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1.
Medicine (Baltimore) ; 98(47): e18072, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31764839

RESUMO

INTRODUCTION: Appendectomy is one of the most common emergency surgical operations. Stump appendicitis is a rare complication after appendectomy and is caused by acute inflammation of the remnant part of the appendix. Because of the low index of suspicion owing to a previous history of appendectomy, the diagnosis of stump appendicitis is often delayed. METHODS: Between January 2008 and December 2017, 6 patients were diagnosed with stump appendicitis with or without perforation at a single institution. They had undergone operative management with laparoscopic approach. The clinical data of these patients were retrospectively analyzed by reviewing the medical records and pathologic reports. RESULTS: Five patients were male, with a mean age of 42.4 years (range 11-77 years). The time interval after initial appendectomy ranged from 2 weeks to 30 years. Three patients underwent laparoscopic completion appendectomy, and the others underwent laparoscopic ileocecectomy. The mean hospital stay was 9 days (range 5-13 days). There were no cases of open conversion. CONCLUSIONS: Stump appendicitis is a rare complication after appendectomy. A laparoscopic procedure can be performed for management of stump appendicitis with or without perforation.


Assuntos
Apendicectomia/efeitos adversos , Apendicite/etiologia , Apendicite/cirurgia , Laparoscopia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Adolescente , Adulto , Idoso , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
2.
Clin Ter ; 170(6): e409-e417, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31696901

RESUMO

BACKGROUND: Stump appendicitis is a rare delayed complication post-appendectomy and it represents a diagnostic problem as clinicians are often not very familiar with this pathology. MATERIALS AND METHODS: One case of stump appendicitis has been reported in a 54 year old woman, whose acute phase was conservatively treated in our Department. A review of Medline literature was also carried out, from 1945 to 2015, showing 111 cases of stump appendicitis. RESULTS: Stump appendicitis has been reported after either open or laparoscopic appendectomy, in a range between days to several years from the first procedure. Nowadays, it is not considered yet as a possible differential diagnosis in patients with pain in the right iliac fossa previously undergone appendectomy. For this reason, the diagnosis can be delayed and complications such as acute abdomen, perforation, sepsis can occur. Completion appendectomy is the treatment of choice for stump appendicitis. CONCLUSIONS: The aim of this article is to underline the importance of stump appendicitis. Clinicians should be aware of the possibility of SA and they should confirm any clinical suspicion throughout radiologic images, in order to promptly recognize this entity and to avoid the related complications.


Assuntos
Apendicectomia/efeitos adversos , Apendicite/diagnóstico , Adulto , Apendicite/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico
3.
Am Surg ; 85(10): 1089-1093, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657300

RESUMO

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55-64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure (P < 0.001). After adjustment, the probability of any GE increased with age category (P < 0.001); having any GE was associated with higher probability of all outcomes (P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose-response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.


Assuntos
Apendicectomia/efeitos adversos , Colecistectomia Laparoscópica/efeitos adversos , Colectomia/efeitos adversos , Desbridamento/efeitos adversos , Intestino Delgado/cirurgia , Complicações Pós-Operatórias/epidemiologia , Acidentes por Quedas/estatística & dados numéricos , Fatores Etários , Idoso , Apendicectomia/estatística & dados numéricos , Colecistectomia Laparoscópica/estatística & dados numéricos , Colectomia/estatística & dados numéricos , Desbridamento/estatística & dados numéricos , Desidratação/epidemiologia , Desidratação/etiologia , Delírio/epidemiologia , Delírio/etiologia , Insuficiência de Crescimento/epidemiologia , Insuficiência de Crescimento/etiologia , Feminino , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/etiologia , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Lesão por Pressão/epidemiologia , Lesão por Pressão/etiologia , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Resultado do Tratamento
4.
Am Surg ; 85(10): 1129-1133, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657308

RESUMO

Best management for acute appendicitis (AA) in adults with liver cirrhosis is controversial and needs more investigation. We aimed to examine the impact of different treatment modalities on outcomes in this complex patient population. The Nationwide Inpatient Sample database from 2012 to 2014 was queried to identify AA patients with no cirrhosis, compensated cirrhosis (CC), and decompensated cirrhosis (DC). Each cohort was further stratified according to the treatment type: nonoperative management, open appendectomy, and laparoscopic appendectomy (LA). Chi-square, ANOVA, and binary regression analyses were used to determine differences between groups and risk factors for mortality and complications, with P < 0.05 considered statistically significant. A total of 108,289 AA patients were analyzed; of those, 304 with CC and 134 with DC were identified. Compared with CC and no cirrhosis, DC patients had significantly higher mortality, higher cost, and longer hospital length of stay. LA is accompanied by higher survival, lower cost, shorter duration of hospitalization, and lower incidence of complications across all groups. We conclude that LA is the best management strategy for AA in cirrhotic patients. Even in decompensated cirrhotics, which are associated with worse clinical outcomes, LA is still a favorable option over open appendectomy and nonoperative management.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Laparoscopia , Cirrose Hepática/complicações , Doença Aguda , Adulto , Análise de Variância , Apendicectomia/efeitos adversos , Apendicectomia/economia , Apendicectomia/mortalidade , Apendicite/complicações , Apendicite/mortalidade , Distribuição de Qui-Quadrado , Conversão para Cirurgia Aberta/estatística & dados numéricos , Custos e Análise de Custo , Feminino , Preços Hospitalares , Mortalidade Hospitalar , Humanos , Incidência , Laparoscopia/economia , Laparoscopia/mortalidade , Tempo de Internação/economia , Cirrose Hepática/classificação , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Análise de Regressão , Fatores de Risco , Resultado do Tratamento
5.
Am Surg ; 85(10): 1198-1203, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657324

RESUMO

Overdose of opioids is the number one cause of accidental death in the United States, and surgeons are overprescribing these medications. The aim of this study was to assess the feasibility of implementing postoperative opioid prescribing guidelines for general surgery procedures at a public hospital, where patients have lower socioeconomic status, public insurance, and limited access to care. We implemented a quality improvement project, which included in-service training for surgical staff and distribution of standardized guidelines. An infographic for patients was created to facilitate education on postoperative pain management. Pre- and postintervention opioid prescriptions and emergency room visits were compared for patients undergoing common general surgery procedures (inguinal hernia repair, appendectomy, and laparoscopic cholecystectomy). The median number of narcotic pills prescribed significantly decreased from 30 (n = 64) to 15 (n = 63) after the intervention (P < 0.0001). Morphine milligram equivalents decreased from a median [range] of 150 [20,600] to 90 [5,300] (P < 0.0001). The percentage of patients with postoperative pain-related emergency department visits remained low (1.6%). Standardization of postoperative opioid prescription practices was successfully implemented at a public hospital without an increase in the number of emergency room visits for pain.


Assuntos
Analgésicos Opioides/uso terapêutico , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Melhoria de Qualidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Apendicectomia/efeitos adversos , Colecistectomia Laparoscópica/efeitos adversos , Prescrições de Medicamentos/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Herniorrafia/efeitos adversos , Hospitais Públicos , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Guias de Prática Clínica como Assunto , Adulto Jovem
6.
Dis Colon Rectum ; 62(11): 1363-1370, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31596762

RESUMO

BACKGROUND: Controversy exists regarding the use of postoperative antibiotics for nonperforated gangrenous appendicitis. OBJECTIVE: The aim of this study was to evaluate the rate of postoperative infectious complications and the effect of postoperative antibiotic use among patients with nonperforated gangrenous appendicitis. DESIGN: This was a prospective cohort study conducted during 2 months. SETTINGS: A national multicenter observational study was conducted in 62 Dutch hospitals. PATIENTS: All of the consecutive patients who had surgery for suspected acute appendicitis were included. Patients were excluded if no appendectomy was performed or appendectomy was performed for pathology other than acute appendicitis. MAIN OUTCOMES MEASURES: Type of appendicitis was categorized as phlegmonous, gangrenous, or perforated. The primary end point was the rate of infectious complications (intra-abdominal abscess and surgical site infection) within 30 days after appendectomy. Univariable and multivariable logistic regression analyses were performed to identify predictors of infectious complications. RESULTS: A total of 1863 patients were included: 1321 (70.9%) with phlegmonous appendicitis, 181 (9.7%) with gangrenous appendicitis, and 361 (19.4%) with perforated appendicitis. Infectious complications were more frequent in patients with gangrenous versus phlegmonous appendicitis (7.2% vs 3.8%; p = 0.03). This association was no longer statistically significant in multivariable analysis (OR = 1.09 (95% CI, 0.49-2.44)). There was no significant difference in infectious complications between ≤24 hours (n = 57) of postoperative antibiotics compared with >24 hours (n = 124; 3.6% vs 8.9%; p = 0.35) in patients with gangrenous appendicitis. LIMITATIONS: Possible interobserver variability in the intraoperative classification of appendicitis was a study limitation. CONCLUSIONS: Patients with nonperforated gangrenous appendicitis are at higher risk of infectious complications than patients with phlegmonous appendicitis, yet gangrenous disease is not an independent risk factor. Postoperative antibiotic use over 24 hours was not associated with decreased infectious complications. See Video Abstract at http://links.lww.com/DCR/A1000. RESULTADOS POSTOPERATORIOS DE PACIENTES CON APENDICITIS GANGRENOSA NO PERFORADA: UN ANÁLISIS DE COHORTE PROSPECTIVO MULTICÉNTRICO NACIONAL:: Existe controversia sobre el uso de antibióticos postoperatorios para la apendicitis gangrenosa no perforada.El objetivo de este estudio fue evaluar la tasa de complicaciones infecciosas postoperatorias y el efecto del uso de antibióticos postoperatorios en pacientes con apendicitis gangrenosa no perforada.Estudio de cohorte prospectivo realizado durante dos meses.Estudio observacional multicéntrico nacional en 62 hospitales holandeses.Todos los pacientes consecutivos sometidos a cirugía por sospecha de apendicitis aguda. Los pacientes fueron excluidos si no se realizó una apendicectomía o si se realizó una apendicectomía para otra patología que no fuera la apendicitis aguda.El tipo de apendicitis se clasificó como flegmonosa, gangrenosa o perforada. El criterio de valoración primario fue la tasa de complicaciones infecciosas (absceso intraabdominal e infección en el sitio quirúrgico) dentro de los 30 días posteriores a la apendicectomía. Se realizaron análisis de regresión logística univariables y multivariables para identificar predictores de complicaciones infecciosas.Se incluyeron un total de 1863 pacientes: 1321 (70,9%) con apendicitis flegmonosa, 181 (9,7%) con apendicitis gangrenosa y 361 (19,4%) con apendicitis perforada. Las complicaciones infecciosas fueron más frecuentes en pacientes con apendicitis gangrenosa frente a flegmonosa (7,2% frente a 3,8%, p = 0,03). Esta asociación ya no fue estadísticamente significativa en el análisis multivariable (OR 1,09; IC del 95%: 0,49 a 2,44). No hubo diferencias significativas en las complicaciones infecciosas entre ≤ 24 h (n = 57) de los antibióticos postoperatorios en comparación con> 24 h (n = 124) (3,6% vs. 8,9%, p = 0,35) en pacientes con apendicitis gangrenosa.Posible variabilidad interobservador en la clasificación intraoperatoria de la apendicitis.Los pacientes con apendicitis gangrenosa no perforada tienen un mayor riesgo de complicaciones infecciosas que los pacientes con apendicitis flegmonosa, aunque la enfermedad gangrenosa no es un factor de riesgo independiente. El uso de antibióticos postoperatorios durante 24 horas no se asoció con una disminución de las complicaciones infecciosas. Vea el Resumen del Video en http://links.lww.com/DCR/A1000.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Apendicectomia/efeitos adversos , Apendicite/cirurgia , Apêndice/patologia , Infecções Intra-Abdominais , Complicações Pós-Operatórias , Infecção da Ferida Cirúrgica , Adulto , Antibioticoprofilaxia/métodos , Antibioticoprofilaxia/estatística & dados numéricos , Apendicectomia/métodos , Apendicite/diagnóstico , Celulite (Flegmão) , Estudos de Coortes , Feminino , Gangrena , Humanos , Infecções Intra-Abdominais/diagnóstico , Infecções Intra-Abdominais/tratamento farmacológico , Infecções Intra-Abdominais/etiologia , Masculino , Países Baixos/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Medição de Risco , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/tratamento farmacológico
7.
Chirurgia (Bucur) ; 114(4): 467-474, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31511133

RESUMO

Background: The high prevalence of Human Immunodeficiency Virus (HIV) has added a new dimension to the management and outcomes of many general surgical conditions in South Africa. However, there is a paucity of data describing the impact of HIV status on surgical outcomes in our setting. Appendicitis is a most common gastrointestinal emergency, and its surgical outcomes in areas of high HIV prevalence are poorly described in the literature. Thus, the aim of this study is to describe and compare the outcomes of appendectomy between HIV-infected (HIV+) and HIV-negative (HIV-) patients. Methods: This is a retrospective cohort study of patients undergoing appendectomy at a large regional hospital over a 12-month period. Demographic data, duration of pre-hospital symptoms, HIV status, surgical approach, operative findings, histopathology reports, hospital stay and complications were recorded. Data for the HIV+ and HIV- patient cohorts were then described, analysed and compared. Results: The study group comprised 134 patients; 18 (13.4 %) tested positive for HIV. HIV+ patients were significantly older (mean age of 29.3 vs. 20.3 years, P= 0.002) and had longer duration of pre-hospital symptoms (mean of 3.94 vs. 2.57 days, P= 0.03). Postoperative complications (44.4 % vs. 17.2 %, P= 0.03) and lengthier hospital stays (7.28 days vs. 5.95 days, P= 0.004) were also more frequently seen in the HIV+ patients. There were no differences in appendiceal rupture rates, histopathological findings and mortality. Conclusions: Presentation in HIV+ patients was delayed and surgery was associated with significant postoperative morbidity and longer hospital stay.


Assuntos
Apendicectomia , Apendicite/cirurgia , Infecções por HIV/complicações , Adulto , Apendicectomia/efeitos adversos , Apendicite/complicações , Humanos , Tempo de Internação , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
8.
BMC Surg ; 19(1): 110, 2019 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-31412833

RESUMO

BACKGROUND: Appendectomy is considered the first treatment choice for appendicitis. However, controversy exists since conservative therapy is associated with fewer complications than appendectomy for patients with acute appendicitis (AA). This meta-analysis aimed to compare the outcomes between conservative therapy and appendectomy in the management of adult AA. METHODS: A literature search was performed to screen eligible clinical studies. Subgroup analyses of the uncomplicated population, complicated population and mixed population of randomized clinical trials were subsequently performed. Clinical outcomes included the overall effective rate of treatment, complication rate, relapse rate (reoperation rate) and overall length of stay (LOS). RESULTS: Eleven trials totalling 2751 patients (conservative = 1463, appendectomy = 1288) were analysed. Patients receiving conservative treatment had a lower overall effective rate (OR: 0.11 ~ 0.17) and complication rate (OR: 0.21 ~ 0.51). The conservative group had a higher reoperation rate (5.6, 95% CI: 3.1% ~ 10.2%) than the appendectomy group (OR: 9.58 ~ 14.29). Conservative treatment was associated with a shorter overall length of stay (0.47 day, 95% CI: 0.45 ~ 0.5 day) than appendectomy. CONCLUSIONS: For both uncomplicated and complicated adult AA, non-operative management with antibiotics was associated with significantly fewer complications and a shorter length of stay but a lower effective rate and higher relapse rate.


Assuntos
Antibacterianos/uso terapêutico , Apendicectomia , Apendicite/tratamento farmacológico , Apendicite/cirurgia , Tratamento Conservador , Doença Aguda , Adulto , Apendicectomia/efeitos adversos , Humanos , Tempo de Internação , Seleção de Pacientes , Complicações Pós-Operatórias , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Reoperação , Resultado do Tratamento
9.
JSLS ; 23(3)2019.
Artigo em Inglês | MEDLINE | ID: mdl-31427852

RESUMO

Background: Laparoscopic surgery is safe in pregnancy, but is not without risk. Inadvertent uterine perforation of the gravid uterus is a rare complication. Cases: Three pregnant women had inadvertent uterine perforation during laparoscopic surgery. All patients were counseled regarding the risks of an "incidental fetoscopy" and elected to continue the pregnancy. Two delivered after preterm premature rupture of membranes at 32 and 36 weeks' gestation, and one twin pregnancy delivered at 30 weeks due to preeclampsia. Conclusion: Surgical planning of the gravid patient undergoing laparoscopic surgery should include demarcation of the most superior aspect of the uterine fundus, either via physical examination or, if not conclusive, via preoperative or intraoperative ultrasound.


Assuntos
Apendicectomia/efeitos adversos , Colecistectomia Laparoscópica/efeitos adversos , Complicações Intraoperatórias/etiologia , Laparoscopia/efeitos adversos , Complicações na Gravidez/etiologia , Perfuração Uterina/etiologia , Útero/lesões , Adulto , Apendicite/cirurgia , Cesárea , Feminino , Ruptura Prematura de Membranas Fetais/etiologia , Humanos , Recém-Nascido , Complicações Intraoperatórias/cirurgia , Trabalho de Parto Prematuro/etiologia , Pré-Eclâmpsia/etiologia , Gravidez , Complicações na Gravidez/cirurgia , Resultado da Gravidez , Gravidez Múltipla , Perfuração Uterina/cirurgia
10.
Am Surg ; 85(6): 625-630, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31267904

RESUMO

Prior studies elucidate a high predictive value of imaging to diagnose appendicitis in small, regional cohorts. This cross-sectional study uniquely analyzes diagnostic imaging in a national appendectomy population. Using the 2016 ACS NSQIP database, positive predictive values (PPVs) for CT, ultrasound (US), and MRI were evaluated using chi-squared tests. Univariate and multivariate analyses considered patient-specific factors. Imaging was performed in 94.63 per cent of 11,841 appendectomy cases; most frequently via CT (78.69%), then combination CT and US (7.52%), US (7.15%), and MRI (0.30%). CT PPV was higher in overweight (98.70%) versus underweight patients (94.85%) (P = 0.01). Gender and age did not impact CT PPV. Imaging from a referral site did not change CT or US PPV. Our study describes imaging frequencies and confirms high PPV. We found imaging equally predictive in women of childbearing age and elderly individuals compared with the general population. Furthermore, repeat scanning is unnecessary with prior positive imaging at outside sites.


Assuntos
Apendicectomia/métodos , Apendicite/diagnóstico por imagem , Apendicite/cirurgia , Diagnóstico por Imagem/métodos , Adolescente , Adulto , Apendicectomia/efeitos adversos , Apendicite/diagnóstico , Distribuição de Qui-Quadrado , Criança , Estudos Transversais , Bases de Dados Factuais , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Medição de Risco , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Ultrassonografia Doppler/métodos
12.
Cir Cir ; 87(4): 410-415, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31264979

RESUMO

Objective: To assess compliance of antibiotic prophylaxis in surgery for acute appendicitis in children and its effect on surgical site infection. Methods: We carried out a prospective cohort study to evaluate compliance of antibiotic prophylaxis in appendectomies in children. An assessment of the level of compliance with prophylaxis was made, as well as the causes of non-compliance. The effect of non-compliance of antibiotic prophylaxis on the incidence of surgical site infection was studied with the adjusted relative risk (RR) with a backstep logistic regression model. Results: The study included a total of 412 patients. Antibiotic prophylaxis was indicated in 348 patients, and administered in 95.7% of cases, with an overall protocol compliance of 90.7%. The principal cause of non-compliance was time of initiation. Cumulative incidence of surgical site infection was 2.7%. No relationship was found between inadequate prophylaxis compliance and infection (RR: 1.01; 95% confidence interval: 0.95-1.11; p = 0.61). Conclusions: Compliance of antibiotic prophylaxis was high, but could be improved. No relationship was found between prophylaxis compliance and surgical site infection rate.


Assuntos
Antibioticoprofilaxia , Apendicectomia/efeitos adversos , Apendicite/cirurgia , Fidelidade a Diretrizes/estatística & dados numéricos , Infecção da Ferida Cirúrgica/prevenção & controle , Doença Aguda , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Ampicilina/uso terapêutico , Antibioticoprofilaxia/estatística & dados numéricos , Cefazolina/uso terapêutico , Ceftriaxona/uso terapêutico , Criança , Pré-Escolar , Intervalos de Confiança , Esquema de Medicação , Feminino , Gentamicinas/uso terapêutico , Humanos , Incidência , Modelos Logísticos , Masculino , Adesão à Medicação/estatística & dados numéricos , Metronidazol/uso terapêutico , Estudos Prospectivos , Infecção da Ferida Cirúrgica/epidemiologia
13.
J Trauma Acute Care Surg ; 87(1): 100-103, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31259870

RESUMO

BACKGROUND: Postoperative outpatient narcotic overprescription plays a significant role in the opioid epidemic. Outpatient opioid prescription ranges from 150 to 350 oral morphine equivalent (OME) for a laparoscopic cholecystectomy or appendectomy, with 75 OME (10 pills of 5 mg of oxycodone) being the lowest recommendation (National Institute on Drug Abuse, 2018). We hypothesized that the addition of nonopioid medications to the outpatient pain control regimen would decrease the need for narcotics. METHODS: In this prospective, observational pilot study, we prescribed a 3-day regimen of ibuprofen and acetaminophen to patients after uncomplicated laparoscopic cholecystectomies and appendectomies. An additional opioid prescription for 5 pills of 5 mg of oxycodone (37.5 OME) was written for breakthrough pain. During their postoperative visit, we evaluated patients' adherence to the pain control regime, their postdischarge opioid use, and the adequacy of their pain control. RESULTS: Sixty-five patients were included in the study (52% male). The majority (80%) of surgeries were performed urgently or emergently. The visual analog scale pain score at home was significantly better than upon discharge (3.7 vs. 5.5, p = 0.001). The average number of oxycodone pills taken postdischarge was 1.8 pills. Half (51%) of the patients did not take any opioids. All but four patients reported that their pain was adequately controlled. No patient required additional opioid prescriptions or visited the emergency department. CONCLUSION: This study demonstrated that opioids can be eliminated in at least half of the patients and that five pills of 5 mg of oxycodone (37.5 OME) is sufficient for outpatient pain control when a 3-day course of ibuprofen and acetaminophen is prescribed. LEVEL OF EVIDENCE: Therapeutic study, level V.


Assuntos
Acetaminofen/uso terapêutico , Analgésicos não Entorpecentes/uso terapêutico , Ibuprofeno/uso terapêutico , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Analgésicos Opioides/uso terapêutico , Apendicectomia/efeitos adversos , Apendicectomia/métodos , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxicodona/uso terapêutico , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Projetos Piloto , Estudos Prospectivos
14.
BMC Surg ; 19(1): 54, 2019 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-31138196

RESUMO

BACKGROUND: Appendicitis in elderly patients is associated with increased risk of postoperative complications. The choice between laparoscopy and open appendectomy remains controversial in treating elderly patients with appendicitis. METHODS: Comprehensive search of literature of MEDLINE, Embase, Cochrane Library and ClinicalTrials was done in January 2019. Studies compared laparoscopy and open appendectomy for elderly patients with appendicitis were screened and selected. Postoperative mortality, complications, wound infection, intra-abdominal abscess and operating time, length of hospital stay were extracted and analyzed. The Review Manage 5.3 was used for data analysis. RESULTS: Twelve studies with 126,237 patients in laparoscopy group and 213,201 patients in open group. Postoperative mortality was significantly lower following laparoscopy (OR, 0.33; 95% CI, 0.28 to 0.39). Postoperative complication and wound infection were reduced following laparoscopy ((OR, 0.65 95% CI, 0.62 to 0.67; OR,0.27, 95% CI, 0.22 to 0.32). Intra-abdominal abscess was similar between LA and OA (OR,0.44;95% CI, 0.19 to 1.03). Duration of surgery was longer following laparoscopy and length of hospital stay was shorter following laparoscopy (MD, 7.25, 95% CI, 3.13 to 11.36; MD,-2.72, 95% CI,-3.31 to - 2.13). CONCLUSIONS: Not only laparoscopy is safe and feasible, but also it is related with decreased rates of mortality, post-operative morbidity and shorter hospitalization.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Laparoscopia/métodos , Abscesso Abdominal/epidemiologia , Abscesso Abdominal/cirurgia , Idoso , Apendicectomia/efeitos adversos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Infecção dos Ferimentos/epidemiologia
15.
Indian Pediatr ; 56(4): 299-303, 2019 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-31064898

RESUMO

OBJECTIVE: To compare the outcomes of treatment in children with acute appendicitis between laparoscopic and open surgical approaches. Design: Retrospective study. SETTING: Division of Pediatric Surgery at a tertiary-care hospital in Croatia between January 2012 to December 2016. PATIENTS: 834 children [median (IQR) age 13 (11,15)] who underwent appendectomy; 301 in the laparoscopic group and 533 in the open group. MAIN OUTCOME MEASURES: Postoperative complications, duration of hospitalization, re-operation, and the quantity of analgesics used. RESULTS: The median length of hospital stay was 3 days in laparoscopic group compared to 6 days in open group (P<0.001). The amount of analgesics used was lower in patients with laparoscopic appendectomy compared to patients who underwent open procedure (P=0.042). Significantly higher number of wound infections was recorded in the open group (n=21; 3.9%) compared to laparoscopic group (n=3; 1%) (P=0.014). The frequency of re-operation in both groups was equal (1.3%). The median duration of surgery was shorter in the group of patients with laparoscopic appendectomy compared to the open approach (30 vs. 45 min; P<0.001). In five-year period, the proportion of laparoscopic appendectomies increased by 21.5%. CONCLUSIONS: Laparoscopic appendectomy was safe and effective in children. Advantages of laparoscopic approach were shorter hospital stay, lower number of wound infections and lower usage of analgesics.


Assuntos
Apendicectomia , Apendicite/cirurgia , Adolescente , Apendicectomia/efeitos adversos , Apendicectomia/métodos , Apendicectomia/estatística & dados numéricos , Apendicite/epidemiologia , Criança , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento
16.
J Surg Res ; 242: 111-117, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31075655

RESUMO

BACKGROUND: Mucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. MATERIALS AND METHODS: After IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. RESULTS: Of 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). CONCLUSIONS: Mucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.


Assuntos
Apendicite/diagnóstico , Apêndice/diagnóstico por imagem , Mucosa Intestinal/patologia , Leucocitose/diagnóstico , Adolescente , Apendicectomia/efeitos adversos , Apendicectomia/estatística & dados numéricos , Apendicite/complicações , Apendicite/cirurgia , Apêndice/patologia , Apêndice/cirurgia , Criança , Diagnóstico Diferencial , Feminino , Humanos , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Contagem de Leucócitos , Leucocitose/sangue , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Estudos Retrospectivos , Ultrassonografia
17.
J Laparoendosc Adv Surg Tech A ; 29(7): 965-969, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31099710

RESUMO

Background: Previous studies regarding same-day discharge (SDD) after laparoscopic appendectomy for pediatric patients have been limited by the cohort size and lack of specificity regarding the definition of SDD. Our study evaluates the safety of appendectomy performed with SDD in pediatric patients when compared to appendectomy followed by an overnight stay, using a large nationwide database and a strict definition of SDD by using hospital length of stay (LOS). Methods: Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) registry, we identified patients younger than 18 years of age who underwent outpatient laparoscopic appendectomy, with SDD (n = 2647) or overnight stay (n = 5045). One-to-one propensity score matching was performed to compare 30-day readmission rates and postsurgical complications. Results: Non-Hispanic black race was associated with a higher likelihood of overnight stay after laparoscopic appendectomy. In the propensity score-matched analysis (N = 2443 pairs), SDD was not associated with an increased risk of 30-day unplanned readmission (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.6-1.4; P = .667) or any 30-day complication (OR = 0.8, 95% CI: 0.6-1.1; P = .258). Conclusion: SDD after laparoscopic appendectomy in pediatric patients was not associated with an increased risk of 30-day hospital admission or complication rate. Protocols to expedite perioperative care, including standardization of intraoperative care, may facilitate same-day hospital discharge, resulting in a decrease in health care costs.


Assuntos
Apendicectomia/métodos , Laparoscopia , Tempo de Internação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Adolescente , Afro-Americanos/estatística & dados numéricos , Apendicectomia/efeitos adversos , Criança , Feminino , Humanos , Masculino , Alta do Paciente , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Sistema de Registros , Estudos Retrospectivos
18.
BMC Surg ; 19(1): 41, 2019 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-31023289

RESUMO

BACKGROUND: Recently, laparoscopic appendectomies (LAs) have been widely performed instead of open appendectomies (OAs) during pregnancy. However, concerns about the safety of LA during pregnancy remain. This systematic review and meta-analysis aimed to evaluate the current evidence relating to the safety of LA versus OA for suspected appendicitis during pregnancy. METHODS: Comprehensive literature searches were conducted using the PubMed, EMBASE, and Cochrane Library databases to identify articles describing LA versus OA in pregnancy, without restrictions regarding the publication date. The primary endpoints were fetal loss and preterm delivery. RESULTS: After screening 801 studies, 22 comparative cohort studies were included in the analysis, which involved 4694 women, of whom 905 underwent LAs and 3789 underwent OAs. Fetal loss was significantly higher among those who underwent LAs compared with those who underwent OAs, and the pooled odds ratio (OR) was 1.72 (95% confidence interval [CI]: 1.22-2.42) without heterogeneity. The sensitivity analysis showed that the effect size was influenced by one of the studies, because its removal resulted in there being no significant difference between LA and OA with respect to the risk of fetal loss (OR 1.163, 95% CI: 0.68-1.99; P = 0.581). A significant difference was not evident between LA and OA with respect to preterm delivery (OR 0.76, 95% CI: 0.51-1.15), a result that did not change following the sensitivity analysis. The patients who underwent LA had shorter hospital stays (mean difference - 1.01, 95% CI: -1.61--0.41) and a lower wound infection risk (OR 0.40, 95% CI: 0.21-0.76) compared with those who underwent OA. CONCLUSION: It is not reasonable to conclude that LA in pregnant women might be associated with a greater risk of fetal loss. The difference between LA and OA with respect to preterm delivery was not significant.


Assuntos
Apendicectomia/efeitos adversos , Apendicectomia/métodos , Apendicite/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Complicações na Gravidez/cirurgia , Bases de Dados Factuais , Feminino , Morte Fetal , Humanos , Tempo de Internação , Razão de Chances , Gravidez , Estudos Retrospectivos , Resultado do Tratamento , Infecção dos Ferimentos
19.
Rev Paul Pediatr ; 37(2): 161-165, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30892542

RESUMO

OBJECTIVE: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. METHODS: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. RESULTS: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. CONCLUSIONS: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.


Assuntos
Apendicectomia , Apendicite/cirurgia , Apêndice/patologia , Laparoscopia , Complicações Pós-Operatórias , Dor Abdominal/diagnóstico , Dor Abdominal/etiologia , Adolescente , Apendicectomia/efeitos adversos , Apendicectomia/métodos , Apendicectomia/estatística & dados numéricos , Apendicite/diagnóstico , Apendicite/epidemiologia , Apendicite/fisiopatologia , Criança , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Espanha/epidemiologia
20.
Ulus Travma Acil Cerrahi Derg ; 25(2): 129-136, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30892680

RESUMO

BACKGROUND: Preoperative classification of complicated and uncomplicated appendicitis (AA) is challenging. However, the differences in surgical outcomes necessitate the establishment of risk factors in developing, complicated AA. This study was an analysis of the clinical outcomes of laparoscopic appendectomies (LA), as well as preoperative risk factors for the development of complicated AA. METHODS: The data of 618 patients who underwent LA in 18 surgical units across Poland and Germany were collected in an online web-based database created by the Polish Videosurgery Society. The surgical outcomes of patients with complicated and uncomplicated appendicitis were compared. Uni- and multivariate logistic regression models were used to establish risk factors for the development of complicated appendicitis. RESULTS: In all, 1269 (27.5%) patients underwent LA for complicated appendicitis (Group 1) and 3349 (72.5%) for uncomplicated appendicitis (Group 2). The conversion rate, number of intra-operative adverse events, re-intervention rate, postoperative complications, and readmission rate was greater in Group 1. The preoperative risk factors associated with complicated appendicitis were: female sex (Odds ratio [OR]: 1.58), obesity (OR: 1.51), age >50 years (OR: 1.51), symptoms >48 hours (OR: 2.18), high Alvarado score (OR: 1.29 with every point), and C-reactive protein level >100 mg/L (OR: 3.92). CONCLUSION: Several demographic and clinical risk factors for complicated AA were identified. LA for complicated appendicitis was associated with poorer outcomes.


Assuntos
Apendicectomia , Apendicite , Laparoscopia , Apendicectomia/efeitos adversos , Apendicectomia/estatística & dados numéricos , Apendicite/epidemiologia , Apendicite/cirurgia , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Masculino , Polônia/epidemiologia , Complicações Pós-Operatórias , Fatores de Risco , Resultado do Tratamento
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