RESUMO
INTRODUCTION: The optimal laparoscopic appendectomy approach is not clear, comparing single site laparoscopic appendectomy (SILA) to conventional 3-port appendectomy (CLA). We investigated outcomes in pediatric patients comparing SILA to CLA: length of operation, length of stay, time to resumption of regular diet, follow up, rehospitalization, and cost. METHODS: Data was collected from children 1 to 18 years with appendectomy at Loma Linda University from 2018 to 2020, operated by two surgeons. Analysis utilized two-sample T, chi-squared, and Fisher's exact tests. RESULTS: Of 173 patients, 77 underwent SILA and 96 had CLA. There was no gender, age, or race difference between groups. Mean WBC was 17.5 × 103/mL in SILA group, compared to 15.3 × 103/mL in CLA group (P = 0.004). Operative time was 47.0 SILA compared to 49.5 minutes CLA (P = 0.269). Of SILA cases, 55.8% were simple appendicitis, while 53.3% of the CLA cases were simple (P = 0.857). Regular diet was resumed after 1.7 days in the SILA group, 1.1 days in CLA (P = 0.018). Length of stay was 2.9 days for SILA, 2.4 days for CLA (P = 0.144). Seven children required hospital readmission, 5 SILA and 2 CLA (P = 0.244). Five of the children who returned had intra-abdominal abscesses, of whom 4 had SILA. There was no difference in cost. CONCLUSIONS: The operative techniques had similar outcomes and operative times. There was a trend toward more intra-abdominal abscesses in the SILA group. Further study and longer follow up is needed to determine if there is an advantage to one laparoscopic approach over another.
Assuntos
Abscesso Abdominal/epidemiologia , Apendicectomia/efeitos adversos , Apendicite/cirurgia , Laparoscopia/efeitos adversos , Dor Pós-Operatória/epidemiologia , Abscesso Abdominal/economia , Abscesso Abdominal/etiologia , Adolescente , Apendicectomia/economia , Apendicectomia/métodos , Apendicite/economia , Criança , Pré-Escolar , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Lactente , Laparoscopia/economia , Laparoscopia/métodos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. METHODS: Patients of 8 years and older undergoing appendectomy for acute complex appendicitis - defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess - are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at É 0.025). Both per-protocol and intention-to-treat analyses will be performed. DISCUSSION: This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. TRIAL REGISTRATION: Dutch Trial Register, NTR6128 . Registered on 20 December 2016.
Assuntos
Abscesso Abdominal/prevenção & controle , Antibacterianos/administração & dosagem , Apendicectomia , Apendicite/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Abscesso Abdominal/economia , Abscesso Abdominal/microbiologia , Abscesso Abdominal/mortalidade , Administração Intravenosa , Antibacterianos/efeitos adversos , Antibacterianos/economia , Apendicectomia/efeitos adversos , Apendicectomia/economia , Apendicectomia/mortalidade , Apendicite/economia , Apendicite/microbiologia , Apendicite/mortalidade , Ensaios Clínicos Fase IV como Assunto , Análise Custo-Benefício , Esquema de Medicação , Custos de Medicamentos , Estudos de Equivalência como Asunto , Feminino , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Estudos Multicêntricos como Assunto , Países Baixos , Estudos Prospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Contrast-enhanced CT remains the first-line imaging for evaluating postoperative abscess (POA) after appendicitis. Given concerns of ionizing radiation use in children, we began utilizing quick MRI to evaluate POA and summarize our findings in this study. MATERIALS AND METHODS: Children imaged with quick MRI from 2015 to 2017 were compared to children evaluated with CT from 2012 to 2014 using an age and weight matched case-control model. Radiation exposure, size and number of abscesses, length of exam, drain placement, and patient outcomes were compared. RESULTS: There was no difference in age or weight (p>0.60) between children evaluated with quick MRI (n=16) and CT (n=16). Mean imaging time was longer (18.2±8.5min) for MRI (p<0.001), but there was no difference in time from imaging order to drain placement (p=0.969). No children required sedation or had non-diagnostic imaging. There were no differences in abscess volume (p=0.346) or drain placement (p=0.332). Thirty-day follow-up showed no difference in readmissions (p=0.551) and no missed abscesses. Quick MRI reduced imaging charges to $1871 from $5650 with CT. CONCLUSION: Quick MRI demonstrated equivalent outcomes to CT in terms of POA detection, drain placement, and 30-day complications suggesting that MRI provides an equally effective, less expensive, and non-radiation modality for the identification of POA. TYPE OF STUDY: Retrospective Case-Control Study. LEVEL OF EVIDENCE: Level III.
Assuntos
Abscesso Abdominal/diagnóstico por imagem , Apendicectomia , Apendicite/cirurgia , Análise Custo-Benefício , Imageamento por Ressonância Magnética/economia , Complicações Pós-Operatórias/diagnóstico por imagem , Tomografia Computadorizada por Raios X/economia , Abscesso Abdominal/economia , Abscesso Abdominal/etiologia , Doença Aguda , Adolescente , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Imageamento por Ressonância Magnética/métodos , Masculino , Análise por Pareamento , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , WisconsinRESUMO
BACKGROUND: Appendicitis is a common surgical emergency in pediatric patients, and broad-spectrum antibiotic therapy is warranted in their care. A simplified once-daily regimen of ceftriaxone and metronidazole (CTX plus MTZ) is cost effective in perforated patients. The goal of this evaluation is to compare a historic regimen of cefoxitin (CFX) in nonperforated cases and ertapenem (ERT) in perforated and abscessed cases with CTX plus MTZ for all cases in terms of efficacy and cost. METHODS: A retrospective review compared outcomes of nonperforated, perforated, and abscessed cases who received the historic regimen or CTX plus MTZ. Length of stay, time to afebrile, time to full feeds, postoperative abscess, and wound infection rates, inpatient readmissions, and antibiotic costs were evaluated. RESULTS: There were a total of 841 cases reviewed (494 nonperforated, 247 perforated, and 100 abscessed). Overall, the CTX plus MTZ group had a shorter time to afebrile (P < .001). Treatment groups did not differ in length of stay. Postoperative abscess rates were similar between groups (4.1% vs 3.3%, not significant). Other postoperative complications were similar between groups. Total antibiotic cost savings were over $110 000 during the study period (from November 2010 to June 2013). CONCLUSIONS: Both CFX and/or ERT and CTX plus MTZ result in low abscess and complication rates, suggesting both are effective strategies. Treatment with CTX plus MTZ results in a shorter time to afebrile, while also providing significant antibiotic cost savings. Ceftriaxone plus MTZ is a streamlined, cost-effective regimen in the treatment of nonperforated, perforated, and abscessed appendicitis.
Assuntos
Apendicite/tratamento farmacológico , Cefoxitina/uso terapêutico , Ceftriaxona/uso terapêutico , Metronidazol/uso terapêutico , beta-Lactamas/uso terapêutico , Abscesso Abdominal/tratamento farmacológico , Abscesso Abdominal/economia , Adolescente , Apendicectomia , Apendicite/economia , Cefoxitina/economia , Ceftriaxona/economia , Criança , Pré-Escolar , Redução de Custos/estatística & dados numéricos , Análise Custo-Benefício/economia , Esquema de Medicação , Substituição de Medicamentos , Quimioterapia Combinada/economia , Ertapenem , Feminino , Humanos , Lactente , Laparoscopia , Masculino , Metronidazol/economia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem , beta-Lactamas/economiaRESUMO
BACKGROUND AND OBJECTIVES: Pasireotide decreases leak rates after pancreatic resection, though significant drug cost may be prohibitive. We conducted a cost-effectiveness analysis to determine whether prophylactic pasireotide possesses a reasonable cost profile. METHODS: A cost-effectiveness model compared pasireotide administration after pancreatic resection versus usual care, populated by probabilities of clinical outcomes from a randomized trial and hospital costs (2013 US$) from a university pancreatic disease center. Sensitivity analyses were performed to identify influential clinical components of the model. RESULTS: With the cost of pasireotide included, per patient costs of pancreatectomy, including those for readmission, were lower in the intervention arm (41,769 versus 42,159$; net savings of 390$, or 1%). This was associated with a 56% reduction in pancreatic fistula/pancreatic leak/abscess (PF/PL/A; 21.9-9.2%). Pasireotide cost would need to increase by over 15.4% to make the intervention strategy more costly than usual care. Sensitivity analyses exploring variability of key model inputs demonstrated that the three strongest drivers of cost were (i) cost of pasireotide; (ii) probability of readmission; and (iii) probability of PF/PL/A. CONCLUSIONS: Prophylactic pasireotide administration following pancreatectomy is cost savings, reducing expensive post-operative sequealae (major complications and readmissions). Pasireotide should be utilized as a cost-saving measure in pancreatic resection. J. Surg. Oncol. 2016;113:784-788. © 2016 Wiley Periodicals, Inc.
Assuntos
Análise Custo-Benefício , Hormônios/uso terapêutico , Custos Hospitalares , Pancreatectomia , Complicações Pós-Operatórias/prevenção & controle , Somatostatina/análogos & derivados , Abscesso Abdominal/economia , Abscesso Abdominal/epidemiologia , Abscesso Abdominal/etiologia , Abscesso Abdominal/prevenção & controle , Fístula Anastomótica/economia , Fístula Anastomótica/epidemiologia , Fístula Anastomótica/prevenção & controle , Redução de Custos , Árvores de Decisões , Esquema de Medicação , Hormônios/economia , Humanos , Modelos Econômicos , Ohio , Fístula Pancreática/economia , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Fístula Pancreática/prevenção & controle , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Somatostatina/economia , Somatostatina/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Abdominal abscesses are a common complication in Crohn's disease (CD). Percutaneous drainage of such abscesses has become increasingly popular and may deliver outcomes comparable to surgical treatment; however, such comparative data are limited from single-center studies. There have been no nationally representative studies comparing different treatment modalities for abdominal abscesses. METHODS: We identified all adult CD-related non-elective hospitalizations from the Nationwide Inpatient Sample 2007 that were complicated by an intra-abdominal abscess. Treatment modality was categorized into 3 strata-medical treatment alone, percutaneous drainage, and surgery. We analyzed the nationwide patterns in the treatment and outcomes of each treatment modality and examined for patient demographic, disease, or hospital-related disparities in treatment and outcome. RESULTS: There were an estimated 3,296 hospitalizations for abdominal abscesses in patients with CD. Approximately 39 % were treated by medical treatment alone, 29 % with percutaneous drainage, and 32 % with surgery with a significant increase in the use of percutaneous drainage since 1998 (7 %). Comorbidity burden, admission to a teaching hospital, and complicated Crohn's disease (fistulae, stricture) were associated with non-medical treatment. Use of percutaneous drainage was more common in teaching hospitals. Mean time to percutaneous drainage and surgical treatment were 4.6 and 3.3 days, respectively, and early intervention was associated with significantly shorter hospitalization. CONCLUSIONS: We describe the nationwide pattern in the treatment of abdominal abscesses and demonstrate an increase in the use of percutaneous drainage for the treatment of this subgroup. Early treatment intervention was predictive of shorter hospitalization.
Assuntos
Abscesso Abdominal/terapia , Doença de Crohn/complicações , Padrões de Prática Médica/tendências , Abscesso Abdominal/economia , Abscesso Abdominal/etiologia , Adulto , Doença de Crohn/economia , Bases de Dados Factuais , Drenagem/economia , Drenagem/métodos , Drenagem/estatística & dados numéricos , Drenagem/tendências , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Laparotomia/economia , Laparotomia/estatística & dados numéricos , Laparotomia/tendências , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Pontuação de Propensão , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND/PURPOSE: We compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children. METHODS: From June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy. RESULTS: Patients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies. CONCLUSIONS: Patients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.
Assuntos
Apendicectomia/economia , Apendicite/economia , Efeitos Psicossociais da Doença , Gerenciamento Clínico , Custos Hospitalares/estatística & dados numéricos , Hospitais Pediátricos/economia , Hospitais Urbanos/economia , Abscesso Abdominal/tratamento farmacológico , Abscesso Abdominal/economia , Abscesso Abdominal/cirurgia , Absenteísmo , Adolescente , Adulto , Antibacterianos/uso terapêutico , Apendicectomia/estatística & dados numéricos , Apendicite/tratamento farmacológico , Apendicite/cirurgia , Boston , Cuidadores/economia , Criança , Pré-Escolar , Drenagem/economia , Drenagem/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Estudos ProspectivosRESUMO
PURPOSE: The aim of this study was to evaluate clinical outcomes, quality-adjusted life-years, and the cost-effectiveness gained from percutaneous drainage followed by elective surgery vs. initial surgery for abdominopelvic abscesses related to Crohn's disease. METHODS: All consecutive patients with spontaneous Crohn's disease-related abdominopelvic abscess from 1997 to 2007 were reviewed. The authors excluded postoperative and perirectal abscesses. Decision analysis during one year of patient life was used to calculate quality-adjusted life-years and the cost-effectiveness of each strategy. RESULTS: Of 94 patients, 48 (51 percent) were initially approached with percutaneous drainage. Thirty-one (65 percent) had successful percutaneous drainage and delayed elective surgery. The factors significantly associated with percutaneous drainage failure were steroid use, colonic phenotype, and multiple or multilocular abscesses. The initial treatment was surgery in the remaining 46 (49 percent) patients. The initial approach with percutaneous drainage gave higher quality-adjusted life-years and was more cost-effective than initial surgery. Percutaneous drainage was the optimal strategy in spite of the risk of failure and septic complications within the plausible range. CONCLUSIONS: Percutaneous drainage failure is associated with steroid use, colonic phenotype, and multiple or multilocular abscesses. When feasible, percutaneous drainage is the most effective strategy from the perspective of patients and third-party payers.
Assuntos
Abscesso Abdominal/economia , Abscesso Abdominal/terapia , Doença de Crohn/complicações , Avaliação de Processos e Resultados em Cuidados de Saúde , Abscesso Abdominal/etiologia , Adolescente , Corticosteroides/administração & dosagem , Corticosteroides/efeitos adversos , Adulto , Idoso , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Drenagem/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fenótipo , Anos de Vida Ajustados por Qualidade de VidaRESUMO
BACKGROUND: The purpose of this study was to report how conservative treatment with interval appendectomy (IA) of ruptured appendicitis with localized abscess or phlegmon affects the outcome of patients. PATIENTS AND METHODS: From January 2001 to December 2005, 121 patients with ruptured appendicitis with localized abscess or phlegmon were treated in our hospital. 104 patients underwent appendectomy (Group A); 17 patients underwent antibiotic treatment with interval appendectomy (Group B). The clinical characteristics (age and sex), laboratory data, mean time to surgery, operative time, complications, hospital days and cost of hospitalization were recorded. RESULTS: The sex, age, white blood cell count (WBC), body temperature, operation time, length of stay after surgery, first flatus, oral feeding, passage of stools, cost and overall complications (including wound infection, wound disruption, intra-abdominal abscess and enterocutaneous fistula) were not significantly different between the two groups. However, the length of stay after diagnosis established of group B was significantly longer in group B than in group A. CONCLUSION: Conservative treatment with IA is a safe and effective method to treat perforated appendicitis with localized abscess and phlegmon, but the recovery time may be longer and also the hospital stay (since diagnosis established). Thus this method is not cost-saving.
Assuntos
Antibacterianos/administração & dosagem , Apendicectomia/métodos , Apendicite/cirurgia , Emergências , Laparoscopia , Abscesso Abdominal/diagnóstico , Abscesso Abdominal/economia , Abscesso Abdominal/cirurgia , Adulto , Antibacterianos/economia , Apendicectomia/economia , Apendicite/diagnóstico , Apendicite/economia , Celulite (Flegmão)/diagnóstico , Celulite (Flegmão)/economia , Celulite (Flegmão)/cirurgia , Análise Custo-Benefício , Emergências/economia , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Readmissão do Paciente/economia , Peritonite/diagnóstico , Peritonite/economia , Peritonite/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/economia , Estudos Retrospectivos , TaiwanRESUMO
BACKGROUND: Duration of intravenous (IV) treatment, surgical/radiologic interventions for infection control, and hospital length of stay (LOS) are important cost considerations in complicated intra-abdominal infections (cIAIs). METHODS: Data were pooled from two multinational, double-blind studies conducted in hospitalized adults with cIAIs who were randomized (1:1) to receive tigecycline (100 mg IV initial dose then 50 mg IV every 12 h) or imipenem-cilastatin (500 mg IV every 6 h) for 5 to 14 days in order to assess tigecycline safety and efficacy. This report focuses on developing predictors of cure and health care resource utilization, including the need for repeat surgical/radiologic interventions, duration of IV antibiotic therapy, and hospital LOS. Multiple regression models were applied for each of the above outcomes, incorporating both baseline and on-treatment potential covariates. Logistic modeling was used for categorical outcomes (cure; repeat surgical/radiologic interventions) and least squares modeling for continuous outcomes (duration of IV antibiotic therapy; LOS). Stepwise selection was used to retain only those predictors found to be significant (p < 0.05) independent risk factors. RESULTS: The most common causative pathogen was Escherichia coli (63.0%), with 63.3% of the patients exhibiting polymicrobial infections. The most common cIAI diagnosis was complicated appendicitis (51.9%). Lack of clinical cure (+ 6.1 days; p < 0.0001), perforation of the intestine (+3.7 days; p < 0.0001), an Acute Physiology and Chronic Health Evaluation (APACHE) score >15 (+3.1 days; p=0.039), abnormal plasma sodium concentration (+3.7 days; p=0.026), and repeat surgical/radiologic intervention (+2.2 days; p=0.0097) were identified as key risk factors for longer LOS. Inadequate source control was associated with reduced odds of cure, longer IV treatment duration (+1.5 days; p=0.007), and longer LOS. The treatment groups did not differ in terms of LOS, IV treatment duration, or clinical cure. CONCLUSION: Tigecycline was similar to imipenem-cilastatin in terms of both efficacy and health resource utilization. Risk factors identified in this study for both outcome measures are offered as support for guiding clinical practice.