Appendectomy for Vague Symptoms and Equivocal Physical Findings on Physical Exam and Computed Tomography.

Background: Appendicitis is a common condition affecting 7-8% of the general population. With the improvement of noninvasive imaging, the diagnostic approach and treatment algorithm for patients with clear signs and symptoms suggestive of acute appendicitis are well agreed-upon. However, patients without pathognomonic signs and symptoms, but with equivocal imaging pose a diagnostic dilemma. These patients may still have acute appendicitis and could potentially benefit from laparoscopic appendectomy. This may be especially true in the subset of patients with appendicoliths.Methods: Our case series exams a group of patients with atypical symptoms who eventually underwent appendectomy and were followed after surgery for at least a month. This case series consists of eight patients with abdominal pain accompanied by a variety of other signs and symptoms in addition to laboratory results and imagining characteristics which were nondiagnostic. These patients had initial Alvarado scores ranging from 0-6.Results: All of these patients were subsequently taken to the operating room for diagnostic laparoscopy and laparoscopic appendectomy. Of these patients, six were known to have appendicoliths based on computed tomography obtained during initial diagnostic workup.Conclusions: All patients underwent a diagnostic laparoscopy and appendectomy. Four had appendicitis and four also had resolution of their symptoms. There exist atypical presentations of appendiceal disease. Patients with abdominal pain/tenderness, even without diagnostic laboratory results or imaging characteristics, may benefit from laparoscopic appendectomy.

An experimental comparison of the effects of bacterial colonization on biologic and synthetic meshes.

PURPOSE: Biologic meshes are being used with increasing frequency to repair contaminated abdominal wall defects despite high long-term recurrence and infection rates associated with their use. Recent clinical reports describing the success of lightweight, macroporous synthetic meshes in contaminated ventral hernia repairs have led some surgeons to challenge the belief that synthetics are contraindicated in contaminated fields. We aimed to determine whether a frequently used biologic mesh (Strattice(TM)) is more resistant to bacterial colonization than macroporous synthetic mesh (Parietex(TM) Progrip(TM)) after inoculation with two common pathogens. METHODS: Rats (n = 48) were implanted subcutaneously with Strattice(TM) or Progrip(TM). Meshes were inoculated with sterile saline or a suspension containing 10(6) colony-forming units of Staphylococcus aureus or Escherichia coli prior to wound closure (n = 8 per subgroup). Meshes were explanted at 4 weeks and underwent microbiologic and histologic analyses. RESULTS: Progrip(TM) demonstrated superior bacterial clearance compared to Strattice(TM) (E. coli, 88 vs. 17% clearance, p = 0.03; S. aureus, 75 vs. 50%, p = 0.61; combined bacterial strains, 81 vs. 36%, p = 0.02; respectively). In the Strattice(TM) group, severely degraded meshes were observed in 100% of animals inoculated with E. coli (but 0% inoculated with S. aureus). In contrast, all Progrip(TM) meshes remained intact regardless of inoculum. Scores for neovascularization were higher in the synthetic group irrespective of contamination (p < 0.05). CONCLUSIONS: Biologic meshes may not be more resistant to bacterial colonization than reduced-weight synthetics, and their resistance may differ in response to different pathogens. The routine use of biologics in contaminated ventral hernia repair should be questioned, particularly in the presence of E. coli.

Evaluation of Six Split-thickness Skin Graft Donor-site Dressing Materials in a Swine Model.

BACKGROUND: Numerous dressings for split-thickness skin graft donor sites are commercially available with no conclusive evidence-based consensus regarding the optimal dressing choice. This study was conducted to identify which of 5 commonly used materials promotes wound healing most effectively for use on split-thickness donor sites in comparison with our standard dressing, Xeroform (petrolatum gauze). METHODS: Twenty-four partial-thickness wounds were created on the backs of 4 pigs using a dermatome. Wounds (n = 4 per dressing type per pig) were treated with Xeroform, Opsite (polyurethane film), Kaltostat ( calcium sodium alginate), DuoDERM (hydrocolloid), Aquacel (hydrofiber), and Mepilex (silicone foam). Full-thickness skin samples were excised at 3 or 5 days and evaluated histologically for reepithelialization and inflammation. Comparisons also included incidence of infection, ease of use, and cost analyses. RESULTS: DuoDERM elicited the greatest percent reepithelialization (81%) and Mepilex the lowest (33%) after 3 days (P = 0.004). All dressings demonstrated complete reepithelialization except Mepilex (85%) at 5 days. There were no infections and inflammation was mild among all treatments. Mepilex was easiest to use, whereas Aquacel, Kaltostat, and Opsite were most difficult (P = 0.03). Xeroform was most cost-effective and Aquacel most expensive. Combined scoring revealed DuoDERM = Xeroform > Opsite = Mepilex > Kaltostat > Aquacel. CONCLUSIONS: DuoDERM and Xeroform were most effective overall. DuoDERM tended to outperform all dressings in reepithelialization at 3 days, while Xeroform was least expensive, easy to use, and demonstrated rapid reepithelialization. These findings suggest that Xeroform may be preferred for use on large donor-site areas. DuoDERM may be more appropriate for small donor sites when healing time is a priority.