IntroductionThe evaluation of patients with suspected appendicitis strives to identify all patients with presenting symptoms while minimizing negative appendectomy rate. The aim of the study was to identify the optimal combination of clinical and laboratory parameters that should facilitate the emergency department surgeon’s definite decision.Materials and methodsThe study group comprised 120 patients with suspicion of acute appendicitis (AA). In 60 patients the AA diagnosis was confirmed intraoperatively and by histological analysis. Clinical parameters included: appetite, vomiting, diarrhea, dysuria, signs of localized peritonitis and pain migration. Measured laboratory parameters were: C-reactive protein (CRP), complete blood count (CBC) and the urine test strip.ResultsThe control group of patients were more likely to present following symptoms: no changes in appetite (P < 0.001), diarrhea (P = 0.009) and dysuria (P = 0.047). CRP and white blood cell count (WBC) were significantly higher in the group with confirmed AA compared to the control group (44.7 vs. 6.6, and 13.6 ± 3.9 vs. 9.0 ± 3.4, respectively; P < 0.001). The multivariate logistic regression analysis identified lack of appetite (P = 0.013), absence of diarrhea (P = 0.004), and positive finding of signs of localized peritonitis (P = 0.013), as well as WBCs (P < 0.001) and negative urine test strip results (P = 0.009) as statistically significant predictors of AA. The highest percentage of correctly classified cases (82%) was achieved by combination of common clinical exam and basic inexpensive laboratory parameters (WBCs and urine test strip).ConclusionsAcute appendicitis in the emergency setting may be successfully ruled in based on elevated WBCs and negative urine test strip in combination with signs of localized peritonitis, lack of appetite and absence of diarrhea. Since CRP did not contribute to the overall diagnostic accuracy, its use in AA diagnostic protocols is of no value.
<p><strong>Objective. </strong>Diagnosing acute appendicitis (AA) is challenging and this has stimulated surgeons to develop scoring systems that could potentially decrease the rate of misdiagnosis in patients with suspected appendicitis. One of the most widely used today is the Modified Alvarado scoring system (MASS), however its sensitivity and specificity varies a great deal between studies. As a result, we wanted to assess the diagnostic accuracy of MASS retrospectively at our institution to achieve the highest possible value of sensitivity and decrease the number of false negative patients.</p><p><strong>Material and Methods. </strong>We retrospectively calculated MASS for all subsequent patients who had undergone an appendectomy at our institution between July 2015 and March 2017.</p><p><strong>Results. </strong>In 118 out of 146 operated patients, AA was confirmed intraoperatively. There was a statistically significant difference between the average MASS score in the positive and negative appendectomy groups (6 v. 4, respectively, P<0.001), with a significantly higher number of females among the negative appendectomies (P<0.001). When lowering the cut-off to a value as low as ≥3, the sensitivity of the MASS score increased to 97.45% (95% CI: 92.7 – 99.5), thus obtaining a very low false negative rate of merely 2.55%.</p><p><strong>Conclusion. </strong>This retrospective diagnostic accuracy study confirmed the higher average MASS score in the group of patients with confirmed AA diagnosis. A MASS score above the proposed low cut-off value (≥3) can be a useful tool to help surgeons ruling in patients with AA in order to reduce the risk of missing diagnosis.</p>
SUMMARY -Despite progress in laparoscopic surgery and increasing surgical experience, the incidence of bile duct injury during laparoscopic cholecystectomy fails to fall below 0.3%-0.6% and it is still higher than those recorded in the era of open cholecystectomy. Bile duct injuries belong to the most serious complications of abdominal surgery in general and often end up with liver transplantation as the only hope for cure. We present a case of a 78-year-old jaundiced male patient who sustained common hepatic duct injury during laparoscopic cholecystectomy eight months earlier. Exploratory laparotomy, ERCP and MRCP revealed a metal clip placed just below hepatic duct confl uence and causing stricture of bile duct with dilatation of bile ducts proximal to the level of stenosis (Strasberg classifi cation type E3 injury). Repair of the injury was performed by creating termino-lateral hepaticojejunostomy between the right and left hepatic ducts and retrocolic Roux en-Y jejunal limb. By presenting this case, we wish to emphasize the importance of timely conversion and execution of intraoperative cholangiography in all cases when identifi cation of the structures of Calot's triangle is not clear enough. Successful treatment of bile duct injury is only possible with joint approach of radiologist, gastroenterologist and experienced hepatobiliary surgeon.
Introduction Surgical fear is common and has a negative impact on surgery and its outcome. Recent research has identified individual religiousness as an important factor among patients with associations to mental health, particularly anxiety. Objective This study aimed to examine associations between religiousness and surgical fear in a representative sample of adult surgical patients in Croatia. Design Cross-sectional study among elective surgery patients at different departments of a single hospital. Setting University Hospital Sveti Duh, a tertiary health care facility in Croatia. Measurements Religiousness and surgical fear were the variables of interest and assessed through self-report instruments. The Croatian version of the Duke Religiosity Index questionnaire (DUREL) assessed organizational religious activity (ORA), non-organizational religious activity (NORA), and intrinsic religiousness (IR). The Croatian version of the Surgical Fear Questionnaire (SFQ) measured surgical fear and its subscales the fear of the short-term and long-term consequences of surgery. Additionally, sociodemographic characteristics and medical history were assessed. Analyses were carried out using descriptive and linear regression analyses. Results 178 subjects were included for data analysis. Univariate linear regression found two dimensions of religiousness (non-organizational religious activity, intrinsic religiousness) to be weak, but significant predictors of greater surgical fear (adj. R2 = 0.02 and 0.03 respectively). In the multiple linear regression model together with age, gender, education and type of surgery, all three dimensions of religiousness were found to be significant independent predictors of greater surgical fear. Limitations The study was single-center and cross-sectional and did not assess patients’ specific religious identity. Conclusions This study demonstrated significant positive associations between dimensions of religiousness and surgical fear, potentially suggesting that surgical patients experience increased religiousness to cope with heightened anxiety. Assessment and intervention to address patient religiousness is warranted in the context of surgical fear among religious patients, and the importance of religiousness in the context of surgical fear needs to be further addressed in research.
Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality.Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy.Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.
Clear cell adenocarcinomas of the colon are defined as a subtype of colorectal adenocarcinoma with clear cell morphology. A 65-year old man was admitted to a Gastroenterology Department for diagnostic evaluation of a tumor in the sigmoid colon found on CT. There, the patient developed complete bowel obstruction and was operated urgently, where intraoperatively, a large tumor in the sigmoid fixated to the lateral abdominal wall was revealed. A subtotal colectomy was performed. Histopathological analysis of the surgical specimen was conducted. The immunohistochemistry staining was positive for CEA, CDX2, and CD20 and negative for CK7, CD10, MUC2, AFP, and PAS staining. Mismatch repair protein testing was negative. The pathological diagnosis was mucinous carcinoma with a clear cell component which bears an extremely low incidence that has been scarcely reported in literature. This stresses the need for more case reports like ours to be published.
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