Simple Ligation of Stump without Embedding Suture during Appendectomy Caused No Increased Complication Rates

PURPOSE: There have been several reports claiming benefits for the simplified method of appendectomy over the traditional method of embedding suture at the stump, without contradictory opinions ever having been published. Nevertheless, most surgeons continue to carry out purse-string sutures in daily practices of open appendectomy as long as the stump situation permits. In case where the cecum near the stump is friably swollen due to the spread of inflammation in advanced appendicitis, we have often faced uncomfortable pulling of cecal stitches during embedding procedures experiencing tearing or incomplete approximation of the pulled wall. To avoid this difficulty and shorten the procedure, we have been performing simple double ligations of the stump and observed the results. METHODS: Prospectively we assigned patients to an operative method of either simple ligations or embedding sutures, alternatively upon admission, and performed this method of stump management with two surgeons for 4 years, and postoperative complications were observed in 362 and 273 cases respectively. RESULTS: There was no advantage of one method over the other in recovery course, and in view of the complication rates associated with stump inadequacy and adhesive ileus, even in cases of perforated appendicitis also. CONCLUSION: When possible, Stump ligations simplify appendectomy procedure without increased operative sequelae, even in cases of perforated appendicitis. So this procedure could be recommended instead of purse-string sutures, especially in cases of thick and friable cecal wall due to acutely disseminated appendiceal inflammation.

Vitamin A Effect to Nitrofen Induced Congenital Diaphragmatic Hernia and Pulmonary Hypoplasia in Rats

PURPOSE: Vitamin A has been introduced recently for its feasible effect in curing diaphragmatic defect and accelerating lung development during the perinatal period of experimental rats or humans suffering from congenital diaphragmatic hernia (CDH). Despite continual research attention since the fifties to elucidate the influence and mechanisms of vitamin A on pulmonary growth, many presumptive hypotheses remain, along with an inherently high mortality. So we wondered whether prenatal vitamin A alone or combined with dexamethasone could accomplish better results than dexamethasone against the diaphragmatic defect or lung hypoplasia in neonatal rats. METHODS: Pregnant Sprague-Dawley rats exposed to Nitrofen were classified into 5 groups according to the different treatment options. Studies were performd in 2 phases. In study 1, the 24-hour survival rate and preliminary results were observed. In study 2, the incidence and site of CDH, lung/body weight ratio (L/BWR), radial saccular counts (RSC) and maturation of alveolar sac in 3 histomorphologic grades were evaluated among the 5 groups. RESULTS: Vitamin A treated neonatal rats (group III) showed improved lung development compared with rats without treatments (group II) in 24-hour survival rate, L/BWR and alveolar maturation (P<0.001), leading to lung development that was comparable in every aspect to that of the dexamethasone treated rats (group IV). Combined treatment by vitamin A and dexamethasone (group V) improved the incidence of CDH, L/BWR (P<0.001), RSC (P<0.05) and alveolar maturation (P<0.001) when compared with rats treated alone by vitamin A (group III) or dexamethasone (group IV), leading to a level of development that was closest to that of the normal control lungs (group I). CONCLUSION: Vitamin A had a therapeutic effect on pulmonary hypoplasia in the experimental rats, and when combined with dexamethasone it accomplished a better outcome in the treatment of CDH itself or pulmonary hypoplasia. After the problem of vitamin A toxicity is settled, the future of vitamin A as a prenatal therapeutic agent for CDH might gain in appeal.

Peritoneal Saline Irrigation and Infective Complications in Perforated Appendicitisin at a Single Center

PURPOSE: Until recently, the surgical treatment of perforated appendicitis in South Korea showed a relatively high incidence of postoperative infectious complications compared with centers having protocols for managements. Authors have been performing appendectomies for perforated cases under the principle of massive irrigation of the peritoneal cavity and primary closure of incision wound that leaves a suction drain from pelvic cavity, expecting reducing chance of infective complications and thus reducing the stress faced by operators. METHODS: Among 788 cases of appendicitis from September 1997 to December 2002, 172 patients showing perforation and peritonitis in the operative field were reviewed retrospectively. All the operations were performed by the principle mentioned above, and data were collected on various major complications, especially infective wound and intra-abdominal complications. RESULTS: There were 7 cases of suppurative wound infection, and 5 cases of intra-abdominal abscess, representing a total incidence of 7.0% (n=12) in 172 patients. Other major complications such as adhesive ileus (n=3), intestinal fistula (n=1), or remote organ infective event (n=1) were also recognized. CONCLUSION: Massive saline irrigation during appendectomy of perforated appendicitis-without antibiotic mixture-that leaves a negative suction drain from the pelvic cavity and the primary closure of incision wounds have yielded satisfactory results concerning various aspects, especially in lessening infective postoperative complications.

Carotid Endarterectomy Using Patch Angioplasty without Routine Completion Duplex Scan

PURPOSE: Routine intraoperative duplex color-flow ultrasound carotid examination as a completion study has been welcomed by many vascular surgeons as the most recent, high proficiency tool to detect unsuspected remaining operative defects before the patient leaves the operating room, thereby improving operative outcome after Carotid Endarterectomy (CEA). However, after many years of experience gaining added knowledge about the clinical course and standardization of operative procedures of CEA for mainly occidental patients, the adherence to strict operative procedures using patch angioplasty and liberally added continuous-wave Doppler confirmation has been found to achieve well beyond acceptable operative results in our patients without routine intraoperative duplex scanning (IDS). METHODS: A retrospective review of 455 surgical patients who underwent patch angioplasty in a five year period, from January 1996, was performed to evaluated their operative outcome. Their perioperative morbidity, mortality, and follow up Duplex scan findings on restenosis for a mean of 20.8 months were observed for a comparison between our experience and recently reported results using routine IDS. RESULTS: We had a perioperative combined stroke-death rate of 2.0% (n=9), consisting of death in 0.9% (n=4) and stroke in 1.1% (n=5). Residual stenosis was confirmed by first follow up Duplex scanning in 13 patients a (4.2%), 6 of whom were resolved with time. Twenty-three (5.6%) recurrent stenoses, including 2 occlusions and 1 high grade stenotic internal carotid artery (ICA), and 1 occlusion with 2 severe stenoses in external carotid artery (ECA), appeared among 414 cases during follow up. Except for 2 patients who suffered perioperative stroke, one of whom died, all residual stenosis and recurrent stenosis patients stayed clinically symptom free. Among 5 immediate postoperative transient ischemic attacks (TIA) cases and 5 strokes, one residual stenosis accompanying stroke appeared during follow up. Of five cases that were re-explored in the operating room by continuous wave Doppler information with conversion of primary closure to patching (n=2) and revision of distal arteriotomy (n=2), all remained normal during follow up by duplex scan. CONCLUSION: Routine patch angioplasty, meticulous surgical technique and continuous-wave Doppler information were enough to achieve an acceptable clinical outcome in our patients. IDS might be necessary selectively for concerned cases only.

Carotid Endarterectomy Using Patch Angioplasty without Routine Completion Duplex Scan

PURPOSE: Routine intraoperative duplex color-flow ultrasound carotid examination as a completion study has been welcomed by many vascular surgeons as the most recent, high proficiency tool to detect unsuspected remaining operative defects before the patient leaves the operating room, thereby improving operative outcome after Carotid Endarterectomy (CEA). However, after many years of experience gaining added knowledge about the clinical course and standardization of operative procedures of CEA for mainly occidental patients, the adherence to strict operative procedures using patch angioplasty and liberally added continuous-wave Doppler confirmation has been found to achieve well beyond acceptable operative results in our patients without routine intraoperative duplex scanning (IDS). METHODS: A retrospective review of 455 surgical patients who underwent patch angioplasty in a five year period, from January 1996, was performed to evaluated their operative outcome. Their perioperative morbidity, mortality, and follow up Duplex scan findings on restenosis for a mean of 20.8 months were observed for a comparison between our experience and recently reported results using routine IDS. RESULTS: We had a perioperative combined stroke-death rate of 2.0% (n=9), consisting of death in 0.9% (n=4) and stroke in 1.1% (n=5). Residual stenosis was confirmed by first follow up Duplex scanning in 13 patients a (4.2%), 6 of whom were resolved with time. Twenty-three (5.6%) recurrent stenoses, including 2 occlusions and 1 high grade stenotic internal carotid artery (ICA), and 1 occlusion with 2 severe stenoses in external carotid artery (ECA), appeared among 414 cases during follow up. Except for 2 patients who suffered perioperative stroke, one of whom died, all residual stenosis and recurrent stenosis patients stayed clinically symptom free. Among 5 immediate postoperative transient ischemic attacks (TIA) cases and 5 strokes, one residual stenosis accompanying stroke appeared during follow up. Of five cases that were re-explored in the operating room by continuous wave Doppler information with conversion of primary closure to patching (n=2) and revision of distal arteriotomy (n=2), all remained normal during follow up by duplex scan. CONCLUSION: Routine patch angioplasty, meticulous surgical technique and continuous-wave Doppler information were enough to achieve an acceptable clinical outcome in our patients. IDS might be necessary selectively for concerned cases only.