico, la virulencia y la evolución de estos enfermos. Es fundamental mejorar el índice de sospecha clínica inicial y plantear la posible resección del segmento colónico enfermo ante el primer episodio de recidiva de los mismos