Appendiceal mass: conservative therapy followed by interval laparoscopic appendectomy. Treatment of appendiceal mass: prospective, randomized clinical trial. Is a long delay necessary before appendectomy after appendiceal mass formation? A preliminary report. Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study. Laparoscopy in children with complicated appendicitis. Pilot Study to Evaluate Feasibility of Image-Guided
Breast-Conserving Therapy in the Advanced Multimodal
Image-Guided Operating (AMIGO) Suite Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. Management of Staple Line Leaks After Sleeve Gastrectomy in a Consecutive Series of 378 Patients Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. Danish national guidelines for treatment of diverticular disease. Diagnostic accuracy of computed tomography-guided percutaneous biopsy of renal masses. Cost-effectiveness of ultrasound-guided liver biopsy. The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Ultrasound-based decision making in the treatment of acute appendicitis in children. Specific Antibiotic Prophylaxis Based on Bile Cultures Is Required to Prevent Postoperative Infectious Complications in Pancreatoduodenectomy Patients Who Have Undergone Preoperative Biliary Drainage Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. Management of acute cholecystitis in the laparoscopic era: Results of a prospective, randomized clinical trial Is intraabdominal drainage necessary after pancreaticoduodenectomy? Prospective evaluation of patients with acute cholecystitis treated with percutaneous cholecystostomy and interval laparoscopic cholecystectomy. A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues? Comparative trial of four antibiotic combinations for perforated appendicitis in children. Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess
BACKGROUND Current therapy of patients with appendiceal abscess or phlegmon is in evolution . Controversial areas include initial conservative therapy , drainage of periappendiceal abscesses , and the role of interval appendectomy . OBJECTIVE To evaluate the safety and efficacy of conservative therapy and of interval laparoscopic appendectomy ( ILA ) . PATIENTS AND METHODS Patients with signs and symptoms of acute appendicitis and a palpable right lower quadrant mass were included . Abscess/phlegmon was documented with ultrasound or computerized tomography . After initial therapy with antibiotics , patients were discharged to home . ILA was performed 6 to 12 weeks later . RESULTS Twelve patients were included . Four patients had phlegmonous appendicitis and eight had an abscess , but only four had percutaneous drainage . All patients improved without surgical exploration and were subjected to ILA . ILA was successful in 11 of 12 patients ; a median hospital postoperative stay of 1 day was required , and no perioperative morbidity was encountered . All patients returned to routine activities within 2 weeks of surgery . CONCLUSIONS 1 ) Initial conservative management of patients with appendiceal abscess/phlegmon is prudent , safe , and effective . 2 ) Interval laparoscopic appendectomy can be performed safely and effectively BACKGROUND Appendiceal mass may be treated in several ways . However , no r and omized trial has been conducted to find the best option . OBJECTIVE To compare the three most commonly used methods for treating appendiceal mass . METHODS Over a three-year period , 60 consecutive patients with appendiceal mass were r and omly allocated to three groups : Group A -- initial conservative treatment followed by interval appendectomy six weeks later ; Group B -- appendectomy as soon as appendiceal mass resolved using conservative means ; Group C -- conservative treatment alone . Short-term outcome measures included operative time , operative difficulty , postoperative complications , length of hospital stay , and duration of time away from work . Long-term outcome measures were : number of hospital visits made , presence of severe incisional pain , scar appearance , and patients with recurrent appendicitis . RESULTS Baseline characteristics were comparable in the three groups . In patients in Group A , operative time was less , adhesions were encountered less frequently , the incision had to be extended less often and post-operative complications were fewer , as compared to Group B. Patients in Group C had the shortest hospital stay and duration of work-days lost ; only 2 of 20 patients in this group developed recurrent appendicitis during a follow-up period of 24 - 52 ( median 33.5 ) months . CONCLUSION Of the three treatment modalities compared , conservative treatment without subsequent appendectomy appears to be the best The st and ard treatment for an appendiceal mass is conservative therapy followed by appendectomy after 6 to 10 weeks . With the advent of antibiotics design ed to prevent the growth of anaerobes , early appendectomy can now be carried out without complication . The authors studied 56 patients with appendiceal mass formation , 26 ( group A ) treated conventionally and 30 ( group B ) treated by early appendectomy .  In group B , the infection rate was 17 % , the mean operating time was 38.7 minutes , the mean hospital stay was 15 days and there was an early return to work . The corresponding parameters for group A were an infection rate of 8 % , a mean operating time of 35.2 minutes , a hospital stay of 19.1 days and a late return to work . Furthermore , 15 % of the patients in group A had a recurrent acute episode during the waiting period . Overall , early appendectomy appears to be a safe and cost-effective treatment for appendiceal mass formation BACKGROUND The management of an appendiceal mass remains controversial with 2 schools of thought ; early surgical intervention vs nonoperative management with or without interval appendectomy . The aim is to determine the role and safety of early laparoscopic appendectomy ( LA ) in children with acute appendicitis presenting with an appendiceal mass . METHODS This is a prospect i ve study of 88 consecutive pediatric patients who underwent attempted LA for suspected acute appendicitis at KK Women 's and Children 's Hospital , Singapore , between May and October 2003 . RESULTS A total of 88 patients with a mean age of 10 + /- 3 years ( range , 3 - 16 years ) underwent LA for an appendiceal mass ( n = 22 ) , simple appendicitis ( n = 36 ) , other complicated ( gangrenous or perforated ) appendicitis ( n = 23 ) , and a normal appendix ( n = 7 ) . There were 7 conversions to  open appendicectomy  , 3 of which occurred in patients with an appendiceal mass . There were no perioperative or postoperative mortalities . Morbidity occurred in only one patient who underwent LA for perforated appendicitis . He had prolonged sepsis that resolved after 2 weeks of intravenous antibiotics . None of the patients with an appendiceal mass developed complications . Patients who underwent early LA for an appendiceal mass had a statistically significant ( P < .05 ) longer operating time ( median , 103 minutes ; interquartile range , 90 - 151 minutes , vs median , 87 minutes ; interquartile range , 71 - 112 minutes ) , prolonged time to ambulation ( median , 2.0 days ; interquartile range , 2 - 2.5 days , vs median , 1.0 days ; interquartile , 1 - 2 days ) , increased time to resumption of diet ( median , 4 days ; interquartile , 3 - 5 days , vs median , 2 days ; interquartile , 2 - 3 days ) , and longer postoperative stay ( median , 6.0 days ; interquartile , 5.5 - 6.5 days , vs median , 4.0 days ; interquartile , 3 - 5.5 days ) compared with patients presenting with appendicitis without mass formation . However , there was no statistical difference in these parameters when LA for an appendiceal mass was compared with LA for other complicated appendicitis ( perforated and gangrenous ) . CONCLUSION Although early LA for an appendiceal mass is a technically dem and ing procedure , it can be performed safely in children with minimal morbidity and mortality . In an era where patients ' dem and for " key-hole " surgery is rising , early LA is a safe and viable option in the management of children with an appendiceal mass . It also offers the advantage of avoiding misdiagnoses and the need for a second hospitalization BACKGROUND / PURPOSE Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children . The role of laparoscopy in complicated acute appendicitis is more controversial . The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis . METHODS A total of 102 children with suspected acute appendicitis were selected r and omly to undergo either a laparoscopic or an open appendectomy . The outcomes of 25 children with complicated appendicitis , 13 in the laparoscopic group and 12 in the open appendectomy group , were analyzed . Children , their parents , and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation . All 25 children completed a 30-day follow-up . RESULTS There were no differences in terms of patients ' age , sex , weight , height , and appendiceal histology between the 2 groups . All laparoscopic procedures were completed without conversion . The mean ( + /-SD ) operating time was 63 ( + /-31 ) minutes in the laparoscopic group and 37 ( + /-18 ) minutes in the open appendectomy group ( mean difference 26 minutes , 95 % CI 5 to 47 minutes , P = .02 ) . There were 2 major complications in the laparoscopic group in children with appendiceal masses . One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation . Another child had a pelvic abscess that resolved with antibiotic treatment . Superficial wound infections were encountered in 2 patients in the open appendectomy group . CONCLUSIONS Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis . Good surgical judgement is necessary in patients with an established appendiceal abscess Background The rate of reexcision in breast-conserving surgery remains high , leading to delay in initiation of adjuvant therapy , increased cost , increased complications , and negative psychological impact to the patient.1–3 We initiated a phase 1 clinical trial to determine the feasibility of the use of intraoperative magnetic resonance imaging ( MRI ) to assess margins in the advanced multimodal image-guided operating ( AMIGO ) suite . Methods All patients received contrast-enhanced three-dimensional MRI while under general anesthesia in the supine position , followed by st and ard BCT with or without wire guidance and sentinel node biopsy . Additional margin reexcision was performed of suspicious margins and correlated to final pathology ( Fig. 1 ) . Feasibility was assessed via two components : demonstration of safety and sterility and acceptable duration of the operation and imaging ; and adequacy of intraoperative MRI imaging for interpretation and its comparison to final pathology . Fig . 1Schema of AMIGO trial Results Eight patients ( mean age 48.5 years ) , 4 with stage I breast cancer and 4 with stage II breast cancer , were recruited . All patients underwent successful BCT in the AMIGO suite with no AMIGO-specific complications or break in sterility during surgery . The mean operative time was 113 min ( range 93–146 min ) . Conclusions Our experience with AMIGO suggests that it is feasible to use intraoperative MRI imaging to evaluate margin assessment in real time . Further research is required to identify modalities that will lead to a reduction in reexcision in breast cancer therapy INTRODUCTION Perforated appendicitis is a common condition in children , which , in a small number of patients , may be complicated by a well-formed abscess . Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy . Although this strategy has become well accepted , there are no published data comparing initial nonoperative management ( drainage/interval appendectomy ) to appendectomy upon presentation with an abscess . Therefore , we conducted a r and omized trial comparing these 2 management strategies . METHODS After internal review board approval ( # 06 11 - 164 ) , children who presented with a well-defined abdominal abscess by computed tomographic imaging were r and omized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess  ( when possible ) , followed by interval laparoscopic appendectomy approximately 10 weeks later . This was a pilot study with a sample size of 40 , which was based on our recent volume of patients presenting with appendicitis and abscess . RESULTS On presentation , there were no differences between the 2 groups regarding age , weight , body mass index , sex distribution , temperature , leukocyte count , number of abscesses , or greatest 2-dimensional area of abscess in the axial view . Regarding outcomes , there were no differences in length of total hospitalization , recurrent abscess rates , or overall charges . There was a trend toward a longer operating time in patients undergoing initial appendectomy ( 61 minutes versus 42 minutes mean , P = .06 ) . CONCLUSIONS Although initial laparoscopic appendectomy trends toward a requiring longer operative time , there seems to be no advantages between these strategies in terms of total hospitalization , recurrent abscess rate , or total charges Introduction : Laparoscopic sleeve gastrectomy ( LSG ) is gaining acceptance as a st and -alone bariatric procedure with proven efficacy on weight loss and obesity-related comorbidities . A specific and potentially severe complication of LSG is the staple line leak ( SLL ) . Our aim was to report the SLL rate and its management in a prospect i ve cohort of 378 LSGs . Patients and Methods : A total of 378 patients underwent LSG from July 2005 to July 2011 . The gastric transection was performed by an initial 60 mm firing of 4.5 mm staples at the antrum and successive 60 mm firings of 3.5 mm staples at the gastric body and fundus toward the left diaphragmatic crus . A 36 Fr bougie was used to calibrate the gastric tube . The staple line was systematic ally reinforced with a partial-thickness running suture . Results : The overall complications and SLL rate were 20/378 ( 5.29 % ) and 9/378 ( 2.38 % ) , respectively . SLLs were managed by laparoscopic ( n=2 ) or open ( n=1 ) exploration , drainage and endoscopic self-exp and able covered stent , computed tomography – guided percutaneous drainage ( n=2 ) , or a self-exp and able covered stent alone ( n=4 ) . Medical support including total parenteral nutrition and adapted antibiotics was started in all patients . The combined treatment modalities were successful in all cases . Conclusions : SLL was the most common complication of LSG accounting for half of the overall complications . Percutaneous drainage and self-covered stents combined with antibiotics and parenteral nutrition are effective for SLL and should be proposed as first-line treatment in stable patients BACKGROUND Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial . We studied the results of initial conservative treatment ( antibiotics and percutaneous drainage if necessary , with or without interval appendectomy ) compared with immediate surgery . METHODS We undertook an observational , retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon , treated in our hospital between January 1997 and March 2009 . Patients younger than 14 , with severe sepsis or with diffuse peritonitis were excluded . A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment . A control group was composed of the other patients , who all underwent  urgent appendectomy  , matched for age and later r and omized 1:1 . The infectious risk stratification was established with the National Nosocomial Infections Surveillance System ( NNIS ) index . Dependent variables were hospital stay and surgical site infection . Analysis was with SPSS , with p < 0.05 considered significant . RESULTS Interval appendectomy  was performed in 7 study group patients . Surgical site infection episodes were more frequent in the control group ( 6 vs. 0 , p < 0.001 ) . A greater percentage of high risk patients ( NNIS ≥ 2 ) was identified in the control group ( 80 vs. 28.7 % , p < 0.03 ) , mostly related with contaminated or dirty procedures in this group ( p < 0.001 ) . No significant difference between groups was found in hospital stay . CONCLUSION Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon In order to elaborate evidence -based , national Danish guidelines for the treatment of diverticular disease the literature was review ed concerning the epidemiology , staging , diagnosis and treatment of diverticular disease in all its aspects . The presence of colonic diverticula , which is considered to be a mucosal herniation through the intestinal muscle wall , is inversely correlated to the intake of dietary fibre . Other factors in the genesis of diverticular disease may be physical inactivity , obesity , and use of NSAIDs or acetaminophen . Diverticulosis is most common in Western countries with a prevalence of 5 % in the population aged 30 - 39 years and 60 % in the part of the population > 80 years . The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5 - 4/100,000 . Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis . Complicated diverticulitis is staged by the Hinchey classification 1 - 4 ( 1 : mesocolic/pericolic abscess , 2 : pelvic abscess , 3 : purulent peritonitis , 4 : faecal peritonitis ) . Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and /or CRP ; but the clinical diagnosis is not sufficiently precise . Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey . The distinction between Hinchey 3 and 4 is done by laparoscopy or , when not possible , by laparotomy . Uncomplicated diverticulitis is treated by conservative means . There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis , but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection . Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics . When the abscess is < 3 cm in diameter , drainage may be unnecessary , and only antibiotics should be instituted . The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies : The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or , alternatively , resection of the sigmoid with primary anastomosis . Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease . Evidence so far for the lavage regime is promising , comparing favourably with resection strategies , but lacking in solid proof by r and omized , controlled investigations . In recent years , morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities . Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed . Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures , since prophylactic resection of the sigmoid , evaluated from present evidence , confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society . Any recommendation for routine resection following multiple cases of diverticulitis should await results of r and omized studies . Laparoscopic resection is preferred in case of need for elective surgery . When malignancy is ruled out preoperatively , a sigmoid resection with preservation of the inferior mesenteric artery , oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended . Fistulae to bladder or vagina , or stenosis of the colon may be dealt with according to symptoms and comorbidity . Resection of the diseased segment of colon is preferred when possible and safe ; alternatively , a diverting stoma can be the best solution OBJECTIVE Modern imaging modalities increase the detection of small ( < or=4 cm ) renal tumors , of which about 20 % are benign . As a result , minimal invasive treatments , such as radiofrequency ablation and cryotherapy , and surveillance strategies are gaining popularity . Information that would be helpful when choosing the most appropriate management strategy for this patient group could be obtained from pretherapeutic image-guided biopsy . METHODS Under computed tomography (CT)-fluoroscopic guidance  78 patients with solid renal tumors prospect ively underwent 18-gauge core biopsy . In addition , using the same sheath , fine-needle aspiration was taken in 44 patients and analyzed cytologically . The renal masses were subsequently removed surgically and evaluated histologically . RESULTS Mean patient age was 63+/-13.5 yr ; mean tumor size was 4+/-1.8 cm . The sensitivity of  core biopsy and fine-needle aspiration for the detection of renal cell carcinoma ( RCC ) was 93.5 % and 90.6 % , respectively ; Fuhrman grade was correctly predicted in 76 % and 28 % and the correct histologic subtype was identified 91 % and 86 % , respectively . Cytology from fine-needle aspiration revealed a sensitivity in detecting malignant and benign lesions of 100 % and 75 % , respectively . Two of the renal tumors diagnosed as oncocytomas on core biopsy were hybrid tumors with scattered areas of oncocytomas and chromophobe RCC . Complications of CT-guided biopsy included one marginal pneumothorax , which resolved under conservative management , and four small perirenal hematomas detected at follow-up ultrasonography not requiring further therapy . CONCLUSION CT-guided percutaneous preoperative renal tumor biopsy had a high diagnostic accuracy , particularly in predicting malignancy The risk of a major complication from " blind " percutaneous liver biopsy is reported to be in the range of 0.24 % to 3.8 % . In a recent r and omized trial , patients whose liver biopsies were performed with ultrasonography  had a significant reduction in complications requiring hospitalization compared with patients without ultrasound-guided biopsies  ( 0.5 % vs. 2.2 % , P < .05 ) . Despite this , routine use of ultrasonography for liver biopsies has not been implemented because of controversies with respect to cost-effectiveness . The aim of our study was to analyze the relative cost-effectiveness of performing ultrasound-guided liver biopsies using decision analysis . A decision tree was constructed to compare a strategy of liver biopsy using ultrasonography with a strategy without ultrasonography . The major outcomes included were minor complications such as pain requiring analgesics and major complications , which require hospitalization . Costs included were direct medical costs from the payer 's perspective . In our baseline model , the cost from complications per patient with and without ultrasonography was $ 62 and $ 129 , respectively . The marginal effectiveness expressed as the number of major complications avoided was 1.2/100 liver biopsies . The incremental cost to avoid one major complication was $ 2,731 . The model was most sensitive to the frequency of major complications and the additional cost of ultrasonography  . Our decision analysis model suggests that ultrasound-guided liver biopsy is cost-effective . Future studies assessing the efficacy of image-guided liver biopsies should be conducted PURPOSE Although many patients receive antibiotic therapy for uncomplicated appendicitis , the relatively high treatment failure and recurrence rates are problematic . We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm , have better outcomes . The purpose of this prospect i ve non-r and omized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm . METHODS Over 2 years , we enrolled 119 patients who initially received antibiotic therapy .  The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis . Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively . We evaluated the rates of treatment failure , peritonitis , and recurrence . RESULTS Nine patients ( 7.6 % ) failed to respond to initial antibiotic therapy , and 6 had true appendicitis after subsequent surgery . Two patients had complicated appendicitis ( peritonitis ) , but no patient displayed intra-abdominal abscess postoperatively . During a median follow-up period months of 14 months , 14 patients ( 12.7 % ) experienced recurrence . CONCLUSIONS Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm BACKGROUND / PURPOSE Imaging techniques are used widely to diagnose appendicitis . However , the negative appendectomy rate remains at about 15 % . The authors assessed ultrasound-based decision making in the treatment of acute appendicitis in children . METHODS The authors prospect ively studied 165 consecutive children ( 3 to 15 years old ) evaluated for appendicitis . Diagnosis and treatment were based solely on ultrasound scan findings . Criterion for appendicitis was a diameter exceeding 6 mm . Severity was classified into 4 grade s based on the appearance of intramural appendiceal structure . Patients with grade s I or II received antibiotic therapy . Patients with grade s III or IV underwent appendectomy . RESULTS Ultrasound scan diagnosed appendicitis in 93 children ( grade I , 7 ; grade II , 17 ; grade III , 41 ; and grade IV , 28 ) . All but 2 patients with grade s I or II underwent  antibiotic therapy  without complication . All grade s III or IV patients underwent appendectomy . There was no negative appendectomy among 76 appendectomies during this period . Ultrasound-based prediction of severity was correct in 67 cases ( 88 % ) . Ultrasonography identified other pathology in 39 . CONCLUSIONS Ultrasonography in children can not only visualize all inflamed appendices but also predict severity of disease . Treatment based entirely on ultrasound scan identified patients who required surgery for severe appendicitis and permitted successful conservative treatment for mild appendicitis Background Preoperative biliary drainage ( PBD )  is associated with bacterial contamination of bile , but the effects of PBD on morbidity after pancreatoduodenectomy remain controversial . The aim of this study was to characterize bile contamination to develop successful specific antibiotic prophylactic strategies for pancreatoduodenectomy . Methods Ninety-one consecutive patients who underwent pancreatoduodenectomy for periampullary tumor were prospect ively evaluated .  Prophylactic antibiotics were selected based on preoperative bile cultures . Bile cultures and postoperative complications were compared in 46 patients who underwent PBD ( drainage group ) versus 45 patients who did not ( nondrainage group ) . Results The incidence of positive bile cultures was higher in the drainage group ( 78 % ) than in the nondrainage group ( 36 % ) ( P < 0.001 ) . In the drainage group , positive bile cultures were frequently polymicrobial ( 61 % ) and demonstrated resistance to several antibiotics , including cefazolin ( 83 % ) , cefmetazole ( 72 % ) , and cefpirome ( 64 % ) . Overall morbidity ( 30 % and 22 % ) and infectious morbidity ( 13 % and 11 % ) did not differ significantly between the drainage and nondrainage groups , respectively . Conclusions PBD had a notable influence on bile microbial contamination , including a higher rate of antibiotic resistance . Therefore , specific antibiotic prophylaxis based on bile culture is required for preventing infectious complications in pancreatoduodenectomy patients who undergo PBD PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options The aim of this prospect i ve , r and omized study was to determine whether laparoscopic cholecystectomy should be performed as an early or a delayed operation in patients with acute cholecystitis . After diagnostic workup , patients were r and omized to one of two groups : ( 1 ) early laparoscopic cholecystectomy  ( i.e. , within 7 days after onset of symptoms ) or ( 2 ) initial conservative treatment followed by delayed laparoscopic cholecystectomy 6 to 8 weeks later .  Seventy-four patients were placed in the early-operation group , and 71 patients were assigned to the delayed-operation strategy . There was no significant difference in conversion rates ( early 31 % vs. delayed 29 % ) , operating times ( early 98 [ range 30 to 355 ] minutes vs. delayed 100 [ 45 to 280 ] minutes ) , or complications . Failure with the conservative treatment strategy was noted in 26 % of these patients . The total hospital stay was significantly shorter in the early group ( 5 [ range 3 to 63 ] days ) vs. the delayed group ( 8 [ range 4 to 50 ] days ; P < 0.05 ) . Despite a high conversion rate , early laparoscopic cholecystectomy offered significant advantages in the management of acute cholecystitis compared to a conservative strategy . The greatest advantage was a reduced total hospital stay Closed suction drains after pancreaticoduodenectomy are theoretically used to drain potential collection s and anastomotic leaks . It is unknown whether such drains are effective , harmful , or affect the outcome after this operation . Eighty-nine consecutive patients underwent pancreaticoduodenectomy for presumed periampullary malignancy and were retrospectively review ed . Thirty-eight had no intraabdominal drains and 51 had drains placed at the conclusion of the operation . We analyzed patient , nutritional , laboratory , and operating room factors with end points being complications and length of hospital stay . Intra-abdominal complications were defined as intra-abdominal abscess and pancreatic or biliary fistula . Postoperative interventions were defined as CT-guided drainage and reoperation . Analysis was by Student ’s t test and chi-square test . Two of eight surgeons contributed 92 % of the patients without drains . The groups were equivalent with respect to demographic , nutritional , and operative factors . Time under anesthesia was significantly shorter in the group without drains ( P = 0.0001 ) . There was no statistical difference in the rate of fistula , abscess , CT drainage , or length of hospital stay . Intra-abdominal drainage did not significantly alter the risk of fistula , abscess , or reoperation or the necessity for CT-guided intervention after pancreaticoduodenectomy . Routine use of drains after pancreaticoduodenectomy may not be necessary and should be subjected to a r and omized trial BACKGROUND Emergency laparoscopic cholecystectomy has been advocated for the treatment of acute cholecystitis ; however it can be a difficult task , especially in public hospitals , with relatively high conversion and complication rates . Percutaneous cholecystostomy is a simple and effective procedure allowing patients to recover from the acute event and undergo elective laparoscopic surgery at a later stage . METHODS We prospect ively assessed a protocol of initial conservative treatment in patients admitted with acute cholecystitis . Patients who did not respond to medical treatment were treated by percutaneous cholecystostomy .  Following discharge the patients were seen in the outpatient clinic and elective laparoscopic cholecystectomy was considered and scheduled as necessary . The details of the operation were collected with emphasis on complications and conversion rate . RESULTS During a 3-year period , 224 patients who were admitted with acute calculous cholecystitis entered the protocol . Fifty-four patients did not improve under medical treatment and percutaneous cholecystostomy was performed . In spite of adequate drainage , 5 patients still did not improve : 3 patients were successfully operated upon urgently and recovered , while 2 patients who had severe concomitant diseases and multi-organ failure , died . Forty-nine patients were discharged with the catheter and later re-evaluated for elective operation . In 7 patients common bile duct stones were found and were removed by ERCP prior to the elective operation . Twenty-five patients underwent delayed laparoscopic cholecystectomy with a low conversion rate ( 8 % ) , and only minor complications ( 16 % ) . CONCLUSIONS Conservative treatment and delayed operation is still an acceptable choice in the treatment of acute cholecystitis . Percutaneous cholecystostomy is an effective tool , with high success rate and low morbidity , and allows for better pre-operative evaluation of the biliary system and safe interval laparoscopic surgery . Laparoscopic cholecystectomy after drainage of the gall bladder is a low morbidity procedure with relatively low conversion rate Introduction : The management approach for acute appendicitis has been challenged in recent years , with numerous r and omized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment , with lower complication rates . Methods : A national survey of all consultant general surgeons evaluating their practice s was performed . Reasons for changed practice s , choice of antibiotics and follow-up investigations were evaluated . In addition , the role of interval appendicectomy and conservative management in the pediatric population was also assessed . Results : The response rate for this survey was 74.7 % ( n = 74/99 ) . Over one-fifth ( n = 17 , 22.9 % ) routinely treat acute appendicitis conservatively , while another 14.8 % ( n = 11 ) consider this approach in selected cases . Main reasons for modified practice s included the presence of inflammatory phlegmon ( 75 % ) , delayed presentation ( 64 % ) , and recent evidence -based medicine developments ( 46 % ) . Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management ( 53 % ) . Alternatively , combinations of antibiotics were also utilized . One-third felt interval appendicectomy was warranted , while one-fifth supported conservative management in the paediatric setting . The overwhelming majority ( > 95 % ) advocate follow-up colonoscopy ± computed tomography in any patient aged > 40 years managed conservatively . Conclusion : Considerable variation in management of uncomplicated appendicitis  remains in Irel and despite growing evidence suggesting that the non-operative approach is safe . Reasons for adopting a conservative management practice have been identified and reflect the exp and ing literature on this subject OBJECTIVE To compare the therapeutic efficacy of four antibiotic regimens : penicillin , tobramycin , and clindamycin ; penicillin , tobramycin , and ornidazole ; piperacillin alone ; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis . DESIGN Prospect i ve r and omised study . SETTING Teaching hospital , Turkey . SUBJECTS 200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were r and omly assigned to one of four groups each consisting of 50 patients . INTERVENTIONS Preoperative antibiotics given intravenously , peritoneal drainage by Penrose drains without irrigation , appendicectomy with the inversion of the stump by a purse string , taking peritoneal swabs , and primary skin closure . MAIN OUTCOME MEASURES Comparability of the groups , duration of fever , leucocytosis , antibiotic treatment , stay in hospital , nasogastric intubation , and drainage , as well as results of cultures and complications . RESULTS There were no significant differences between the groups for any variable studied . The predominant bacterial species were Escherichia coli , Klebsiella spp , Pseudomonas spp , Fusobacteria , and Peptostreptococci which were appropriately covered by all the antibiotic regimens . Fourteen patients had complications including wound infections ( n = 10 ) , prolonged ileus ( n = 2 ) and intra-abdominal abscess ( n = 2 ) all of which were treated conservatively . There was no mortality and no major complications . All regimens had the same clinical and bacteriological efficacy . CONCLUSION There is no gold st and ard for antimicrobial chemotherapy in perforated appendicitis . Different antibiotic combinations or a single broad spectrum antibiotic , which include both aerobic and anaerobic coverage , can safely be used in children with perforated appendicitis OBJECTIVE The aim of the present study is to determine the feasibility and safety of antibiotics for uncomplicated simple appendicitis in pregnancy . METHOD We conducted a 6-year prospect i ve observational study on 20 pregnant women in whom uncomplicated simple appendicitis ( appendiceal diameter ≤11 mm and with no signs of appendicoliths , perforation , or abscess ) was radiologically verified and managed with a 4-day course of antibiotics . Treatment failure rate , defined as the need for an appendectomy during hospitalization and recurrence in the follow-up period ( median 25 months ) , and maternal or fetal complications during the pregnancy were evaluated . RESULTS Mean age of patients was 33.4 years , and gestational age was 17.8 weeks . Three patients failed to respond to antibiotic therapy  during hospitalization and underwent subsequent appendectomy ( 2 suppurative and 1 perforated appendicitis ) . There was 1 wound infection postoperatively . During follow-up , 2 patients during their ongoing pregnancy experienced recurrence at 3 and 6 months post-treatment , and a new course of antibiotics was determined . Patients also experienced recurrence at 8 and 10 months post-treatment and underwent appendectomy . Treatment failure occurred in 5 patients ( 25 % ) with no fetal complications during the pregnancy . CONCLUSIONS Antibiotic therapy for uncomplicated appendicitis in pregnancy may be a feasible treatment option without severe maternal and fetal complications Background The present study was design ed to compare the therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of appendicitis complicated by periappendiceal abscess . Methods In a prospect i ve study , 50 patients with acute appendicitis complicated by periappendiceal abscess ≥ 3 cm in size were r and omly assigned to two groups . The first group received treatment with ultrasound guided-percutaneous drainage and i.v . antibiotics ( ampicillin , cefuroxime , and metronidazole ) , and the other group received antibiotics only .  Patient ’s baseline characteristics , duration of hospital stay , and treatment outcome and complications were analyzed . Results Appendectomy was avoided in 16/25 patients in the drainage group and 2/25 patients in the non-drainage group during follow-up with RR of 0.39 ( 95 % CI = 0.22–0.62 ; p < 0.05 ) . One patient in the drainage group and 8 patients in the non-drainage group underwent surgery in the first month after the beginning of treatment . Eight patients in the drainage group and 15 in the non-drainage group underwent interval appendectomy . There was no statistically significant difference between the two groups regarding patient demographics , abscess size , and pretreatment clinical symptoms . Hospital stay up to the subsidence of clinical and sonographic signs was significantly shorter ( p < 0.001 ) in the drainage group , with a mean difference of 6.4 days ( 95 % CI = 5.0–7.9 ; p < 0.05 ) . Conclusions Percutaneous drainage with antibiotics is a safe and effective way of treating acute perforated appendicitis . The recurrence rate for these patients is relatively low , and very often interval appendectomy is not required . For patients with periappendiceal abscess ≥ 3 cm in diameter , antibiotic therapy alone is insufficient and the recurrence rate is high
Operation with appendectomy for appendiceal mass carries a high risk of complications compared with conservative treatment or drainage .
Drainage may lower the risk of treatment failure but entails a risk of complications .
INTRODUCTION The treatment strategy for appendiceal mass is controversial , ranging from operation or image-guided drainage to conservative treatment with or without antibiotics .
The aim of this study was to assess the various treatment modalities with respect to complications and treatment failure .