Acute appendicitis in the elderly: risk factors for perforation.

BACKGROUND: Acute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis. METHODOLOGY: The medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier. RESULTS: During the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient's pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group. CONCLUSION: Acute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

Laparoscopic splenectomy: consensus and debatable points.

INTRODUCTION: The emergence of minimally invasive techniques has broadened interest in splenectomy for a variety of haematological illnesses. Laparoscopic splenectomy (LS) is currently considered the gold standard for the treatment of various haematological disorders. PURPOSE: The literature was reviewed to highlight points of consensus and debatable points regarding best practice in LS, looking at issues such as bleeding and conversion, splenomegaly, splenic retrieval techniques, types of instruments used, hand-assisted LS (HALS), complications, approaches, accessory spleen and splenosis. Our goal was to share our experience with LS and compare it with other reports. BACKGROUND: LS has emerged as the standard of care for elective splenectomy for benign haematological diseases. However, doubts have been raised regarding the suitability of patients with splenomegaly for LS. There is also uncertainty about its efficacy in major trauma. HALS has emerged as an option for safe manipulation and splenic dissection. METHOD: We performed 25 consecutive LSs at King Abdullah University Hospital (KAUH), Jordan, from 2001 to 2008. Patient demographics, operative time, intra- and postoperative complications, conversion rate, additional procedures and length of hospital stay were retrospectively reviewed. RESULTS: The mean age of the patients was 38.8 years (range 11-77 years), mean operative time was 132 minutes (90- 170 minutes), and length of hospital stay was 2.9 (standard deviation 2.7) days. One case was converted to open surgery (5%). There was 1 case of superficial wound infection in the series (5%), and no deaths. CONCLUSION: LS is a well- accepted minimally invasive procedure, but knowledge and skill are required to perform it with minimal morbidity and mortality.

Vascular access infection among hemodialysis patients in Northern Jordan: incidence and risk factors.

OBJECTIVES: Vascular access infection (VAI) causes significant mortality and morbidity in hemodialysis patients. The aim of this prospective, descriptive, exploratory survey of end-stage renal disease patients was to explore the incidence and risk factors of VAI. METHODS: A total of 188 patients were included in the study from five different hospital/dialysis units in northern Jordan. All patients answered a questionnaire related to their vascular access (VA) and infection. Demographic information, etiology of renal failure, and infection history related to the access were also collected and analyzed. RESULTS: Diabetes mellitus was the most common etiology of renal failure, followed by hypertension, urinary tract infection, and congenital malformation. The infection rate was variable according to the hospital and the type of VA; of 188 patients, 65 patients had a VAI during the year of study. Of these, 36 of 64 were because of catheters, 24 of 105 were because of arteriovenous fistulas (AVFs), and 5 of 19 were because of arteriovenous graft. Of the 65 with a VAI, 58 patients had a low level of education. CONCLUSIONS: VAI was common in hemodialysis patients, and the risk varied substantially among different VA types and different dialysis units. The infection rate from catheters and AVFs was similar to that reported in many studies, but the infection rate in the arteriovenous graft group was lower than that for AVFs. These results can be improved by strictly following the National Kidney Foundation Disease Output Quality Initiative clinical practice guidelines for dialysis access.