Bowel obstruction following appendectomy: what is the true incidence?

INTRODUCTION: Appendicitis is a common problem that is typically treated with an appendectomy. Following abdominal surgery, adhesions may form and may cause a subsequent small bowel obstruction (SBO). The purpose of our study was to determine the rate of post-appendectomy SBO in an adult population, and to observe any difference in SBO rates between open versus laparoscopic appendectomies. METHODS: All patients who underwent an appendectomy at an adult hospital in the Calgary Health Region between 1999 and 2002 were identified by using the administrative discharge database. Pathology and operative technique (laparoscopic, McBurney incision, midline laparotomy) were reviewed. Using those regional health numbers, any further admissions with a diagnostic code for bowel obstruction were identified. Medical charts (n = 1777) were reviewed to confirm the rate of post-appendectomy SBO. A logistic regression was performed to identify risk factors of post-appendectomy SBO and expressed as odds ratios (95% confidence interval). RESULTS: The overall SBO rate was 2.8% over an average 4.1-year follow-up period. The risk factors for developing SBO following appendectomy for appendicitis included, perforated appendicitis (odds ratio [OR] = 3.1, 95% confidence interval [CI]: 1.5-6.6), and midline incisions (OR = 5.4, 95% CI: 2.8-10.4). Those with pathology of cancer or chronic appendicitis conferred the greatest overall risk of SBO (OR = 7.4, 95% CI: 2.7-20.3). CONCLUSIONS: The rate of SBO following appendectomy in adults was 2.8%, or 0.0069 cases per person-year. The greatest risk factors for developing SBO were midline incision and nonappendicitis pathology. There is no statistically significant difference in SBO rates following laparoscopic appendectomy compared with open approaches.

Effect of ambient air pollution on the incidence of appendicitis.

BACKGROUND: The pathogenesis of appendicitis is unclear. We evaluated whether exposure to air pollution was associated with an increased incidence of appendicitis. METHODS: We identified 5191 adults who had been admitted to hospital with appendicitis between Apr. 1, 1999, and Dec. 31, 2006. The air pollutants studied were ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and suspended particulate matter of less than 10 micro and less than 2.5 micro in diameter. We estimated the odds of appendicitis relative to short-term increases in concentrations of selected pollutants, alone and in combination, after controlling for temperature and relative humidity as well as the effects of age, sex and season. RESULTS: An increase in the interquartile range of the 5-day average of ozone was associated with appendicitis (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.03-1.25). In summer (July-August), the effects were most pronounced for ozone (OR 1.32, 95% CI 1.10-1.57), sulfur dioxide (OR 1.30, 95% CI 1.03-1.63), nitrogen dioxide (OR 1.76, 95% CI 1.20-2.58), carbon monoxide (OR 1.35, 95% CI 1.01-1.80) and particulate matter less than 10 micro in diameter (OR 1.20, 95% CI 1.05-1.38). We observed a significant effect of the air pollutants in the summer months among men but not among women (e.g., OR for increase in the 5-day average of nitrogen dioxide 2.05, 95% CI 1.21-3.47, among men and 1.48, 95% CI 0.85-2.59, among women). The double-pollutant model of exposure to ozone and nitrogen dioxide in the summer months was associated with attenuation of the effects of ozone (OR 1.22, 95% CI 1.01-1.48) and nitrogen dioxide (OR 1.48, 95% CI 0.97-2.24). INTERPRETATION: Our findings suggest that some cases of appendicitis may be triggered by short-term exposure to air pollution. If these findings are confirmed, measures to improve air quality may help to decrease rates of appendicitis.

Comparison of stapled versus handsewn loop ileostomy closure: a meta-analysis.

The purpose of this study was to compare the rates of small bowel obstruction, anastomotic complications, and wound infections between stapled and handsewn closures of loop ileostomies. A literature search in Embase, PubMed, and Cochrane Database for Clinical Trials using search terms "closure," "loop ileostomy," and "stapled" was performed. All abstracts were reviewed to identify relevant articles, and their references were hand searched for additional studies. Six articles were identified for inclusion. Three independent reviewers extracted the following data: rates of small bowel obstruction, anastomotic complications, wound infection; length of hospital stay; and operative time. Data analysis was performed using Stata statistical software. Comparing stapled versus hand-sewn closures, there were no statistically significant differences in bowel obstruction (relative risk [RR] 0.69, 95% confidence interval [CI] 0.44 to 1.09), wound infection (RR 0.91, 95% CI 0.53 to 1.97), or anastomotic complication rates (RR 1.01, 95% CI 0.99 to 1.03). Two studies showed shorter operative times favoring stapled anastomoses. No difference was seen in length of stay. Current literature suggests no statistically significant differences between stapled and hand-sewn loop ileostomy closures, but there may be a trend favoring stapled closures with regard to lower small bowel obstruction rates and shorter operative time.

Client participation in managing social work service--an unfinished quest.

"Client participation" is a popular ideal and object of rhetorical commitment in social work service. But the much-touted potential of this concept requires careful and critical scrutiny. This article reports on a study of client-participation initiatives in the Hong Kong welfare sector. The study identified significant differences in the institutional structure ofclient-participation initiatives and their social dynamics between service units targeting elderly people or people with disabilities and those targeting a clientele with supposed moral or psychosocial failures. The findings suggest that client-participation mandates allowing sustained interaction with service users through regular membership in a structure for discussion are more effective than ad hoc measures with unstable participation, assuming that the goal is mutuality and trust in cooperative inquiry with service users. The findings also suggest that both a service provider's genuine belief in the primacy of the users' voice and a user's legitimate claim of experiential knowledge are imperative to realizing the potential of client participation.