Ten years after its introduction, the contribution and indications for computed tomography (CT) in the diagnosis of appendicitis remain the subject of controversy among surgeons. Many argue that CT is frequently superflu...Ten years after its introduction, the contribution and indications for computed tomography (CT) in the diagnosis of appendicitis remain the subject of controversy among surgeons. Many argue that CT is frequently superfluous and costly, results in excessive radiation exposure, and delays surgical treatment. On our service, we perform 150 to 180 adult appendectomies annually. We feel that CT helps us to avoid unnecessary appendectomy, to clear up diagnostic uncertainty, and, most importantly, to guide the choice of surgical approach. We illustrate our experience through ten clinical cases in which the use of preoperative imaging has resulted in improved care.
The diagnosis of acute appendicitis relies largely on clinical experience; the performance of complementary tests is oftentimes unnecessary. We have created a score based on clinical and laboratory findings which can rel...The diagnosis of acute appendicitis relies largely on clinical experience; the performance of complementary tests is oftentimes unnecessary. We have created a score based on clinical and laboratory findings which can reliably categorize three zones of diagnostic probability : probable, doubtful, or improbable. Only the intermediate category requires complementary imaging. Alvarado first developed a scoring system based on operative findings and this has been modified and improved by others. In our experience, the scoring system of François has been most useful. This score is based on simple clinical data and findings such as age, sex, duration of symptoms, leucocytosis, palpable mass on rectal exam, and urinary symptoms. We have validated this score in a cohort of 202 patients presenting with right lower quadrant abdominal pain and found a sensitivity of 94.7% and a negative predictive value of 97.4% for patients falling into the probable and improbable categories. Management of patients with either very high or very low scores can proceed more expeditiously and with less expense. Diagnostic imaging can be reserved for those patients with intermediate scores where the diagnosis is in doubt. We have established a clinical pathway in our emergency department based on this scoring system.
There are three main histologic types of appendiceal tumor: adenoma, adenocarcinoma, and neuroendocrine tumor. Neuroendocrine tumors (carcinoids) are by far the most common and account for two-third of all appendiceal tu...There are three main histologic types of appendiceal tumor: adenoma, adenocarcinoma, and neuroendocrine tumor. Neuroendocrine tumors (carcinoids) are by far the most common and account for two-third of all appendiceal tumors. Adenomas and adenocarcinomas are both rare; they share two particularities: (a) a mucinous component is both frequent and predominant, (b) they have a tendency to intraperitoneal dissemination. Rupture of any mucinous tumor-whether spontaneous or occurring during surgery-may result in pseudomyxoma peritonei; treatment of this condition requires complete resection of all lesions followed by hyperthermic intraperitoneal chemotherapy. For unruptured appendiceal tumor, the appendix should be removed by a carcinologic right hemicolectomy if the tumor appears aggressive.
The diagnosis of acute appendicitis is still made on the basis of clinical findings in the majority of cases. When the clinical picture is unclear, ultrasound examination is a simple and effective tool to confirm the dia...The diagnosis of acute appendicitis is still made on the basis of clinical findings in the majority of cases. When the clinical picture is unclear, ultrasound examination is a simple and effective tool to confirm the diagnosis. When ultrasound is unsatisfactory due to patient habitus or otherwise fails to clarify clinical uncertainty, abdominopelvic CT scan yields excellent results in terms of both sensitivity and specificity. While recognizing these evidence-based results, the surgeon must remain pragmatic and realize that the quality of each exam depends on the quality of the examination and the experience of the radiologist.
The management of acute appendicitis in the pediatric patient has undergone radical rethinking in recent years. It has been shown that simple uncomplicated acute appendicitis can be successfully managed with antibiotic t...The management of acute appendicitis in the pediatric patient has undergone radical rethinking in recent years. It has been shown that simple uncomplicated acute appendicitis can be successfully managed with antibiotic therapy and may not even require interval appendectomy. Appendicitis complicated by perforation, abscess, or inflammatory phlegmon can be successfully treated by initial antibiotic therapy (with or without percutaneous drainage) and delayed interval appendectomy. While the laparoscopic approach has proved to be well-adapted to many other pediatric surgical procedures, its utility in the treatment of uncomplicated acute appendicitis remains open to debate; compared to standard open appendectomy, it offers only minimal advantages with regard to post-operative care, length of hospital stay, and complications. Children can be managed either by general surgeons or pediatric surgeons depending on the organization of the emergency service; there may be a higher incidence of removal of a normal appendix in non-specialized services.
The current treatment for acute appendicitis is an appendectomy. Several studies have, however, assessed the efficacy of an antibiotic for treating acute appendicitis that is either uncomplicated or complicated by local...The current treatment for acute appendicitis is an appendectomy. Several studies have, however, assessed the efficacy of an antibiotic for treating acute appendicitis that is either uncomplicated or complicated by local peritonitis. A meta-analysis in 2007 that collected the results of 44 prospective studies showed that antibiotics were efficacious in 92.8% of cases of appendicitis complicated by local peritonitis, with percutaneous drainage of an abscess when necessary. No predictive factor for failure was identified. The failure of antibiotic treatment did not increase morbidity. Over time and on the whole, the recurrence rate was only 8.9%. The risk of cancer of the appendix (1.5%) nonetheless led to the recommendation of an interval appendectomy for adults. Four randomized controlled trials have compared antibiotic treatment with an appendectomy for the treatment of uncomplicated acute appendicitis. The efficacy of the antibiotic treatment ranged from 86 to 100% and the recurrence rate from 10.4 to 35%. These studies have had various methodological impediments; however, too few patients were included (40 and 80 patients), or only a clinical diagnosis was made before inclusion, or important protocol violations occurred, in particular for almost half the patient in the antibiotic therapy group in the 2009 study. These problems prevent us from relying on these authors' findings. Antibiotics have a role in the initial treatment of acute appendicitis complicated by local peritonitis. In uncomplicated acute appendicitis, the methodological inadequacy of the currently available randomized trials makes it impossible to reach a definitive conclusion about the efficacy of antibiotics.
Over the last 20 years, the treatment of acute appendicitis has been transformed by the development of the laparoscopic approach. And yet the net value of this approach continues to be debated. Laparoscopic appendectomy...Over the last 20 years, the treatment of acute appendicitis has been transformed by the development of the laparoscopic approach. And yet the net value of this approach continues to be debated. Laparoscopic appendectomy is associated with a lower complication rate and a shorter period of disability in the general population. While operative costs are higher, the global cost of laparoscopic appendectomy is lower than for open appendectomy. There is a somewhat higher rate of abdominal abscess for the laparoscopic route. Laparoscopic appendectomy shows clear advantages in obese patients and in those with gangrenous or ruptured appendicitis. The laparoscopic approach is contra-indicated during pregnancy due to a higher incidence of miscarriage. Treatment of the appendiceal stump by ligature decreases the expense associated with the use of a surgical stapler. When Meckel's diverticulum is encountered during appendectomy, it should be removed in all pediatric patients; in adults, Meckel's diverticulectomy in adults should be performed only for clear-cut pathology. Surgeons continue to innovate and refine appendectomy techniques but many questions remain to be answered.
UNLABELLED: The Committee for the Assessment of Devices and Health Technologies (CEPP), one of the specialist committees of the French National Authority for Health (HAS), reassessed the use of prosthetic mesh for hernia...UNLABELLED: The Committee for the Assessment of Devices and Health Technologies (CEPP), one of the specialist committees of the French National Authority for Health (HAS), reassessed the use of prosthetic mesh for hernia repair in 2008. Mesh use is reimbursed by French national health insurance for use in adult and pediatric surgery. This reassessment had two primary purposes: (a) to define the indications and clinical situations justifying the use of mesh, and to describe the technical requirements; (b) to define the conditions of prescriptions and of use and to contribute to decisions for the renewal of inscription. METHODS: We performed a systematic review of published data and manufacturers' licenses and applied the judgment of a multidisciplinary working group of involved healthcare professionals. The CEPP first analyzed the different sorts of prosthetic mesh according to operative indications; they then compared the performance of each prosthesis based on comparative data from the literature or based on expert opinion when there was no available comparative data. The committee recommended three types of prosthesis: flat patch mesh, three-dimensional mesh (plug), and double-sided patch. Additional studies were recommended to confirm the benefits of selected products. The cost of meshes has been integrated into the reimbursement of each Diagnostic Related Group (DRG) and is no longer included in the List of Reimbursable Products and Services (Liste des produits et prestations remboursables [LPPR]); the High Authority for Health (HAS) recommends the selection of those prostheses evaluated by the CEPP in order to optimize the quality and cost of health care.
The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.jchir.2009.09.002. The duplicate article has therefore been withdrawn.The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.jchir.2009.09.002. The duplicate article has therefore been withdrawn.
Central venous catheter placement with an implanted port (portacath) is used to provide long-term venous access. We report a case of metastatic implantation at a port site from a primary cancer of the base of the tongue....Central venous catheter placement with an implanted port (portacath) is used to provide long-term venous access. We report a case of metastatic implantation at a port site from a primary cancer of the base of the tongue. Insertion of portacaths must be performed using full sterile precautions to avoid spread of tumor cells; in no case should the port site incisions be in contact with the surgical field in which the tumor resection was performed.
Esophageal perforation during nasogastric tube insertion is a very unusual occurrence. In this case report, radiologic images revealed a right-sided aortic arch with a right-sided thoracic aorta. This anatomical anomaly...Esophageal perforation during nasogastric tube insertion is a very unusual occurrence. In this case report, radiologic images revealed a right-sided aortic arch with a right-sided thoracic aorta. This anatomical anomaly probably contributed to the complication and necessitated a modified approach to the surgical repair.
A delayed colo-anal anastomosis has been proposed as a way to avoid diverting stoma after low anterior resection. Surgical and functional results were reviewed in 17 patients operated between 1999 and 2007 using this tec...A delayed colo-anal anastomosis has been proposed as a way to avoid diverting stoma after low anterior resection. Surgical and functional results were reviewed in 17 patients operated between 1999 and 2007 using this technique. Complications included one colonic necrosis, two pelvic abscesses and one colovaginal fistula. Results of continence and quality of life scores were satisfactory. Rates of parietal and septic complications are low after delayed colo-anal anastomosis and functional results are good. The use of this technique is particularly effective to avoid diverting ileostomy and for use in patients with a high risk of pouch fistula.
GOAL: The aim of this study was to perform a detailed analysis of income and expense in a department of general surgery in a French hospital under the new system of funding based on a "fee-for-service" principle. METHODS...GOAL: The aim of this study was to perform a detailed analysis of income and expense in a department of general surgery in a French hospital under the new system of funding based on a "fee-for-service" principle. METHODS: All hospital stays of year 2006 were analysed retrospectively. The conditions of admission (elective vs. emergency), the principal diagnosis, and surgical procedures were examined. We determined hospital costs and the reimbursement for every admission. RESULTS: One thousand nine hundred and eighty-five hospitalizations generated an income of 8Meuros with a deficit of 1.3Meuros. The 775 elective admissions generated 50% of the income and 13% of the deficit (178,562euros). Seven hundred and forty-nine emergency admissions generated 45% of the income and 82% of deficit (1.1Meuros). Four hundred and sixty-one admissions for endoscopy generated 5% of the income and 5% of the deficit (67,249euros). Hospital stays of less than two days (the minimum duration of stay for total reimbursement) caused a loss of 122,624euros. Length of hospital stay below the lower limit caused a loss of 42,850euros. CONCLUSION: Elective surgical activity in digestive surgery can generate a balanced budget provided the length of hospital stay is reduced to the minimum, sometimes to the detriment of patient comfort. Emergency admissions result in a large deficit between cost and reimbursement; this fact may lead hospitals to avoid emergency activity in the future unless appropriate remedial measures are taken.
BACKGROUND: Obstruction due to colorectal cancer is a common occurrence. It often arises in patients in poor general condition with malnutrition and advanced tumor stage. Prognosis can be improved by prompt resolution of...BACKGROUND: Obstruction due to colorectal cancer is a common occurrence. It often arises in patients in poor general condition with malnutrition and advanced tumor stage. Prognosis can be improved by prompt resolution of obstruction through a mininimally invasive approach. GOAL: To analyze the management of cases of acute colorectal obstruction and evaluate the efficacity and morbidity/mortality associated with the use of endocolic stent prostheses. MATERIAL AND METHODS: This retrospective study at a single center evaluated patients presenting with acute colorectal obstruction between January 2003 and May 2008, assessing the patient sample, cancer characteristics, treatment, and morbidity/mortality. RESULTS: The mean age of the 26 patients was 75 years; ASA Class was greater than III in 63% of cases, The colorectal cancer was located in the sigmoid in 65% of cases and was a Stage IV tumor in 73% of cases. Placement of an endocolic stent was the primary intervention in 94% of patients. Morbidity was 12% and mortality was 4%. CONCLUSION: Colonic stenting is an effective therapeutic option in the elderly with painful symptoms of obstruction and should be the initial approach.