IntroductionBased on the epidemiological and clinical data, acute appendicitis can present either as uncomplicated or complicated. The aetiology of these different appendicitis forms remains unknown. ...Antibiotic therapy has been shown to be safe, efficient and cost-effective for CT-confirmed uncomplicated acute appendicitis. Despite appendicitis being one of the most common surgical emergencies, there are very few reports on appendicitis aetiology and pathophysiology focusing on the differences between uncomplicated and complicated appendicitis. Microbiology APPendicitis ACuta (MAPPAC) trial aims to evaluate these microbiological and immunological aspects including immune response in the aetiology of these different forms also assessing both antibiotics non-responders and appendicitis recurrence. In addition, MAPPAC aims to determine antibiotic and placebo effects on gut microbiota composition and antimicrobial resistance.Methods and analysisMAPPAC is a prospective clinical trial with both single-centre and multicentre arm conducted in close synergy with concurrent trials APPendicitis ACuta II (APPAC II) (per oral (p.o.) vs intravenous+p.o. antibiotics, NCT03236961) and APPAC III (double-blind trial placebo vs antibiotics, NCT03234296) randomised clinical trials. Based on the enrolment for these trials, patients with CT-confirmed uncomplicated acute appendicitis are recruited also to the MAPPAC study. In addition to these conservatively treated randomised patients with uncomplicated acute appendicitis, MAPPAC will recruit patients with uncomplicated and complicated appendicitis undergoing appendectomy. Rectal and appendiceal swabs, appendicolith, faecal and serum samples, appendiceal biopsies and clinical data are collected during the hospital stay for microbiological and immunological analyses in both study arms with the longitudinal study arm collecting faecal samples also during follow-up up to 12 months after appendicitis treatment.Ethics and disseminationThis study has been approved by the Ethics Committee of the Hospital District of Southwest Finland (Turku University Hospital, approval number ATMK:142/1800/2016) and the Finnish Medicines Agency. Results of the trial will be published in peer-reviewed journals.Trial registration number NCT03257423
Forgetting a foreign body in the abdominal cavity is an unpleasant and avoidable situation. It usually occurs when the preventive protocols are not followed precisely. In such a case clinical ...consequences are unpredictable and relaparotomy may become necessary.
We present the case of a temporary intestinal obstruction six months after a transabdominal hysterectomy. Diagnostic workup revealed a laparotomy-gauze left in the abdominal cavity at the previous operation. Exploration showed that the gauze was actually located in the intestinal lumen. The inflammatory reaction elicited by the foreign body eroded the intestinal wall and allowed its intraluminal migration. The gauze moved distally due to peristalsis until it became trapped in the ileocecal valve causing obstruction. When it finally passed through the valve the obstruction was relieved. Intraoperative maneuvers advanced the foreign body further forward until it was removed transanally.
The formal processes - counting the gauzes continually and double crossing the counting - must be kept in every laparotomy to avoid the unpleasant experience of gauze remaining in the peritoneal cavity. In such an unfortunate case traditional open surgery provides a safe solution to the patient's problem.
Background and aims
Secondary peritonitis is still associated with high mortality, especially when multiorgan dysfunction complicates the disease. Good prognostic tools to predict long term outcome ...in individual patients are lacking and therefore require further study.
Patients and methods
163 consecutive patients with secondary peritonitis were included, except those with postoperative or traumatic peritonitis. In 58 patients treated in the intensive care unit (ICU), organ dysfunction was quantified using Sequential Organ Failure Assessment (SOFA) score in the first 4 days. Predictive factors for poor outcome were evaluated in all patients. Hospital and 1-year mortality was assessed.
Results
Hospital mortality was 19% and 1-year mortality 23%. Acute physiology and chronic health evaluation II (APACHE II), previous functional status, and sepsis category were predictive of fatal outcome in the total cohort (
p
= 0.034,
p
< 0.001, and
p
< 0.001). In patients treated in the ICU, advanced age and admission SOFA score were independent predictors of death (
p
= 0.014,
p
< 0.0001). The SOFA score showed the best discriminative ability for poor outcome (AuROC 0.78).
Conclusion
Degree of organ dysfunction measured using SOFA score was the best predictor of hospital mortality in patients suffering from secondary peritonitis.
Background and Aims:
This prospective study aimed to review the trustworthiness of the initial clinical assessment in acute appendicitis without employment of imaging modalities, laparoscopy or any ...other adjunct diagnostic test.
Patients and Methods:
717 patients were operated on for appendicitis by six different surgeons. Initial clinical and laboratory examination were evaluated in relation to the intraoperative and the pathological appreciation of the appendiceal inflammation.
Results:
598 patients were found to have appendicitis, 34 a different condition, 41 had both appendicitis and an additional condition and 44 no pathology. 6% of the laparotomies and 11 % of the appendectomies were unnecessary. The severity of the inflammation correlated significantly with periumbilical pain, pain migrating to right lower quadrant, loss of appetite, fever, rebound tenderness, local rigidity, polymorphonuclear predominance on deferential, polymorhonucleosis and leukocytosis. Leukocytosis was less frequent in aged patients. All the six surgeons were found to be equally reliable, although they all underestimated the setting compared to the pathologists. Patients with a long duration of symptoms had milder forms of inflammation and increased percentage of unanticipated abdominal conditions.
Conclusions:
Appendicitis can be reliably diagnosed clinically without employment of adjunct tests. These can be reserved for equivocal cases.
Even though evidence for nonantibiotic treatment of uncomplicated diverticulitis exists, it has not gained widespread adoption.
The aim of this prospective single-arm study was to analyze the safety ...and efficacy of symptomatic (nonantibiotic) treatment for uncomplicated diverticulitis during a 30-day follow-up period.
This study is a single-arm prospective trial (ClinicalTrials.gov ID NCT02219698).
This study was performed at an academic teaching hospital functioning as both a tertiary and secondary care referral center.
Patients, who had CT-verified uncomplicated acute colonic diverticulitis (including diverticulitis with pericolic air), were evaluated for the study. Patients with ongoing antibiotic therapy, immunosuppression, suspicion of peritonitis, organ dysfunction, pregnancy, or other infections requiring antibiotics were excluded.
Symptomatic in- or outpatient treatment consisted of mild analgesics (nonsteroidal anti-inflammatory drug or paracetamol).
The incidence of complicated diverticulitis was the primary outcome.
Overall, 161 patients were included in the study, and 153 (95%) completed the 30-day follow-up. Four (3%) of these patients were misdiagnosed (abscess in the initial CT scan). A total of 14 (9%) patients had pericolic air. Altogether, 140 (87%) patients were treated as outpatients, and 4 (3%) of them were admitted to the hospital during the follow-up. None of the patients developed complicated diverticulitis or required surgery, but, 2 days (median) after inclusion, antibiotics were given to 14 (9%, 6 orally, 8 intravenously) patients.
This study is limited by the lack of a comparison group and by the relatively short follow-up.
Symptomatic treatment of uncomplicated diverticulitis without antibiotics is safe and effective.
Trauma systems in Europe Leppäniemi, Ari
Current opinion in critical care
11, Številka:
6
Journal Article
The purpose of this review is to evaluate the current state and recent developments of trauma systems in Europe.
The introduction of a pilot trauma system in the United Kingdom seemed to halve the ...mortality rate in 6 years. This improvement was thought to result, at least in part, from improved patient care. A comparison of United States and French trauma systems suggested equivalent outcomes among patients who survive to reach the hospital. Epidemiologic studies from Europe show an incidence of 30 to 52 per 1,00,000 per year of major trauma (Injury Severity Score above 15), the vast majority of injuries caused by blunt trauma. The total economic costs of traffic accidents in European countries vary from approximately 7,500 US dollars to 1,20,000 US dollars per injury.
There is little original research on trauma systems in Europe, although some positive effects on mortality of trauma system creation are reported. The level of trauma system development in Europe shows great country-by-country variation. It seems to be in a more advanced stage in the central European countries and less developed in other countries, including the Scandinavian countries, the Baltic states, the United Kingdom, and the Mediterranean countries. In general, specialized trauma surgery training is more advanced in countries with a higher level of trauma system development.
In a prospective, randomized trial the safety and cost-effectiveness of selective nonoperative management was compared to mandatory laparotomy in patients with abdominal stab wounds not requiring ...immediate laparotomy for hemodynamic instability, generalized peritonitis, or evisceration of abdominal contents. Fifty-one patients were randomly assigned to mandatory laparotomy or expectant nonoperative management and compared for early (<90 days) mortality and morbidity, length of hospital stay, and hospital costs. There was no early mortality. The morbidity rate was 19% following mandatory laparotomy and 8% after observation (p = 0.26). Four patients (17%) managed nonoperatively required delayed laparotomy. The hospital stay was shorter in the observation group (median 2 days versus 5 days;p = 0.002). About $2800 (US) was saved for every patient who underwent successful nonoperative management. It is concluded that selective nonoperative management of abdominal stab wounds, although resulting in delayed laparotomy in some patients, is safe and the preferred strategy for minimizing the days in hospital with concomitant savings in hospital costs. Mandatory laparotomy detects some unexpected organ injuries earlier and more accurately but results in a high nontherapeutic laparotomy rate and surgical management of minor injuries that in many cases could be managed nonoperatively.
The extremely high cost of motor-vehicle accidents in public health leads to the necessity of a better injury data collection in the Accident and Emergency Hospital Departments. The 'Asclepeion' of ...Voula Hospital covers the southeastern suburban areas of the greater Athens area (1 000 000 population). The aim of this study is to present information on the pattern of injuries in Athens, in order to understand the magnitude of the problem and develop rational prevention programmes. Specially trained health visitors of the Emergency Department Injury Surveillance System (EDISS) interviewed in person every injured victim who was brought into the Emergency Service of the 'Asclepeion' of Voula Hospital. The study was performed during a 3-year period, from 1996 to 1998; 4564 persons were interviewed. Traffic accidents were more frequent on weekdays with a seasonal peak in July and among young Greeks (aged 25 - 34 years). The usual type of injuries seen in vehicle-accident victims were cerebral contusion and concussion, while in motorcycle-accident victims, head contusion and fractures. The most common reasons for the accident were excessive speed, poor condition of road, inattention, abstraction or drowsiness and drug effects. A total of 29.8% of motorcycle drivers and 5.7% of motorcycle passengers wore a helmet and 26.3% of car drivers and 14.1% of car passengers were using seatbelts. The identification of road traffic injury patterns can contribute to the development of injury prevention measures and guide rational preventive interventions that can reduce the incidence of these injuries. The EDISS system established at 'Asclepeion' of Voula Emergency Service can provide useful and accurate information about this serious and multidimensional problem of Greek Public Health.
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