Intra-abdominal Abscess Rate Research Articles

The role of abdominal drainage to prevent of intra-abdominal complications after laparoscopic cholecystectomy for acute cholecystitis: prospective randomized trial.

Routine drainage of the abdominal cavity after surgery has been a robust dogma for many decades. Nevertheless, the policy of routine abdominal drainage is increasingly questioned. Many surgeons believe that routine drainage after surgery may prevent postoperative intra-abdominal infection. The goal of this study was to assess the role of drains in laparoscopic cholecystectomy (LC) for acute cholecystitis. From May 2008 to July 2012, 160 patients that underwent LC due to acute cholecystitis at Gangnam Severance Hospital, Yonsei University Health System, Seoul, Korea, were enrolled in this study. After surgery, patients were randomly allocated to undergo drain placement in the subhepatic space (Group A) or no drainage (Group B). There was no significant difference in the intra-abdominal abscess rate, which was 0.0 % with Group A and 1.3 % with Group B (P = 0.319). The median subhepatic fluid collection was 4.1 mL (1.1–60 mL) in Group A and 4.5 mL (1.1–80.0 mL) in Group B (P = 0.298). However, the median hospital stay was 2 days (1–4 days) in Group B and 3 days (2–7 days) in group A (P = 0.001). The subgroup of empyema patients did not have any significant differences in intra-abdominal fluid collection or intra-abdominal abscess rate. This study suggests that postoperative routine drainage of the abdominal cavity for acute cholecystitis does not prevent intra-abdominal infections.

Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital

BackgroundLaparoscopic appendectomy is not yet unanimously considered the “gold standard” in the treatment of acute appendicitis because of its higher operative time, intra-abdominal abscess risk, and costs compared to open appendectomy. This study aimed to compare outcomes and cost of laparoscopic and open appendectomy in a district hospital.MethodsA retrospective analysis of 230 patients who underwent appendectomy at the Division of General Surgery of the Civil Hospital of Ragusa, Italy, from May 2008 to May 2012 was performed. The variables analyzed included patients data (age, gender, previous abdominal surgery, preoperative WBC count, duration of symptoms, ASA risk score), rate of uncomplicated or complicated appendicitis, operative time, postoperative complications, length of hospital stay, and total costs. The patients were divided in two groups according to the surgical approach and compared for each variable. The results were analyzed using the t Student test for quantitative variables, and the Chi-square test with Yates correction and Fisher exact test for categorical.ResultsLaparoscopic appendectomy was performed in 139 patients, open appendectomy in 91. Two cases (1.4%) were converted to open procedure and included in the laparoscopic group data. Patient data and rate of complicated appendicitis were similar in the two study groups. There was no statistical difference (p = 0.476) in the mean operative time between the laparoscopic (52.2 min; range, 20–155) and open appendectomy (49.3 min; range, 20–110) groups. The overall incidence of minor and major complications was significantly lower (p = 0.006) after laparoscopic appendectomy (2.9%, 4 cases) than after open appendectomy (13.2%, 12 cases); rate of intra-abdominal abscess were similar. The length of hospital stay was significantly shorter (p = 0.001) in laparoscopic group (2.75 days; range, 1–8) than in open group (3.87 days; range, 1–19). The mean total cost was 2282 Euro in laparoscopic group and 2337 Euro in open group, with a no significant difference of 55 Euro (p = 0.812).ConclusionLaparoscopic appendectomy is associated with fewer complications, shorter hospital stay, and similar operative time, intra-abdominal abscess rate, and total costs, compared with open appendectomy. Therefore, laparoscopic appendectomy can be recommended as preferred approach in acute appendicitis.

Radiofrequency-assisted versus clamp-crush liver resection: a systematic review and meta-analysis

BackgroundConflicting results were found between radiofrequency-assisted liver resection (RF-LR) and clamp-crush liver resection (CC-LR) during liver surgery. We conducted a systematic review and meta-analysis that included randomized controlled trials (RCTs) and non-RCTs to compare the effectiveness and safety of RF-LR versus CC-LR during liver surgery. MethodsArticles comparing RF-LR and CC-LR that were published before December 2012 were retrieved and subjected to a systematic review and meta-analysis. Data synthesis and statistical analysis were carried out by Review Manager Version 5.2 software. ResultsIn all, four RCTs and five nonrandomized studies evaluating 728 patients were included. Compared with CC-LR, the RF-LR group had significantly reduced total intraoperative blood loss (weighted mean difference [WMD] = −187 mL; 95% confidence interval [CI] = −312, −62; data on 628 patients), and blood loss during liver transection (WMD = −143.7 mL; 95% CI = −200, −87; data on 190 patients). However, RF-LR is associated with a higher rate of intra-abdominal abscess than the clamp-crushing method (odds ratio = 3.61; 95% CI = 1.26, 10.32; data on 366 patients). No significant difference was observed between both the groups for the incidence of both blood transfusion and bile leak. ConclusionsThere is currently not sufficient evidence to support or refute the use of RF-LR in liver surgery. RF-LR has advantages in terms of reducing blood loss. However, RF-LR may increase the rates of both bile leak and abdominal abscess. So, the safety of RF-LR has not been established. Future well-designed RCTs are awaited to further investigate the efficacy and safety of RF devices in liver resection.

Less morbidity after introduction of a new departmental policy for patients who undergo open distal pancreatectomy

The aim of this study was to retrospectively compare morbidity and mortality before and after introduction of a new departmental policy for patients who undergo distal pancreatectomy. We have introduced the use of an ultrasonically-activated device in distal pancreatectomy, an "early removal of drains" policy and perioperative management using a clinical pathway since May 2006. Group A consisted of 52 consecutive patients from 2000 to February 2006. Group B consisted of 57 consecutive patients from May 2006 to 2010. Although there was no difference in the fluid collection rate within 30 postoperative days (Group A, 44% vs. Group B, 35%), the rates of intra-abdominal abscess (A, 19% vs. B, 4%) and grade 3/4 of the Clavien classification (A, 23% vs. B, 9%) in Group B were significantly lower than in Group A (P < 0.05). Time of drain removal (median 3 days vs. 8 days) and length of in-hospital stay (median 8 days vs. 17 days) in Group B were significantly shorter than in Group A (P < 0.001). The implementation of new departmental guidelines for distal pancreatectomy was closely associated with a low frequency of intra-abdominal abscess and grade 3/4 Clavien score, resulting in a shorter in-hospital stay.

Modification of an evidence-based protocol for advanced appendicitis in children

IntroductionWe previously developed an evidence-based clinical pathway for children with advanced appendicitis. The pathway standardized the choice and duration of antibiotic therapy and established discharge criteria. Initially, the pathway led to a 50% decrease in the rate of superficial and deep surgical site infections and a significant decrease in hospital length of stay. Four years after implementation, we noted an increase in the infectious complication rate and the emergence of resistant bacteria to commonly used antibiotics. In this study, we prospectively collected peritoneal fluid cultures at the time of appendectomy in an effort to optimize our antibiotic therapy and decrease complication rates. MethodsMicrobiology analysis of peritoneal fluid cultures obtained at the time of appendectomy was performed in patients with an intraoperative diagnosis of advanced appendicitis. Clinical information, including demographics, laboratory data, and postoperative outcomes were collected and compared to the historic cohort. X2, Student’s t-test, and Fisher exact test were used where appropriate. ResultsThe historic and prospective cohorts were similar with respect to clinical and demographic data. The postoperative intra-abdominal abscess rate remained unchanged (28% from 24%, P = 0.603). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated aerobic bacteria from peritoneal fluid in the prospective cohort. Thirty-two percent of these patients had Pseudomonas spp., and 12% had Enterococcus spp. or Escherichia coli resistant to cefoxitin in their peritoneal fluid cultures. DiscussionA significant proportion (40%) of children with advanced appendicitis had organisms either not susceptible or resistant to our first line antibiotic in their peritoneal fluid cultures. Our clinical pathway now recommends piperacillin-tazobactam as the most effective empiric therapy for advanced appendicitis in children. Microbiologic analysis of peritoneal fluid at appendectomy may be used to tailor antibiotic therapy in advanced appendicitis.

Evidence-based laparoscopic appendectomy practice requires national database studies

Dear Editor, As the article by Saia et al. [1] indicates, administrative databases are useful in comparing different surgical techniques: randomized, controlled trials are difficult to realize, require large sample sizes, and are mostly subject to blinding biases. The results demonstrated in this study contribute to the discussion around data published in two surveys concerning dissemination of laparoscopic appendectomy (LA) in Italy, commissioned by two different scientific surgical societies [2, 3]. The overview provided of the situation, 7 years after these initial results, confirm the increasing rate of LAs, particularly in fertile women. The use of LA is undoubtedly evidence based; no hard evidence confirms its application to subgroups different from premenopausal women, where the rate of differential diagnoses, after exploratory laparoscopy, is quite high. A Cochrane review by Sauerland et al. [4] emphasizes the poor quality of evidence in support of the advantages of an all-comers policy for LA. Similarly, the noted trend of performing fewer appendectomies can be due to the increasing application of antibiotic therapy to uncomplicated cases, which can be effective in most patients and can help avoid the need for surgery, as proved in a recent meta-analysis [5]. The major concern for the surgeon and the patient in the dissemination of LA has been the suspected increase in the rate of postoperative intra-abdominal abscesses, which might require a prolongation of the hospital stay or the need for a second surgery; thus, it would be interesting to retrieve from the Veneto regional database the number of readmissions, so as to ascertain the real entity of this problem and its trend over the 8-year period. More recent reports have downplayed this complication [6], but the problem remains unresolved. Today, surgical training and standardization of the technique seem of utmost importance. Surgeon training is a fundamental issue, and it must be analyzed, in the existing health care systems, on the basis of a single ward or practice. One of the above-mentioned national surveys demonstrated that LA is performed in more than 90 % of the hospitals, but in low numbers (30–60 % of appendectomies) and by a selected laparoscopic team (\30 % of the surgeons working in the same practice), and is not related to case volume [2]. One of the answers to the extreme regional variability in the number of LAs performed might be standardization of the surgical approach through the wide adoption of surgical evidence-based guidelines that must be realized, implemented, and controlled by national scientific societies in tandem with a central health institute. This has been accomplished in Italy with the drafting of evidence-based guidelines and their diffusion through the scientific literature [7, 8] and through the Italian Istituto Superiore di Sanita (http://www.snlg-iss.it/cms/files/LG_ACOI_appendicectomia_ %20laparoscopica.pdf). This correspondence is written on behalf of ACOI (Associazione Chirurghi Ospedalieri Italiani) and SICE (Societa Italiana Chirurgia Endoscopica e Nuove Tecnologie).

Abscess rate of patients with penetrating abdominal injury in Zaria

Background: Penetrating abdominal injury occurs when a foreign object pierces the skin. The morbidity and mortality associated with penetrating abdominal trauma is related to the intra-abdominal complications. This study is, therefore, intended to determine the abscess rate resulting from penetrating abdominal trauma in Ahmadu Bello University Teaching Hospital Zaria. Method: A 6-year (January 2006-December 2011) retrospective study of penetrating abdominal trauma emphasizing on the rate of development of intra-abdominal abscess. Information was obtained from patients’ case notes, operating room log books and surgical audit data. Information extracted included cases of penetrating abdominal trauma, intra-operative findings and cases of intra-abdominal abscesses. Results: A total of 39 cases of penetrating abdominal trauma were treated within this period of six years. 3 (7.7%) were treated in 2006, 6 (15.4%) in 2007, 3 (7.7%) in 2008 and 11 (28.2%) in 2009, 8 (20.5%) in 2010, 9 (23.1%) in 2011. 26 (66.7%) were adult while 13 (33.3%) were paediatric cases. The male were 37 (94.9%) and the female were 2 (5.1%), with a sex ratio of 18.5:1 (male to female). The age range was 5 -60 years (39.92 mean). The commonest cause of injury was road traffic accident. At exploration, 13 (33.3%) had organ injury only, 17 (43.6%) suffer from both organ injury and intra-peritoneal emorrhage, 9 (23.1%) had retroperitoneal haemorrhage only. The intra-abdominal abscess rate of penetrating abdominal injury in Zaria was found to be 2.6%. Conclusion: Contamination from either foreign object or organ injury is found to increase the risk of post-operative intra-abdominal abscess. In this center, the abscess rate of penetrating abdominal trauma is comparatively low.

Single institution’s experience in laparoscopic appendectomy as a suitable therapy for complicated appendicitis

Although laparoscopic appendectomy (LA) for acute appendicitis (AA) is widely performed, the value of LA for the treatment of complicated appendicitis (CA) is still controversially discussed. In a retrospective study, we analyzed the clinical records of 404 patients who underwent LA or conversion (intention-to-treat group) or open appendectomy (OA) for AA or CA at the Alfried Krupp Hospital Essen-Rüttenscheid, Germany between January 2007 and December 2010. AA was treated in 64.2 % by LA and in 35.8 % by OA; the LA-to-OA conversion rate amounts to 3.7 %. CA was treated in 56 % by LA and in 44 % by OA. The LA-to-OA conversion rate here is 13.1 %, and compared to AA, it is significantly (P < 0.01) higher. Comparing LA with OA in both patient groups, we find no significant difference in the overall complication rate, the rate of postoperative intraabdominal abscesses and postoperative ileus. However, in both patient groups, the wound infection rate was significantly lower in patients who had undergone LA (AA P < 0.05 versus CA P < 0.01). In contrast to patients suffering from AA, patients with CA needed significantly less resurgery when treated by LA as compared to OA (P < 0.001). While the duration of surgery for the treatment of AA and CA was similar, the hospitalization time was significantly shorter with LA than with OA (AA P < 0.05 versus CA P < 0.001). The data suggest that LA is advantageous not only in the treatment of AA, but also in the therapy of CA. Thus, LA may become a proper and safe routine method if performed by an experienced surgeon.

Feasibility of Single-Incision Pediatric Endosurgery for Treatment of Appendicitis in 415 Children

Single-incision pediatric endosurgery (SIPES) has gained popularity for ablative procedures such as appendectomy in many pediatric surgical centers. This study evaluates the outcome of SIPES for treatment of appendicitis in our institution. After Institutional Review Board approval was obtained, data were prospectively collected on all patients undergoing SIPES appendectomy in our hospital from March 2009 through October 2011. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded. SIPES appendectomy was attempted in 415 children (mean age, 10.9 years; age range, 1.4-17.9 years; 266 males, 149 females; median weight, 43 kg; weight range, 9.8-146 kg). Intraoperatively, acute appendicitis was found in 298 cases and perforated appendicitis in 79 cases. Thirty-eight patients underwent interval appendectomy. Appendectomy was carried out solely as SIPES in 397 cases (96%). Median operative time was 40±16 minutes (37±16 minutes for fellows [n=284] and 46±15 minutes for residents [n=131]). There were three intraoperative complications, which could be handled during the procedure. Pathologic reports revealed inflammatory changes of the appendix (n=386), other pathology (n=11), and no pathologic change (n=18). Overall, 24 patients (5.8%) were readmitted for intra-abdominal abscess (n=14), umbilical wound infection (n=3), and other reasons (n=7). Twelve patients (2.9%) underwent reoperation: drainage of intra-abdominal abscess (n=8) (3 by the surgeon, 5 by the interventional radiologist), wound drainage (n=3), and right hemicolectomy for carcinoid (n=1). In perforated appendicitis the postoperative intra-abdominal abscess rate was 10 of 79 cases (12.7%), which is similar to the previous report with conventional laparoscopic appendectomy from our institution (13.6%). The wound infection rate (5 of 79 cases [6.3%]) was also similar to the previously report (6.8%) with conventional laparoscopic appendectomy for perforated appendicitis. Appendectomy can be accomplished successfully and safely using single-incision endosurgery in children with acceptable operative times without leaving any appreciable scar. Additional trocars are infrequently necessary. So far, the intraoperative and postoperative complication rates are comparable to those of triangulated laparoscopic appendectomy.

The effects of irrigation on outcomes in cases of perforated appendicitis in children

IntroductionAppendicitis is the most common indication for urgent abdominal operation in children. Approximately 20%–30% of patients will have a perforation at operation. Intra-abdominal abscess after appendectomy is reported in 3%–20% of patients and adds significantly to hospital stay with increased morbidity and overall cost. Surgical dogma has long advocated for irrigation in the setting of gross pus to prevent abscess formation. MethodsFollowing IRB approval, data were retrospectively collected for children who had undergone appendectomy for perforated appendicitis at one of two children's hospitals over the course of 5 y. Perforation was determined by review of operative notes. All patients had free fluid in their peritoneal cavity evacuated by suction, whereas some of the patients also had their peritoneal cavity irrigated with normal saline. Postoperative intra-abdominal abscess rates were determined based on clinical symptoms and confirmatory radiologic studies. ResultsThere were 99 patients in the suction-only group and 139 in the irrigation group. Standard demographics were relatively similar between the two groups. There were significantly lower rates of intra-abdominal abscess formation (4.0% versus 17.2%, P = 0.002) and wound infection (1.0% versus 8.6%, P = 0.003) in the suction-only group compared with the irrigation group. We further analyzed abscess rates by surgical treatment, either laparoscopic or open appendectomy. There were 85 patients in the laparoscopic group and 152 patients in the open appendectomy group. In this subgroup analysis, there were also significantly lower rates of abscess formation in patients treated with suction only compared with irrigation in the laparoscopic (3.5% versus 18.8%, P = 0.012) and open appendectomy groups (4.2% versus 16.3%, P = 0.036). ConclusionsResults of this retrospective review indicate that a suction-only approach significantly decreased rates of abscess formation and wound infections compared to irrigation in cases of perforated appendicitis in children.

Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis

Laparoscopic appendicectomy (LA) in the obese population has been controversial. A recent SAGES guideline and a Cochrane Review have suggested a benefit for LA over the open approach but did not provide supporting data. This study is the first systematic review and meta-analysis to compare the LA with open surgery in the obese population to provide a quantitative estimate of the relative benefits. A comprehensive search of the online databases identified seven retrospective and prospective randomized studies that contained sufficient data on obese patients. Analysis was based on intention-to-treat. We calculated pooled odds ratios (ORs) and 95 % confidence intervals using a random-effects model. The LA group contained more females (43 vs. 32 %, p < 0.001), had fewer perforations (18 vs. 23 %; p < 0.001), and fewer overall complications (OR: 0.49; 95 % CI: 0.37-0.63), including fewer wound infections (OR: 0.34; 95 % CI: 0.18-0.66). There was no difference in the intra-abdominal abscess rate between the groups (OR: 0.99; 95 % CI: 0.29-3.37). The LA group had a shorter length of stay (2.46 vs. 3.63 days; p < 0.001) but a longer operation time (96 vs. 78 min, p < 0.001). There was no heterogeneity between the studies. This meta-analysis of the current published data establishes the laparoscopic approach to appendicectomy as the preferred technique for the obese population, delivering a 50 % reduction in morbidity, with a 66 % reduction in wound infections and a significantly shorter inpatient hospital stay without increasing the intra-abdominal abscess rate.

Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution on Infections after Elective Colorectal Cancer Surgery

Colorectal surgery may lead to infections because despite meticulous aseptic measures, extravasation of microorganisms from the colon lumen is unavoidable. A prospective, randomized study was performed between January 2010 and December 2010. Patient inclusion criteria were a diagnosis of colorectal neoplasms and plans to undergo an elective curative operation. Patients were divided into 2 groups: Group 1 (intra-abdominal irrigation with normal saline) and Group 2 (intraperitoneal irrigation with a solution of 240 mg gentamicin and 600 mg clindamycin). The occurrence of wound infections and intra-abdominal abscesses were investigated. After the anastomosis, a microbiologic sample of the peritoneal surface was obtained (sample 1). A second sample was collected after irrigation with normal saline (sample 2). Finally, the peritoneal cavity was irrigated with a gentamicin-clindamycin solution and a third sample was obtained (sample 3). There were 103 patients analyzed: 51 in Group 1 and 52 in Group 2. There were no significant differences between the groups in age, sex, comorbidities, or type of colorectal surgery performed. Wound infection rates were 14% in Group 1 and 4% in Group 2 (p = 0.009; odds ratio [OR] 4.94; 95% CI 1.27 to 19.19). Intra-abdominal abscess rates were 6% in Group 1 and 0% in Group 2 (p = 0.014; OR 2.14; 95% CI 1.13 to 3.57). The culture of sample 1 was positive in 68% of the cases, sample 2 was positive in 59%, and sample 3 in 4%. Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infections.

Perioperative complications in a consecutive series of 1000 duodenal switches

BackgroundIn the past 10 years, most bariatric surgeries have seen an important reduction in the early complication rate, partly associated with the development of the laparoscopic approach. Our objective was to assess the current early complication rate associated with biliopancreatic diversion with duodenal switch (BPD-DS) since the introduction of a laparoscopic approach in our institution, a university-affiliated tertiary care center. MethodsA consecutive series of 1000 patients who had undergone BPD-DS from November 2006 to January 2010 was surveyed. The primary endpoint was the mortality rate. The secondary endpoints were the major 30-day complication rate and hospital stay >10 days. The data are reported as a mean ± SD, comparing the laparoscopic (n = 228) and open (n = 772) groups. ResultsThe mean age of the patients was 43 ± 10 years (40 ± 10 years in the laparoscopy group versus 44 ± 10 years in the open group, P < .01). The preoperative body mass index was 51 ± 8 kg/m2 (47 ± 7 laparoscopy versus 52 ± 8 kg/m2 open, P < .01). The conversion rate in the laparoscopy group was 2.6%. There was 1 postoperative death (.1%) from a pulmonary embolism in the laparoscopy group. The mean hospital stay was shorter after laparoscopic surgery (6 ± 6 d versus 7 ± 9 d, P = .01), and a hospital stay >10 days was more frequent in the open group (4.4% versus 7%, P = .04). Major complications occurred in 7% of the patients, with no significant differences between the 2 groups (7% versus 7.4%, P = .1). No differences were found in the overall leak or intra-abdominal abscess rate (3.5% versus 4%, P = .1); however, gastric leaks were more frequent after open surgery (0% versus 2%, P = .02). During a mean 2-year follow-up, 1 additional death occurred from myocardial infarction, 2 years after open BPD-DS. ConclusionThe early and late mortality rate of BPD-DS is low and comparable to that of other bariatric surgeries.

Are enterococci playing a role in postoperative peritonitis in critically ill patients?

This prospective non-interventional study is aimed at evaluating the role of enterococci in the postoperative course of postoperative peritonitis (POP) and the predictive factors for isolating Enterococcus spp. All adult patients, hospitalized in intensive care, who had POP between September 2006 and February 2010 were analysed. The patients' baseline clinical characteristics and microbiological and surgical characteristics of the first episode of POP were recorded. The rates of surgical and non-surgical complications and mortality were studied. A total of 139 patients were analysed and Enterococcus spp. were recovered in 61 patients (43%). The presence of enterococci was associated with significantly more intra-abdominal abscesses (26% vs 12%, p=0.025), but did not affect the rate of reoperation or mortality. Antibiotic use before reoperation was the only independent predictive factor for isolating enterococci (OR=2.19, CI95%: 1.02-4.70, p<0.043). Although mortality was not affected by the presence of Enterococcus spp., a higher rate of intra-abdominal abscess was found, suggesting that enterococci play a significant role in postoperative peritonitis, but the need to treat them remains to be determined. Previous antibiotic use before reoperation was a key factor in predicting the subsequent recovery of enterococci.

Pancreas Transplant Salvage by Proximal Loop Ileostomy and Distal Ileostotomy Tube for Duodenal Stump Leak after Enteric Conversion

After pancreas transplantation, some patients with bladder drainage (BD) of the pancreatic duct will need to be converted to enteric drainage (ED) because of reflux pancreatitis, metabolic acidosis, and urological complications. However, ED is associated with higher rates of duodenal stump leak, intra-abdominal abscess, and peritonitis. In some cases of enteric anastomosis leakage, a primary repair can be attempted, but in more severe cases, graft pancreatectomy is indicated. We report one patient who received a combined kidney and pancreas transplant with BD of exocrine secretions, but who required ED conversion 6 years later because of persistent metabolic acidosis and adverse urological symptoms. However, a significant duodenal leak was discovered 4 days post-operatively. To salvage the transplanted pancreas, we performed a diverting loop ileostomy proximal to the entero-entero anastomosis and the distal section was drained retrogradely with an ileostostomy tube, allowing the area of the leak to heal. Three months later, the ileostomy was reversed without complications, the symptoms that led to the ED conversion resolved, and the kidney and pancreas allografts remain functional 48 months later. We suggest that this might be a method by which transplanted pancreas may be salvaged in the case of leakage after ED conversion.

Does Use of Intraoperative Irrigation with Open or Laparoscopic Appendectomy Reduce Post-Operative Intra-abdominal Abscess?

To date, no study shows a decrease in postoperative abscess with the use of irrigation during appendectomy. Postoperative abscess rate for laparoscopic and open appendectomy is 3.3 and 2.6 per cent. The purpose of this study is to determine if irrigation at appendectomy decreases the postoperative intra-abdominal abscess rate. Retrospective chart review of 176 consecutive appendectomies, open (39%) and laparoscopic (61%), at a university affiliated tertiary care facility from July 2007 to November 2008 for use of intraoperative irrigation was performed. Patients under age 18 were excluded. There were no differences between the irrigation groups in regards to age, sex, or weight. Perforation was observed in 28 per cent (50/176), of which 86 per cent (43/50) of patients received intraoperative irrigation. Eleven patients (9.6%) with irrigation developed postoperative abscess compared with two (3.3%) patients without irrigation (P = 0.22). Our results do not show decrease in postoperative intra-abdominal abscess with use of intraoperative irrigation. Thirteen patients developed postoperative abscess: 11 with irrigation, two without irrigation. Ten of 13 patients who developed abscess were perforated; nine with irrigation and one without. These results suggest routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided.

Akute Appendizitis - Wandel in Epidemiologie, Diagnostik und Therapie

Appendicitis is the most common cause of an -acute abdomen. Around 135 000 patients undergo appendectomy in Germany every year. Acute -appendicitis shows changes in epidemiology, -diagnosis and therapy. Epidemiological data indicate a continuing decrease in the incidence of acute non-perforated appendicitis. The incidence of perforated appendicitis has remained constant despite laparoscopy and imaging diagnostics. The status of sonography and CT scanning is increasing in the diagnosis of appendicitis. But there are differences between the sensitivity and specifity of study results and the clinical routine. The in-crease of imaging diagnostics does not correlate with a decrease in the incidence of perforated -appendicitis. Laparoscopic appendectomy has -developed as a dominant method for operative therapy. There is no proof of a higher rate of postoperative intraabdominal abscesses any more. The use of a stapler is mostly required for appendical stump closure.

Implications of overweight in gastric cancer: A multicenter study in a Western patient population

Aims The purpose of this study was to evaluate the effects of overweight on surgical and long-term outcomes in a Western population of patients with gastric cancer (GC). Methods An electronic database of all patients with resectable GC treated between 1986 and 1998 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group was reviewed. Overweight was defined as a body mass index (BMI) of 25 kg/m 2 or higher. Results Four hundred and ninety-two of 1992 (25%) patients were overweight. Postoperatively, higher BMI was associated with higher rates of cardiopulmonary complications (16% vs 12%, P = 0.001) and intra-abdominal abscess (6.9% vs 2.9%, P < 0.001). However, other complications and mortality rates were unaffected. The median disease-specific survival of overweight patients was significantly higher (36.7 months, 95% confidence interval (CI) 29.0–44.4) than those with BMI<25 kg/m 2 (25.7 months, 95%CI 23.2–28.1; P = 0.003). These differences were due to the lower frequencies of patients with T3 and T4 tumours, metastatic lymph nodes, distant metastases, and non-curative resections. A Cox proportional hazards model identified age, depth of infiltration, lymph node metastases, distant metastases, and residual tumour category as the independent prognostic factors. Conclusions Overweight is not the independent prognostic factor for long-term survival in a Western-type population of GC.

Role of Preoperative Optimization of the Liver for Resection in Patients with Hilar Cholangiocarcinoma Type III

Long-term survival after complete resection of hilar cholangiocarcinoma remains disappointing. The aim of this retrospective study was to assess the impact of liver optimization on postoperative outcome of hilar cholangiocarcinoma type III. In a retrospective, single-center analysis, outcomes in patients with hilar cholangiocarcinoma type III who underwent resection after preoperative liver optimization (preoperative transhepatic biliary drainage [PTBD], bile replacement, and/or portal vein embolization [PVE]) were compared with nonoptimized controls. Of 41 patients undergoing surgery, 38 patients undergoing curative intent procedures were identified, of whom 15 underwent preoperative optimization. After PTBD, direct bilirubin decreased from 218.0 ± 184.2 to 75.9 ± 42.7 μmol/L (P = 0.03), and there was a trend toward decreased AST and ALT levels. Overall, 3- and 5-year survival rates were 47.9 ± 9.1 and 41.9 ± 9.8%. The primary endpoint, 5-year survival after surgery, was not significantly different between groups. Preoperative jaundice was identified as an independent prognostic factor for poor outcome (hazard ratio [HR] 2.12, P = 0.02). Four patients (10.5%) without preoperative optimization died of liver failure within the first 30 days postsurgery, preceded in three cases by intra-abdominal abscesses. PTBD was associated with a lower rate of postoperative intra-abdominal abscesses; however this factor was not independently predictive of higher survival. Preoperative optimization of the liver in hilar cholangiocarcinoma Type III reduced the incidence of intra-abdominal abscesses, but its impact on postoperative survival remains unclear.

Current analysis of endoloops in appendiceal stump closure

An inadequate closure of the appendix stump leads to intra-abdominal surgical site infection. The effectiveness of various appendiceal stump closure methods, for instance, staplers or endoloops, was evaluated. Many analyses show that the use of a stapler for transection and closure of the appendiceal stump lowers the risk of this infection but a statistically significant risk of postoperative intra-abdominal abscess or wound infection was not considered in any randomized study. The aim of this study was to evaluate the complications after using endoloops in a high-volume center. The data of 1,790 patients who underwent laparoscopic appendectomy between January 1998 and December 2006 and a single center was prospectively acquired. The standard procedure used was an appendiceal stump closure using endoloops and a selective use of staplers. The outcome criteria for inclusion in the study were intra-abdominal abscess formations, other specific intraoperative and postoperative complications, and the different costs of the operation. Laparoscopic appendectomy was performed in 1,790 (80.8%) patients and open appendectomy in 425 (19.2%) patients. Conversion to open surgery occurred in 74 (4.13%) patients. Laparoscopic appendectomy with stump closure using endoloops was performed in 1,670 (97.3%) patients and stump closure using a stapler in 46 (2.7%) patients. Among 851 patients with acute appendicitis, 284 patients with perforated appendicitis, and 535 patients with other or no pathology, the rate of intra-abdominal abscess after using an endoloop or a stapler was not significantly different (1.5 vs. 0%, p = 0.587; 3.5 vs. 4.2%, p = 0.870; 0.7% vs. 0, p = 0.881, respectively). There were no significant differences between the endoloop group and the stapler group with respect to the other specific intraoperative and postoperative complications. This study shows the safety of the endoloop for clinical daily routine. A selective procedure for stump closure has been established. Appendiceal stump closure using an endoloop is an easy, safe, and cost-effective procedure.