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Appendicitis Acute [keywords]
- Nonoperative Treatment With Antibiotics Versus Surgery for Acute Nonperforated Appendicitis in Children: A Pilot Randomized Controlled Trial. [JOURNAL ARTICLE]
- Ann Surg 2014 Jul 28.
The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children.A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year.Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination.Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
- [Giant abscessed urachal cyst in adult. Case report.] [JOURNAL ARTICLE]
- Cir Cir 2013 July-August; 81(4):348-352.
Background: during gestation, the urachus represents the connection between the dome of the bladder and the allantoic duct. This infection occurs preferentially in young adults, advocating the haematogenous or lymphatic pathway as possible routes of transmission, while a cord or bladder origin may also occur. Urachal cysts are rare in adult life, and is observed in only about 2% of adults. Clinic case: A 30-year-old male patient with a history of alcoholic hepatitis, diabetes mellitus type 2, chronic malnutrition, increased volume beginning with generalized abdominal pain, abdominal tumor of 20 by 15 cm, mobile, solid, without signs of peritoneal irritation. CT showed the presence of tumor, probably bladder-dependent, and apparently cystic. Exploratory laparotomy was found infected urachal cyst, draining 3,000 cc purulent material. A partial resection of the anterior face, keeping the back by firm adherence to bowel loops was done and is evolving satisfactorily. Discussion: urachal abnormalities are rare, with male / female ratio of 2 / 1. Although urachal abscess is an infection confined to an enclosed space, definitive treatment should not be the simple incision and drainage, because of the possibility of malignant transformation of urachal remnants. The definitive treatment should be considered complete excision of urachal cyst, when the infection is limited. Conclusion: the urachus cyst is a rare pathology and is a diferencial diagnosis for acute appendicitis and it is necessary to know this treatment.
- [Appendicovesical fistula treated with elective laparoscopic surgery.] [JOURNAL ARTICLE]
- Cir Cir 2013 July-August; 81(4):344-347.
Background: appendicovesical fistula is a rare complication of advanced acute appendicitis and represents a rare type of enterovesical fistula. Its symptoms are vague and imprecise and its diagnosis is difficult, requiring a high level of suspicion. Exploratory laparotomy has been the key for diagnosis and definitive treatment for many years, but recently the laparoscopic approach is standing out among different experienced groups as the method of choice. Clinical case: we report a new case of appendicovesical fistula in a 45 year old female, who was remitted from Urology with symptoms of persistent dysuria and pyuria. She was finally diagnosed by computerized tomography and the appendicovesical fistula was resolved by laparoscopic surgery. This case adds to the one hundred and fifteen cases published so far and to the four treated by the laparoscopic approach. Discussion: conventional imaging methods are not reliable for the diagnosis of enterovesical fistula. Since most appendicovesical fistula are found to be secondary to non-diagnosed and advanced acute appendicitis in the majority of the consulted publications laparotomy is the key for the diagnosis of apendicovesical fistula. However laparoscopy is described as a diagnostic and therapeutic tool in few articles. We only found three articles in the literature referring to the laparoscopic approach as a therapeutic option. Conclusion: computerized tomography is the diagnostic method of choice when communication between the digestive tract and urinary tract is suspected, particularly if the suspected fistula is an appendicovesical one. The laparoscopic approach of an appendicovesical fistula is able to confirm the radiological diagnosis and provide a definitive treatment.
- Does selective use of computed tomography scan reduce the rate of "white" (negative) appendectomy? [Journal Article]
- Isr Med Assoc J 2014 Jun; 16(6):335-7.
Appendectomies are the most common operations performed on an emergency basis. The accepted rate of "white" appendectomies is around 20%. In recent years, computed tomography (CT) scanning has been recognized as a valuable tool with high sensitivity and specificity in the diagnosis of acute appendicitis. The use of CT scans in the management of patients with suspected acute appendicitis is increasing worldwide.To assess whether introducing more liberal use of CT in the management of patients presenting to the emergency room with right lower quadrant pain or suspected acute appendicitis would reduce the rate of "white" appendectomies.We conducted a retrospective study of the pathology reports and CT scans of all patients who underwent appendectomy during a 3 year period. We examined the correlation between the rate of CT scans performed and the rate of "white" appendectomies.Overall, we performed 797 appendectomies during the study period. In 2004, we performed 272 appendectomies and CT in 34 patients (12.5%). In 2005, we performed 275 appendectomies and CT in 83 patients (30.2%). In 2006, we performed 250 appendectomies and CT in 88 patients (35.2%). The percentage of "white" appendectomies decreased from 29% in 2004 to 21.1% in 2005 and to 18.8% in 2006.It appears that a more selective use of CT scans in the management of suspected appendicitis could reduce the rate of "white" appendectomies.
- Drainage of Periappendiceal Abscess and Removal of Free Fecalith-Extraperitoneal Approach. [JOURNAL ARTICLE]
- Int Surg 2014 July-August; 99(4):379-383.
Abstract Treatment of complicated acute appendicitis is controversial. The dilemma is further complicated by presence of free fecalith in a well-circumscribed abscess, which has been repeatedly demonstrated to be a major predicting factor of treatment failure of nonoperative treatment of acute appendicitis complicated with appendiceal abscess. If left behind after drainage of the abscess, further operations for removal of retained fecalith or recurrence of abscess might be required. However, little had been stressed over the significance of removal of the free fecalith when it was first encountered. We report our experience of drainage of appendiceal abscess and removal of free fecalith by taking an extraperitoneal approach. Both of our cases made a smooth recovery without any complication or recurrence after a 2-year follow-up. Treatment with this approach avoids many of the complications associated with formal laparotomy. Unlike image-guided drainage or laparoscopic drainage, this procedure is relatively simple and straightforward and can be performed in any level of hospital, including private practitioners and in less well-developed areas and countries. With proper case selection, we recommend this approach as one of the alternatives in the treatment of late-presenting appendiceal abscess with free fecalith.
- Quantitative measurement of elasticity of the appendix using shear wave elastography in patients with suspected acute appendicitis. [Journal Article]
- PLoS One 2014; 9(7):e101292.
Shear wave elastography (SWE) has not been studied for diagnosing appendicitis. We postulated that an inflamed appendix would become stiffer than a normal appendix. We evaluated the elastic modulus values (EMV) by SWE in healthy volunteers, patients without appendicitis, and patients with appendicitis. We also evaluated diagnostic ability of SWE for differentiating an inflamed from a normal appendix in patients with suspected appendicitis.Forty-one patients with clinically suspected acute appendicitis and 11 healthy volunteers were prospectively enrolled. Gray-scale ultrasonography (US), SWE and multi-slice computed tomography (CT) were performed. The EMV was measured in the anterior, medial, and posterior appendiceal wall using SWE, and the highest value (kPa) was recorded.Patients were classified into appendicitis (n = 30) and no appendicitis groups (n = 11). One case of a negative appendectomy was detected. The median EMV was significantly higher in the appendicitis group (25.0 kPa) compared to that in the no appendicitis group (10.4 kPa) or in the healthy controls (8.3 kPa) (p<0.001). Among SWE and other US and CT features, CT was superior to any conventional gray-scale US feature or SWE. Either the CT diameter criterion or combined three CT features predicted true positive in 30 and true negative in 11 cases and yielded 100% sensitivity and 100% specificity. An EMV of 12.5 kPa for the stiffest region of the appendix predicted true positive in 28, true negative in 11, and false negative in two cases. The EMV (≥12.5 kPa) yielded 93% sensitivity and 100% specificity.Our results suggest that EMV by SWE helps distinguish an inflamed from a normal appendix. Given that SWE has high specificity, quantitative measurement of the elasticity of the appendix may provide complementary information, in addition to morphologic features on gray-scale US, in the diagnosis of appendicitis.
- Single-incision laparoscopic appendectomy for treating appendicitis in a patient with gastrointestinal malrotation. [JOURNAL ARTICLE]
- Int J Surg Case Rep 2014 Jun 30.
Intestinal malrotation is a rare congenital anomaly, and acute appendicitis associated with intestinal malrotation is extremely rare. PRESENTATION OF CASE We report a rare case of a 47-year-old Japanese woman diagnosed with barium-related perforated appendicitis associated with intestinal malrotation. We used a transumbilical single-incision laparoscopic approach to resect the appendix, and the procedure was completed successfully without perioperative complications.To our knowledge, single-incision laparoscopic surgery for appendicitis associated with intestinal malrotation has not been reported yet. In cases with mobile cecum such as this one, mobilization from inflammatory adhesion of the surrounding structures is easy.We conclude that transumbilical single-incision laparoscopic appendectomy is a simple and less invasive method for treating appendicitis associated with intestinal malrotation.
- [Clostridial myonecrosis of the abdominal wall - case report.] [JOURNAL ARTICLE]
- Rozhl Chir 2014; 93(6):328-330.
The authors present a case report of a forty-five-year-old patient operated on for acute appendicitis who developed gas gangrene of the abdominal wall within 48 hours after an appendectomy and subsequently also clostridial sepsis. Due to early diagnosis and intensive care, the patient survived. Clostridial myonecrosis is a rare complication after abdominal surgery and may be fatal in many cases. In our literature, there are only a few publications describing cases of patients who survived this rare postoperative complication. Key words: clostridial sepsis - gas gangrene of the abdominal wall - appendectomy.
- Appendiceal carcinoids in children-management and outcomes. [JOURNAL ARTICLE]
- J Surg Res 2014 Jun 24.
Appendiceal carcinoid tumors are very rare in children, and management has been guided by adult presentations and outcomes. Here, we present our experience with pediatric appendiceal carcinoid tumors.We undertook a retrospective review of all cases of appendiceal carcinoids in children over a 20-y period. Data regarding clinical presentation, diagnosis, pathology, follow-up, and outcomes were collected and analyzed.We identified 13 cases of appendiceal carcinoids. All cases were diagnosed after appendectomy for presumed appendicitis (nine acute and four interval;), with no patient having carcinoid syndrome. Mean age at diagnosis was 13.7 y, and all but one case was female. Tumor size ranged from microscopic foci of tumor cells to 2.1 cm (mean, 0.93 cm). Seven cases had invasion of the mesoappendix, three of which underwent a subsequent right hemicolectomy. The patient with the largest tumor (2.1 cm) had evidence of lymphatic invasion with three nodes positive for tumor after right colectomy. No patient had elevation of 5-hydroxyindoleacetic acid or serum chromogranin A, and surveillance computed tomographic scans did not reveal any liver metastases.This is a relatively large series of carcinoids of the appendix in children. We found no evidence of carcinoid syndrome or metastatic disease in these cases other than lymphatic. The need for a secondary colectomy is perhaps questionable.
- Inflammatory appendix mass in patients with acute appendicitis: CT diagnosis and clinical relevance. [JOURNAL ARTICLE]
- Emerg Radiol 2014 Jul 20.
The purpose of our study was to analyze the clinical relevance of computerized tomography (CT) in providing the diagnosis of inflammatory appendix mass (IAM) in patients with acute appendicitis. The CT images of 134 patients were reviewed. Two groups of patients were made according to the presence (group 1; n = 21) or the absence (group 2; n = 113) of IAM. Clinical signs of patients, CT features, complications at surgery, and histological examinations were noted. Inter-observer agreement was assessed by using kappa statistics. Twenty-one patients presenting with CT features of IAM were diagnosed. An excellent inter-observer agreement (κ = 0.94) was assessed for the diagnosis of IAM. No significant statistical difference in the age distribution was observed between patients with IAM (mean age 55) and patients without (mean age 45) (p = 0.2232). No clinical sign showed a statistically significant association with the presence of IAM (p = 0.707) or with complication encountered at surgery (p = 0.180). Delay to CT examination was 5.4 days in patients presenting with CT features of IAM and of 1.7 days for patients presenting without (p = 0.0001). Conversely to acute appendicitis complicated by simple perforation (p = 0.153) or peri-appendicular abscess (p = 0.501), acute appendicitis presenting with IAM showed a statistically significant association with complications encountered at surgery (p = 0.0003) and the need for conversion to open surgery (p = 0.001). Performing CT in complicated acute appendicitis provides the diagnosis of IAM. Distinction of IAM appeared to be of clinical relevance, since immediate surgery in IAM was statistically associated with surgical complications and conversion to open surgery in our study.