A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

Presentation and management of a case of rectal cancer complicated by perforation and necrotizing soft tissue infection.

A 68-year-old man presented with septic shock and severe perineal pain from a perforated low-rectal cancer causing a perineal necrotizing soft tissue infection. He underwent laparoscopic diverting colostomy and multiple surgical debridements resulting in extensive perineal and left leg wounds. A multidisciplinary rectal cancer team recommended against neoadjuvant chemoradiation or chemotherapy in his current state. He underwent up-front, urgent robotic-assisted abdominoperineal resection with immediate oblique rectus abdominus muscle flap closure. Final pathology demonstrated a T4N1b adenocarcinoma with negative resection margins. The patient subsequently underwent adjuvant chemotherapy. Now at over 18 months, he remains cancer free.

Preoperative tattooing and improved lymph node retrieval rates from colectomy specimens in patients with colorectal cancers.

HYPOTHESIS: India ink tattooing at the time of colonoscopy increases the yield of lymph nodes found in pathological analysis of colectomy specimens. DESIGN: Retrospective study. SETTING: Virginia Mason Medical Center, Seattle, Washington. PATIENTS: Two hundred nine patients with colorectal cancers underwent surgical resections between April 5, 2006, and June 25, 2009, at one institution. MAIN OUTCOME MEASURES: A retrospective review of a prospectively collected database was performed, with review of pathology reports for all cases. Adequate lymph node analysis was defined as evaluation of at least 12 lymph nodes. RESULTS: Of 209 patients undergoing resections, 174 had colonic neoplasms, and 35 had rectal neoplasms. Sixty-two of 174 patients with colon cancer had India ink tattooing at the time of colonoscopy. The mean (range) numbers of lymph nodes examined in tattooed and nontattooed specimens were 23 (7-77) and 19 (2-74), respectively (P = .03). At least 12 lymph nodes were analyzed for 87.1% of the tattooed specimens compared with 72.3% of the nontattooed specimens (P = .02). Eight of 35 patients with rectal cancer had India ink tattooing at the time of colonoscopy. Fifty-four percent of patients with rectal cancer had undergone neoadjuvant chemoradiotherapy. The median numbers of lymph nodes examined in tattooed and nontattooed specimens were 19 and 16, respectively. CONCLUSIONS: Tattooing of colonic lesions at the time of preoperative colonoscopy seems to increase the quality of lymph node analysis. We advocate routine tattooing of all suspicious neoplasms at the time of colonoscopy.