Background
The aim of this study is to investigate the outcomes of conservative management of non-complicated acute appendicitis (AA) using our unique institutional protocol, and to compare between ...these and the outcomes of operative management.
Methods
Patients admitted to our institution between March 2016 and October 2019 with non-complicated AA were grouped according to their initial management: non-operative versus surgical. Our unique protocol for non-operative management includes: pain < 3 days; afebrile upon admission; non-gravid; WBC <15,000 (× 10
9
/L); CRP < 5 mg/dl; appendix diameter < 1 cm; no appendicolith on imaging; no prior episode of AA; no history of Inflammatory Bowel Disease; no evidence of peritonitis on physical examination. The primary outcome measured was failure of non-surgical management during the index admission. Secondary outcomes included recurrence rate, readmissions, complications, length of antibiotic treatment and length of stay (LOS).
Results
A total of 695 patients were included, 436 in the operative group and 259 in the non-surgical treatment group. The mean follow-up time was 1004.9 ± 205.7 days. Patients initially treated conservatively rarely required surgery during their index admission (6.9%). Recurrence rate was 19.1% after a mean follow up of 33.4 months. The overall failure rate of conservative management was documented in 20.8% of the patients. The complication rate was higher in those treated with upfront surgery (1.6% vs. 0.4%,
p
< 0.001). The overall LOS was not statistically different between the groups.
Conclusions
Our composite protocol for non-surgical management of non-complicated AA results in a low failure rate. A well calculated patient treatment allocation in non-complicated AA can advocate for wide-spread use of the conservative approach.
Despite established evidence on the advantages of laparoscopy in colon cancer resection,the use of laparoscopy for rectal cancer resection is still controversial.The initial concern was mainly ...regarding the feasibility of laparoscopy to achieve an adequate total mesorectal excision specimen.These concerns have been raised following early studies demonstrating higher rates of circumferential margins positivity following laparoscopic resection,as compared to open surgery.Similar to colon resection,patients undergoing laparoscopic rectal cancer resection are expected to benefit from a shorter length of hospital stay,less analgesic requirements,and a faster recovery of bowel function.In the past decade there have been an increasing number of large scale clinical trials investigating the oncological and perioperative outcomes of laparoscopic rectal cancer resection.In this review we summarize the current literature available on laparoscopic rectal cancer surgery.
Introduction The role of percutaneous cholecystostomy (PC) in the management of patients with acute calculous cholecystitis (ACC) remains controversial. The aim of this study is to report operative ...outcomes in a large cohort of patients undergoing PC before their delayed laparoscopic cholecystectomy (DLC). Methods All patients who underwent DLC because of ACC between 2003 and 2012 were included. Outcomes of patients with and without previous PC were compared. Results Of 639 patients who underwent DLC because of ACC at our institution during a 10-year time interval beginning 2003, 163 (25.5%) patients had PC before their DLC. Patients who underwent PC were older (64 ± 1 years vs 48 ± 0.8 years, P < .001) and had more comorbid conditions ( P < .001). Accumulated duration of stay was longer in the PC group (16.2 ± 0.4 days vs 9.7 ± 0.1 days, P < .001). Rate of conversion to open procedure was greater in the PC group (11% vs 4%, P = .001) and operative time was longer (142 ± 4 minutes vs 107 ± 4 minutes, P < .001). Patients in the PC group had a greater rate of biliary-related complications (10% vs 4%, P = .003) and surgical-site infections; both superficial (5% vs 1%, P = .004) and deep (7% vs 3%, P = .04). On multivariable analysis PC was an independent risk factor for conversion to open cholecystectomy (odds ratio 2.67 95% CI 1.18–6.72) as well as to biliary-related complications (odds ratio 4.85 95% CI 1.57–14.92). Conclusion DLC for ACC in patients with previous PC is associated with longer duration of stay, more readmissions, and, most importantly, greater conversion rate, biliary related complications, and surgical-site infections.
Purpose
To determine whether specific ultrasonographic features can predict failure of conservative treatment of acute appendicitis.
Methods
A 2-year retrospective study was conducted on children ...admitted with acute appendicitis. Those with uncomplicated appendicitis diagnosed solely by ultrasound, and treated conservatively, were followed 18–24 m to assess treatment outcome. Management was considered successful if recurrent acute appendicitis was not observed during follow-up. Appendix diameter, wall thickness, presence of mucosal ulceration, hyperechogenic fat, free fluid, and lymph nodes were evaluated as potential discriminatory ultrasonographic predictors.
T
-tests, chi-square, sensitivity, specificity, and odds ratios were calculated.
Results
Out of 556 consecutive patients that were admitted with acute appendicitis, 180 (32%) managed conservatively. One hundred eleven (62%) imaged by US only. Ninety-two out of 111 (83%) were followed 18–24 m to assess treatment outcome, and 19/111 (17%) were lost to follow-up. Conservative management was successful in 72/92 (78.2%), with treatment failure in 20/92 (21.8%) (5/92 (5.4%) with recurrent acute appendicitis and 15/92 (16.3%) underwent appendectomy). Of the ultrasonographic features studied, mucosal ulceration demonstrated statistically significant predictive value. Fifteen out of 20 (75%) treatment failures had mucosal ulceration, compared to 21/72 (29.2%) of the patients with successful treatment (
p
< 0.001). This yielded a positive odds ratio of 7.3 (2.3–22.6, 95% CI), 70.8% (58.9–80.9, 95% CI) specificity, and 75% (50.9–91.3, 95% CI) sensitivity. Positive predictive value was 41.6% (31.5–52.5, 95% CI) while intact mucosa had negative predictive value of 91% (82.4–95.6, 95% CI) for conservative management success.
Conclusion
The presence or absence of appendiceal mucosal ulceration at ultrasound can predict conservative management outcome in the setting of acute appendicitis, potentially improving pediatric patient selection for conservative management.
Abstract Background Multifocality is an important factor when recommending surgery for papillary thyroid cancer (PTC). The aim of this study is to assess the incidence and characterize the spread ...pattern of multifocal PTC (mPTC) in patients undergoing total thyroidectomy. Methods All thyroidectomies performed between 2003 and 2008 were reviewed identifying 289 patients. Data were obtained for demographics, clinical data, and histopathological findings. Results Of the patients with papillary carcinoma, mPTC was identified in 150 patients (57%), of which 71% had lesions in the contralateral lobe. There were no significant differences in multifocality rate for gender, pathology type, and all tumor size subgroups including ≤1 cm. Pathology examination of representative sections versus the entire gland examination resulted in a significantly lower incidence of contralateral disease ( P = .04). Conclusions Multifocal and contralateral lesions are common in PTC and their incidence is not related to tumor size. Pathology entire gland examination is strongly recommended to properly assess the rate of mPTC.
Although thyroid nodules are common and diagnosed in over 5% of the adult population, only 5% harbor malignancy. Patients with clinically suspicious thyroid nodules need to undergo fine-needle ...aspiration biopsy (FNAB). The main limitation of FNAB remains indeterminate cytopathology. Only 20%-30% of the indeterminate nodules harbor malignancy, and therefore up to 80% of patients undergo unnecessary thyroidectomy. The aim of this study was to identify and validate a panel of microRNAs (miRNAs) that could serve as a platform for an FNAB-based diagnostic for thyroid neoplasms.
The study population included 27 consecutive patients undergoing total thyroidectomy for FNAB-based papillary thyroid cancer (n = 20) and benign disorders (n = 7). Aspiration biopsy was performed from the index lesion and from the opposite lobe normal tissue in all study patients at the time of operation. RNA was extracted from all aspiration biopsy samples. Quantitative polymerase chain reaction on a panel of previously selected miRNAs was performed. Polymerase chain reaction results were compared with final histopathology. miRNA from tumor tissues was amplified using the highest value of each miRNA expression in normal tissue as a threshold for malignancy detection.
Diagnostic characteristics were most favorable for mir-221 in differentiating benign from malignant thyroid pathology. mir-221 was overexpressed in 19 patients (p < 0.0001) with a sensitive yield of 95%. Specificity, negative and positive predictive value, and accuracy of the miRNA panel were 100%, 96%, 100%, and 98%, respectively.
miRNA quantification for differential diagnosis of thyroid neoplasms within aspiration biopsy samples is feasible and may improve the accuracy of FNAB cytology.
Long non-coding RNAs (lncRNAs) have been shown to have functional roles in cancer biology and are dys-regulated in many tumors. Colon Cancer Associated Transcript -1 (CCAT1) is a lncRNA, previously ...shown to be significantly up-regulated in colon cancer. The aim of this study is to determine expression levels of CCAT1 in gastric carcinoma (GC).
Tissue samples were obtained from patients undergoing resection for gastric carcinoma (n=19). For each patient, tumor tissue and normal appearing gastric mucosa were taken. Normal gastric tissues obtained from morbidly obese patients, undergoing laparoscopic sleeve gastrectomy served as normal controls (n=19). A human gastric carcinoma cell line (AGS) served as positive control. RNA was extracted from all tissue samples and CCAT1 expression was analyzed using quantitative real time-PCR (qRT-PCR).
Low expression of CCAT1 was identified in normal gastric mucosa samples obtained from morbidly obese patients mean Relative Quantity (RQ) = 1.95±0.4. AGS human gastric carcinoma cell line showed an elevated level of CCAT1 expression (RQ=8.02). Expression levels of CCAT1 were approximately 10.8 fold higher in GC samples than in samples taken from the negative control group (RQ=21.1±5 vs. RQ=1.95±0.4, respectively, p<0.001). Interestingly, CCAT1 expression was significantly overexpressed in adjacent normal tissues when compared to the negative control group (RQ = 15.25±2 vs. RQ=1.95±0.4, respectively, p<0.001). Tissues obtained from recurrent GC cases showed the highest expression levels (RQ = 88.8±31; p<0.001). Expression levels increased with tumor stage (T4- 36.4±15, T3- 16.1±6, T2- 4.7±1), however this did not reach statistical significance (p=0.2). There was no difference in CCAT1 expression between intestinal and diffuse type GC (RQ=22.4±7 vs. 22.4±16, respectively, p=0.9). Within the normal gastric tissue samples, no significant difference in CCAT1 expression was observed in helicobacter pylori negative and positive patients (RQ= 2.4±0.9 vs. 0.93±0.2, respectively, p=0.13).
CCAT1 is up-regulated in gastric cancer, and may serve as a potential bio-marker for early detection and surveillance.
Background
Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.
Methods
A retrospective review ...was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18 < age < 50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.
Results
Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9 ± 0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7 ± 0.8 years). Groups did not differ in male gender (44 vs. 43 %,
p
= 0.9), preoperative BMI (42.6 ± 0.7 vs. 42.6 ± 0.6,
p
= 0.97), and length of follow-up (17 ± 2 vs. 22 ± 1.4 months,
p
= 0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %,
p
< 0.001). Excess weight loss (EWL) was higher in the younger group (75 ± 2.4 vs. 62 ± 3 %,
p
= 0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %,
p
< 0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %,
p
< 0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %,
p
= 0.13).
Conclusions
LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.
Trans-anal total mesorectal excision (Ta-TME) is a novel approach for the resection of rectal cancer. Low anterior resection syndrome (LARS) is a frequent functional disorder that might follow ...restorative proctectomy. Data regarding bowel function after Ta-TME are scarce. The aim of this study was to evaluate the incidence and risk factors for the development of LARS following Ta-TME.
A prospectively maintained database of all patients who underwent Ta-TME for rectal cancer at our institution was reviewed. All patients who were operated on from January 2018 to December 2021 were evaluated. The LARS score questionnaire was used via telephone interviews. Incidence, severity and risk factors for LARS were evaluated.
Eighty-five patients underwent Ta-TME for rectal cancer between January 2018 and December 2021. Thirty-five patients were excluded due to ostomy status, death, local disease recurrence, ileal pouch or lack of compliance. Fifty patients were included in the analysis. LARS was diagnosed in 76% of patients. Anastomosis distance from dentate line was identified as a risk factor for LARS via multivariate analysis (
= 0.042). Neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS.
LARS is a frequent condition following ta-TME, as it is used for other approaches to low anterior resection. Anastomosis distance from dentate line is an independent risk factor for LARS. In this study neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. Further studies with longer follow-up times are required to better understand the functional outcomes following Ta-TME.
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