Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial.

BACKGROUND: A pilot randomized controlled trial (RCT) conducted in children (2-17 â€‹y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs. METHODS: We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models. RESULTS: We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379). CONCLUSIONS: PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

Costs associated with postoperative intra-abdominal abscess in pediatric perforated appendicitis: A retrospective cohort study.

BACKGROUND: Intra-abdominal abscess, the most common complication after perforated appendicitis, is associated with considerable economic burden. However, costs of intra-abdominal abscesses in children are unknown. We aimed to evaluate resource utilization and costs attributable to intra-abdominal abscess in pediatric perforated appendicitis. METHODS: A single-center retrospective analysis was performed of children (<18 years) who underwent appendectomy for perforated appendicitis (2013-2019). Hospital costs incurred during the index admission and within 30 postoperative days were obtained from the hospital accounting system and inflated to 2019 USD. Generalized linear models were used to determine excess resource utilization and costs attributable to intra-abdominal abscess after adjusting for confounders. RESULTS: Of 763 patients, 153 (20%) developed intra-abdominal abscesses. Eighty-one patients with intra-abdominal abscesses (53%) underwent percutaneous abscess drainage. Intra-abdominal abscess was independently associated with a nearly 8-fold increased risk of 30-day readmission (adjusted risk ratio, 7.8 [95% confidence interval, 4.7-13.0]). Patients who developed an intra-abdominal abscess required 6.1 excess hospital bed days compared to patients without intra-abdominal abscess (95% confidence interval, 5.3-7.0). Adjusted mean hospital costs for patients with intra-abdominal abscess totaled $27,394 (95% confidence interval, $25,688-$29,101) versus $15,586 (95% confidence interval, $15,102-$16,069) for patients without intra-abdominal abscess. Intra-abdominal abscess was associated with an incremental cost of $11,809 (95% confidence interval, $10,029-$13,588). Hospital room costs accounted for 66% of excess costs. CONCLUSION: Postoperative intra-abdominal abscess nearly doubled pediatric perforated appendicitis costs, primarily due to more hospital bed days and associated room costs. Intra-abdominal abscesses resulted in estimated excess costs of $1.8 million during the study period. Even small reductions in intra-abdominal abscess rates or hospital bed days could yield substantial health care savings.

Improving metronidazole prescription practices in surgical patients: a full cycle audit.

INTRODUCTION: Metronidazole is commonly prescribed for intra-abdominal infections. Oral metronidazole has high bioavailability (>95%) and intravenous metronidazole should be reserved for patients not suitable for oral preparations. METHODS AND MATERIALS: This full cycle audit evaluated the type of metronidazole preparation prescribed in adult emergency surgical patients requiring first-line empirical antimicrobial therapy for intra-abdominal infections. The criterion for audit was the proportion of patients who were prescribed intravenous metronidazole when the oral route was available. The first cycle included all consecutive eligible patients between 20 April and 14 May 2020. After an intervention phase educating prescribers about the similar pharmacokinetic properties of oral and intravenous metronidazole, clinical practice was reaudited between 22 June and 16 July 2020. Data were collected by case note and drug chart review. RESULTS: A total of 54 patients were included in the first audit cycle. Of these, 11 (20.4%) were prescribed oral metronidazole and 43 (79.6%) were prescribed intravenous metronidazole. In the majority of cases (35/43, 81.4%), intravenous metronidazole was prescribed in the absence of clear contraindications to the oral preparation. Of the 61 patients included in the reaudit cycle, 23 (37.7%) were prescribed oral metronidazole and 38 (62.3%) were prescribed intravenous metronidazole. The proportion of patients prescribed intravenous metronidazole despite being suitable for oral preparation decreased from 81.4% in the first cycle to 34.2% (13/38) in the reaudit cycle (risk ratio 0.42, 95% CI: 0.26 to 0.67, p<0.0001). Prescribing oral metronidazole when suitable saved up to £10.53/day per patient. CONCLUSION: This full cycle audit led to a significant improvement in the use of oral metronidazole in suitable patients, as well as a considerable reduction in healthcare costs.

Single site versus conventional laparoscopic appendectomy: some pain for no gain?

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.

Post-operative abdominal infections: epidemiology, operational definitions, and outcomes.

Postoperative abdominal infections are an important and heterogeneous health challenge in intensive care units (ICU) and encompass postoperative infectious processes developing within the abdominal cavity that may be caused by either bacterial or fungal pathogens. In this narrative review, we discuss postoperative bacterial and fungal abdominal infections, covering also multidrug-resistant (MDR) pathogens. We also cover clinically preeminent aspects such as the definition of postoperative abdominal infections, which still remains difficult owing to their heterogeneity in patient characteristics, clinical presentation, ecology and antimicrobial treatment. With regard to treatment, modifiable factors such as source control and antimicrobial therapy play a key role in influencing the prognosis of postoperative abdominal infections, but several conditions may hamper their correct application; thus efforts should necessarily be devoted towards improving their appropriateness and timing. Hot topics regarding the characteristics and management of postoperative abdominal infections are discussed in this narrative review.

Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: A systematic review.

INTRODUCTION: In ovarian cancer (OC), survival benefit in case of complete cytoreduction with absence of residual tumor has been clearly demonstrated; however, it often requires extensive surgery. Particularly, pancreatic resection during cytoreduction, may severely impact perioperative morbidity and mortality. OBJECTIVES: The aim of this systematic review is to evaluate complication rates and related optimal management of ovarian cancer patients undergoing pancreatic resection as part of cytoreductive surgery. METHODS: Literature was searched for relevant records reporting distal pancreatectomy for advanced ovarian cancer. All cohorts were rated for quality. We focused our analysis on complications related to pancreatic surgical procedures evaluating the following outcomes: pancreatic fistula (PF), abdominal abscess, pancreatitis, iatrogenic diabetes, hemorrhage from splenic vessels and pancreatic-surgery-related mortality. RESULTS: The most frequent complication reported was PF. Similar rates of PF were reported after hand-sewn (20%) or stapled closure (24%). Continued drainage is the standard treatment, and often, the leak can be managed conservatively and does not require re-intervention. Abdominal abscess is the second most frequent complication and generally follows a non-adequately drained PF and often required re-laparotomy. Pancreatitis is a rare event that could be treated conservatively; however, death can occur in case of necrotic evolution. Cases of post-operative hemorrhage due to splenic vessel bleeding have been described and represent an emergency. CONCLUSIONS: Knowledge of pancreatic surgery and management of possible complications ought to be present in the oncologic-gynecologic armamentarium. All patients should be referred to specialized, dedicated, tertiary centers in order to reduce, promptly recognize and optimally manage complications.

[Comparación entre ligadura con lazo hemostático y engrapadora mecánica lineal para el cierre de base apendicular]. / Comparison between endoloop and linear mechanical stapler for the appendicular stump closure.

INTRODUCCIÓN: En las últimas décadas es creciente el abordaje por mínima invasión de patologías abdominales debido a sus beneficios evidentes. El cuadro apendicular es la principal emergencia quirúrgica, con diferentes métodos del cierre de la base apendicular. En este artículo comparamos dicho cierre con engrapadora lineal o ligadura con lazo hemostático, para analizar la frecuencia de complicaciones como absceso, dehiscencia y seroma. MÉTODO: Se realizó un estudio prospectivo, observacional y descriptivo, con un total de 703 procedimientos, empleando en 567 pacientes ligadura con lazo hemostático y en 136 engrapadora lineal, operados por los mismos cirujano y equipo quirúrgico, con curva de aprendizaje concluida. RESULTADOS: Las complicaciones referidas en el presente estudio son absceso (n = 5), dehiscencia (n = 3) y seroma (n = 3). De acuerdo con las fases de la patología apendicular: fase 1 o apéndice congestivo, no presentaron complicaciones; fase 2 o supurativo, se reportó un caso de dehiscencia de herida quirúrgica con el uso de ligadura con lazo hemostático; fase 3 o necrótico, se reportó un caso de seroma en un paciente tratado con ligadura con lazo hemostático; y fase 4 o perforado, se encuentra diferencia significativa en el caso de abscesos, reportando cinco con el uso de ligadura con lazo hemostático y ninguno con engrapadora lineal. CONCLUSIONES: En nuestro estudio no existe diferencia estadísticamente significativa entre el uso de engrapadora lineal o ligadura con lazo hemostático en las fases apendiculares 1-3; en la fase 4 es de utilidad significativa el uso de engrapadora lineal ante la incidencia de abscesos. INTRODUCTION: In the last decades, the approach by minimally invasive surgery of abdominal pathologies is growing due to its evident benefits; the appendicular cases being the main surgical emergency, with different methods of closing the appendicular base. In this article, we compared the appendicular base closure with linear stapler and endoloop, to analyze the frequency of complications such as abscess, dehiscence and seroma. METHOD: A prospective, observational and descriptive study was conducted, with a total of 703 procedures, using 567 endoloop patients and 136 linear stapler, operated by the same surgeon and surgical team, with a completed learning curve. RESULTS: The complications referred in the present study were patients with abscess (n = 5), dehiscence (n = 3) and seroma (n = 3). According to the phases of the appendiceal pathology: phase 1 or congestive appendix did not present complications; phase 2 or suppurative was reported one case of surgical wound dehiscence in the use of endoloop; in phase 3 or necrotic, one case of seroma was reported in a patient treated with endoloop; while in phase 4 or perforated there is a significant difference in the case of abscesses, reporting five in the use of endoloop and none in the case of a linear stapler. CONCLUSIONS: In our study there is no statistically significant difference between the use of linear stapler or endoloop in the early appendicular phases; being of significant utility in Phase 4 the use of linear stapler for the incidence of abscesses.

Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis.

Importance: The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals. Objective: To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis. Design: This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children's hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014. Main Outcomes and Measures: Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals. Results: A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P < .001), and higher hospital cost (rate ratio, 1.35; 95% CI, 1.19-1.53; P < .001). Significant differences were found among different combinations of intraoperative findings for all outcomes, including a 3.6-fold difference in rates of surgical site infection (range, 7.5% for fecalith alone to 27.2% for all 4 findings; P = .002), a 2.6-fold difference in revisit rates (range, 8.9% for exudate alone to 22.9% for all 4 findings; P = .001), a 2.2-fold difference in length of stay (range, 4.0 days for exudate alone to 8.9 days for all 4 findings; P < .001), and a 2.4-fold difference in mean cumulative cost (range, $13 296 for exudate alone to $32 282 for all 4 findings; P < .001). Conclusions and Relevance: More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource use. Severity adjustment may be needed to ensure fair reimbursement and comparative performance reporting, particularly at hospitals treating underserved populations where more severe presentations are common.

Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial.

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 ɑ 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.

The cost effectiveness and utility of a "quick MRI" for the evaluation of intra-abdominal abscess after acute appendicitis in the pediatric patient population.

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.

Early appendectomy reduces costs in children with perforated appendicitis.

BACKGROUND: Perforated appendicitis can be managed with early appendectomy, or nonoperative management followed by interval appendectomy. We aimed to identify the strategy with the lowest health care utilization and cost. METHODS: We retrospectively reviewed the medical records of all children ≤18 years old with perforated appendicitis admitted to a single institution between January 2009 and March 2016. After excluding immunosuppressed patients and transfers from outside hospitals, we grouped the remaining patients by early or interval appendectomy. Cost accounting data were obtained from our institutional database. The primary outcome was total hospital cost over 2 y from initial admission for appendicitis. Other outcomes analyzed included initial admission costs, number of admissions, emergency room and clinic visits, percutaneous procedures, cross-sectional and overall imaging studies, and length of stay. RESULTS: A total of 203 children with perforated appendicitis were identified. After exclusion of immunosuppressed patients and outside hospital transfers, 94 patients were included in the study. Thirty-nine underwent early appendectomy and 55 initial nonoperative management; of these, 54 underwent elective interval appendectomy. Five of 55 patients (9%) failed initial nonoperative management and required earlier-than-planned appendectomy. Total cost over 2 y was significantly lower with early appendectomy than initial nonoperative management ($19,300 ± 14,300 versus $26,000 ± 17,500; P = 0.05). Early appendectomy resulted in fewer hospital admissions, clinic visits, invasive procedures, and imaging studies. CONCLUSIONS: Early appendectomy results in lower hospital costs and less health care utilization compared with initial nonoperative management with elective interval appendectomy. A prospective study will shed more light on this question and can assess the role of nonoperative management without interval appendectomy in children with perforated appendicitis.

Measuring the Value of a Clinical Practice Guideline for Children With Perforated Appendicitis.

OBJECTIVE: To determine the incremental cost-effectiveness of a clinical practice guideline (CPG) compared with "usual care" for treatment of perforated appendicitis in children. Secondary objective was to compare cost analyses using hospital accounting system data versus data in the Pediatric Health Information System (PHIS). BACKGROUND: Value-based surgical care (outcomes relative to costs) is frequently touted, but outcomes and costs are rarely measured together. METHODS: During an 18-month period, 122 children with perforated appendicitis at a tertiary referral children's hospital were treated using an evidence-based CPG. Clinical outcomes and costs for the CPG cohort were compared with patients in the 30-month period before CPG implementation (n = 191 children). RESULTS: With CPG-directed care, intra-abdominal abscess rate decreased from 0.24 to 0.10 (adjusted risk ratio 0.44, 95% confidence interval [CI] 0.26-0.75). The rate of any adverse event decreased from 0.30 to 0.23 (adjusted risk ratio 0.82, 95% CI 0.58-1.17). Mean total hospital costs per patient (hospital accounting system) decreased from $16,466 to $10,528 (adjusted absolute difference-$5451, 95% CI -$7755 to -$3147), leading to estimated adjusted total savings of $665,022 during the study period. Costs obtained from the PHIS database also showed reduction with CPG-directed care (-$6669, 95% CI -$8949 to -$4389 per patient). In Bayesian cost-effectiveness analyses, likelihood that CPG was the dominant strategy was 91%. CONCLUSIONS: An evidence-based CPG increased the value of surgical care for children with perforated appendicitis by improving outcomes and lowering costs. Hospital cost accounting data and pre-existing cost data within the PHIS database provided similar results.

Once-Daily Ceftriaxone Plus Metronidazole Versus Ertapenem and/or Cefoxitin for Pediatric Appendicitis.

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.

Clinical assessment of children with renal abscesses presenting to the pediatric emergency department.

BACKGROUND: Renal abscesses are relatively uncommon in children but may result in prolonged hospital stays and life-threatening events. We undertook this study to analyze the clinical spectrum of renal abscesses in children admitted to the pediatric emergency department (ED) and to find helpful clinical characteristics that can potentially aid emergency physicians for detecting renal abscesses in children earlier. METHODS: From 2004 to 2011, we retrospectively analyzed 17 patients, aged 18 years or younger, with a definite diagnosis of renal abscess admitted to the ED. The following clinical information was studied: demographics, clinical presentation, laboratory testing, microbiology, imaging studies, treatment modalities, complications, and long-term outcomes. We analyzed these variables among other potential predisposing factors. RESULTS: During the 8-year study period, 17 patients (7 males and 10 females; mean age, 6.1 ± 4.5 years) were diagnosed with renal abscesses on the basis of ultrasonography and computed tomography findings. The 2 most common presenting symptoms were fever and flank pain (100% and 70.6%, respectively). All of the patients presented with leukocytosis and elevated C-reactive protein (CRP) levels. Organisms cultured from urine or from the abscess were identified in 11 (64.7%) patients, and Escherichia coli was the most common organism cultured. All patients were treated with broad-spectrum intravenous antibiotics with the exception of 4 children who also required additional percutaneous drainage of the abscess. CONCLUSIONS: Renal abscesses are relatively rare in children. We suggest that primary care physicians should keep this disease in mind especially when children present with triad symptoms (fever, nausea/vomiting, and flank pain), pyuria, significant leukocytosis, and elevated CRP levels. However, aggressive percutaneous drainage may not need to be routinely performed in children with renal abscesses.

[Sigmoid colon diverticulitis : Treatment modalities 2011-2013]. / Sigmadivertikulitis : Behandlungsmodalitäten 2011 bis 2013.

INTRODUCTION: Diverticulosis is a relevant disease in Germany with a prevalence of over 60 % in patients aged ≥70 years. The S2k guidelines for the treatment of diverticulosis were recently published. Systematic epidemiological data on treatment modalities do not exist. METHODS: Analysis of in-hospital treatment modalities for diverticulosis based on data from the Federal Office of Statistics. RESULTS: Approximately 130,000 inpatient cases of diverticulosis are treated in Germany per year. Approximately 25 % undergo surgery and of these slightly under 50 % (12,000 procedures) are carried out by laparoscopy. The complication rates are 18 % in a best case scenario and up to 85 % in a worst case scenario. A stage-adjusted classification of treatment modalities based on data from the Federal Office of Statistics is currently practically impossible. CONCLUSION: To enable stage-adjusted epidemiological analysis of diverticulosis, a standardized and transparent documentation system enabling systematic analysis is necessary, which does not currently exist (e. g. ICD 10 coding); moreover, information on conservative and interventional treatment options are not included in the operations and procedures key (OPS) coding system.

Prophylactic pasireotide administration following pancreatic resection reduces cost while improving outcomes.

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.

Trends in Use of Percutaneous Versus Open Surgical Drainage of Abdominal Abscesses.

PURPOSE: To compare recent trends in the use of percutaneous and surgical approaches to treating abdominal abscesses in a large population. METHODS: The nationwide Medicare Physician/Supplier Procedure Summary Master Files for 2001 through 2013 were searched. Current Procedural Terminology-4 codes were selected for the four types of abdominal abscesses that had distinct codes for both open surgical and percutaneous drainage-appendiceal, peritoneal, subphrenic, and liver. Medicare specialty codes were used to determine if the procedures were performed by radiologists or other nonradiologist physicians. Trends in use of the two approaches were compared. RESULTS: In 2001, a total of 14,068 abdominal abscesses were drained percutaneously. This volume increased progressively every year thereafter, reaching 28,486 in 2013 (+102%). Open surgical drainage volume was 8,146 in 2001, decreasing progressively to 6,397 in 2013 (-21%). In 2001, 63% of all abdominal abscesses had been drained percutaneously; by 2013, this figure had risen to 82%. In 2001, radiologists had performed 90% of all percutaneous abdominal abscess drainages; this percentage share increased to 97% in 2013. Of all abdominal abscesses treated in 2013 in Medicare patients, 79% were treated by radiologists. CONCLUSIONS: Use of percutaneous drainage of abdominal abscesses has steadily increased, whereas use of open surgical drainage has declined. The vast majority of these abscesses are now treated percutaneously. Radiologists are a strong majority of those performing the procedures. Although this database does not provide information on outcomes, percutaneous drainage is another good example of radiology-related value.

Immunoenhancing enteral and parenteral nutrition for gastrointestinal surgery: a multiple-treatments meta-analysis.

OBJECTIVE: Frequentist meta-analyses have demonstrated that immunoenhancing parenteral nutrition (IMPN) and enteral nutrition (IMEN) reduce the incidence of infection and shorten the length of hospital stays compared with standard parenteral nutrition (SPN) and enteral nutrition (SEN). The aim of this study was to evaluate which kind of nutrition-SPN, SEN, IMPN, and IMEN-is most efficacious for reducing the incidence of complications after gastrointestinal surgery. METHODS: An English literature search was carried out for randomized controlled trials published from January 1990 to February 2013 that evaluated the clinical efficacy of 4 kinds of nutrition after gastrointestinal surgery. A Bayesian framework was used to calculate the odds ratio between each treatment and the rank order. RESULTS: Seventy-four studies (7572 participants) were included. According to the surface below the cumulative ranking curve (SUCRA) ordering from the best to the worst, IMEN was ranked first for reducing the incidence of 7 complications-any infection (SUCRA = 0.86), overall complication (SUCRA = 0.88), mortality (SUCRA = 0.81), wound infection (SUCRA = 0.79), intra-abdominal abscess (SUCRA = 0.98), anastomotic leak (SUCRA = 0.79), and sepsis (SUCRA = 0.92). Also, IMEN was ranked second for pneumonia and urinary tract infection. IMPN was ranked first for pneumonia (SUCRA = 0.81) and urinary tract infection (SUCRA = 0.86), third for mortality, and fourth for both intra-abdominal abscess and anastomotic leak. SPN showed an inferior efficacy for almost all outcomes. CONCLUSIONS: This study suggests that IMEN outperformed other nutrition types for reducing complications and IMEN should be considered the best available option.

Two different methods for appendiceal stump closure: metal clip and Hem-o-lok clip.

INTRODUCTION: Closure of the appendiceal stump (CAS) is the most crucial part of appendectomy procedures because most of the complications occur by a leak of the stump. The aim of this retrospective clinical study is to emphasize two different methods (metal clip and Hem-o-lok(®) [Teleflex Medical, Research Triangle Park, NC] clip) for CAS. MATERIALS AND METHODS: The cases were divided into two subgroups according to the type of CAS. Subgroups were compared with each other according to age, intraabdominal abscess formation, operation duration, and complication rate. RESULTS: No intraoperative complications were seen in either subgroup. There were 22 postoperative complications in the metal clip subgroup (13 intraabdominal abscesses, 9 wound infections) and 8 postoperative complications in the Hem-o-lok clip subgroup (five intraabdominal abscesses, three wound infections). The cost of the closure was $7 for the metal clip group and $50 for the Hem-o-lok clip group. CONCLUSIONS: The use of Hem-o-lok clips and metal clip for CAS in laparoscopic appendectomy is a feasible, safe, and cost-effective procedure in patients with a mild to moderately inflamed appendix base of less than 10 mm in diameter.