Distinguishing fecal appendicular peritonitis from purulent appendicular peritonitis.

INTRODUCTION: Fecal appendicular peritonitis (FAP) is a poorly studied, rare form of acute appendicitis, corresponding to peritoneal inflammation with the presence of feces secondary to ruptured appendix. The purpose of this study was to describe FAP and to compare FAP with purulent appendicular peritonitis (PAP). PATIENTS AND METHODS: This single-center, retrospective study was conducted in consecutive patients to compare the FAP group and the PAP group. The primary endpoint was the 30-day postoperative morbidity and mortality according to the Clavien-Dindo classification. The secondary endpoints were description and comparison of intraoperative data (laparoscopy rate, conversion rate, type of procedure and the mean operating time), and short-term outcomes (types of complications, length of stay, readmission rate, and reoperation rate), comparison of intraoperative bacteriological samples of FAP and PAP as well as the rate of resistance to amoxicillin and clavulanic acid, used as routine postoperative antibiotic therapy. RESULTS: Between January 2006 and January 2016, 2.2% of appendectomies were performed for FAP. Patients of the FAP group reported a longer history of pain than patients of the PAP group (mean: 58 h [range: 24-120] vs 24 h [range: 6-504], p = 0.0001) and hyperthermia was more frequent in the FAP group than in the PAP group (72% vs 26%, p = 0.0001). Mean preoperative CRP was also higher in the FAP group than in the PAP group (110 mg/L [range: 67-468] vs 37.5 mg/L [range: 3.1-560], p = 0.007). Significantly less patients were operated by laparoscopy in the FAP group (89.7% vs 96.6%, p < 0.0001). Mean length of stay was significantly longer in the FAP group than in the PAP group (10 days [range: 3-24] vs 5 days [range: 1-32], p = 0.001). The overall 30-day complication rate was significantly higher in the FAP group than in the PAP group (62.1% vs 24.7%, p = 0.0005). The readmission rate was not significantly different between the two groups (14% vs 11.2%, p = 0.2), but the reoperation rate was higher in the FAP group than in the PAP group (31% vs 11%, p = 0.01). No significant difference was observed between the FAP and PAP groups in terms of the positive culture rate (75.9% vs 65.6%, p = 0.3). No significant difference was observed between the two groups in terms of resistance to amoxicillin and clavulanic acid (18.2% vs 20.5%, p = 0.8). CONCLUSION: FAP is associated with significantly more severe morbidity compared to PAP. Clinicians must be familiar with this form of appendicitis in order to adequately inform their patients.

Compliance with an empirical antimicrobial protocol improves the outcome of complicated intra-abdominal infections: a prospective observational study.

BACKGROUND: Despite improvements in medical and surgical care, mortality attributed to complicated intra-abdominal infections (cIAI) remains high. Appropriate initial antimicrobial therapy (ABT) is key to successful management. The main causes of non-compliance with empirical protocols have not been clearly described. METHODS: An empirical ABT protocol was designed according to guidelines, validated in the institution and widely disseminated. All patients with cIAI (2009-2011) were then prospectively studied to evaluate compliance with this protocol and its impact on outcome. Patients were classified into two groups according to whether or not they received ABT in compliance with the protocol. RESULTS: 310 patients were included: 223 (71.9%) with community-acquired and 87 (28.1%) with healthcare-associated cIAI [mean age 60(17-97) yr, mean SAPS II score 24(16)]. Empirical ABT complied with the protocol in 52.3% of patients. The appropriateness of empirical ABT to target the bacteria isolated was 80%. Independent factors associated with non-compliance with the protocol were the anaesthetist's age ≥36 yr [OR 2.1; 95%CI (1.3-3.4)] and the presence of risk factors for multidrug-resistant bacteria (MDRB) [OR 5.4; 95%CI (3.0-9.5)]. Non-compliance with the protocol was associated with higher mortality (14.9 vs 5.6%, P=0.011) and morbidity: relaparotomy (P=0.047), haemodynamic failure (P=0.001), postoperative pneumonia (P=0.025), longer duration of mechanical ventilation (P<0.001), longer ICU stay (P<0.001) and longer hospital stay (P=0.002). On multivariate logistic regression analysis, non-compliance with the ABT protocol was independently associated with mortality [OR 2.4; 95% CI (1.1-5.7), P=0.04]. CONCLUSIONS: Non-compliance with empirical ABT guidelines in cIAI is associated with increased morbidity and mortality. Information campaigns should target older anaesthetists and risk factors for MDRB.

Ambulatory management of gastrointestinal emergencies: what are the current literature data?

INTRODUCTION: Ambulatory management is a modality of care defined in France by a hospitalization of less than 12h without an overnight stay. Currently, few data are available on its role in the management of gastrointestinal emergencies, such as appendectomy for acute appendicitis, cholecystectomy for acute cholecystitis or emergency proctologic surgery. The aim of this systematic review was to study the published data regarding the feasibility of ambulatory management of emergency visceral surgery and to enquire about the possibilities of further development of this form of management. MATERIALS AND METHODS: A literature search was conducted from the PubMed(®) databank taking into account all published data up to July 2013. RESULTS: For acute appendicitis, the success rate of short-stay hospitalization was 72% with unplanned read-mission rates ranging from 0 to 53%, a rate of unscheduled consultations ranging from 0 to 11%, and unplanned inpatient hospitalization rates ranging from 0% to 5%. For acute cholecystitis and proctology, there are few published data. CONCLUSION: Ambulatory management has been sparingly studied in the setting of gastrointestinal surgical emergencies. However, there is probably a place for development of this form of management.

Virtual reality-based simulator for training in regional anaesthesia.

BACKGROUND: The safe performance of regional anaesthesia (RA) requires theoretical knowledge and good manual skills. Virtual reality (VR)-based simulators may offer trainees a safe environment to learn and practice different techniques. However, currently available VR simulators do not consider individual anatomy, which limits their use for realistic training. We have developed a VR-based simulator that can be used for individual anatomy and for different anatomical regions. METHODS: Individual data were obtained from magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) without contrast agent to represent morphology and the vascular system, respectively. For data handling, registration, and segmentation, an application based on the Medical Imaging Interaction Toolkit was developed. Suitable segmentation algorithms such as the fuzzy c-means clustering approach were integrated, and a hierarchical tree data structure was created to model the flexible anatomical structures of peripheral nerve cords. The simulator was implemented in the VR toolkit ViSTA using modules for collision detection, virtual humanoids, interaction, and visualization. A novel algorithm for electric impulse transmission is the core of the simulation. RESULTS: In a feasibility study, MRI morphology and MRA were acquired from five subjects for the inguinal region. From these sources, three-dimensional anatomical data sets were created and nerves modelled. The resolution obtained from both MRI and MRA was sufficient for realistic simulations. Our high-fidelity simulator application allows trainees to perform virtual peripheral nerve blocks based on these data sets and models. CONCLUSIONS: Subject-specific training of RA is supported in a virtual environment. We have adapted segmentation algorithms and developed a VR-based simulator for the inguinal region for use in training for different peripheral nerve blocks. In contrast to available VR-based simulators, our simulation offers anatomical variety.