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1.
BMC Surg ; 20(1): 242, 2020 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-33069217

RESUMO

BACKGROUND: A retained surgical sponge, also known as a gossypiboma, is a rare cause of serious postoperative complications. Diverse retained surgical materials including instruments such as clamps and sutures have been reported, but surgical sponges are the most common material. We report an unusual case of a gossypiboma mimicking a complicated urachal cyst that led to perforation of the umbilicus. CASE PRESENTATION: A 38-year-old female patient presented in our facility with a palpable periumbilical mass and discharge of pus from the umbilicus for 7 months after an open appendectomy. Since the onset of symptoms, the patient had been treated conservatively in a peripheral hospital where she had been operated on. As no improvement was seen, an ultrasound scan was performed that suggested an intraperitoneal abscess adjacent to the umbilicus. Consequently, the patient was referred to our specialist outpatient department for surgical intervention. Suspecting a complicated urachal cyst, an exploratory laparotomy was performed but revealed a retained surgical sponge as the underlying cause. The gossypiboma was resected, and the postoperative period was unremarkable. CONCLUSION: This case demonstrates that gossypibomas, even though rare, continue to occur. They may clinically and radiologically mimic other pathologies, especially abscesses and tumors. Preventive measures as well as the inclusion of gossypibomas in the differential diagnosis of intraabdominal masses or fistulation detected in patients with a history of surgery are of utmost importance to minimize morbidity, mortality, and potential medicolegal implications.


Assuntos
Abscesso Abdominal/etiologia , Apendicectomia/efeitos adversos , Corpos Estranhos/diagnóstico por imagem , Laparotomia/métodos , Tampões de Gaze Cirúrgicos/efeitos adversos , Umbigo/diagnóstico por imagem , Abscesso Abdominal/diagnóstico por imagem , Adulto , Diagnóstico Diferencial , Feminino , Corpos Estranhos/cirurgia , Humanos , Complicações Pós-Operatórias , Resultado do Tratamento , Ultrassonografia , Cisto do Úraco
2.
Khirurgiia (Mosk) ; (10): 49-59, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33047586

RESUMO

OBJECTIVE: To analyze the role of mesoappendixectomy in the development of intra-abdominal surgical site infection (IAB SSI) after LAE. MATERIAL AND METHODS: A prospective randomized non-blind multiple-center registered (ClinicalTrials.gov NCT03754777) study has been performed for the period from 2016 to 2018. The study was devoted to effectiveness and safety of the modified enhanced recovery protocol in LAE. In the main group, this protocol (n=56) included routine mesoappendixectomy, restrictive strategy for abdominal drainage and postoperative antibiotic prevention. In the control group (n=71), mesoappendixectomy was performed only in case of necrotic changes. Both groups were comparable by demographic parameters and severity of comorbidities. RESULTS: In the main group, significant decrease in the incidence of IAB SSI was found (0% versus 9.8%). Moreover, the main group was characterized by reduced length of hospital-stay (1.43±1.34 d versus 2.94±2, 43 days). CONCLUSION: Mesoappendixectomy should be evaluated in further research as a potential factor in prevention of IAB SSI.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Mesocolo/cirurgia , Peritonite/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Antibacterianos/administração & dosagem , Apendicectomia/efeitos adversos , Apendicite/tratamento farmacológico , Drenagem , Recuperação Pós-Cirúrgica Melhorada , Humanos , Peritonite/etiologia , Estudos Prospectivos , Infecção da Ferida Cirúrgica/etiologia
3.
Mymensingh Med J ; 29(4): 887-894, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33116092

RESUMO

The aim of this prospective study was to evaluate the role and application of laparoscopy in the management of acute appendicitis and its complications. The study was conducted between January 2011 to February 2019 in Bangabandhu Sheikh Mujib Medical University (BSMMU) and some private hospitals of Dhaka, Bangladesh. A total of 641 patients who presented with acute appendicitis and its complications were treated by laparoscopic method. Around 70% (449) patients had classical presentation, 20% (128) were atypical and 10% (64) were recurrent or chronic presentation. Maximum (527, 82%) came with acute appendicitis. Eighty eight (13.72%) patients had burst (perforated) appendicitis, 12(1.87%) patients had appendicular abscess, 11(1.71%) showed early appendicular lump, 2(0.4%) had stump appendicitis and 1(0.2%) had previous laparoscopic clip control of stump. Energy source was unipolar diathermy. Intracorporeal knotting, endoloop and haemoclip were used for haemostosis and ligation of appendicular stump. Mean duration of surgery was 20minutes and mean hospital stay was 36 hours. Histopathological patterns were acute appendicitis (554, 86.42%), gangrenous appendicitis (58, 9.04%), catarrhal (13, 2.02%), chronic appendicitis (10, 1.56%) lymphoid hyperplasia (6, 0.93%) and carcinoid tumor (1, 0.15%), among the complications (25) were single or multiple port infections, port TB, paralytic ileus and diarrhea. Conversion was 1(0.15%) for controlling haemorrhage of burst appendicitis. The rest of the patients recovered quickly and uneventfully. In conclusion, it can be stated that laparoscopic appendicectomy is safe, convenient and achievable and can become the gold standard of management of acute appendicitis and its complications.


Assuntos
Apendicite , Laparoscopia , Apendicectomia/efeitos adversos , Apendicite/cirurgia , Bangladesh/epidemiologia , Humanos , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos
4.
Ann Surg ; 272(2): 248-252, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675537

RESUMO

BACKGROUND: There is limited evidence for the use of postoperative antibiotics for simple appendicitis (SA) in children. Our aim was to conduct a prospective double-blinded randomized controlled trial to investigate this after a laparoscopic appendicectomy. METHODS: Following ethical approval, children (≤16 years) undergoing appendicectomy were recruited at a single institution. Patients were randomized intraoperatively to receive either 2 postoperative intravenous doses of placebo or antibiotics (Abx). All patients received a dose of Abx at induction of anesthesia. Primary outcome was the incidence of postoperative wound infection (WI), and secondary outcome was the incidence of intra-abdominal abscess formation. Data are reported as number of cases (%), median (range), relative risk, and analyzed using Mann Whitney U test, Chi-square test, as appropriate, a P-value ≤0.05 was considered significant. RESULTS: A total of 304 patients were randomized. Sixty-one were subsequently excluded due to protocol violations or recruitment errors; therefore, 243 were included in the final analysis. One hundred twenty-two patients received placebo and 121 Intravenous Abx. There was no difference between the sex (50F/72 M vs 47F/74 M, P = 0.8), median age (12.4 vs 12.2 years, P = 0.5), and postoperative length of stay in a hospital (27.2 vs 25.6 hours, P = 0.7). There was also no difference in the preoperative blood results. A total of 9 WIs occurred: 8/122 (6.6%) placebo versus 1/121 (0.8%) Abx, P = 0.01 [relative risk for WI 7.9 (95% confidence interval: 1.0-62.4)]. There were no intra-abdominal abscess in either groups. CONCLUSIONS: This prospective randomized double blinded randomized controlled trial has revealed a significant decrease in WI rates by giving 2 postoperative intravenous doses of Abx, suggesting postoperative Abx are of benefit in SA.


Assuntos
Antibacterianos/administração & dosagem , Apendicectomia/métodos , Apendicite/cirurgia , Laparoscopia/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Cicatrização/efeitos dos fármacos , Apendicectomia/efeitos adversos , Apendicite/diagnóstico , Austrália , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Método Duplo-Cego , Esquema de Medicação , Feminino , Seguimentos , Humanos , Injeções Intravenosas , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Estudos Prospectivos , Medição de Risco , Estatísticas não Paramétricas , Resultado do Tratamento , Cicatrização/fisiologia
5.
Am Surg ; 86(7): 837-840, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32705882

RESUMO

BACKGROUND: Acute care surgery patients are often unfasted at the time of surgery, presenting a unique opportunity to study the effects of fasting on the risk of pulmonary aspiration. We aimed to determine the relative risk of aspiration in patients who were fasted at the time of surgery according to guidelines versus those in an unfasted state. METHODS: A retrospective chart review of 100 patients who underwent appendectomy (n = 76) or exploratory laparotomy (n = 24) was conducted at a single institution in 2016-2017. Using the American Society of Anesthesiologists (ASA) Practice Guidelines for Preoperative Fasting, patients were stratified into study and control groups according to whether they were unfasted (nothing by mouth for <8 hours prior to surgery) or fasted (nothing by mouth for >8 hours prior to surgery). Data controlled for patients' age, sex, body mass index (BMI), most recent hemoglobin A1c, presence of gastroesophageal reflux disease (GERD), and presence of hiatal hernia. RESULTS: Of the 76 patients who underwent appendectomy, 15% were unfasted with a total of 0 aspiration events (P < .001). Of the 24 patients who underwent exploratory laparotomy, 42% were unfasted with a total of 0 aspiration events (P < .001). This yields a relative risk of pulmonary aspiration of 1.0 (absolute risk of 0) in both the study and control groups. DISCUSSION: In an acute care surgery population including patients who were not fasted according to guidelines, there was no increase in the risk of pulmonary aspiration. LEVEL OF EVIDENCE: Epidemiological study; Level III.


Assuntos
Apendicectomia/efeitos adversos , Cuidados Críticos , Jejum , Laparotomia/efeitos adversos , Pneumonia Aspirativa/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Feminino , Humanos , Masculino , Cuidados Pré-Operatórios , Estudos Retrospectivos , Risco
6.
Niger J Clin Pract ; 23(7): 975-979, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32620728

RESUMO

Background: Open appendectomy (OA) has been the gold standard for a long time. Laparoscopic appendectomy (LA) has gained wide acceptance and popularity, outdoing open approach. Yet, conversion may be required when laparoscopic approach fails. Aims: To predict conversion from laparoscopic appendectomy to open appendectomy sing Oreo-ratio radiological appendices diameter. Materials and Methods: This is a retrospective cohort study conducted on 320 (included) patients who underwent appendectomy between January 2018 and August 2018 in the General Surgery departmentof Haseki Training and Research Hospital, Istanbul, Turkey. Appendiceal diameter obtained during preoperative radiological screening was evaluated about its relationship to conversion from LA to OA. Age, sex, inflammatory serum parameters and pathology reports were also investigated. Results: A total of 269 (84%) cases were started LA and 17 (6,3%) laparoscopic cases were converted to open. The appendix diameter, the grade of inflammation (perforated or gangrenous), age, and c-reactive protein (CRP) were found to have significant importance in conversion, P = 0.003, P = 0.000, P = 0.042, and P = 0.018, respectively. When a cutoff of 50 years was chosen for age, the odds ratio (OR) was 3. For the appendiceal diameter of 14 mm, the OR was 3.0286. Conclusion: Preoperative evaluation of appendix diameter is a quick and useful method for a surgeon to distinguish cases with risk of conversion in the emergency department. The other risk factors associated with conversion of LA to OA are grade of inflammation, age and CRP levels.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Apêndice/diagnóstico por imagem , Laparoscopia/métodos , Tomografia Computadorizada por Raios X/métodos , Adulto , Apendicectomia/efeitos adversos , Apendicite/diagnóstico por imagem , Apêndice/anatomia & histologia , Apêndice/patologia , Proteína C-Reativa/análise , Proteína C-Reativa/metabolismo , Feminino , Humanos , Inflamação/sangue , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Estudos Retrospectivos , Resultado do Tratamento , Turquia/epidemiologia
7.
Ulus Travma Acil Cerrahi Derg ; 26(4): 639-641, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32589254

RESUMO

Trocar site hernias are a type of incisional hernias and may occur within a variable time shift after surgery. A mean incidence of 1.85% was reported, and the first trocar site hernia was narrated by Maio et al. in 1991 describing small bowel obstruction due to trocar site herniation after laparoscopic cholecystectomy. The 10-mm-trocar port is more frequently problematic, and a trocar site hernia in 5 mm port is very rare. This report unveils a 5mm trocar site herniation of right fallopian tube following laparoscopic appendectomy. In this case study, a 19-year-old female patient applied to the emergency department because of a discharge in the right lower quadrant was reported. She explained that she had undergone laparoscopic appendectomy two days before and discharged the next day uneventfully. The surgical report described a suction drain in the right lower quadrant where the patient was suffering from the discharge. The physical examination revealed no tenderness, but an abdominal CT disclosed an edematous tubular structure herniating from the 5 mm trocar site where the drain was put. She was re-operated laparoscopically due to early trocar site hernia, and the right fallopian tube was observed herniating through the defect. After the reduction into the abdomen, the fallopian tube was observed fine, and the defect was closed using 2/0 polypropylene suture. Trocar site hernias are rare but may cause serious complications after laparoscopic surgery. They may occur early after the surgery, but the time shift is variable. Although mechanical bowel obstructions are more frequent endpoint, it should be remembered that any organ within the abdominal cavity may herniate.


Assuntos
Apendicectomia/efeitos adversos , Tubas Uterinas/fisiopatologia , Hérnia , Laparoscopia/efeitos adversos , Instrumentos Cirúrgicos/efeitos adversos , Adolescente , Feminino , Hérnia/diagnóstico , Hérnia/etiologia , Hérnia/fisiopatologia , Humanos
8.
J Surg Res ; 254: 384-389, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32535257

RESUMO

BACKGROUND: Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm2. We sought to determine the adherence to and effectiveness of this algorithm. METHODS: This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P < 0.05 was significant. RESULTS: Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess. CONCLUSIONS: Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.


Assuntos
Abscesso Abdominal/cirurgia , Apendicectomia/efeitos adversos , Drenagem , Fidelidade a Diretrizes/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Abscesso Abdominal/etiologia , Adolescente , Algoritmos , Criança , Pré-Escolar , Feminino , Humanos , Tempo de Internação , Masculino , Estudos Prospectivos
9.
J Surg Res ; 254: 314-317, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32505924

RESUMO

BACKGROUND: Postoperative small bowel obstruction (SBO) is an important complication of laparoscopic appendectomy in children, resulting in readmission and potential for intestinal loss. We reviewed our experience with early postoperative SBO. METHODS: A retrospective review was performed of patients undergoing an appendectomy with subsequent SBO from 2014 to 2018. Patients were excluded if a concurrent gastrointestinal procedure was done during the appendectomy, or if they had previous abdominal surgery. RESULTS: Of 793 appendectomies performed at our institution during the study period, only six patients met the inclusion criteria for our chart review (7.6 SBO per 1000 appendectomies), ranging in age from 4 to 19 y. Four patients had uncomplicated appendicitis, and all underwent laparoscopic appendectomy within 24 h. Five were discharged postoperatively, with one patient remaining hospitalized for persistent ileus. Median time to representation with SBO was 7 d (range, 2-37). Three patients had indications for urgent exploration and underwent re-exploration shortly after presentation. Three patients underwent initial nonoperative management, but subsequently, all patients failed to progress and required operative exploration. Staples were found to be the culprit lesion in four of six patients, all of which notably initially presented with uncomplicated appendicitis, with two patients found to have ischemic bowel at the time of exploration. CONCLUSIONS: Although rare, pediatric patients with SBO soon after laparoscopic appendectomy should be considered for early operative management, especially if the appendicitis was uncomplicated. When staples are used for appendectomy, stray staples should not be left as they can serve as a nidus for obstruction.


Assuntos
Apendicectomia/efeitos adversos , Obstrução Intestinal/etiologia , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Suturas/efeitos adversos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Adulto Jovem
10.
J Trauma Acute Care Surg ; 88(6): 839-846, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32459449

RESUMO

OBJECTIVE: The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking. METHODS: Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.-Clinical Modification codes to determine presence of perforation for comparison. RESULTS: A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied. CONCLUSION: Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes. LEVEL OF EVIDENCE: Prospective/Epidemiologic, Level III.


Assuntos
Apendicectomia/efeitos adversos , Apendicite/diagnóstico , Benchmarking/métodos , Complicações Pós-Operatórias/epidemiologia , Índice de Gravidade de Doença , Adulto , Apendicite/cirurgia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Risco Ajustado/métodos , Sociedades Médicas , Traumatologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
11.
Surgery ; 168(2): 322-327, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32461001

RESUMO

BACKGROUND: The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission. METHODS: The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis. RESULTS: From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01-2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12-1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79-8.25, P = .116), compared with the younger cohort. CONCLUSION: Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy.


Assuntos
Abscesso Abdominal/epidemiologia , Apendicectomia , Apendicite/cirurgia , Idoso , Apendicectomia/efeitos adversos , Neoplasias do Apêndice/epidemiologia , Apendicite/mortalidade , Conversão para Cirurgia Aberta/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Laparoscopia , Tempo de Internação/estatística & dados numéricos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
12.
Ned Tijdschr Geneeskd ; 1642020 05 14.
Artigo em Holandês | MEDLINE | ID: mdl-32406639

RESUMO

In this clinical lesson we present two patient cases. A 66-year-old female patient with a clinical, biochemical and radiological suspicion of complex appendicitis. The patient undergoes an appendectomy and post-operative recovery is beset with complications. The other case involves a 24-year-old male patient with suspected simple appendicitis. He is successfully treated with antibiotics and without surgery. By using these patients as examples, we discuss the revised clinical guideline for diagnosing and treating acute appendicitis. Besides that, we also discuss the differentiation between simple and complex appendicitis and how this can influence the treatment plan.


Assuntos
Antibacterianos/uso terapêutico , Apendicectomia , Apendicite/diagnóstico , Apendicite/terapia , Doença Aguda , Idoso , Apendicectomia/efeitos adversos , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Adulto Jovem
13.
Ulus Travma Acil Cerrahi Derg ; 26(3): 384-388, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32436964

RESUMO

BACKGROUND: In this study, we aimed to evaluate the superiority of intracorporeal sutures and Hem-o-lok clips about efficiency, reliability and cost. METHODS: We performed laparoscopic surgery for acute appendicitis in this study. Appendiceal stump was closed by Hem-o-lok clips (Group I) and intracorporeal knotting (Group II) in a randomized manner. Groups were compared for demographic data (age, sex, body mass index, American Society of Anesthesiologists score) operation time, total cost, 2.6.12.24.hours and 7th day pain score. RESULTS: Demographic data, such as age, gender and BMI, were similar between groups (p>0.05). There was no significant difference between the groups concerning peroperative and postoperative complications (p>0.05). No postoperative nausea, vomiting, ileus and intraabdominal abscess were observed in patients. There was no significant difference between the groups about duration of operation, length of hospital stay and cost analysis (p>0.05). There was no significant difference in pain scores of groups. The effect of the operation type on pain scores was not statistically significant (p>0.05). CONCLUSION: This study showed that both intracorporeal knotting and Hem-o-loc clips were effective, reliable and similar cost-effective in laparoscopic appendectomy. The decision should be based on the surgeon's experience.


Assuntos
Apendicectomia , Apêndice/cirurgia , Laparoscopia , Técnicas de Fechamento de Ferimentos , Apendicectomia/efeitos adversos , Apendicectomia/instrumentação , Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/instrumentação , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Instrumentos Cirúrgicos , Suturas , Técnicas de Fechamento de Ferimentos/efeitos adversos , Técnicas de Fechamento de Ferimentos/instrumentação , Técnicas de Fechamento de Ferimentos/estatística & dados numéricos
16.
J Surg Res ; 252: 89-95, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278221

RESUMO

BACKGROUND: Surgical resection is the gold standard in the treatment of neoplasia involving the appendiceal orifice (Ao). Endoscopic mucosal resection (EMR) of adenomas involving the Ao can be challenging because of the risk of appendicitis, perforation, or incomplete resection. Surgical resection of Ao lesions is limited by the difficulty of ensuring a negative lateral margin without compromising the ileocecal valve and usually necessitates ileocecal resection. Although combined endoscopic and laparoscopic surgery has become more widely accepted for a variety of conditions, a structured approach to lesions involving the Ao has yet to be described. We describe a novel approach to the treatment of periappendiceal, cecal, and appendiceal adenomas-and present an algorithm to guide decision-making regarding the application of these techniques. METHODS: All patients referred to our therapeutic endoscopy practice with tumors involving the Ao between August 2013 and July 2017 were included. Based on tumor size and involvement of the os, patients were either referred for extended laparoscopic appendectomy (ELA), EMR, or a combined approach. RESULTS: In total, 47 patients were included; 25 patients underwent EMR only, 13 patients underwent ELA only, and nine patients underwent combined resection. Two patients undergoing EMR had postpolypectomy syndrome. One EMR-only patient with a positive lateral margin was referred for appendectomy, but declined. No patient required ileocecectomy. Pathologic examination revealed a high rate of sessile serrated adenoma (SSA; 36%). CONCLUSIONS: Our results introduce a decision algorithm and suggest that EMR combined with ELA is a safe and curative technique for the treatment of large cecal adenomas involving the Ao.


Assuntos
Adenoma/cirurgia , Apendicectomia/métodos , Neoplasias do Apêndice/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Adenoma/patologia , Idoso , Algoritmos , Apendicectomia/efeitos adversos , Neoplasias do Apêndice/patologia , Apêndice/patologia , Apêndice/cirurgia , Tomada de Decisão Clínica/métodos , Ressecção Endoscópica de Mucosa/efeitos adversos , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Carga Tumoral
17.
Ulus Travma Acil Cerrahi Derg ; 26(2): 306-313, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32185777

RESUMO

BACKGROUND: Despite the development of clinical, laboratory, and imaging methods, the diagnosis of acute appendicitis is not always easy, and negative appendectomy rates are still high. This study aims to reveal the effects of different scoring systems on the diagnostic accuracy of acute appendicitis and negative appendectomy rates, alone or when evaluated together with ultrasonography. METHODS: In this study, 202 consecutive patients who underwent emergency appendectomy for acute appendicitis were included. Clinical scores of all patients were preoperatively calculated using Ohmann, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), Lintula, Eskelinen, and Alvarado scoring systems. Abdominal ultrasonography (USG) was performed randomly in all cases. The sensitivity and specificity of scoring systems were calculated according to the threshold values. The area under the curve (AUC) was calculated using ROC analysis. In the regression model, histological diagnosis of appendicitis was used as the dependent variable, while scoring systems and USG were preferred as independent variables. RESULTS: The negative appendectomy rate was 15.8%. In the diagnosis of acute appendicitis, Ohmann was the most predictive for both genders (DOR=24.2, 95% CI 6.98-84.44). Similarly, the lowest negative appendectomy rates were obtained with the Ohmann score as 6.9% in females and 3.4% in males. When the scores were combined with USG, the rate of diagnostic accuracy for acute appendicitis was not increased. However, when Ohmann and USG were combined, negative appendectomy rates were further reduced for women from 6.9% to 4%. CONCLUSION: In addition to being a good diagnostic predictor of acute appendicitis in male and female patients, Ohmann score provides the best negative appendectomy rates. The combination of USG and scoring systems does not increase the diagnostic accuracy of acute appendicitis. However, negative appendectomy rates are significantly reduced when the USG and Ohmann scale are used together in females, while this reduction is minimal in men.


Assuntos
Apendicectomia , Apendicite , Ultrassonografia/estatística & dados numéricos , Apendicectomia/efeitos adversos , Apendicectomia/estatística & dados numéricos , Apendicite/diagnóstico por imagem , Apendicite/cirurgia , Humanos , Sensibilidade e Especificidade , Procedimentos Desnecessários
19.
Int J Surg ; 76: 16-24, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32068181

RESUMO

INTRODUCTION: Acute appendicitis is among the most common indications for emergency abdominal surgery. The risk of perforation might increase with a delay in treatment. Therefore, appendicitis is considered a surgical emergency, leading to appendectomies being frequently performed off-hours. However, numerous studies from other medical specialties have shown less favourable outcomes in patients admitted or treated off-hours than in those treated during regular working hours. The purpose of this study was to determine whether the time of day of the procedure and preoperative delay in appendectomy have significant impacts on morbidity and mortality rates. METHODS: All appendectomies recorded in a prospective national quality measurement database (Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie (AQC)) between 2010 and 2017 were retrospectively analysed. The inclusion criteria were appendicitis (International Classification of Diseases diagnostic codes K35-K37), surgical treatment (appendectomy), and available information on the time of day the appendectomy was performed. We stratified patients into four groups according to the start of the operation-'MORNING' for surgeries started between 7:00 a.m. and 12:59 p.m., 'AFTERNOON' for surgeries started between 1:00 p.m. and 6:59 p.m., 'EVENING' for surgeries started between 7:00 p.m. and 11:59 p.m., and 'NIGHT' for surgeries started between midnight and 6:59 a.m. In a further analysis, we examined differences between patients who underwent surgery on the admission day and those who underwent surgery later. A total of 9224 patients with a mean age of 36 ± 19 years (54% men) were included and further analysed. The occurrence of any complication was the primary outcome, whereas in-hospital mortality was the secondary outcome. Variables were entered into bivariate and multivariate analyses. RESULTS: Of the appendectomies, 38% were performed during the afternoon, 31% in the evening, 18% in the morning, and 13% at night-time. Patients who underwent surgery at night had slightly lower American Society of Anesthesiologists scores, were more often managed as emergency cases (98% of the cases), had fewer comorbidities, and were more often covered by statutory instead of private health insurance than the other patients. Junior attending and resident surgeons performed 88% of all night-time operations. The average duration of surgery was not significantly longer in the night-time group than in the day-time groups. The overall complication rate was 4.7%, ranging from 3.5% in the 'NIGHT' group to 5.0% in the 'AFTERNOON' group. However, the differences between the groups were not significant. The in-hospital mortality rate was 0.12% (n = 11), ranging from 0.082% (n = 1) in the 'NIGHT' group to 0.17% (n = 5) in the 'EVENING' group. The timing of appendectomy was not associated with mortality. However, the rates of complications, in-hospital mortality, and conversion were all significantly higher in patients with a preoperative delay of >24 h. CONCLUSIONS: The time of day of performing an appendectomy does not seem have any significant effect on complication and mortality rates. However, a longer length of preoperative stay significantly increases the risk of complications and mortality. Night-time operations should be preferred over next-day surgery considering the equal perioperative risks observed in this study.


Assuntos
Apendicectomia/efeitos adversos , Apendicite/cirurgia , Complicações Pós-Operatórias , Tempo para o Tratamento , Doença Aguda , Adolescente , Adulto , Procedimentos Cirúrgicos Ambulatórios , Apendicectomia/métodos , Comorbidade , Bases de Dados Factuais , Emergências , Serviço Hospitalar de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
20.
J Trauma Acute Care Surg ; 88(5): 619-628, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32039972

RESUMO

BACKGROUND: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE: Epidemiological, level III.


Assuntos
Apendicectomia/economia , Benchmarking/estatística & dados numéricos , Colecistectomia Laparoscópica/economia , Custos Hospitalares/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Adulto , Apendicectomia/efeitos adversos , Apendicectomia/estatística & dados numéricos , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/estatística & dados numéricos , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Hospitais/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estados Unidos , Carga de Trabalho/economia , Carga de Trabalho/estatística & dados numéricos
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