AIM To investigate the epidemiology,treatment and outcomes of acute appendicitis(AA) in a large population study.METHODS This is a retrospective cohort study derived from the administrative dataset ...of the Bergamo district healthcare system(more than 1 million inhabitants) from 1997 to 2013.Data about treatment,surgery,length of stay were collected.Moreover for each patients were registered data about relapse of appendicitis and hospital admission due to intestinal obstruction.RESULTS From 1997 to 2013 in the Bergamo district we collected 16544 cases of AA,with a crude incidence rate of 89/100000 inhabitants per year; mean age was 24.51 ± 16.17,54.7% were male and the mean Charlson’s comorbidity index was 0.32 ± 0.92.Mortality was < 0.0001%.Appendectomy was performed in 94.7% of the patients and the mean length of stay was 5.08 ± 2.88 d; the cumulative hospital stay was 5.19 ± 3.36 d and 1.2% of patients had at least one further hospitalization due intestinal occlusion.Laparoscopic appendectomy was performed in 48% of cases.Percent of 5.34 the patients were treated conservatively with a mean length of stay of 3.98 ± 3.96 d; the relapse rate was 23.1% and the cumulative hospital stay during the study period was 5.46 ± 6.05 d.CONCLUSION The treatment of acute appendicitis in Northern Italy is slowly changing,with the large diffusion of laparoscopic approach; conservative treatment of non-complicated appendicitis is still a neglected option,but rich of promising results.
Perianal abscess is a common condition among adults. The treatment of choice includes early and efficient drainage. The data regarding risk factors for abscess recurrence, fistula formation, and ...complications are limited as recent publications mainly focus on patients with inflammatory bowel disease.BACKGROUNDPerianal abscess is a common condition among adults. The treatment of choice includes early and efficient drainage. The data regarding risk factors for abscess recurrence, fistula formation, and complications are limited as recent publications mainly focus on patients with inflammatory bowel disease.To determine risk factors for abscess recurrence and fistula formation with regard to patient and surgical characteristics.OBJECTIVESTo determine risk factors for abscess recurrence and fistula formation with regard to patient and surgical characteristics.A retrospective analysis was performed on patients who presented to the emergency department and were diagnosed with perianal abscess between 2011-2020.METHODSA retrospective analysis was performed on patients who presented to the emergency department and were diagnosed with perianal abscess between 2011-2020.We included 983 consecutive patients; 741 men, average age 43 years. Recurrence was documented in 434 cases. Crohn's disease was reported in 70, of which 50 had recurrent episodes (P < 0.0001); 121 of the 234 patients who smoked had recurrence (P = 0.0078); 8% had short symptomatic period (< 24 hours), which was a predisposing factor for recurrence, P < 0.0001. Patients in the non-recurrent group waited 2.53 hours less for surgical intervention (P < 0.0005(. The average time for recurrent episode was 18.95 ± 33.7 months. Fistula was diagnosed in 16.9% of all cases, while 11.6% were within the recurrent group. Surgical expertise of the physician did not significantly change the recurrence rate.RESULTSWe included 983 consecutive patients; 741 men, average age 43 years. Recurrence was documented in 434 cases. Crohn's disease was reported in 70, of which 50 had recurrent episodes (P < 0.0001); 121 of the 234 patients who smoked had recurrence (P = 0.0078); 8% had short symptomatic period (< 24 hours), which was a predisposing factor for recurrence, P < 0.0001. Patients in the non-recurrent group waited 2.53 hours less for surgical intervention (P < 0.0005(. The average time for recurrent episode was 18.95 ± 33.7 months. Fistula was diagnosed in 16.9% of all cases, while 11.6% were within the recurrent group. Surgical expertise of the physician did not significantly change the recurrence rate.Crohn's disease and smoking were the only significant risk factors for recurrence of perianal abscess. Timely intervention and drainage of sepsis should not be delayed. Involvement of more experienced surgeons did not seem to alter the natural history of the disease.CONCLUSIONSCrohn's disease and smoking were the only significant risk factors for recurrence of perianal abscess. Timely intervention and drainage of sepsis should not be delayed. Involvement of more experienced surgeons did not seem to alter the natural history of the disease.
Laparoscopic Appendectomy in the Days of COVID-19 Abramov, Roi; Neymark, Mariya; Harbi, Asaf ...
Surgical laparoscopy, endoscopy & percutaneous techniques,
10/2021, Letnik:
31, Številka:
5
Journal Article
Recenzirano
Background:
Acute appendicitis is one of the most common emergencies treated by general surgeons. The treatment of choice in the majority of cases is laparoscopic appendectomy. In the era of the ...COVID-19 pandemic, there is a concern for a delayed referral of patients and thus a more advanced presentation of the disease leading to a prolonged and complicated course.
Methods:
Retrospective review of a computerized database of patients who were admitted with acute appendicitis and underwent laparoscopic appendectomy during the COVID pandemic in a single tertiary center in Israel. Patients were compared with those who were admitted and operated for appendicitis in the same period in the previous year.
Results:
One hundred twenty-three patients underwent laparoscopic appendectomy in the study period in 2020, compared with 109 who had surgery in 2019. During the COVID pandemic 41 patients presented with complicated appendicitis versus 22 patients in 2019 (
P
=0.0174). The placement of peritoneal drains was more prevalent during the pandemic, 5.5% versus 11.4%, and the use of stapler device for appendicular stump closure (
P
=0.0105).
Conclusions:
During the first stage of the COVID-19 pandemic, there was a significant increase in the rate of complicated appendicitis. Patients should be strongly encouraged not to refrain from medical treatment and go to the emergency room with the persistence of symptoms.
The learning curve for transition from open to laparoscopic proctectomies is difficult. Most surgeons have considerable laparoscopic experience prior to performing robotic-assisted procedures. There ...are data regarding the transition from open to robotic proctectomies. Minimally invasive anterior resection for rectal cancer has gained widespread popularity in recent years, especially when using a robotic platform.
To analyze the experience to the transition from open to robotic anterior resection for rectal cancer.
We performed a retrospective analysis of a computerized database. All patients who had a robotic-assisted proctectomy between December 2016 and March 2019 were included and were compared to patients who underwent an open anterior resection in the same time period. A single experienced colorectal surgeon with no prior experience in colorectal laparoscopic surgery performed the procedures.
During the study period, 55 patients underwent robotic-assisted proctectomy and 55 had an open proctectomy. Patients had similar pre-operative demographic and clinical characteristics with the majority of patients receiving neoadjuvant chemoradiation. The surgical time was significantly lower in the open surgery group (168 minutes vs. 310 minutes, P = 0.005). Both the surgical and pathological outcomes did not differ significantly between the two groups, with good short-term oncologic outcomes and low complication rates.
The transition from open to robotic-assisted proctectomy is feasible and safe and provides a good alternative for undertaking a minimally invasive surgery for the experienced open colorectal surgeon.
Background
Acute anorectal abscess and fistula are common conditions that usually presents as a painful lump close to the anal margin. Tumors in the distal rectum and in the perianal region may mimic ...the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. The purpose of this study was to describe patients presenting with acute perianal abscess or fistula who were subsequently diagnosed with anorectal cancer.
Methods
We performed a retrospective, review of all cases presenting with acute perianal abscess or fistula who were subsequently found to have anorectal carcinoma on biopsy in two tertiary centers. We analyzed the data focusing on the clinical features, laboratory values, clinical staging of the tumors, the subsequent management, the pathological staging, and the outcome of each patient.
Results
Overall, 3219 patients presenting with anorectal abscess or fistula were reviewed. Cancer was diagnosed in 16 (.5%) patients, 12 with adenocarcinoma of the rectum and 4 with squamous cell carcinoma of the anus. In 5 patients (31.2%), cancer was diagnosed in the setting of chronic perianal fistula, 4 of them had Crohn’s disease. In 10 patients (62.5%), cancer was not diagnosed during the initial evaluation of the acute symptoms.
Conclusions
A high index of suspicion is required to make the diagnosis of perianal tumors when assessing patients presenting with perianal sepsis, particularly those with Crohn’s disease, a long history of persistent perianal disease, and an advanced age. In most cases, proper drainage followed by proximal diversion are the surgical treatment of choice in the acute setting.
Objective
The aim of the present study was to compare the outcomes of conservative versus surgical treatment for acute appendicitis.
Background
Although acute appendicitis is a common disease, great ...debate exists regarding the appropriate management of patients. Conservative treatment has shown positive results in several RCTs, eliciting questions about indications to surgery, therapeutic appropriateness and ethical conduct.
Methods
Data were prospectively collected; a Propensity Score-based matching method was implemented in order to reduce bias arising from characteristics of the patients; a proportion of patients (69 in total) were excluded to obtain two comparable groups of study (1a). Main outcomes of the study were: failure rate, in-hospital length of stay (at first admission and cumulative), post-discharge absence from work. Within the medical group, failure was defined as the necessity for appendectomy after conservative treatment, while it was identified with complications and negative appendectomy within the surgical group (Failure 1). In parallel, an additional definition of failure was proposed (Failure 2) and excluded negative appendectomy from the reasons for failure within the surgical group (5b).
Results
The failure rate for the conservative treatment resulted to be inferior, as compared to the surgical treatment (16.5 vs. 28.4%, OR 0.523
p
= 0.019), considering negative appendectomy as a reason for failure. When excluding negative appendectomy from the definition of failure, medical and surgical treatment appeared to perform equally (failure rate: 16.5 vs. 18.3%, OR 1.014
p
= 0.965). Patients managed conservatively showed to have a shorter length of stay at first admission than the patients who underwent appendectomy (3.11 vs. 4.11 days,
β
= −0.628 days,
p
< 0.0001). A lower number of lost work days after discharge resulted from a conservative approach (6 vs. 14.64 days,
β
= −8.7 days,
p
< 0.0001).
Conclusions
Considering each outcome as part of a wide-angle analysis, the conservative management of acute appendicitis resulted to be safe and effective in the selected group of patients. In terms of failure rate, the medical treatment resulted to perform as effectively as surgical treatment, if negative appendectomy was excluded from failure, or better, when negative appendectomy was included in the definition of failure. A diminished length of stay during the first admission and a reduced number of lost work days were evident with a conservative approach. The comparison between medical and surgical treatment for acute appendicitis requires a change in perspective, from a spare ‘effectiveness analysis’ to a more thorough ‘appropriateness analysis’: in the present study, the conservative treatment showed to address the clinical requirements in terms of therapeutic appropriateness. Although acute appendicitis is considered a ‘surgical disease’, increasing evidence supports the effectiveness and safety of a conservative approach for selected groups of patients.
Laparoscopic cholecystectomy has a 0.3% to 0.5% morbidity rate due to major biliary injuries. The majority of surgeons have routinely performed the so-called "infundibular" technique for gallbladder ...hilar dissection since the introduction of laparoscopy in the early nineties. The "critical view of safety" approach has only been recently discussed in controlled studies. It is characterized by a blunt dissection of the upper part of Calot's space, which does not usually contain arterial or biliary anomalies and is therefore ideal for a safe dissection, even in less experienced hands.
We applied and compared the critical view of safety triangle approach with the infundibular approach in a retrospective cohort study. We divided 174 patients into 2 groups, with a similar case-mix (cholelithiasis, chronic cholecystitis, and acute cholecystitis). Results of operations performed by a young surgeon using critical view of safety dissection were compared to results of the infundibular approach performed by an experienced surgeon. Outcome values and operative times were examined with univariate analysis (Student t test).
No difference occurred in terms of morbidity (even though comparison for biliary injuries is inconclusive because of insufficient power) and outcome; significant differences were found in operative time, favoring the critical view of safety approach in every stage of gallbladder disease, with minor significance for acute cases.
We suggest this technique as the gold standard for resident teaching, because it has a similar rate of biliary and hemorrhagic complications but has a shorter operative time, builds self-confidence, and is a simple standardized method both for complicated and uncomplicated gallbladder lithiasis.
AIM To investigate the epidemiology, treatment and outcomes of acute appendicitis (AA) in a large population study. METHODS This is a retrospective cohort study derived from the administrative ...dataset of the Bergamo district healthcare system (more than 1 million inhabitants) from 1997 to 2013. Data about treatment, surgery, length of stay were collected. Moreover for each patients were registered data about relapse of appendicitis and hospital admission due to intestinal obstruction. RESULTS From 1997 to 2013 in the Bergamo district we collected 16544 cases of AA, with a crude incidence rate of 89/100000 inhabitants per year; mean age was 24.51 ± 16.17, 54.7% were male and the mean Charlson’s comorbidity index was 0.32 ± 0.92. Mortality was < 0.0001%. Appendectomy was performed in 94.7% of the patients and the mean length of stay was 5.08 ± 2.88 d; the cumulative hospital stay was 5.19 ± 3.36 d and 1.2% of patients had at least one further hospitalization due intestinal occlusion. Laparoscopic appendectomy was performed in 48% of cases. Percent of 5.34 the patients were treated conservatively with a mean length of stay of 3.98 ± 3.96 d; the relapse rate was 23.1% and the cumulative hospital stay during the study period was 5.46 ± 6.05 d. CONCLUSION The treatment of acute appendicitis in Northern Italy is slowly changing, with the large diffusion of laparoscopic approach; conservative treatment of non-complicated appendicitis is still a neglected option, but rich of promising results.
The role of angioembolization in managing hemodynamically stable patients with liver injury has obviated the need for surgery. Although mortality and morbidity rates after the adoption of this ...technique have decreased, this procedure is not devoid of complications. This study assesses the impact of this procedure and its associated complications. We performed a case series analysis of patients with hepatic trauma in a level one trauma center over 10 years (2008–2017). Data were collected from hospital records of patients with liver injury and analyzed according to demographics, injury type, management strategy, procedure time, efficacy, complications of embolization, and outcome. We included all patients who underwent angioembolization. Patients who underwent surgery only or had incomplete records were excluded. Of 366 patients with liver trauma, eighteen were managed with angioembolization. Of which, thirteen had grade IV injury or higher, while five had grade II or III. Twelve patients had blunt liver trauma. Six patients were initially managed by laparotomy followed by angioembolization. The most common embolized artery was the right hepatic artery (eleven patients). Nine patients had at least one complication after the procedure. The liver collection was the most common complication (seven patients). There was one hepatic complication-related death. Morbidity was more common in patients who underwent exploratory laparotomy before angioembolization compared to angioembolization alone. Those who had a laparotomy before the angioembolization may have a higher complication rate.
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