"What you see is not what you get". A plea to remove a 'normal' appendix during diagnostic laparoscopy.

BACKGROUND: Diagnostic laparoscopy (DL) is a well established alternative option to coeliotomy for suspected appendicitis. When a 'normal' appendix is found, appendectomy is often believe unnecessary. Little is known however about how normal a normal appearing appendix is. In this study we postulated that a normal appendix seen at DL, may show pathological indications at microscopy, and thus, to leave the appendix untouched may be unsafe. METHODS: A retrospective review of data from 48 patients which, in a five year period (1995-1999), had virtually normal appendices removed as completion of DL for lower abdominal pain. RESULTS: No procedure-related drawback and no subsequent complications were recorded. Symptoms subsided in all the patients. Mean hospital stay was 2.1 days. When receiving specimens, incidence of pathologic changes of the appendix were observed in 58 percent of the cases (n = 28). The negative predictive value of DL was 41 percent. CONCLUSIONS: Due to the consistently false negative rate of DL, and the low morbidity rate for laparoscopic appendectomy, we support incidental appendectomy in patients with lower abdominal pain.

[Intestinal reconstruction after a Hartmann intervention: a high-risk procedure?]. / Ricostruzione intestinale dopo intervento di Hartmann: una procedura ad alto rischio?

BACKGROUND/AIM: Restoration of the bowel continuity after Hartmann's procedure has been reported to carry a high rate of both general and anastomosis-related complications. Aim of the study was to test the hypothesis of the Hartmann's procedure reversal as high-risk surgery. STUDY DESIGN, SETTING: Retrospective analysis of a cases series, University hospital, Italy. MATERIAL: Forty patients (male n = 25; female n = 15) with a mean age of 64.8 yrs. (range 35 to 82 yrs.) who underwent manual (n = 4; 10%) or stapled (n = 36; 90%) colorectal anastomosis. The mean interval between the Hartmann's procedure and the colostomy closure was 259 days. MAIN OUTCOME MEASURES: Mortality, morbidity, anastomotic complications. RESULTS: No death was recorded. The overall complication rate was 37.5 per cent (n = 15 patients), being wound infection the most common (n = 9). Complications of the colorectal anastomosis were observed in n = 5 patients (12.5%). In details, four patients (10%) developed stenosis of the anastomosis and one (2.5%) bled from the suture line. No instance of leak was observed. Surgery was required to correct a recurrent stenosis of the colorectal anastomosis. CONCLUSION: Restoration of the bowel continuity after Hartmann's procedure is safe and has an acceptable rate of general and anastomosis-related morbidity. Most of the anastomotic complications will resolve without further surgery.

[Prognostic risk factors in patients operated on for perforated peptic ulcer. A retrospective analysis of critical factors of mortality and morbidity in a series of 40 patients who underwent simple closure surgery]. / Fattori di rischio prognostico in pazienti operati per ulcera peptica perforata. Analisi retrospettiva dei fattori critici per la mortalità e morbilità su una serie di 40 pazienti sottoposti ad intervento di sutura semplice.

STUDY OBJECTIVE: To identify factors affecting mortality and morbidity in patients operated on for perforated peptic ulcer. DESIGN: Retrospective analysis. SETTING: University Hospital, Italy. PATIENTS: Forty patients consecutively operated on for perforated peptic ulcer by simple suture procedure performed either by laparotomy (n = 26) or laparoscopic (n = 14) approach. MEASUREMENTS AND MAIN RESULTS: Mortality was 20% (n = 8) and morbidity in survivors was 25% (n = 8). Compared to survivors, non-survivors were older (mean age 79.3 yrs. vs 60.0 yrs., p < 0.01), had worse APACHE II and SAPS scores (mean 20.1 vs 8.5, p < 0.001; and 13.1 vs. 5.5, p < 0.0001 respectively), were treated later (mean interval from outbreak of symptoms to surgery 30.8 hrs. vs. 11.1 hrs., p < 0.01), and the size of their perforation was larger (mean 15.1 mm. vs. 8.6 mm, p < 0.05). The laparoscopic approach was the only factor that significantly was associated with morbidity in survivors (p < 0.01). The presence of at least two risk factors, enhanced the probability of death. CONCLUSION: Old age, great APACHE II and SAPS scores, delay in treatment and large size of the perforation were associated significantly to mortality in perforated peptic ulcer patients. Efforts should be made perioperatively for patients having these risk factors.

Laparoscopic compared with open appendicectomy for acute appendicitis: a prospective study.

OBJECTIVE: To assess the benefits of laparoscopic appendicectomy over open appendicectomy and to evaluate the impact of the severity of appendicitis and of peritonitis on the advantages of the laparoscopic approach. DESIGN: Prospective unrandomised study. SETTING: University hospital, Italy. SUBJECTS: 137 consecutive patients with acute appendicitis, 60 of whom were treated by open and 77 by laparoscopic appendicectomy. Patients were subdivided according to the severity of appendicitis and the presence of peritonitis. MAIN OUTCOME MEASURES: Duration of operation, consumption of analgesics, duration of hospital stay, overall complications, wound infection. RESULTS: Hospital stay (median 2.5 days, range 1-18 compared with 4, range 2-22 p < 0.0001). and wound infection (3/77 (4%) compared with 13/60 (22%), p 0.02) were significantly lower after laparoscopic operation. The incidence of wound infection was significantly lower when subgroups were analysed separately. CONCLUSIONS: Hospital stay and wound infection rates were significantly lower after laparoscopic appendicectomy. With the exception of the wound infection rate, the variables studied may differ depending on the severity of the appendicitis and the presence of peritonitis. Result of comparative studies should be carefully interpreted when the two groups are not stratified for these features.

Intraoperative sonography of biliary tree during laparoscopic cholecystectomy.

The use of routine cholangiography during laparoscopic cholecystectomy is still under debate. Previous reports have suggested that intraoperative sonography can replace cholangiography in the evaluation of common duct lithiasis during open cholecystectomy. The present study was performed to evaluate the possible role of sonography during laparoscopic cholecystectomy. Thirty patients underwent intraoperative sonography of the biliary tree during laparoscopic cholecystectomy. In cases with a diagnosis of common bile duct lithiasis, intraoperative cholangiography was performed. In 26 cases, sonography did not show the presence of stones; in three cases, stones were identified at both sonography and cholangiography; in one case, stones were diagnosed by sonography alone. In this last case, stones were confirmed on later review of cholangiogram. No complications related to the method were observed. We suggest that intraoperative sonography can represent an adequate substitute for intraoperative cholangiography as a screening procedure for stone identification during laparoscopic cholecystectomy.