Delay In Surgical Treatment Research Articles

Three cases of vaginal radical trachelectomy during pregnancy

Vaginal radical trachelectomy (VRT) is a surgical procedure that can be used to treat young women with cervical carcinoma while preserving the uterine fundus and future fertility [1]. A challenging clinical problem is the treatment of cervical carcinoma during pregnancy. There is little data regarding this topic in the literature (Table 1) and clear guidelines for the optimal management of cervical cancer complicating pregnancies are lacking. Delay of surgical staging and treatment will improve the fetal outcome but could be detrimental for the mother. We report three pregnancies complicated by cervical cancer treated by VRT with preservation of the concurrent pregnancy and the birth of healthy infants (Table 1).

Nerve Monitoring During Proximal Humeral Fracture Fixation: What Have We Learned?

The incidence of neurologic injury after proximal humerus fractures is variable, ranging from 6.2% to as much as 67%. However, it is unclear what factors might contribute to these injuries or whether they can be prevented by intraoperative nerve monitoring. Therefore, using intraoperative nerve monitoring, we assessed the incidence, pattern of nerve involvement, and predisposing factors for nerve injury before and during shoulder fracture fixation. We used continuous intraoperative monitoring of the brachial plexus in 37 patients undergoing open operative treatment of proximal humerus fractures. Impending intraoperative compromise of nerve function was signaled by sustained neurotonic EMG activity or greater than 50% amplitude attenuation of transcranial electrical motor evoked potentials (MEPs) (or both). When a nerve alert occurred, current surgical activity and arm and retractor position were recorded and adjustments were made to relieve tension. The intraoperative affected nerves included axillary (46%), combined (mixed plexopathy) (23%), radial (23%), musculocutaneous (4%), and ulnar (4%). Postoperatively, three patients had transient nerve palsies, which fully resolved within 3 weeks of surgery. Low body mass index (BMI) (22.7 ± 2.8), history of cervical spine disease, diabetes mellitus, and delay in surgical treatment (14 ± 2.9 days from time of injury) were associated with an increased incidence of nerve dysfunction. Our observations suggest transcranial electrical MEPs are sensitive indicators of impending iatrogenic injury to the brachial plexus or peripheral nerves (or both) during open operative treatment of proximal humerus fractures. The use of intraoperative nerve monitoring during these procedures may be considered for the prevention of nerve injury, particularly in patients with underlying cervical spine disease, low BMI, diabetes mellitus, and/or delay in surgical treatment greater than approximately 14 days. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Effects of Delayed Hip Fracture Surgery on Mortality and Morbidity in Elderly Patients

The effects of delaying hip fracture surgery on mortality and morbidity in elderly patients are not completely understood. We examined the effects of delays in surgical treatment of hip fracture on mortality, postoperative complications, length of stay in hospital, and functional recovery, in elderly patients. We studied two groups of patients with hip fractures. The first group was studied retrospectively (n = 109); these patients had been exposed to an average delay in receiving surgical treatment of more than 1 week owing to a fire at our hospital. Patients in the second group (n = 79), which we studied prospectively, were operated on within 48 hours of experiencing the fracture or as soon as their medical condition permitted. Rates of mortality and complications were registered for each group. We found a larger number of complications in the group with a delay in surgical treatment (pressure ulcer, urinary infection, deep vein thrombosis, and postoperative length of stay), but there were no differences in mortality or functional recovery at 3 months and 1 year. A 1-week delay in the surgical treatment of elderly patients with hip fractures did not increase the mortality rate or prolong the period of recovery but did increase the incidence of postoperative complications. Our experience suggests elderly patients with hip fractures should be operated on as soon as their medical condition permits. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Ankle fractures: impact of swelling on timing of surgery, length of hospital stay and the economic burden

Introduction: Ankle fractures are among the commonest orthopaedic injuries. A delay in operating is often due to the swelling associated with such fractures. On the other hand, the delay in operative fixation beyond 24 h from injury is associated with a lengthening of hospital stay which costs approximately £225 per patient per day for an acute trauma bed. Objectives: The aim of this study was to analyse the relationship between the delay in surgical intervention of open reduction and internal fixation of ankle fractures from presentation due to ankle swelling, and the length of hospital stay and postoperative complications. Patients and Methods: A retrospective study of 145 consecutive patients treated for ankle fractures over a period of 12 months between January and December 2008. results were collated excluding talar and pilon fractures. Emergency department presentation times were noted and time of anaesthetic to determine surgical delay. Notes were reviewed for inpatient stay and postoperative complications. Results: There were 62 male and 83 female patients with a mean age of 49 years. In total, 117 (80%) patients were operated on within 24 hours of presentation (early group). 28 patients’ surgery was delayed beyond 24 hours (delayed group). Of the 117 patients the mean inpatient stay was 3.79 days (± 2.39) whereas in the delayed group the mean stay was 8.57 days (± 6.54). Of the delayed group, 57% of the cases had swelling as the cause of a postponed operation, whereas other causes included lack of theatre time and lack of fitness for surgery. In the early group, 5 patients (4.27%) had wound infections and one patient had a chest infection (0.85%). Four patients (14.28%) from the delayed group developed wound infections all of whom were from patients with ankle swelling. Conclusion: We recommend that policies be put in place to provide early operative intervention for patients with fractured ankles prior to the development of swelling as this would result in improved patient outcome and significant financial savings. If an operation is not feasible within 24 hours of admission and the ankle is swollen resulting in a high operative risk, we recommend sending the patient home for a period of 5–7 days with advice on RICE and anticoagulation which would both permit surgery and cut down costs.

Reasons for the delay of surgical treatment among patients with age-related cataracts in urban Chongqing, China

This prospective study sought to determine the demographic and socioeconomic factors that predicted the delay of cataract surgery in patients suffering from hyper-mature or mature cataracts in urban Chongqing, China. A total of 576 patients who had mature or hyper-mature age-related cataracts were interviewed to determine the reasons why a delay in their cataract treatment had occurred and to identify factors associated with the delay. These data were collected in urban Chongqing, China from 1st January, 2008 to 31st December, 2008. The major factors associated with the delay of surgical treatment included the following: a diagnosis of an “immature” cataract; partially intact vision; unawareness of presence of cataract. The amount of time in which cataract surgery was delayed was associated with age, medical insurance, and eye examination (P < 0.05). Aging, lack of medical insurance, and an annual eye examination were all factors that impeded cataract patients from seeking cataract surgery. In order to convince patients to receive timely cataract surgery, it is important that individuals 50 years of age and older have an annual eye examination and are educated about cataracts and the importance of cataract surgery, as well as the expansion of medical insurance coverage. Key words: Cataract, surgery, prospective, delaying, urban.

Prolapse of bowel via patent vitello intestinal duct—a rare occurrence

This report describes the presentation of prolapse of small bowel through the patent omphalomesenteric or vitello intestinal duct in a child. In spite of diagnosing the anomaly earlier, there was delay in surgical intervention that led to prolapse of the small bowel through patent remnants, which was life threatening. The patient presented to us with questionable viability of prolapsed bowel. Early surgery is recommended for this entity. As this is a very rare occurrence, it is being reported with a brief review of the relevant literature.

Invited Commentary

Achalasia is the most common and best characterized primary esophageal motility disorder with a prevalence of 10 per 100,000 individuals, with an annual incidence of 0.5 cases per 100,000 individuals. The natural pathology of achalasia is such that progressive neural degeneration leads to dysphagia, a defunctionalized esophagus, and eventually end-stage disease that requires an esophagectomy. Finley and colleagues [1Finley C. Kondra J. Clifton J. Yee J. Finley R. Factors associated with postoperative symptoms after laparoscopic Heller myotomy.Ann Thorac Surg. 2010; 89: 392-396Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar] have investigated the effects of initial nonoperative management in short- and long-term symptoms after myotomy for a 14-year period of study. The most concerning finding was that Botox therapy at initial presentation was associated with a higher rate of dysphagia 1 year after surgical myotomy. A surgical concern with Botox is the development of fibrosis leading to difficulty in submucosal dissection during the myotomy and even possible incomplete myotomy. These findings suggest that initial temporizing procedures are not without consequences. Every study has its limitations. This article provides useful information, although ascertainment bias is likely present because all subjective data were recorded by the operating surgeon. There must also be some caution used to interpret the initial treatment data because of the neat separation of the three initial treatments (ie, 62.3% medication, 38.7% pneumatic dilation, and 11.1% Botox). There is no description of overlap between the three treatments, which is common to everyday practice. Half of the patients in this study underwent fundoplication. Many United States' surgeons believe that a myotomy of this extent should be followed by a partial fundoplication to prevent reflux. A prospective randomized trial conducted in the United States on 43 patients demonstrated a lower incidence of reflux without increased dysphagia in patients who underwent myotomy plus Dor compared with myotomy alone [2Richards W.O. Torquati A. Holzman M.D. et al.Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind trial.Ann Surg. 2004; 240: 405-412Crossref PubMed Scopus (423) Google Scholar]. Despite this data, the role of fundoplication remains controversial, especially outside the United States. The myotomy does not reverse the underlying pathophysiology of neural degeneration, but it does convert the esophagus into a passive conduit dependent on gravity for evacuation. A balance between obtaining a complete myotomy and the avoidance of excessive reflux is the primary goal. Delay in surgical treatment will only increase the likelihood of long-term sequela (ie, mega-esophagus, thereby leading to esophagectomy for end-stage disease). Finley and colleagues [1Finley C. Kondra J. Clifton J. Yee J. Finley R. Factors associated with postoperative symptoms after laparoscopic Heller myotomy.Ann Thorac Surg. 2010; 89: 392-396Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar] provide additional evidence to support the early treatment of achalasia by surgical intervention rather than exhaustive conservative treatments. Factors Associated With Postoperative Symptoms After Laparoscopic Heller MyotomyThe Annals of Thoracic SurgeryVol. 89Issue 2PreviewOur objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia. Full-Text PDF

A Case of Jeujunogastric Intussusception Presented with Hematemesis after Distal Gastrectomy

Adult intussusception represents 5% of all cases of intussusception and accounts for only 1-5% intestinal obstructions. Intussusception is a rare complication after gastric surgery with an incidence estimated at 0.1%. Early diagnosis of the acute onset intussusception is critical because mortality rates increase abruptly with delay in surgical treatment. We present here a case of jejunogastric intussusception diagnosed by gastroscopy in a patient with a history of distal gastrectomy due to early gastric cancer who had experienced hematemesis.

Biopsy of pheochromocytomas and paragangliomas: Potential for disaster

Pheochromocytomas and paragangliomas are highly vascular neuroendocrine neoplasms that often secrete catecholamines. Percutaneous biopsy has been associated with life-threatening hemorrhage, hypertensive crisis, capsular disruption with tumor implantation, and death. We sought to determine the outcomes of biopsy in 20 consecutive patients. We reviewed retrospectively the medical records of patients with biopsied pheochromocytomas and paragangliomas referred to our Endocrine Division for subsequent management between 1995 and 2005. Biopsy complications, operative findings, and outcomes were reviewed. Twenty patients (14 pheochromocytomas and 6 paragangliomas) were biopsied percutaneously prior to referral. Mean tumor diameter was 6.4 cm (range, 1-15). Pre-biopsy biochemical testing was not performed in 90% of patients, and was negative in the remainder. Fourteen patients (70%) developed a biopsy-related complication, including: increased difficulty of the definitive operation in 7 of 17 (41%) operative cases with 1 patient requiring conversion to an open procedure; severe hypertension (15%); hematoma (30%); incorrect or inadequate biopsy (25%); severe pain (25%); and delay in surgical treatment (15%). Mean follow-up was 58 months, with 4 tumor-related deaths and 2 recurrences. Biochemical testing prior to biopsy of adrenal or suspicious retroperitoneal masses is critical to exclude a catecholamine-secreting neoplasm because serious complications and increased operative difficulty can result.

Surgical interventions for idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) can present with severe loss of vision or with ongoing vision loss despite maximal medical therapy; these situations require aggressive management with surgical interventions. To date, optimal surgical management has not been clearly defined. A review of the recent literature is undertaken to clarify the role of surgical interventions in IIH. To date, no prospective, randomized study has been performed comparing lumboperitoneal shunt, ventriculoperitoneal shunt and optic nerve sheath fenestration/decompression. Procedure choice appears to be based on local availability and expertise, as well as the prominence of presenting symptoms. Delay in surgical intervention for fulminant and medically refractory cases leads to worse visual outcomes. Surgical intervention for IIH will likely be based on local expertise until well designed, multicentered clinical trials clarify which intervention best suits a particular patient.

A Clinical Analysis of Shoulder and Hip Joint Infections in Children

Septic arthritis of the shoulder is a rare infection in healthy children. This infection requires prompt surgical drainage and antibiotic treatment. A delay in surgical intervention can result in damage to the articular surface of the glenohumeral joint, adjacent osteomyelitis, and possible growth disturbance. The clinical course of septic arthritis of the shoulder was compared with that of septic arthritis of the hip, a more common disease in children. We identified 9 children with infections of the glenohumeral joint who presented to our pediatric hospital between 2001 and 2007. The average age at presentation was 7 years (range: 7 mo to 12 y). These patients were compared with 14 selected patients treated for septic arthritis of the hip (mean age 7 y, range: 1 to 12 y). Surgical drainage was performed by open arthrotomy in each case. A retrospective review and analysis of the medical records, laboratory tests, and radiographs of these patients were performed. Children with shoulder infections differed significantly (P<0.05) from patients with hip infections with regard to temperature, white blood cell count, and erythrocyte sedimentation rate at the time of admission. The average time from the onset of symptoms to presentation was notably longer in the shoulder group compared with the hip group (P=0.012). Adjacent osteomyelitis was found in 67% of the shoulders and 36% of the hips (P=0.214). Children suffering from septic arthritis of the shoulder showed higher rates of repeat surgical drainage (P=0.056) and extended hospitalizations (P=0.028). The total duration of antibiotics was longer in the shoulder group (P=0.059). Septic arthritis of the shoulder in the pediatric population often has a delayed presentation with a more complicated disease course than an infection of the hip. Children with shoulder infections require a longer duration of treatment and may experience a higher likelihood of skeletal complications. Level III, retrospective comparative study.

Growth of congenital malignant teratoid medulloepithelioma of the ciliary body: a case study

The purpose of this study was to describe the growth pattern of congenital malignant teratoid medulloepithelioma of the ciliary body by reporting clinical and imaging findings with pathological correlation. An 11-month-old little girl presented with a whitish-pink iris mass in the right eye resulting from a small ciliary body mass consistent with medulloepithelioma at both clinical and computed tomography (CT) findings. At CT, the lesion showed heterogeneous attenuation, without intraocular calcifications. Eleven months later, clinical and ultrabiomicroscopy showed a clear enlargement of the mass, which invaded the pupil. At magnetic resonance imaging (MRI), the lesion showed T1-weighted hyperintensity and T2-weighted slight hypointensity when compared to the vitreous and a notch in the anterolateral aspect of the ipsilateral lens. After intravenous gadolinium administration, the lesion showed intense homogeneous enhancement, and there was leakage of gadolinium in the anterior chamber, resulting from impairment of blood-aqueous barrier. Biopsy revealed a malignant teratoid medulloepithelioma. The eye was then enucleated, and histology confirmed the diagnosis. Systemic chemotherapy and radiotherapy were not performed, since there was no extraocular extension. The 57-month clinical and MRI follow-up did not show disease relapse. This uncommon case displays the natural history of congenital malignant teratoid medulloepithelioma of the ciliary body. While the tumour might have been successfully treated by local excision at diagnosis, the delay in surgical treatment led to tumour overgrowth with consequent need for enucleation. The most important prognostic feature is extraocular extension, which carries a risk of local recurrence, eventually resulting in intracranial extension and/or lymphatic spread.

Effect of modest delays in primary surgical treatment on progression of tumor size in breast cancer patients

622 Background: Evaluation of medical co-morbidities, coordination of reconstructive surgery and referral to tertiary care centers can delay surgical treatment in breast cancer. These delays raise concerns for tumor progression in the interim. We evaluated the time from initial imaging at a cancer center to surgical treatment and the change in tumor size. Methods: We identified 823 patients who underwent surgery as their first therapeutic modality for invasive breast cancer diagnosed from December 2003 to September 2005. Baseline tumor size was determined by mammogram (MMG) and ultrasound (US) reports, and tumor size at surgery was determined by pathology reports. Results: The median time from imaging at our facility to surgery was 0.69 months (range 0.03 to 4.34). Multivariate modeling indicated that older patient age, undergoing total mastectomy, and undergoing reconstruction predicted a longer time from initial imaging to surgery. Comparing radiographic to pathologic size, a moderate correlation was demonstrated for both MMG (Spearman r = 0.58; p &lt; 0.0001) and US (Spearman r = 0.66, p &lt; 0.0001). Pathologic size was the same as MMG size in 14%, smaller in 49%, and larger in 37% of patients. Differences in tumor size estimates were not significantly associated with time lapse between MMG and surgery, but in a multivariate model, MMG tumor size, tumor histology, and tumor grade were significant predictors (p &lt; 0.0001 for all) of differences in mammographic and pathologic size. The pathologic tumor size was the same as US in 10%, smaller in 38%, and larger in 52% of patients. Time lapse to surgery was not significantly associated with differences in US and pathologic tumor size. In a multivariate model, US tumor size (p &lt; 0.0001), tumor histology (p = 0.0006) and tumor grade (p = 0.005) were significant predictors of differences in US and pathologic tumor size estimates. Conclusions: There is no evidence that time lapse from initial imaging to surgical intervention leads to significant changes in tumor size thus allowing patients to complete preoperative workup and planning without significant clinical disease progression. No significant financial relationships to disclose.

Control de calidad en la gestión de las reclamaciones de los usuarios del área sanitaria 10 de atención especializada de la comunidad de Madrid (2000-2005)

ObjectiveTo analyse the complaints made by users of the National Health System in the University Hospital of Getafe (Madrid, Spain), to characterise trends in complaint rates over time and to appraise the quality control in the management of complaints. Material and methodsAll complaints made between January 2000 and December 2005 were recorded and the incidence rate and annual percent change were calculated. The relationships between complaints and time were analysed. Finally, the percentage of complaints correctly dealt with in less than 30 days was calculated. ResultsThe number of complaints increased from 132.93 to 482.28 per 100,000 inhabitants. The annual percent increase was +15.21. There was a relationship between several types of complaints and time (disagreement with health care, the organisation, with loss of documents, with clinical information, with delays in surgical and non-surgical treatment and cancellations. In 2004, only 24.8% of complaints were answered in time, but increased to 44% in 2005. ConclusionsThere was an increase in the incidence of the complaints in the University Hospital of Getafe (Madrid) during the period studied. The users give greater importance to the technical and human aspects of health care compared to organisational and planning aspects. The quality control in the management of the complaints is poor.

Late Intestinal Obstruction due to an Intestinal Volvulus in a Pregnant Patient with a Previous Roux-en-Y Gastric Bypass

This is a case of a 33 weeks pregnant woman, presented 2 years after laparoscopic Roux-en-Y gastric bypass, with abdominal pain for 2 days. A laparoscopic cholecystectomy was performed 1 day earlier in another hospital, without improving the pain. She presented at our hospital with acute abdominal pain and clinical signs of intestinal obstruction, undergoing an exploratory laparotomy that revealed a volvulus and necrosis of the jejunum from the gastroenteroanastomosis through the lateral enteroenterostomy, which was resected with the reconstruction of the Roux-en-Y limb performed at the same operation. Patient and neonate presented with improvement after surgery and the patient was discharged on postoperative day 15. Internal hernias after bariatric surgery have been reported as the cause of acute abdomen problems during pregnancy, which may progress to necrosis and perforation. The delay of surgical intervention could have brought a tragic outcome for mother and neonate.

Limitations of “Classic” Risk Factors to Predict Neoadjuvant Chemotherapy Response for Operable Breast Cancer

To the Editor, Preoperative or neoadjuvant chemotherapy (NC) has been the standard of clinical practice in locally advanced breast cancer. This approach offers the potential of tumor downstaging, allowing breast-conserving surgery (BCS) for women with large tumors at diagnosis. It is also used more and more frequently for patients with early-stage breast cancer. Despite several advantages, however, NC also has limitations, including incomplete surgical resection in BCS after NC and a delay in definitive surgical treatment that may harm patients whose disease does not respond to the treatment. The study reported by Shien et al. [1] in a recent issue of the World Journal of Surgery provides data supporting the limitations of current clinicopathologic factors in predicting pathological complete response (pCR) to NC. We congratulate the authors for the accuracy and objective interpretation of their data. We wish to comment on this study precisely because the information provided may influence surgeons in their clinical practice. We also wish to increase awareness of the potential ability of genetics, gene expression-profiling, and genome-wide association studies to improve pCR prediction when neoadjuvant chemotherapy and targeted therapy are applied. Predicting pCR may help breast surgeons with the selection of

Mortality increases when radical cystectomy is delayed more than 12 weeks: results from a Surveillance, Epidemiology, and End Results-Medicare analysis.

Single-institution series have documented the adverse impact of a 12-week delay between resection of muscle-invasive bladder cancer and radical cystectomy. These data are derived from tertiary centers, in which referral populations may confound outcomes. The authors sought to examine the survival impact of a delay in radical cystectomy using nationally representative data. From the linked Surveillance, Epidemiology, and End Results-Medicare dataset, the authors identified subjects with stage II transitional cell carcinoma (TCC) of the bladder who underwent radical cystectomy between 1992 and 2001. They examined delays of 8, 12, and 24 weeks and incorporated these delay cutoffs into multivariate Cox proportional hazards survival models. Covariates included age, race/ethnicity, marital status, Charlson comorbidity index, and cancer grade. The authors identified 441 subjects with stage II TCC who underwent cystectomy during the study period. Compared with immediate surgery (ie, within 4-8 weeks of transurethral resection), longer time to cystectomy increased the risk of both disease-specific and overall mortality (hazard ratio [HR], 2.0; P < .01 and HR, 1.6; P < .01, respectively, for those delayed 12-24 weeks; HR, 2.0; P < .01 for disease-specific and overall death among those delayed beyond 24 weeks 1 year after diagnosis). Covariates associated with overall mortality included older age (HR, 1.04; P < .01) and comorbidity (HR, 2.0 for Charlson >or=3 vs Charlson 0-1; P < .01). Delay in definitive surgical treatment beyond 12 weeks conferred an increased risk of disease-specific and all-cause mortality among subjects with stage II bladder cancer.

Brucellosis presenting as a spinal epidural abscess in a 41-year-old farmer: a case report

IntroductionBrucellar epidural abscess is rare but potentially fatal medical entity and very few cases have been reported so far. Whilst in developed countries, cases of brucellar spondylitis and epidural abscess are unusual, since brucellosis has practically been eradicated in animals, in Greece it is one of the most frequent zoonosis. By reporting this case report we want to stress out the importance of early diagnosis and management and also that physicians should keep an open mind and high index of suspicion especially in regions where brucellosis is endemic or when their patients have traveled to these areas and have consumed unpasteurized dairy products.Case presentationWe present the case of a 41-year-old male Caucasian farmer complaining of acute, progressively worsening low back pain of five days duration. Fever with rigors, malaise and profuse night sweating were added to the symptoms, two days before admission. Magnetic Resonance imaging clearly showed the lesion and blood and tissue cultures were positive for Brucella melitensis.ConclusionSpinal epidural abscess is a rare condition, difficult to diagnose, may be complicated by potentially disastrous neurological or vascular complications, and it can be fatal if left untreated. Patients complaining of fever and back pain, particularly in endemic areas should be investigated as possible cases of brucellosis and MRI is the method of first choice in the diagnostic process. Neurological dysfunction is often disproportionate to the observed degree of compression. A delay in diagnosis or surgical treatment may result in deleterious sequelae such as permanent paralysis or even death for patients with spinal epidural abscess.

Complications of Distal Biceps Tendon Repairs

Surgical repair is the most reliable method of restoring flexion and supination strength of the elbow and forearm after acute rupture of the distal biceps tendon. Although there may be small measurable deficits in power, endurance, and terminal forearm rotation when carefully evaluated, most of the patients regain near normal upper extremity motion and function and can return to preinjury activities. There are currently 2 basic surgical approaches for distal biceps tendon repair, using 1 anterior incision or using 1 anterior and 1 lateral incision. Anterior repair alone has the advantage of a minimal risk of heterotopic bone formation, but carries a greater chance of injury to the posterior interosseous nerve. In turn, the 2-incision technique markedly diminishes the risk of radial nerve palsy, but is associated with a greater likelihood of heterotopic bone formation limiting forearm rotation. Rerupture of the distal biceps tendon after repair is uncommon with either technique, and the risk of all complications seems to increase with a delay in surgical intervention after rupture. When motion limiting heterotopic ossification does occur, surgical resection can proceed when the process becomes mature as defined by plain radiographs. Fortunately, functional forearm motion can be commonly restored in these cases with careful attention to surgical details and postoperative rehabilitation.

Timing of intervention does not affect outcome in acute appendicitis in a large community practice

Background Surgical management of acute appendicitis remains one of the most frequent problems faced by gastrointestinal surgeons. Traditional management has emphasized urgent surgical care. Recent literature suggests delayed surgery for acute appendicitis does not affect outcome. The outcomes of patients undergoing urgent and delayed appendectomy in a large community surgical practice are compared. Methods All patients undergoing appendectomy between August 2002 and May 2007 were reviewed retrospectively. The data were gathered from a large community surgical practice. Patient demographics, treatment times, and surgical, pathologic, and postsurgical outcomes were documented. Results A total of 1,198 patients underwent appendectomy (575 female/623 male). The mean time to surgical intervention was 7.1 hours (range, 1–24 h). The percentage of patients undergoing laparoscopy versus open versus surgical conversion was 63%, 33%, and 4%, respectively. The percentage of patients with acute appendicitis versus perforated acute appendicitis versus negative exploration was 77%, 14%, and 8.5%, respectively. Postoperative wound or intra-abdominal septic complications were observed in 5.3% and 2.6% of patients, respectively. There was no correlation between the duration of symptoms or time to surgical intervention and surgical approach, pathologic outcome, length of stay, or postoperative septic complications. Conclusions Outcome variables documented in this study were independent of duration of symptoms or time to surgical intervention. This would suggest that short delays in surgical intervention for acute appendicitis are well tolerated. Outcome is related more clearly to the severity of the acute appendicitis at presentation.