Synchronous presentation of acute cholecystitis and acute appendicitis successful treatment in one step laparoscopic procedure. A case series and literature review.

INTRODUCTION: Hundreds of thousands of cholecystectomies and appendectomies are performed in the United States annually. Due to the prevalence of cholecystitis and appendicitis, a subset of patients will require both operations. The limited literature describing these patients supports a laparoscopic approach over open surgery; consistent with the advantages of laparotomy over open surgery in the treatment of each condition individually. CASE PRESENTATION: We report two cases where a patient presented with cholecystitis and appendicitis simultaneously. An abdominal computer tomography (CT) scan revealed the presence of the two diagnoses, which was then confirmed by an abdominal ultrasound. A four-access port was utilized for simultaneous appendectomy and cholecystectomy. DISCUSSION: A review of the literature indicates that simultaneous infection with appendicitis and cholecystitis is rare, and thus clinical presentation, lab work, and imaging studies are all needed to support such a diagnosis. Potential findings on imaging in these patients may include distended gallbladder with thickened wall and fluid-filled dilated appendix with mural enhancement. In the event that both clinical presentation and further work-up indicate both pathologies, laparoscopic intervention is suitable. A four-access port is deemed the conservative approach to dealing with such cases. CONCLUSION: Finding a single diagnosis responsible for a patient's illness is a high priority in an acute care setting, a concept known as diagnostic parsimony. However, it is inevitable that very common illnesses will be comorbid in a subset of patients, and physicians should be prepared to consider contemporaneous illness in the isolated circumstances it is warranted.

Accuracy of Computed Tomography in Diagnosis of Intra-abdominal Injuries in Stable Patients With Anterior Abdominal Stab Wounds: A Systematic Review and Meta-analysis.

BACKGROUND: Workup for patients presenting to the emergency department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP); however, workup of stable, asymptomatic or nonperitoneal patients is not clearly defined. OBJECTIVES: The objective was to evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intraabdominal injuries requiring therapeutic laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient? METHODS: We searched PubMed, Embase, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and inpatient observation in those who were managed nonoperatively. In those who underwent LAP, THER-LAP was considered as disease positive. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate the risk of bias and assess the applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) using a random-effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model. RESULTS: Seven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% confidence interval [CI] = 30.5%-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were as follows: sensitivity = 50% to 100%, specificity = 39% to 97%, LR+ = 1.0 to 15.7, and LR- = 0.07 to 1.0. The high heterogeneity (I2  > 75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated. DISCUSSION: The articles revealed a high prevalence (8.7%, 95% CI = 6.1%-12.2%) of injuries requiring THER-LAP in patients with a negative CT scan and almost half (47%, 95% CI = 30%-64%) of those injuries involved the small bowel. CONCLUSIONS: In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries.

A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit.

INTRODUCTION: Trauma centers successfully save lives of severely injured patients who would have formerly died. However, survivors often have multiple complications and morbidities associated with prolonged intensive care unit (ICU) stays. Because the reintegration of patients into the society to lead an active and a productive life is the ultimate goal of trauma center care, we questioned whether our "success" may condemn these patients to a fate worse than death? METHODS: Charts on all patients > or =18 years with ICU stay > or =10 days, discharged alive between June 1, 2002, and May 31, 2005, were reviewed. Patients with complete spinal cord injuries were excluded. Demographics, Injury Severity Score (ISS), presence of severe traumatic brain injury (TBI; Head Abbreviated Injury Scale [AIS] score = 4 or 5), presence of extremity fractures, need for operative procedures, ventilator days, complications, and discharge disposition were collected. Glasgow Outcome Scale score was calculated on discharge. Patients were contacted by phone to determine general health, work status, and using this data, Glasgow Outcome Scale score and a modified Functional Independence Measure (FIM) score were calculated. RESULTS: Two hundred and forty-one patients met inclusion criteria. Thirty-three patients died postdischarge from the hospital and 39 were known to be alive from the electronic medical records but were unable to be contacted. Sixty-nine patients could not be tracked down and were ultimately considered as lost to follow-up. The remaining 100 patients who were successfully contacted participated in the study. Eighty-one percent were men with a mean age of 42 years, mean and median ISS of 28. Severe TBI was present in 50 (50%) patients. Mean and median follow-up was 3.3 years from discharge. At the time of follow-up, 92 (92%) patients were living at home, 5 in nursing homes, and 3 in assisted living, a shelter, or halfway house. FIM scores ranged from 6 to 12 with 55% reached a maximal FIM score of 12. One quarter of patients had FIM scores < or =10 and 10% had locomotion scores of < or =2 (very dependent). Seventy percent considered themselves to be less active. Seventy-six patients were either working or in full-time school before their trauma. Of the 24 patients not working preinjury, 12 were > or =55 years of age. At the time of follow-up, 37 patients (49%) were back to work or school. Severe TBI patients (57%, 21 of 37) were less likely to return to work when compared with 38% (12 of 38; p = 0.03) without severe TBI. There was no relationship with age, ISS, presence of any TBI, head AIS, presence of any extremity fracture, extremity AIS, or ventilator days in patients who did or did not return to work. CONCLUSIONS: These data demonstrate that ICU survivors >3 years after severe injury have significant impairments including inability to return to work or regain previous levels of activity and that the goal of reintegrating patients back into the society is not being met. Further studies better defining the limitations and barriers to improved quality of life are necessary. Survival, although important, is no longer a sufficient outcome to measure trauma center success.