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Lunardi N, Marten E, Sharath S, Kougias P, Pham TH, Balentine CJ. The risks of failed nonoperative management of appendicitis in older adults. Am J Surg 2024; 232:112-117. [PMID: 38320887 PMCID: PMC11090712 DOI: 10.1016/j.amjsurg.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND The consequences of failed nonoperative management of appendicitis in older patients have not been described. METHODS We used the 2004-2017 National Inpatient Sample to identify acute appendicitis patients managed nonoperatively (<65 years old: 32,469; ≥65 years old: 11,265). Outcomes included morbidity, length of stay (LOS), inpatient costs, and discharge to skilled facilities. Differences were estimated using propensity scores. RESULTS For patients <65, nonoperative failure was associated with increased morbidity (7 % [95 % CI 6.9 %-8.1 %]), LOS (3 day [95 % CI 3-4]), costs ($9015 [95 % CI $8216- $9446]), and discharges to skilled facilities (1 % [95 % CI 0.9 %-1.6 %]) compared to successful nonoperative treatment. Patients ≥65 had differences in morbidity (14 % [95 % CI 13.6 %-16.2 %]), LOS (6 days [95 % CI 5-6]), costs ($15,964 [95 % CI $15,181- $17,708]), and discharges to skilled facilities (12 % [95 % CI: 10.0 %-13.3]) compared to nonoperative success. CONCLUSIONS Nonoperative management of appendicitis should be approached cautiously for older adults.
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Affiliation(s)
- Nicole Lunardi
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA; Department of Surgery, North Texas VA Health Care System, Dallas, TX, USA
| | - Elisa Marten
- University of Wisconsin-Madison, Department of Surgery, USA; Wisconsin Surgical Outcomes Research Program, Madison, WI, USA; William S. Middleton VA, Madison, WI, USA
| | - Sherene Sharath
- Department of Surgery, SUNY Downstate Health Sciences Center, Brooklyn, NY, USA; Department of Epidemiology & Biostatistics, SUNY Downstate Health Sciences Center, Brooklyn, NY, USA; Department of Surgery, New York Harbor Health Care System, Brooklyn, NY, USA
| | - Panos Kougias
- Department of Surgery, SUNY Downstate Health Sciences Center, Brooklyn, NY, USA; Department of Surgery, New York Harbor Health Care System, Brooklyn, NY, USA
| | - Thai H Pham
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA; Department of Surgery, North Texas VA Health Care System, Dallas, TX, USA
| | - Courtney J Balentine
- University of Wisconsin-Madison, Department of Surgery, USA; Wisconsin Surgical Outcomes Research Program, Madison, WI, USA; William S. Middleton VA, Madison, WI, USA.
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Korah M, Tennakoon L, Knowlton LM, Tung J, Spain DA, Ko A. Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019. J Surg Res 2024; 298:307-315. [PMID: 38640616 DOI: 10.1016/j.jss.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/08/2024] [Accepted: 03/17/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. METHODS The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. RESULTS Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). CONCLUSIONS NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.
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Affiliation(s)
- Maria Korah
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Lisa M Knowlton
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Jamie Tung
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Ara Ko
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California.
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Padberg FT, Ucuzian A, Dosluoglu H, Jacobowitz G, O'Donnell TF. Longitudinal assessment of health-related quality of life and clinical outcomes with at home advanced pneumatic compression treatment of lower extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2024:101892. [PMID: 38636734 DOI: 10.1016/j.jvsv.2024.101892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/23/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE This prospective, longitudinal, pragmatic study describes at home treatment with a proprietary advanced pneumatic compression device (APCD) for patients with lower extremity lymphedema (LED). METHODS Following institutiona review board approval, four participating Veterans Affairs centers enrolled LED patients from 2016 to 2022. The primary outcome measures were health-related quality of life (HR-QoL) questionnaires (lymphedema quality of life-leg and the generic SF-36v2) obtained at baseline and 12, 24, and 52 weeks. The secondary outcome measures were limb circumference, cellulitis events, skin quality, and compliance with APCD and other compression therapies. RESULTS Because a portion of the trial was conducted during the coronavirus disease 2019 pandemic, 179 patients had 52 weeks of follow-up, and 143 had complete measurements at all time points. The baseline characteristics were a mean age of 66.9 ± 10.8 years, 91% were men, and the mean body mass index was 33.8 ± 6.9 kg/m2. LED was bilateral in 92.2% of the patients. Chronic venous insufficiency or phlebolymphedema was the most common etiology of LED (112 patients; 62.6%), followed by trauma or surgery (20 patients; 11.2%). Cancer treatment as a cause was low (4 patients; 2.3%). Patients were classified as having International Society for Lymphology stage I (68.4%), II (27.6%), or III (4.1%). Of the primary outcome measures, significant improvements were observed in all lymphedema quality of life-leg domains of function, appearance, symptoms, and emotion and the overall score after 12 weeks of treatment (P < .0001) and through 52 weeks of follow-up. The SF-36v2 demonstrated significant improvement in three domains at 12 weeks and in the six domains of physical function, bodily pain, physical component (P < .0001), social functioning (P = .0186), role-physical (P < .0006), and mental health (P < .0333) at 52 weeks. An SF-36v2 score <40 indicates a substantial reduction in HR-QoL in LED patients compared with U.S. norms. Regarding the secondary outcome measures at 52 weeks, compared with baseline, the mean limb girth decreased by 1.4 cm (P < .0001). The maximal reduction in mean limb girth was 1.9 cm (6.0%) at 12 weeks in ISL stage II and III limbs. New episodes of cellulitis in patients with previous episodes (21.4% vs 6.1%, P = .001) were reduced. The 75% of patients with skin hyperpigmentation at baseline decreased to 40% (P < .01) at 52 weeks. At 52 weeks, compliance, defined as use for 5 to 7 days per week, was reported for the APCD by 72% and for elastic stockings by 74%. CONCLUSIONS This longitudinal study of Veterans Affairs patients with LED demonstrated improved generic and disease-specific HR-QoL through 52 weeks with at home use of an APCD. Limb girth, cellulitis episodes, and skin discoloration were reduced, with excellent compliance.
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Affiliation(s)
- Frank T Padberg
- Department of Surgery, VA New Jersey Healthcare System, East Orange, NJ; Division of Vascular Surgery, Rutgers New Jersey Medical School, Newark NJ.
| | - Areck Ucuzian
- VA Maryland Healthcare System, Baltimore, MD; Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Hasan Dosluoglu
- VA Western NY Healthcare System, Buffalo, NY; Division of Vascular Surgery, Department of Surgery, State University of New York, Buffalo, NY
| | - Glenn Jacobowitz
- VA New York Harbor Healthcare System, New York, NY; Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY; Division of Vascular Surgery, Department of Surgery, NYU Grossman School of Medicine, New York, NY
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Safont MJ, García-Figueiras R, Hernando-Requejo O, Jimenez-Rodriguez R, Lopez-Vicente J, Machado I, Ayuso JR, Bustamante-Balén M, De Torres-Olombrada MV, Domínguez Tristancho JL, Fernández-Aceñero MJ, Suarez J, Vera R. Interdisciplinary Spanish consensus on a watch-and-wait approach for rectal cancer. Clin Transl Oncol 2024; 26:825-835. [PMID: 37787973 DOI: 10.1007/s12094-023-03322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.
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Affiliation(s)
- Maria Jose Safont
- Oncology Department, Consorcio Hospital General Universitario de Valencia. Valencia University, Av. de les Tres Creus, 2, 46014, València, Spain.
| | - Roberto García-Figueiras
- Radiology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Jorge Lopez-Vicente
- Gastroenterology Department, Hospital Universitario de Mostoles, Mósteles, Spain
| | - Isidro Machado
- Instituto Valenciano de Oncología, Valencia, Spain
- Pathology Department, Patologika Laboratory QuironSalud, Valencia, Spain
- Pathology Department, University of Valencia, Valencia, Spain
| | | | - Marco Bustamante-Balén
- Gastrointestinal Endoscopy Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | - Mª Jesús Fernández-Aceñero
- Surgical Pathology Department, Hospital Clínico San Carlos, IdiSSC, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Suarez
- General Surgery Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - Ruth Vera
- Medical Oncology Department, Hospital Universitario de Navarra, Instituto de Investigación (Idisna), Pamplona, Spain
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Oyemolade TA, Adeleye AO, Ekanem IN, Akinwalere AK, Kareem AO. Outcome of Nonoperative Management of Selected Cases of Acute Traumatic Intracranial Hematomas in a Rural Neurosurgical Service of a Developing Country. World Neurosurg 2024; 182:61-68. [PMID: 37995994 DOI: 10.1016/j.wneu.2023.11.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE In resource-limited settings, the standard of care prescribed in developed countries for either operative or nonoperative management of traumatic intracranial hematomas (TICHs) frequently has to be adapted to the economic and infrastructural realities. This study aims to present the outcome of selected cases of TICHs managed nonoperatively without routine intensive care unit admission, repeated cranial computed tomography (CT) scan or intracranial pressure monitoring at a rural neurosurgical service in a developing country. METHODS This was a retrospective analysis of a cohort of our patients with cranial CT-confirmed TICHs selected for nonoperative treatment from our prospective head injury (HI) register over a 42-month period. RESULTS There were 67 patients (51 males) in this study with a mean age of 38.6 (standard deviation, 17.6) years, having mild HI in >half, (55.2%, 37/67) and anisocoria in 22.4% (15/67). Road traffic accident was the most common (50/67, 74.7%) trauma etiology. Isolated acute-subdural hematoma, intracerebral hemorrhage, and epidural hematoma occurred in 29.9%, 25.4%, and 22.4% of the patients respectively. Only 2 of 8 patients in whom intensive care unit admission was deemed necessary could afford admission. Repeat cranial CT scan was requested in 8 patients (8/67, 11.9%); only 5 of these could afford the investigation. The outcome of care was good in 82.1% patients (55/67). Increasing severity of the HI (P < 0.01) and presence of pupillary abnormality (P = 0.03) were significant predictors of poor outcome. CONCLUSIONS In a Nigerian rural neurosurgery practice, nonoperative management of a well-selected cohort of TICHs was attended by acceptable level of favorable outcome.
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Affiliation(s)
- Toyin Ayofe Oyemolade
- Division of Neurosurgery, Department of Surgery, Federal Medical Centre, Owo, Ondo, Nigeria.
| | - Amos Olufemi Adeleye
- Department of Neurological Surgery, University College Hospital, UCH, Ibadan, Oyo, Nigeria; Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Oyo, Nigeria
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Li KW, Chen WS, Wang K, Yang C, Deng YX, Wang XY, Hu YP, Liu YX, Li WQ, Ding WW. Open or Not Open the Retroperitoneum: A Pandora's Box for Blunt High-Grade Pancreatic Trauma? J Surg Res 2024; 293:79-88. [PMID: 37734295 DOI: 10.1016/j.jss.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/19/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The optimal management strategy for pancreatic trauma remains unclear. We aimed to determine whether the initial nonoperative management (NOM) strategy based on percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement would improve outcomes for blunt high-grade pancreatic trauma. METHODS Patients with blunt abdominal trauma who were hemodynamically stable without signs of diffuse peritonitis were consecutively enrolled at a high-volume center. The primary outcome was the occurrence of severe complications (Clavien‒Dindo classification ≥ Ⅲb) for patients who underwent initial laparotomy (LAP) versus NOM. Modified Poisson regression was used to model the primary outcome. Propensity score matching and weighting models were included into a regression-based sensitivity analysis. RESULTS Of 119 patients with grade III/IV pancreatic trauma, 29 patients underwent initial NOM, and 90 underwent initial LAP. The incidence of severe complications in the LAP group was higher than that in the NOM group (65/90 [72.2%] versus 9/29 [31.0%], P < 0.001). In the multivariable modified Poisson regression model, the relative risk for severe complications was decreased in the NOM group (relative risk, 0.52; 95% confidence interval, 0.30-0.90; P = 0.020). The results of the sensitivity analysis were consistent with those of the multivariable analysis. The mean number of reinterventions per patient was 1.8 in the NOM group and 2.6 in the LAP group (P = 0.067). CONCLUSIONS For blunt high-grade pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis, the NOM strategy was associated with a lower risk of severe complications (Clavien‒Dindo classification ≥ Ⅲb) and did not require more invasive reintervention procedures. In high-volume centers with sufficient expertise, percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement may serve as an initial reasonable option for selected patients.
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Affiliation(s)
- Kai-Wei Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Wen-Song Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Kai Wang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Chao Yang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yun-Xuan Deng
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Xin-Yu Wang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yue-Peng Hu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yu-Xiu Liu
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China; Division of Data and Statistics, Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Wei-Qin Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Wei-Wei Ding
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
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Lin W, Wee IJY, Seow-En I, Chok AY, Tan EKW. Survival outcomes of salvage surgery in the watch-and-wait approach for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis. Ann Coloproctol 2023; 39:447-456. [PMID: 38185947 PMCID: PMC10781598 DOI: 10.3393/ac.2022.01221.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/07/2023] [Accepted: 02/27/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE This systematic review and meta-analysis compared the outcomes of the watch-and-wait (WW) approach versus radical surgery (RS) in rectal cancers with clinical complete response (cCR) after neoadjuvant chemoradiotherapy. METHODS This study followed the PRISMA guidelines. Major databases were searched to identify relevant articles. WW and RS were compared through meta-analyses of pooled proportions. Primary outcomes included overall survival (OS), disease-free survival (DFS), local recurrence, and distant metastasis rates. Pooled salvage surgery rates and outcomes were also collected. The Newcastle-Ottawa scale was employed to assess the risk of bias. RESULTS Eleven studies including 1,112 rectal cancer patients showing cCR after neoadjuvant chemoradiation were included. Of these patients, 378 were treated nonoperatively with WW, 663 underwent RS, and 71 underwent local excision. The 2-year OS (risk ratio [RR], 0.95; P = 0.94), 5-year OS (RR, 2.59; P = 0.25), and distant metastasis rates (RR, 1.05; P = 0.80) showed no significant differences between WW and RS. Local recurrence was more frequent in the WW group (RR, 6.93; P < 0.001), and 78.4% of patients later underwent salvage surgery (R0 resection rate, 97.5%). The 2-year DFS (RR, 1.58; P = 0.05) and 5-year DFS (RR, 2.07; P = 0.02) were higher among RS cases. However, after adjustment for R0 salvage surgery, DFS showed no significant between-group difference (RR, 0.82; P = 0.41). CONCLUSION Local recurrence rates are higher for WW than RS, but complete salvage surgery is often possible with similar long-term outcomes. WW is a viable strategy for rectal cancer with cCR after neoadjuvant chemoradiation, but further research is required to improve patient selection.
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Affiliation(s)
- Wenjie Lin
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Ian Jun Yan Wee
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Kobayashi T, Tabuchi S, Koganezawa I, Nakagawa M, Yokozuka K, Ochiai S, Gunji T, Ozawa Y, Sano T, Tomita K, Chiba N, Hidaka E, Kawachi S. Early Identification of Patients with Potential Failure of Nonoperative Management for Gastroduodenal Peptic Ulcer Perforation. Dig Surg 2023; 41:24-29. [PMID: 38008080 DOI: 10.1159/000535520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 11/16/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION We aimed to identify objective factors associated with failure of nonoperative management (NOM) of gastroduodenal peptic ulcer perforation (GDUP) and establish a scoring model for early identification of patients in whom NOM of GDUP may fail. METHODS A total of 71 patients with GDUP were divided into NOM (cases of NOM success) and operation groups (cases requiring emergency operation or conversion from NOM to operation). Using logistic regression analysis, a scoring model was established based on the independent factors. The patients were stratified into low-risk and high-risk groups according to the scores. RESULTS Of the 71 patients, 18 and 53 were in the NOM and operation groups, respectively. Ascites in the pelvic cavity on computed tomography (CT) and sequential organ failure assessment (SOFA) score at admission were identified as independent factors for NOM failure. The scoring model was established based on the presence of ascites in the pelvic cavity on CT and SOFA score ≥2 at admission. The operation rates for GDUP were 28.6% and 86.0% in the low-risk (score, 0) and high-risk groups (scores, 2 and 4), respectively. CONCLUSION Our scoring model may help determine NOM failure or success in patients with GDUP and make decisions regarding initial treatment.
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Affiliation(s)
- Toshimichi Kobayashi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan,
| | - Satoshi Tabuchi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Itsuki Koganezawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Masashi Nakagawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Kei Yokozuka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Shigeto Ochiai
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Yosuke Ozawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Eiji Hidaka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Shigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
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Ceccanti S, de Vito C, Migliara G, Cozzi DA. Early Surgery Versus Watchful Waiting Strategy for Infantile Abdominoscrotal Hydrocele. J Pediatr Surg 2023; 58:2238-2243. [PMID: 37349217 DOI: 10.1016/j.jpedsurg.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Infantile abdominoscrotal hydrocele is generally managed with early surgery. However, whether these patients actually benefit from an initial watchful waiting strategy is yet to be determined. METHODS This single-center, comparative observational analysis included 36 consecutive patients (9 bilateral cases) diagnosed between January 1998 and December 2019. Initial 16 patients (21 lesions) underwent surgical repair shortly after diagnosis (Group A) at a mean (SD) age of 8 (4) months. Remaining 20 patients (24 lesions) underwent initial nonoperative management (Group B). Overall follow-up was 82.74 (63.84) months. RESULTS Six lesions of Group B spontaneously regressed at a mean age of 23.8 (7.8) months. Remaining 18 hydroceles underwent surgical management at a mean age of 18.7 (12.6) months. Early postoperative morbidity was high (43%) in both groups (Clavien-Dindo grade I-II). During follow-up, there were 1 recurrent hydrocele and 1 testicular atrophy, both events occurring in Group A patients. Group B patients required a higher need for concomitant ipsilateral orchidopexy (61% versus 14%; p = 0.001), and developed a higher rate of ipsilateral inguinal hernia (39% versus 5%; p = 0.01), occurring within 8.3 (3.53) months of surgery. On multivariable analysis, nonoperative management was associated with unplanned second surgery (odds ratio 5.5, 95% CI 1.25-24.17, p = 0.02), regardless of the type of hydrocelectomy performed. CONCLUSIONS Nonoperative management provides effective spontaneous resolution in about 25% of infantile abdominoscrotal hydrocele. Clinicians must balance the potential benefits of such strategy against the impact of pressure induced detrimental effects on the success of future surgery when dealing with longstanding lesions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Silvia Ceccanti
- Pediatric Surgery Unit, Sapienza University of Rome, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, RM, 00161, Italy
| | - Corrado de Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Giuseppe Migliara
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Denis A Cozzi
- Pediatric Surgery Unit, Sapienza University of Rome, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, RM, 00161, Italy.
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Kupietzky A, Finkin M, Dover R, Eliezer Lourie NE, Mordechai-Heyn T, Juster EY, Mazeh H, Mizrahi I. Higher Rates of Complicated Appendicitis During the COVID-19 Pandemic: A Year-to-Year Analysis. J Surg Res 2023; 290:304-309. [PMID: 37329625 PMCID: PMC10208264 DOI: 10.1016/j.jss.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 04/03/2023] [Accepted: 05/12/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION The COVID-19 pandemic impacted presentation, management strategies, and patient outcomes of numerous medical conditions. The aim of this study is to perform a year-to-year comparison of clinical outcomes of patients with acute appendicitis (AA) before and during the pandemic. METHODS Patients treated for AA during the initial 12-mo period of the pandemic at our institute were compared to those treated for AA during the 12-mo period before. Clinical and laboratory parameters, treatment strategies, intraoperative findings, pathology reports, and postoperative outcomes were compared. RESULTS During the study period, 541 patients presented with AA. The median (interquartile range) age was 28 (21-40) y and 292 (54%) were males. 262 (48%) patients presented during the pre-COVID-19 period, while 279 patients (52%) presented during the COVID 19 pandemic. The groups were comparable for baseline clinical data and imaging results upon index admission. There was no significant difference in rate of nonoperative treatment between the Pre-COVID-19 and During-COVID-19 eras (51% versus 53%, P = 0.6) as well as the success rate of such treatment (95.4% versus 96.4%, P = 0.3). Significantly more patients presented with a periappendicular abscess during COVID-19 (4.6% versus 1.1%, P = 0.01) and median (interquartile range) operative time was significantly longer (78 (61-90) versus 32.5 (27-45) min, P < 0.001). Pathology reports revealed a higher rate of perforated appendicitis during COVID-19 (27.4% versus 10.2%, P < 0.001). CONCLUSIONS Patients with AA present with higher rates of perforated and complicated appendicitis during the COVID-19 pandemic. The success rates of nonoperative management in selected patients with noncomplicated AA did not change during the pandemic and is a safe, feasible, option.
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Affiliation(s)
- Amram Kupietzky
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Miriam Finkin
- Faculty of Medicine, Department of Military Medicine and "Tzameret", Hebrew University of Jerusalem and Medical Corps, Israel Defense Forces, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Roi Dover
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nachum Emil Eliezer Lourie
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tzlil Mordechai-Heyn
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eyal Yonathan Juster
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Haggi Mazeh
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ido Mizrahi
- Faculty of Medicine, Department of Surgery, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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11
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Farid AR, Stearns SA, Atarere JO, Suneja N, Weaver MJ, Von Keudell AG. Trends in non-operative management of low-energy pelvic fracture: An analysis of the Nationwide Inpatient Sample. J Orthop 2023; 43:101-108. [PMID: 37564706 PMCID: PMC10410464 DOI: 10.1016/j.jor.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction Non-operative management is common for low-impact pelvic fractures. In this study, we characterize the epidemiology of those treated nonoperatively following low-energy pelvic fracture, while identifying recent management trends. Methodology Data from the Nationwide Inpatient Sample (NIS) database from 2011 to 2018 were analyzed. We identified adult patients diagnosed with pelvic fracture based on International Classification of Diseases (ICD) codes, excluding fractures of the acetabulum, femur, polytrauma, and open fractures to isolate cases caused by low-impact mechanisms. Codes indicating operative management were excluded. Demographic information and outcomes (length of stay, in-hospital mortality, hospital discharge status) were collected. Sub-analyses were performed to identify trends. Findings 123,936 eligible patients were identified. The average age was 68.7 years. 70% were female, showing a decline from 75% to 66% over the study period. Pubic bone involvement was observed in 59% of fractures. The mean Charlson Comorbidity Index (CCI) was 3.83, corresponding to a 10-year survival rate of 58.5%, which remained relatively stable throughout the study period. 62.4% of patients received treatment at urban teaching hospitals. Average length of hospital stay was 6.3 days. Discharge to a skilled nursing facility (SNF) was the most common outcome, ranging from 62.1% to 65.0% during the study period, while 20.0% of patients were discharged home (18.4%-21.1%). Mean in-hospital mortality was 3.28%, showing no significant change, with higher rates among male patients (5.1%) and patients of Asian descent (3.8%). Conclusion The majority of patients receiving nonoperative treatment for low-energy pelvic fractures were females in their mid-60s with moderate comorbidity. The study reveals a relatively high in-hospital mortality rate of 3.28%, particularly among male patients and those of Asian descent, indicating the need for increased surveillance for further injury in these groups. Most patients were discharged to a SNF, highlighting the necessity for extended rehabilitation in this population. This persistent trend is noteworthy considering the growing emphasis on the cost of inpatient admissions and advancements in outpatient management of orthopedic injuries.
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Affiliation(s)
- Alexander R. Farid
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen A. Stearns
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Okiemute Atarere
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J. Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arvind Gabriel Von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Trauma, Bispebjerg hospitalet, University of Copenhagen, 2400, Copenhagen, Denmark
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12
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Nicholls M, Ingvarsson T, Filbay S, Lohmander S, Briem K. Smoking and secondary ACL rupture are detrimental to knee health post ACL injury-a Bayesian analysis. J Exp Orthop 2023; 10:79. [PMID: 37556084 PMCID: PMC10412518 DOI: 10.1186/s40634-023-00638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/17/2023] [Indexed: 08/10/2023] Open
Abstract
PURPOSE To identify potential prognostic factors for patient-reported outcomes in an Icelandic cohort of ACL injured subjects. METHODS All knee MRI reports written in Iceland between the years 2001 to 2011 were read to identify individuals with a possible ACL injury. These individuals were contacted and asked to complete an online questionnaire regarding their injury and current knee related health. The questionnaire collected information on years since surgery, injury circumstance, brace use, physiotherapy, ACL surgery, second ACL injury and current smoking status. In addition, the baseline status of their meniscii were assessed from the original MRI report and medical records were used to identify any subsequent, non-ACL surgery. The patient-reported Knee Osteoarthritis and Injury Outcome Score (KOOS) was used assess current knee related health. A Bayesian proportional odds model was used to assess the effect of all potential prognostic factors above as well as age and sex on KOOS outcomes. RESULTS A total of 408 subjects completed the questionnaire indicating that they did rupture their ACL. The following variables were associated with worse outcomes across all KOOS subscales: having a subsequent arthroscopy, reinjury to your ACL, and smoking. Having physiotherapy for 9 months was associated with worse KOOS pain scores than having 6 months of physiotherapy. Conversely KOOS pain score tended to be higher if you injured your knee during sports. CONCLUSION Reinjuring your ACL, smoking and having subsequent (non-ACLR) surgery predict your knee related health following an ACL injury. Strategies should be implemented to reduce the risk of secondary ACL injury, and patients should be strongly advised not to smoke.
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Affiliation(s)
- Micah Nicholls
- Faculty of Medicine, Research Centre for Movement Sciences, The University of Iceland, Sæmundargata 2, Reykjavík, 102, Iceland.
| | | | - Stephanie Filbay
- Department of Physiotherapy, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lunds Universitet, Lund, Sweden
| | - Kristin Briem
- Faculty of Medicine, Research Centre for Movement Sciences, The University of Iceland, Sæmundargata 2, Reykjavík, 102, Iceland
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13
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Hakam N, Keihani S, Shaw NM, Abbasi B, Jones CP, Rogers D, Wang SS, Gross JA, Joyce RP, Hagedorn JC, Selph JP, Sensenig RL, Moses RA, Dodgion CM, Gupta S, Mukherjee K, Majercik S, Smith BP, Broghammer JA, Schwartz I, Baradaran N, Zakaluzny SA, Erickson BA, Miller BD, Askari R, Carrick MM, Burks FN, Norwood S, Myers JB, Breyer BN. Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study. World J Urol 2023; 41:1983-1989. [PMID: 37356027 DOI: 10.1007/s00345-023-04432-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/09/2023] [Indexed: 06/27/2023] Open
Abstract
PURPOSE To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. METHODS We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). RESULTS Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. CONCLUSION Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.
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Affiliation(s)
- Nizar Hakam
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Nathan M Shaw
- Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA
- Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Behzad Abbasi
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Charles P Jones
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Douglas Rogers
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Sherry S Wang
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Joel A Gross
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Ryan P Joyce
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Judith C Hagedorn
- Department of Urology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - J Patrick Selph
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel L Sensenig
- Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Rachel A Moses
- Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Shubham Gupta
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sarah Majercik
- Division of Trauma and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA
| | - Brian P Smith
- Division of Trauma and Surgical Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Ian Schwartz
- Department of Urology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Nima Baradaran
- Department of Urology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Scott A Zakaluzny
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | | | - Brandi D Miller
- Department of Urology, Detroit Medical Center, Detroit, MI, USA
| | - Reza Askari
- Division of Trauma, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Frank N Burks
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Scott Norwood
- Department of Surgery, UT Health Tyler, Tyler, TX, USA
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
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14
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Schunn MC, Schäfer J, Neunhoeffer F, Lieber J, Fuchs J. [Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]. Chirurgie (Heidelb) 2023; 94:651-663. [PMID: 37338573 DOI: 10.1007/s00104-022-01798-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 06/21/2023]
Abstract
Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].
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Affiliation(s)
- M C Schunn
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland.
| | - J Schäfer
- Diagnostische und Interventionelle Radiologie, Abteilung für Kinderradiologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - F Neunhoeffer
- Klinik für Kinderheilkunde, Abteilung für Kinderkardiologie, Intensivmedizin und Pulmonologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - J Lieber
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
| | - J Fuchs
- Klinik für Kinder- und Jugendmedizin, Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Deutschland
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15
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Carmichael SP, Kline DM, Mowery NT, Miller PR, Meredith JW, Hanchate AD. Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction. J Surg Res 2023; 286:57-64. [PMID: 36753950 PMCID: PMC10034859 DOI: 10.1016/j.jss.2022.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/06/2022] [Accepted: 12/25/2022] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management. MATERIALS AND METHODS A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO. RESULTS Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission. CONCLUSIONS Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.
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Affiliation(s)
- Samuel P Carmichael
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina.
| | - David M Kline
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Nathan T Mowery
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Preston R Miller
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - J Wayne Meredith
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Amresh D Hanchate
- Division of Public Health Sciences, Department of Social Science and Health Policy, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
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16
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Thomas MN, Whaba R, Datta RR, Bunck AC, Stippel DL, Bruns CJ. [Management and treatment of liver injuries after blunt abdominal trauma]. Chirurgie (Heidelb) 2023:10.1007/s00104-023-01858-1. [PMID: 37142798 DOI: 10.1007/s00104-023-01858-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 05/06/2023]
Abstract
The liver is involved in about 20% of cases of blunt abdominal trauma. The management of liver trauma has changed significantly in the past three decades towards conservative treatment. Up to 80% of all liver trauma patients can now be successfully treated by nonoperative management. Decisive for this is the adequate screening and assessment of the patient and the injury pattern as well as the provision of the appropriate infrastructure. Hemodynamically unstable patients require immediate exploratory surgery. In hemodynamically stable patients, a contrast-enhanced computed tomography (CT) should be performed. If active bleeding is detected angiographic imaging and embolization should be performed to stop the bleeding. Even after initially successful conservative management of liver trauma, subsequent complications can occur that make surgical inpatient treatment necessary.
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Affiliation(s)
- M N Thomas
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
| | - R Whaba
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - R R Datta
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - A C Bunck
- Institut für Diagnostische und Interventionelle Radiologie, Uniklinik Köln, Köln, Deutschland
| | - D L Stippel
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - C J Bruns
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
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Deverakonda DL, Kishawi SK, Lapinski MF, Adomshick VJ, Siff JE, Brown LR, Ho VP. What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients. J Surg Res 2023; 284:29-36. [PMID: 36529078 PMCID: PMC9911375 DOI: 10.1016/j.jss.2022.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). MATERIALS AND METHODS We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. RESULTS We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. CONCLUSIONS Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.
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Affiliation(s)
| | - Sami K Kishawi
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | - Jonathan E Siff
- Department of Emergency Medicine and the Center for Clinical Informatics Research and Education, MetroHealth Medical Center, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
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Huerta CT, Courel SC, Ramsey WA, Saberi RA, Gilna GP, Ribieras AJ, Parreco JP, Thorson CM, Sola JE, Perez EA. Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy. J Pediatr Surg 2023; 58:651-7. [PMID: 36641313 DOI: 10.1016/j.jpedsurg.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Although conservative management followed by readmission for interval appendectomy is commonly used to manage perforated appendicitis, many studies are limited to individual or noncompeting pediatric hospitals. This study sought to compare national outcomes following interval or same-admission appendectomy in children with perforated appendicitis. METHODS The Nationwide Readmission Database was queried (2010-2014) for patients <18 years old with perforated appendicitis who underwent appendectomy using ICD9-CM Diagnosis codes. A propensity score-matched analysis (PSMA) utilizing 33 covariates between those with (Interval Appendectomy) and without a prior admission (Same-Admission Appendectomy) was performed to examine postoperative outcomes. RESULTS There were 63,627 pediatric patients with perforated appendicitis. 1014 (1%) had a prior admission for perforated appendicitis within one calendar year undergoing interval appendectomy compared to 62,613 (99%) Same-Admission appendectomy patients. The Interval Appendectomy group was more likely to receive a laparoscopic (87% vs. 78% same-admission) than open (13% vs. 22% same-admission; p < 0.001) operation. Patients receiving interval appendectomy were more likely to have their laparoscopic procedure converted to open (5% vs. 3%) and receive more concomitant procedures. PSMA demonstrated a higher rate of small bowel obstruction in those receiving Same-Admission appendectomy while all other complications were similar. Although those receiving Interval Appendectomy had a shorter index length of stay (LOS) and lower admission costs, they incurred an additional $8044 [$5341-$13,190] from their prior admission. CONCLUSION Patients treated with interval appendectomy experienced more concomitant procedures and incurred higher combined hospitalization costs while still having a similar postoperative complication profile compared to those receiving same-admission appendectomy for perforated appendicitis. LEVEL OF EVIDENCE III. TYPE OF STUDY Retrospective Comparative Study.
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19
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Lie JJ, Nabata K, Zhang JW, Zhao D, Park CM, Hameed SM, Dawe P, Hamilton TD. Factors associated with recurrent appendicitis after nonoperative management. Am J Surg 2023; 225:915-920. [PMID: 36925417 DOI: 10.1016/j.amjsurg.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 02/23/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The objective of this study is to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively. METHODS This is a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital. Patient demographics, radiographic information, management, and clinical outcomes were recorded. The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a time-to-event competing-risk analysis was performed. RESULTS Of the 699 patients presenting with appendicitis, 74 were treated nonoperatively (35 [47%] were women; median [IQR] age, 48 [33,64] years), and 21 patients (29%) had recurrent appendicitis. On univariate and multivariate analysis, presence of an appendicolith on imaging was the only factor associated with a higher risk of recurrent appendicitis (p = 0.02). CONCLUSIONS The presence of appendicolith was associated with an increased risk of developing recurrent appendicitis within 6 months.
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Affiliation(s)
- Jessica J Lie
- Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada; Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Kylie Nabata
- Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
| | - Jenny W Zhang
- Faculty of Science, University of British Columbia, Vancouver, BC, Canada.
| | - Darren Zhao
- Faculty of Science, University of British Columbia, Vancouver, BC, Canada.
| | - Chan Mi Park
- Harvard T.H. Chan School of Public Health, Boston, MA, USA; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA.
| | - S Morad Hameed
- Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
| | - Philip Dawe
- Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
| | - Trevor D Hamilton
- Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
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20
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Adams UC, Herb JN, Akinkuotu AC, Gallaher JR, Charles AG, Phillips MR. Nonoperative Management Versus Laparoscopic Appendectomy in Children: A Cost-Effectiveness Analysis. J Surg Res 2023; 283:929-936. [PMID: 36915021 DOI: 10.1016/j.jss.2022.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/07/2022] [Accepted: 10/16/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Nonoperative management (NOM) of acute appendicitis in the pediatric population is highly debated with uncertain cost-effectiveness. We performed a decision tree cost-effectiveness analysis of NOM versus early laparoscopic appendectomy (LA) for acute appendicitis in children. METHODS We created a decision tree model for a simulated cohort of 49,000 patients, the number of uncomplicated appendectomies performed annually, comparing NOM and LA. We included postoperative complications, recurrent appendicitis, and antibiotic-related complications. We used the payer perspective with a 1-year time horizon. Model uncertainty was analyzed using a probabilistic sensitivity analysis. Event probabilities, health-state utilities, and costs were obtained from literature review, Healthcare Cost and Utilization Project, and Medicare fee schedules. RESULTS In the base-case analysis, NOM costs $6530/patient and LA costs $9278/patient on average at 1 y. Quality-adjusted life year (QALY) differences minimally favored NOM compared to LA with 0.997 versus 0.996 QALYs/patient. The incremental cost-effectiveness ratio for NOM over LA was $4,791,149.52/QALY. NOM was dominant in 97.4% of simulations, outperforming in cost and QALYs. A probabilistic sensitivity analysis showed NOM was 99.6% likely to be cost-effective at a willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS Our model demonstrates that NOM is a dominant strategy to LA over a 1-year horizon. We use recent trial data demonstrating higher rates of early and late NOM failures. However, we also incorporate a shorter length of index hospitalizations with NOM, reflecting a contemporary approach to NOM and ultimately driving cost-effectiveness. Long-term follow-up data are needed in this population to assess the cost-effectiveness of NOM over longer time horizons, where healthcare utilization and recurrence rates may be higher.
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Affiliation(s)
- Ursula C Adams
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joshua N Herb
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Adesola C Akinkuotu
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jared R Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony G Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael R Phillips
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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21
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Chen N, A Ajani J, Wu A. Nonoperative management of gastrointestinal malignancies in era of neoadjuvant treatment. Chin J Cancer Res 2023; 35:44-57. [PMID: 36910854 PMCID: PMC9992995 DOI: 10.21147/j.issn.1000-9604.2023.01.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/30/2023] [Indexed: 03/14/2023] Open
Abstract
Cancers derived from the gastrointestinal (GI) tract are often treated with radical surgery to achieve a cure. However, recent advances in the management of GI cancers involve the use of a combination of neoadjuvant radiation and chemotherapy followed by surgical intervention to achieve improved local control and cure. Interestingly, a small proportion of patients with highly sensitive tumors achieved a pathological complete response (pCR) (no residual tumor cells in the resected specimen) to neoadjuvant chemoradiation therapy (nCRT). The desire for organ preservation and avoidance of surgical morbidity brings the idea of a nonoperative management (NOM) strategy. Because of the different nature of tumor biology, GI cancers present diverse responses to nCRT, ranging from high sensitivity (anal cancer) to low sensitivity (gastric/esophageal cancer). There is an increasing attention to NOM of localized GI cancers; however, without the use of biomarkers/imaging parameters to select such patients, NOM will remain a challenge. Therefore, this review intends to summarize some of the recent updates from the aspect of current nCRT regimens, criteria for patient selection and active surveillance schedules. We also hope to review significant sequelae of radical surgery and the complications of nCRT to clarify the directions for optimization of nCRT and NOM for oncologic outcomes and quality of life.
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Affiliation(s)
- Nan Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston 77030, USA
| | - Aiwen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
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22
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Kono J, Yoshimaru K, Kondo T, Takahashi Y, Toriigahara Y, Fukuta A, Obata S, Kawakubo N, Nagata K, Matsuura T, Tajiri T. The Volume of Intestinal Decompression can Predict the Necessity of Surgical Intervention for Adhesive Small Bowel Obstruction. J Pediatr Surg 2023:S0022-3468(23)00088-X. [PMID: 36898878 DOI: 10.1016/j.jpedsurg.2023.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND There is no standard timing for switching to surgical management for children with adhesive small bowel obstruction (ASBO) who initially receive conservative treatment. We hypothesized that an increased gastrointestinal drainage volume may indicate the need for surgical intervention. METHODS The study population included 150 episodes in the patients less than 20 years of age who received treatment for ASBO in our department from January 2008 to August 2019. Patients were divided into two groups: the successful conservative treatment group (CT) and the eventual surgical treatment group (ST). Following the analysis of all episodes (Study 1), we limited our analysis to only first ASBO episodes (Study 2). We retrospectively reviewed their medical records. RESULTS There were statistically significant differences in the volume on the 2nd day in both Study 1 (9.1 ml/kg vs. 18.7 ml/kg; p < 0.01) and study 2 (8.1 ml/kg vs. 19.7 ml/kg; p < 0.01). The cut-off value was the same for both Study 1 and Study 2 (11.7 ml/kg). CONCLUSIONS The gastrointestinal drainage volume on the 2nd day in ST was significantly larger than that in CT. Accordingly, we considered that the drainage volume may predict eventual surgical intervention for children with ASBO who initially receive conservative treatment. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jun Kono
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan; Pediatric Emergency and Critical Care Center, Kyushu University Hospital, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Koichiro Yoshimaru
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan.
| | - Takuya Kondo
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshiaki Takahashi
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan; Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Yukihiro Toriigahara
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Atsuhisa Fukuta
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Satoshi Obata
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Naonori Kawakubo
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Toshiharu Matsuura
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Tatsuro Tajiri
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan; Pediatric Emergency and Critical Care Center, Kyushu University Hospital, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
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23
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Hartnett DA, Milner JD, DeFroda SF. Osteoarthritis in the Upper Extremity. Am J Med 2023; 136:415-421. [PMID: 36740213 DOI: 10.1016/j.amjmed.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 02/05/2023]
Abstract
Osteoarthritis is a common cause of morbidity in an increasingly aging population. Although the weight-bearing joints of the leg and foot are frequently affected by osteoarthritis, degenerative changes in the joints of the upper extremity are likewise common and can be both particularly debilitating for affected individuals and uniquely challenging for the health care providers managing it. The present review seeks to overview the epidemiology, anatomy, diagnosis, and management of osteoarthritis in the joints of the shoulder, elbow, and hand with the intent of providing accessible and relevant information to the range of medical professionals involved in patient care.
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Affiliation(s)
- Davis A Hartnett
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Mass.
| | - John D Milner
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Steven F DeFroda
- Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia Mo
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24
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Grotenhuis BA, Beets GL. Watch-and-Wait is an Option in Rectal Cancer Patients: From Controversy to Common Clinical Practice. Clin Oncol (R Coll Radiol) 2023; 35:124-129. [PMID: 36481218 DOI: 10.1016/j.clon.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 10/26/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
Overview of the introduction of organ preservation in rectal cancer patients and future challenges.
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Affiliation(s)
- B A Grotenhuis
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - G L Beets
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands.
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25
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Anteby R, Allar BG, Broekhuis JM, Patel PB, Marcaccio CL, Papageorge MV, Papatheodorou S, Mendoza AE. Thromboprophylaxis Timing After Blunt Solid Organ Injury: A Systematic Review and Meta-analysis. J Surg Res 2023; 282:270-279. [PMID: 36332306 DOI: 10.1016/j.jss.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/29/2022] [Accepted: 10/08/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Trauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation. METHODS A systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation. RESULTS Twelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12). CONCLUSIONS Based on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.
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Affiliation(s)
- Roi Anteby
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of General Surgery, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Benjamin G Allar
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Jordan M Broekhuis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Priya B Patel
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of General Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Christina L Marcaccio
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marianna V Papageorge
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - April E Mendoza
- Department of Surgery, University of California San Francisco - East Bay, Oakland, California
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26
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Duckworth AD, Carter TH, Chen MJ, Gardner MJ, Watts AC. Olecranon fractures : current treatment concepts. Bone Joint J 2023; 105-B:112-123. [PMID: 36722062 DOI: 10.1302/0301-620x.105b2.bjj-2022-0703.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.
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Affiliation(s)
- Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Thomas H Carter
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, UK
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27
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Fokas E, Glynne-Jones R, Fleischmann M, Piso P, Tselis N, Ghadimi M, Hofheinz RD, Rödel C. Radiotherapy dose escalation using endorectal brachytherapy in elderly and frail patients with rectal cancer unsuitable for surgery: Lessons from studies in fit patients and future perspectives. Cancer Treat Rev 2023; 112:102490. [PMID: 36463667 DOI: 10.1016/j.ctrv.2022.102490] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Abstract
Epidemiological data indicate that more than 50 % of patients with newly-diagnosed rectal cancer are older than 70 years, with rising numbers expected over the next decades. Treatment decision-making is challenging in elderly and frail patients with rectal cancer, whereas standardized treatment guidelines for this patient cohort are lacking. Elderly and frail rectal cancer patients are often considered by surgeons as unfit to undergo radical surgery as the risk of surgical complications and postoperative mortality rises with increasing age and comorbidity. Furthermore, these patients often receive no treatment at all, resulting in local and/or systemic disease progression with associated symptoms and impaired quality of life (QoL). Recent data from randomized trials in young fit patients with early stage rectal cancer indicate that RT dose escalation can be safely delivered using external beam (chemo)radiotherapy (EBRT) followed by endoluminal radiotherapeutic modalities, such as contact X-ray brachytherapy (CXB) or high-dose rate endorectal brachytherapy (HDR-BT). However, prospective studies testing this therapeutic concept in elderly and frail patients remain limited. Here, we review the current evidence in the epidemiology and the management of elderly and frail patients with rectal cancer. We summarize the potential of RT dose escalation to achieve long-term local control of the primary tumour, prevent disease-related morbidity, improve QoL and even organ preservation. Future perspectives and open questions will be discussed as well.
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Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany.
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, UK
| | - Maximillian Fleischmann
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Barmherzige Brüder Hospital, 93049 Regensburg, Germany
| | - Nikolaos Tselis
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany
| | - Michael Ghadimi
- Department of General, Visceral, and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Ralf-Dieter Hofheinz
- Department of Medical Oncology, University Hospital Mannheim, University Heidelberg, Heidelberg, Germany
| | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany
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28
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Lari A, Jarragh A, Alherz M, Nouri A, Behbehani M, Alnusif N. Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial. Eur J Trauma Emerg Surg 2023; 49:107-113. [PMID: 35982326 PMCID: PMC9925527 DOI: 10.1007/s00068-022-02078-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 08/08/2022] [Indexed: 02/14/2023]
Abstract
PURPOSE To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB). METHODS This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques. RESULTS Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages. CONCLUSION The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique. LEVEL OF EVIDENCE Therapeutic Level II.
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Affiliation(s)
- Ali Lari
- AlRazi Orthopedic Hospital, AlSabah Medical Region, Kuwait City, Kuwait.
| | - Ali Jarragh
- grid.413527.6Department of Orthopedic Surgery, Jaber Alahmed Alsabah Hospital, Kuwait City, Kuwait
| | - Mohammad Alherz
- grid.8217.c0000 0004 1936 9705Department of Anatomy, Trinity College Dublin, Dublin, Ireland
| | - Abdullah Nouri
- AlRazi Orthopedic Hospital, AlSabah Medical Region, Kuwait City, Kuwait
| | - Mousa Behbehani
- AlRazi Orthopedic Hospital, AlSabah Medical Region, Kuwait City, Kuwait
| | - Naser Alnusif
- AlRazi Orthopedic Hospital, AlSabah Medical Region, Kuwait City, Kuwait
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Witt CE, Sumislawski JJ, Burlew CC. Natural history and nonoperative management of penetrating cerebrovascular injury. Injury 2023; 54:131-137. [PMID: 36376123 DOI: 10.1016/j.injury.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION There is a modern precedent for nonoperative management of select penetrating cerebrovascular injuries (PCVIs); however, there is minimal data to guide management. PATIENTS AND METHODS This study assessed treatments, radiographic injury progression, and outcomes for all patients with PCVIs managed at an urban Level I trauma center from 2016 to 2021 that underwent initial nonoperative management (NOM). RESULTS Fourteen patients were included. There were 11,635 trauma admissions, 378 patients with blunt cerebrovascular injury, and 18 patients with operatively-managed PCVI during this timeframe. All patients received antithrombotic therapy, but this was delayed in some due to concomitant injuries. Three patients had stroke (21%): two before antithrombotic initiation, and one with unclear timing relative to treatment. Three patients underwent endovascular interventions. On follow-up imaging, 14% had injury resolution, 36% were stable, 21% worsened, and 29% had no follow-up vascular imaging. One patient died (7%), one had a bleeding complication (7%), and no patient required delayed operative intervention. DISCUSSION Early initiation of antithrombotic therapy, early surveillance imaging, and selective use of endovascular interventions are important for nonoperative management of PCVI.
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Affiliation(s)
- Cordelie E Witt
- Department of Trauma and Acute Care Surgery, University of Colorado Health Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538, USA.
| | - Joshua J Sumislawski
- Department of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Aurora, CO 80045, USA
| | - Clay Cothren Burlew
- Department of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Aurora, CO 80045, USA
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Park YS. A Case of Gastric Perforation Caused by Excessive Insufflation during Upper Gastrointestinal Endoscopy: Nonoperative Management. Case Rep Gastroenterol 2023; 17:327-332. [PMID: 38020464 PMCID: PMC10651181 DOI: 10.1159/000534866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Upper gastrointestinal endoscopy is used to diagnose and treat upper gastrointestinal diseases, but it can also cause complications, including perforation. Perforation is a serious complication, so it is important to be aware of the risk factors in advance and to take precautions to prevent it. Case Presentation We report a case of gastric perforation caused by excessive insufflation during upper gastrointestinal endoscopy in a 64-year-old man with a history of multiple active gastric ulcers. During the endoscopy, the patient did not cooperate and insufflation was performed for a prolonged period of time. This led to a mucosal laceration and a hole suspected to be a perforation on the lesser curvature of the gastric body. The patient was treated nonsurgically with fasting, intravenous fluids, antibiotics, intravenous proton pump inhibitors, and blood transfusions. No leakage was observed on the follow-up computed tomography scan, and the perforation site was completely healed 2 months later. Conclusion In this case, the patient was successfully treated with conservative therapy alone. The treatment of gastric perforation caused by endoscopy has shifted toward conservative therapy in recent years.
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Affiliation(s)
- Youn Su Park
- Department of Internal Medicine, CHA Ilsan Medical Center, CHA University School of Medicine, Goyang-si, South Korea
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31
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Podda M, De Simone B, Ceresoli M, Virdis F, Favi F, Wiik Larsen J, Coccolini F, Sartelli M, Pararas N, Beka SG, Bonavina L, Bova R, Pisanu A, Abu-Zidan F, Balogh Z, Chiara O, Wani I, Stahel P, Di Saverio S, Scalea T, Soreide K, Sakakushev B, Amico F, Martino C, Hecker A, de'Angelis N, Chirica M, Galante J, Kirkpatrick A, Pikoulis E, Kluger Y, Bensard D, Ansaloni L, Fraga G, Civil I, Tebala GD, Di Carlo I, Cui Y, Coimbra R, Agnoletti V, Sall I, Tan E, Picetti E, Litvin A, Damaskos D, Inaba K, Leung J, Maier R, Biffl W, Leppaniemi A, Moore E, Gurusamy K, Catena F. Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document. World J Emerg Surg 2022; 17:52. [PMID: 36224617 PMCID: PMC9560023 DOI: 10.1186/s13017-022-00457-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.
Methods Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.
Results Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. Conclusion This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.
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Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
| | - Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Marco Ceresoli
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Virdis
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | - Francesco Favi
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Nikolaos Pararas
- Department of General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Raffaele Bova
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Fikri Abu-Zidan
- Department of Applied Statistics, The Research Office, College of Medicine and Health Sciences United Arab Emirates University, Abu Dhabi, UAE
| | - Zsolt Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | | | - Philip Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, USA
| | - Salomone Di Saverio
- Department of Surgery, San Benedetto del Tronto Hospital, AV5, San Benedetto del Tronto, Italy
| | - Thomas Scalea
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Francesco Amico
- Trauma Service, John Hunter Hospital, Newcastle, Australia.,The University of Newcastle, Newcastle, Australia
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl della Romagna, Lugo, Italy
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Nicola de'Angelis
- Unit of General Surgery, Henri Mondor Hospital, UPEC, Créteil, France
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Andrew Kirkpatrick
- General, Acute Care and Trauma Surgery Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Emmanouil Pikoulis
- General Surgery, Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Luca Ansaloni
- Unit of General Surgery, San Matteo Hospital, Pavia, Italy
| | - Gustavo Fraga
- Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil
| | - Ian Civil
- Director of Trauma Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal
| | - Edward Tan
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Kenji Inaba
- University of Southern California, Los Angeles, USA
| | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Milton Keynes University Hospital, Milton Keynes, UK
| | | | - Walt Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, La Jolla, CA, USA
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Fausto Catena
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
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Abstract
The treatment algorithm for locally advanced rectal cancer (LARC) has increased in complexity over the past 10 years. Nonoperative management (NOM) for rectal cancer in patients with clinical complete response (cCR) after neoadjuvant therapy has been gaining acceptance as a potential treatment option for selected LARC patients. The current challenge is to accurately select the patients with an apparent cCR, thereby correctly identifying those would-be appropriate candidates for a NOM strategy. NOM should be part of the treatment discussion of LARC, considering increasing rates of cCR, patient preference, potential quality of life gains, and the potential avoidance of surgical morbidity.
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Affiliation(s)
- Felipe F Quezada-Diaz
- Colorectal Unit, Department of Surgery, Complejo Asistencial Doctor Sótero del Río, Santiago, RM, Chile. https://twitter.com/ffquezad
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue
- SR-201, New York, NY 10065, USA.
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Fleischmann M, Diefenhardt M, Trommel M, Scherf C, Ramm U, Chatzikonstantinou G, Fokas E, Rödel C, Tselis N. Image-guided high-dose-rate brachytherapy for rectal cancer: technical note and first clinical experience on an organ-preserving approach. Strahlenther Onkol 2022; 198:654-662. [PMID: 35445815 PMCID: PMC9217888 DOI: 10.1007/s00066-022-01931-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/10/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE As the population ages, the incidence of rectal cancer among elderly patients is rising. Due to the risk of perioperative morbidity and mortality, alternative nonoperative treatment options have been explored in elderly and frail patients who are clinically inoperable or refuse surgery. METHODS Here we present technical considerations and first clinical experience after treating a cohort of six rectal cancer patients (T1‑3, N0‑1, M0; UICC stage I-IIIB) with definitive external-beam radiation therapy (EBRT) followed by image-guided, endorectal high-dose-rate brachytherapy (HDR-BT). Patients were treated with 10-13 × 3 Gy EBRT followed by HDR-BT delivering 12-18 Gy in two or three fractions. Tumor response was evaluated using endoscopy and magnetic resonance imaging of the pelvis. RESULTS Median age was 84 years. All patients completed EBRT and HDR-BT without any high-grade toxicity (> grade 2). One patient experienced rectal bleeding (grade 2) after 10 weeks. Four patients (67%) demonstrated clinical complete response (cCR) or near cCR, there was one partial response, and one residual tumor and hepatic metastasis 8 weeks after HDR-BT. The median follow-up time for all six patients is 42 weeks (range 8-60 weeks). Sustained cCR without evidence of local regrowth has been achieved in all four patients with initial (n)cCR to date. CONCLUSION Primary EBRT combined with HDR-BT is feasible and well tolerated with promising response rates in elderly and frail rectal cancer patients. The concept could be an integral part of a highly individualized and selective nonoperative treatment offered to patients who are not suitable for or refuse surgery.
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Affiliation(s)
- Maximilian Fleischmann
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Markus Diefenhardt
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Martin Trommel
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Christian Scherf
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Ulla Ramm
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Georgios Chatzikonstantinou
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Emmanouil Fokas
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Partner Site Frankfurt am Main, German Cancer Consortium (DKTK), Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Partner Site Frankfurt am Main, German Cancer Consortium (DKTK), Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
| | - Nikolaos Tselis
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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Entriken C, Weed Z, Parikh PP, Ekeh AP. Complications Following Splenic Embolization for Trauma: Have Things Changed Over Time? J Surg Res 2022; 277:44-49. [PMID: 35460920 DOI: 10.1016/j.jss.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/20/2022] [Accepted: 03/19/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Splenic artery embolization (SAE) is a routinely used adjunct in the nonoperative management (NOM) of blunt splenic injury (BSI). The purpose of this study was to evaluate the rate and type of adverse events that occur in patients undergoing SAE and to compare this with the previous data. METHODS Patients who had SAE for BSI between 2011 and 2018 were identified. Splenic abscess, splenic infarction, and contrast-induced renal insufficiency were considered major complications. Coil migration, fever, and pleural effusions were regarded minor complications. The results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010. RESULTS There were 716 patients admitted with BSI. SAE was performed in 74 (13.3%) of the 557 (78%) NOM patients. The overall complication rate was 33.8%. Major complications occurred in 11 patients (14.9%) and minor in 13 patients (18.9%). There was no association between complications and coil location by logistic regression. CONCLUSIONS SAE continues to be a useful adjunct in the NOM of BSI though complications continue to occur. Fewer minor complications were noted in the period studied compared to past similar studies.
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Affiliation(s)
| | - Zachary Weed
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Priti P Parikh
- Department of Surgery, Wright State University, Dayton, Ohio
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Mourkus H, Phillips NJ, Rangan A, Peach CA. Management of periprosthetic fractures of the humerus : a systematic review. Bone Joint J 2022; 104-B:416-423. [PMID: 35360951 DOI: 10.1302/0301-620x.104b4.bjj-2021-1334.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature. METHODS A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advance Search. For inclusion, studies had to report clinical outcomes following the management of periprosthetic fractures of the humerus. The protocol was registered on the PROSPERO database. RESULTS Overall, 40 studies were included, involving a total of 210 patients. The fractures were reported using very heterogeneous classification systems, as were the functional outcome scores. A total of 60 patients had nonoperative treatment with a 50% rate of nonunion. Fixation was undertaken in 99 patients; successful union was obtained in 93 (93%). Revision of either the humeral stem or the whole arthroplasty was reported in 79 patients with a high rate of union (n = 66; 84%), and a mean rate of complications of 29% (0% to 41%). CONCLUSION This study highlighted a lack of uniformity in classifying these fractures and reporting the outcome of their treatment. The results may help to inform decision-making with patients, particularly about the rate of complications of nonoperative treatment. There is a need to improve the reporting of the pattern of these fractures using a uniform classification system, and the harmonization of the collection of data relating to the outcome of treatment. Based on this review, we propose a minimum dataset to be used in future studies. Cite this article: Bone Joint J 2022;104-B(4):416-423.
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Affiliation(s)
- Hany Mourkus
- Queen Elizabeth University Hospital, Greater Glasgow and Clyde NHS Health Board, Glasgow, UK.,Wythenshawe Hospital, Manchester University NHS FT, Manchester, UK
| | - Nick J Phillips
- Wythenshawe Hospital, Manchester University NHS FT, Manchester, UK
| | - Amar Rangan
- James Cook University Hospital, Middlesbrough, UK.,Medical Sciences Division, University of Oxford, Oxford, UK.,Department of Health Sciences, University of York, York, UK
| | - Chris A Peach
- Wythenshawe Hospital, Manchester University NHS FT, Manchester, UK.,Manchester Metropolitan University, Manchester, UK
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Perez Otero S, Metzger JW, Choi BH, Ramaraj A, Tashiro J, Kuenzler KA, Ginsburg HB, Tomita SS, Fisher JC. It's time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone. J Pediatr Surg 2022; 57:56-62. [PMID: 34674843 DOI: 10.1016/j.jpedsurg.2021.09.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Published data demonstrate that management of uncomplicated pediatric appendicitis with antibiotics-alone is safe and frequently successful. Randomized controlled trials (RCT) comparing antibiotics-alone to appendectomy are lacking, alongside insight into drivers of failure. We sought to validate the antibiotics-alone approach and identify barriers to success using an RCT design. METHODS Patients aged 6-17 years with uncomplicated appendicitis were randomized to appendectomy or intravenous piperacillin/tazobactam for 24-48 h followed by 10 days of oral ciprofloxacin/metronidazole. Enrollment required symptoms <48 h, WBC<18, appendiceal diameter <11 mm, and radiographic absence of perforation. Lack of clinical improvement or persistently elevated WBC resulted in appendectomy. Primary outcomes were 1-year success rate of antibiotics-alone and quality-of-life measures. RESULTS Among 39 children enrolled over 31 months, 20 were randomized to antibiotics-alone and 19 to surgery. At 1 year, 6 nonoperative patients underwent appendectomy (70% success). Four cases were not true antibiotic failures but instead reflected "pragmatic" challenges to executing nonoperative algorithms. Only 2 cases represented recurrent/refractory appendicitis, suggesting a 90% adjusted 1-year success rate. Parental PedsQL™ scores were similar between treatment cohorts (91.3 vs 90.2, P = 0.32). Children treated with antibiotics-alone had faster return to activity (2.0 vs 12 days, P = 0.001) and fewer parental missed work days (0.0 vs 2.5, P = 0.03). CONCLUSIONS These data corroborate findings from non-randomized studies suggesting 70-90% of uncomplicated pediatric appendicitis can be treated with antibiotics-alone, with fewer disability days. Failures appear multifactorial, often reflecting practical hurdles and not antibiotic limitations. As surgeons consider nonoperative protocols for uncomplicated appendicitis, these data further inform the variability of treatment success. LEVEL OF EVIDENCE 1; randomized controlled trial.
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Abstract
Nonoperative management (NOM) of acute appendicitis is becoming more popular, especially in resource-strapped locations, to minimize hospital system costs. In uncomplicated cases of appendicitis, NOM can effectively treat the patient. It does carry a 39.1% risk of recurrence in 5 years, and operative management (OM) does not increase morbidity or risk of complication, so the authors recommend laparoscopic OM for uncomplicated appendicitis. For complicated cases of appendicitis, the authors recommend initial NOM with interval appendectomy in all patients. All appendicitis patients should undergo surveillance endoscopy if older than 40 years to rule out a contributing neoplasm.
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Affiliation(s)
- Cpt Samuel Grasso
- Department of General Surgery, William Beaumont Army Medical Center, 5005 N Piedras Street, El Paso, TX 79920, USA
| | - Ltc Avery Walker
- Department of General Surgery, William Beaumont Army Medical Center, 5005 N Piedras Street, El Paso, TX 79920, USA.
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Chahine AH, Gilyard S, Hanna TN, Fan S, Risk B, Johnson JO, Duszak R, Newsome J, Xing M, Kokabi N. Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study. Acad Radiol 2021; 28 Suppl 1:S138-S147. [PMID: 33288400 DOI: 10.1016/j.acra.2020.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization. MATERIALS AND METHODS The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures. RESULTS Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM. CONCLUSION Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.
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Farné GM, Lauro A, Vaccari S, Marino IR, Khouzam S, D'Andrea V, Cervellera M, Tonini V. Spontaneous Perforated Duodenal Diverticulum: Wait or Cut First? Dig Dis Sci 2021; 66:2876-80. [PMID: 34155566 DOI: 10.1007/s10620-021-07092-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 02/08/2023]
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40
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Saar S, Jorgensen J, Lemma AN, Gaarder C, Naess PA, Leppäniemi A, Sallinen V, Pius R, Reinsoo A, Lepp J, Talving P. Selective non-operative management of penetrating abdominal injuries at Northern European trauma centers: the NordiPen Study. Eur J Trauma Emerg Surg 2021; 48:2023-2027. [PMID: 34309723 DOI: 10.1007/s00068-021-01749-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE A selective nonoperative management (SNOM) of penetrating abdominal injuries (PAI) is a standard of care in numerous established trauma centers. However, available evidence supporting SNOM of PAI in European settings remains scarce. Thus, we performed a multi-center study at selected Northern European trauma centers to investigate the management and outcomes of PAI. We hypothesized that despite a low number of penetrating injuries in included trauma centers, SNOM is successfully utilized with outcomes comparable with trauma centers with a high number of PAI. METHODS All adult patients admitted to participating trauma centers in the Northern European region with PAI between 1/2015 and 12/2016 were retrospectively reviewed. Primary outcomes were mortality and success rate of SNOM. RESULTS Overall, 119 patients were included. Median age was 38 (28-47) years. SNOM was initiated in 55 patients (46.0%) with 94.5% success rate. Three patients (5.5%) failed SNOM and had a delayed laparotomy with one gastric injury, one small bowel injury and one patient with a bleeding from mesentery. Overall mortality of the cohort was 5.0%. However, all patients in the SNOM group survived. Higher median ISS, median Abbreviated Injury Scale score of the abdomen, rate of combined anterior and posterior wounds, rate of in-hospital complications and longer hospital length of stay were observed in the immediate laparotomy group compared to the SNOM group. CONCLUSIONS SNOM of PAI is a safe practice even in regions with a low prevalence of penetrating injuries. The outcomes in our study are comparable with results from trauma centers treating larger numbers of patients with PAI.
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Affiliation(s)
- Sten Saar
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia. .,Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Joakim Jorgensen
- Department of Traumatology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Pal A Naess
- Department of Traumatology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Abdominal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Riinu Pius
- The University of Edinburgh, Edinburgh, Scotland
| | - Arvo Reinsoo
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia.,Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Jaak Lepp
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,North Estonia Medical Centre, Tallinn, Estonia
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Fletcher KL, Perea LL, Morgan ME, Otaibi BW, Hazelton JP. Repeat Imaging in Blunt Hepatic Injuries Can Wait for Clinical Change. J Surg Res 2021; 268:119-124. [PMID: 34304007 DOI: 10.1016/j.jss.2021.06.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/11/2021] [Accepted: 06/08/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is variability regarding the utilization and timing of repeat imaging in adult patients with blunt hepatic injury who are managed nonoperatively. This study examines the rate of delayed complications and interventions in patients with blunt hepatic injuries who undergo repeat imaging prompted either by clinical change (CC) or non-clinical change (NCC). METHODS A nine-year, retrospective, dual-institution study was performed of adult patients with blunt hepatic injuries. Patients were identified based on whether repeat imaging was performed and reason for reimaging: CC or NCC. The incidence of delayed complications and interventions was examined for each type of scan. RESULTS Of 365 patients, 122 (33.4%) underwent repeat imaging [CC, n = 72 (59%); NCC, n=50 (41%)]. Mean time to repeat imaging was shorter in the NCC group [CC = 7.6 ± 8 days; NCC = 4.7 ± 6.3 days, P = 0.034]. Delayed complications were found in 30 (25%) patients reimaged, [CC, n = 20; NCC, n = 10, P = 0.395]. Interventions were performed in 12 (40%) patients [CC, n = 10; NCC, n = 2, P = 0.120]. CONCLUSIONS Repeat imaging due to NCC occurred earlier than imaging performed by CC. One quarter of patients reimaged demonstrated a delayed complication, with nearly half undergoing intervention. There was no difference in incidence of delayed complications or interventions between groups, suggesting repeat imaging can be prompted by clinical change in blunt hepatic injuries.
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Affiliation(s)
- Kelsey L Fletcher
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Lindsey L Perea
- Department of Surgery, Division of Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania.
| | - Madison E Morgan
- Department of Surgery, Division of Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Banan W Otaibi
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Joshua P Hazelton
- Department of Surgery, Division of Trauma and Acute Care Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Ando T, Oka T, Oshima G, Handa K, Maeda S, Yuasa Y, Aiko S. Fecalith in the Proximal Area of the Appendix is a Predictor of Failure of Nonoperative Treatment for Complicated Appendicitis in Adults. J Surg Res 2021; 267:477-484. [PMID: 34246841 DOI: 10.1016/j.jss.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 05/31/2021] [Accepted: 06/09/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The management of complicated appendicitis remains controversial, since this disease has various clinical presentations and is associated with high rates of adverse events. Although initial nonoperative treatment is generally employed for complicated appendicitis, its clinical presentation and the predictors of nonoperative treatment failure are unclear. METHODS Patients diagnosed with complicated appendicitis in our hospital between April 2015 and March 2020 were enrolled. In total, 113 patients were classified into three categories: emergency appendectomy, failure of nonoperative treatment and successful nonoperative treatment. The primary outcome was the rate of failure of nonoperative treatment, as assessed by logistic regression analysis. The secondary outcomes were the operative procedures and postoperative courses of the three groups. RESULTS Of 113 patients, 45 (40%) underwent emergency appendectomy, 25 (22%) failed nonoperative treatment, and 43 (38%) had successful nonoperative treatment. Among these successful cases, 38 patients (88%) underwent interval appendectomy. In multivariate analyses, the presence of a fecalith in the proximal area of the appendix was an independent risk factor for failure of nonoperative treatment (odds ratio, 20.5; 95% confidence interval, 4.37-95.7, P < 0.001). Postoperative outcomes were more unfavorable in cases of failed nonoperative treatment than in cases of emergency and interval appendectomy. CONCLUSIONS The presence of a fecalith in the proximal area of the appendix is an independent predictor for failure of nonoperative treatment for complicated appendicitis in adults. Patients with this risk factor should be considered candidates for surgical treatment.
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Affiliation(s)
- Tomofumi Ando
- Department of Surgery, Eiju General Hospital, Tokyo, Japan.
| | - Taishu Oka
- Department of Surgery, Eiju General Hospital, Tokyo, Japan
| | - Go Oshima
- Department of Surgery, Eiju General Hospital, Tokyo, Japan
| | - Kan Handa
- Department of Surgery, Eiju General Hospital, Tokyo, Japan
| | - Shingo Maeda
- Department of Surgery, Eiju General Hospital, Tokyo, Japan
| | - Yuji Yuasa
- Department of Radiology, Eiju General Hospital, Tokyo, Japan
| | - Satoshi Aiko
- Department of Surgery, Eiju General Hospital, Tokyo, Japan
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Affiliation(s)
- Jonathan B Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Dyrna FGE, Ludwig M, Imhoff AB, Martetschläger F. Off-track Hill-Sachs lesions predispose to recurrence after nonoperative management of first-time anterior shoulder dislocations. Knee Surg Sports Traumatol Arthrosc 2021; 29:2289-2296. [PMID: 32740876 DOI: 10.1007/s00167-020-06176-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 06/11/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE The purpose of this study was to evaluate whether the presence of an off-track Hill-Sachs lesion has an impact on the recurrence rate after nonoperative management of first-time anterior shoulder dislocations. METHODS A retrospective cohort study was planned with a follow-up via questionnaire after a minimum of 24 months. Fifty four patients were included in the study (mean age: 29.5 years; 16 female, 38 male). All of these patients opted for primary nonoperative management after first-time traumatic anterior shoulder dislocation, in some cases even against the clinician's advice. The glenoid track and the Hill-Sachs interval were evaluated in the MRI scans. The clinical outcome was evaluated via a shoulder-specific questionnaire, ASES-Score and Constant Score. Further, patients were asked to report on recurrent dislocation (yes/no), time to recurrent dislocation, pain, feeling of instability and satisfaction with nonoperative management. RESULTS In 7 (13%) patients, an off-track Hill-Sachs lesion was present, while in 36 (67%) the lesion was on-track and 11 (20%) did not have a structural Hill-Sachs lesion at all. In total, 31 (57%) patients suffered recurrent dislocations. In the off-track group, all shoulders dislocated again (100%), while 21 (58%) in the on-track group and 3 (27%) in the no structural Hill--Sachs lesion group had a recurrent dislocation, p = 0.008. The mean age in the group with a recurrence was 23.7 ± 10.1 years, while those patients without recurrent dislocation were 37.4 ± 13.1 years old, p < 0.01. The risk for recurrence in patients under 30 years of age was higher than in those older than 30 years (OR = 12.66, p < 0.001). There were no significant differences between patients with on- and off-track lesions regarding patients' sex, height, weight and time to reduction and glenoid diameter. Off-track patients were younger than on-track patients (24.9 ± 7.3 years vs. 29.6 ± 13.6 years). However, this difference was not statistically significant. CONCLUSION The presence of an off-track Hill-Sachs lesion leads to significantly higher recurrence rates compared to on-track or no structural Hill--Sachs lesions in patients with nonoperative management and should be considered when choosing the right treatment option. Therefore, surgical intervention should be considered in patients with off-track Hill-Sachs lesions. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Felix G E Dyrna
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Munich, Germany
| | - Marius Ludwig
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany
| | - Frank Martetschläger
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany. .,German Center for Shoulder Surgery, ATOS Clinic Munich, Effnerstraße 38, 81925, München, Germany.
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Fowler H, Gachabayov M, Vimalachandran D, Clifford R, Orangio GR, Bergamaschi R. Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review. Int J Colorectal Dis 2021; 36:1367-1383. [PMID: 33677750 DOI: 10.1007/s00384-021-03899-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof. METHOD Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared. RESULTS Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%). CONCLUSION This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.
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Affiliation(s)
| | - Mahir Gachabayov
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Suite D-361, Taylor Pavilion, 100 Woods Rd, Valhalla, NY, 10595, USA
| | | | | | - Guy R Orangio
- Section of Colon and Rectal Surgery, Department of Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Roberto Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Suite D-361, Taylor Pavilion, 100 Woods Rd, Valhalla, NY, 10595, USA.
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Kohga A, Kawabe A, Yajima K, Okumura T, Yamashita K, Isogaki J, Suzuki K, Muramatsu K. Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis? Emerg Radiol 2021; 28:977-983. [PMID: 34173083 DOI: 10.1007/s10140-021-01951-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE Nonoperative management (NOM) has been widely accepted as one of the standard treatments for patients with acute appendicitis. However, predictive factors for the failure of NOM have not been thoroughly investigated. METHODS A total of 196 patients with acute appendicitis underwent NOM between April 2014 and December 2020. Of these 196 patients, 24 patients failed NOM and required emergency surgery (failure group: n = 24), while the other 172 patients were successfully treated with NOM (success group: n = 172). These two groups were compared, and the predictive factors for the failure of NOM were investigated. RESULTS The number of patients who had a previous history of stroke was significantly increased in the failure group (12.5% vs. 2.9%, p = 0.026). Incarceration of an appendicolith on CT images was significantly associated with the failure group (20.8% vs. 1.7%, p < 0.001), while neither the presence of an appendicolith nor abscess was associated. The presence of periappendiceal fluid was significantly associated with the failure group (50.0% vs. 26.7%, p = 0.019). The incarceration of an appendicolith (p < 0.001, odds ratio = 19.85) and periappendiceal fluid (p = 0.009, odds ratio = 3.62) were found to be independent risk factors for failure of NOM. Neither the presence of an appendicolith nor abscess was associated with the recurrence of appendicitis. CONCLUSIONS The presence of an appendicolith or abscess was not a crucial factor for surgery. Incarceration of an appendicolith and periappendiceal fluid on CT images was predictive factors for the failure of NOM.
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Affiliation(s)
- Atsushi Kohga
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan.
| | - Akihiro Kawabe
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kiyoshige Yajima
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Takuya Okumura
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kimihiro Yamashita
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Jun Isogaki
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Kenji Suzuki
- Division of Surgery, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
| | - Katsuaki Muramatsu
- Division of Radiology, Fujinomiya City General Hospital, 3-1, Nishiki-cho, Fujinomiya, Shizuoka, 4180076, Japan
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Prommik P, Tootsi K, Saluse T, Märtson A, Kolk H. Nonoperative hip fracture management practices and patient survival compared to surgical care: an analysis of Estonian population-wide data. Arch Osteoporos 2021; 16:101. [PMID: 34173061 DOI: 10.1007/s11657-021-00973-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/26/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED A notable proportion of hip fracture patients receive nonoperative management, but such practice is seldom analysed. Although highly variable reasons underpin hip fracture nonoperative management, none of these practices conclusively outweigh the superiority of operative management. Nonoperative management should be only considered when surgery is not an option. PURPOSE Reasons underpinning hip fracture (HF) nonoperative management (NOM) are seldom analysed. This study aims to identify the reasons behind NOM and assess the accuracy of these decisions using these patients' survival compared with those treated with operative management (OM). METHODS This is a retrospective cohort study based on population-wide administrative health data, including patients aged ≥ 50 with an index HF diagnosis between January 2009 and September 2017. NOM patients were subgrouped according to their expected prognoses, and their survival up to 36 months was compared with those treated surgically. RESULTS From a total of 11,210 included patients, 6.8% (766) received NOM. Varying reasons lead to NOM, dividing them further into five distinct subgroups: (I) 46% NOM decision due to poor expected prognosis with OM; (II) 29% NOM decision due to poor expected prognosis for mixed reasons; (III) 15% NOM decision due to good expected prognosis with NOM; (IV) 8.0% NOM decision due to patient's refusal of OM; and (V) 1.3% NOM decision due to occult HF. Only poor prognosis and patients who refused OM (I, II, IV) had worse survival than OM patients. However, a relatively high proportion of the poor prognosis patients survived 1 year (29%). CONCLUSION Although there was high variability in reasons underpinning HF NOM, none of these practices conclusively outweigh OM's superiority. NOM should be considered with utmost care and only for patients for whom OM is out of the question - well-defined medical unfitness or carefully considered refusal by understanding the increased mortality risk.
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Affiliation(s)
- Pärt Prommik
- Department of Traumatology and Orthopaedics, University of Tartu, Tartu, Estonia.
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia.
- Institute of Sport Sciences and Physiotherapy, University of Tartu, Tartu, Estonia.
| | - Kaspar Tootsi
- Department of Traumatology and Orthopaedics, University of Tartu, Tartu, Estonia
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia
| | - Toomas Saluse
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia
| | - Aare Märtson
- Department of Traumatology and Orthopaedics, University of Tartu, Tartu, Estonia
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia
| | - Helgi Kolk
- Department of Traumatology and Orthopaedics, University of Tartu, Tartu, Estonia
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia
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Izumi S, Nakai C, Haraguchi T, Henmi S, Mori T, Kinoshita M, Yamaguchi M, Sugimoto K, Nakayama S, Tsukube T. Retrospective study of thoracic endovascular aortic repair as a first-line treatment for traumatic blunt thoracic aortic injury. Gen Thorac Cardiovasc Surg 2021. [PMID: 34137003 DOI: 10.1007/s11748-021-01661-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 05/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study sought to confirm if thoracic endovascular aortic repair (TEVAR) was an appropriate therapeutic strategy for blunt thoracic aortic injury (BTAI). METHODS Between 3/2005 and 12/2020, 104 patients with BTAI were brought to our hospital. The severity of each trauma case was evaluated using the Injury Severity Score (ISS); aortic injuries were classified as type I to IV according to Society for Vascular Surgery guidelines. Initial treatment was categorized into four groups: nonoperative management (NOM), open aortic repair (OAR), TEVAR, or emergency room thoracotomy/cardiopulmonary resuscitation (ERT/CPR). RESULTS The patients' mean age and ISS were 56.7 ± 20.9 years and 48.3 ± 20.4, respectively. Type III or IV aortic injury were diagnosed in 82 patients. The breakdown of initial treatments was as follows: NOM for 28 patients, OAR for four, TEVAR for 47, and ERT/CPR for 25. The overall early mortality rate was 32.7%. Logistic regression analysis confirmed ISS > 50 and shock on admission as risk factors for early mortality. The cumulative survival rate of all patients was 61.2% at 5 years after treatment. After initial treatment, eight patients receiving TEVAR required OAR. The cumulative rate of freedom from reintervention using TEVAR at 5 years was higher in approved devices than in custom-made devices (96.0 vs. 56.3%, p = 0.011). CONCLUSIONS Using TEVAR as an initial treatment for patients with BTAI is a reasonable approach. Patients with severe multiple traumas and shock on admission had poor early outcomes, and those treated with custom-made devices required significant rates of reintervention.
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Guevara-Cuellar CA, Rengifo-Mosquera MP, Parody-Rúa E. Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia. Cost Eff Resour Alloc 2021; 19:34. [PMID: 34112179 PMCID: PMC8194214 DOI: 10.1186/s12962-021-00288-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/01/2021] [Indexed: 02/07/2023] Open
Abstract
Background Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis. Methods We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18–60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. Methods We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18–60 years with a diagnosis of uncomplicated AA from the payer’s perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed. Results LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient. Conclusions LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer’s perspective in the Colombian health system. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00288-2.
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Affiliation(s)
| | | | - Elizabeth Parody-Rúa
- Faculty of Health Sciences, Universidad Icesi, Calle 18 No. 122-135 Pance, 70000, Cali, Colombia
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50
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McCormick BP, Serino J, Orman S, Webb AR, Wang DX, Mohamadi A, Mortensen S, Weaver MJ, Von Keudell A. Treatment modalities and outcomes following acetabular fractures in the elderly: a systematic review. Eur J Orthop Surg Traumatol 2021. [PMID: 34076747 DOI: 10.1007/s00590-021-03002-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The treatment of geriatric acetabular fractures remains controversial. Treatment options include nonoperative management, open reduction and internal fixation (ORIF), total hip arthroplasty (THA) with or without internal fixation, and closed reduction with percutaneous pinning (CRPP). There is currently no consensus on the optimal treatment strategy for geriatric patients with acetabular fractures. The purpose of this study is to compare adverse event rates, functional and radiographic outcomes, and intraoperative results between the various treatment modalities in order to help guide surgical decision making. METHODS We performed a systematic review (registration number CRD42019124624) of observational and comparative studies including patients aged ≥ 55 with acetabular fractures. RESULTS Thirty-eight studies including 3,928 patients with a mean age of 72.6 years (range 55-99 years) and a mean follow-up duration of 29.4 months met our eligibility criteria. The pooled mortality rate of all patients was 21.6% (95% confidence interval [CI] 20.9-22.4%) with a mean time to mortality of 12.6 months, and the pooled non-fatal complication rate was 24.7% (95% CI 23.9-25.5%). Patients treated with ORIF had a significantly higher non-fatal complication rate than those treated with ORIF + THA, THA alone, CRPP, or nonoperative management (odds ratios [ORs] 1.87, 2.24, 2.15, and 4.48, respectively; p < 0.01). Patients that underwent ORIF were significantly less likely to undergo subsequent THA than these treated with CRPP (OR 0.49, 95% CI 0.32-0.77) but were more likely to require THA than patients treated nonoperatively (OR 6.81, 95% CI 4.63-10.02). CONCLUSION Elderly patients with acetabular fractures tend to have favorable functional outcomes but suffer from high rates of mortality and complications. In patients treated with internal or percutaneous fixation, there was a high rate of conversion to THA. When determining surgical treatment in this population, THA alone or concurrent with ORIF should be considered given the significantly lower rate of non-fatal complications and similar mortality rate. Nonoperative management remains a viable option and was associated with the lowest non-fatal complication rate. LEVEL OF EVIDENCE This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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