To establish if the NELA risk calculator underestimates mortality risk in older adults undergoing laparotomy for mesenteric or colonic ischaemia. Methods: A retrospective search of the operative database was performed for all patients over age 65 years who underwent laparotomy across two tertiary centres over a 3-year period. Cases of mesenteric or colonic ischaemia were identified from the operative records. Cases where ischaemia occurred secondarily to a primary obstructive or other pathology were excluded. Cases where a NELA score was not documented preoperatively were excluded. We then compared the NELA scores to the observed 30-day mortality rate. Secondary outcomes were hospital length of stay and intensive care unit length of stay. Results: Sixty cases were included in our analysis. There were 27 cases of colonic ischaemia and 33 cases of mesenteric ischaemia (mesenteric ischaemia group included five cases of distal small-bowel and colonic ischaemia). The overall mean NELA score was 21.9%, while the actual 30-day mortality was 43.3% (p=0.0094). Mean NELA score for mesenteric ischaemia cases only was 20.6% with an actual mortality rate of 45.5%. Mean NELA score for the colonic ischaemia cases was 23.5% with an actual mortality rate of 40.7%. The median time from operation to mortality was 8 days. Mean age was 77 years. Length of stay for survivors was a mean 27 days with intensive care unit length of stay of 9.3 days. Conclusion:The NELA risk score for mortality post-emergency laparotomy underestimates mortality risk by a factor of two in older adults where the primary pathology is mesenteric or colonic ischaemia.
We present a case of extensive stage small cell lung cancer presenting as perforated appendicitis secondary to an appendiceal metastasis. This is a rare presentation with only six reported cases in the literature. Surgeons must be aware of unusual causes for perforated appendicitis as in our case the prognosis can be dire. A 60-year-old man presented with an acute abdomen and septic shock. Urgent laparotomy and a subtotal colectomy were performed. Further imaging suggested the malignancy was secondary to a primary lung cancer. Histopathology demonstrated a ruptured small cell neuroendocrine carcinoma in the appendix with thyroid transcription factor 1 positive immunohistochemistry. Unfortunately, the patient deteriorated due to respiratory compromise and was palliated day six postoperatively. Surgeons should consider a broad differential diagnosis for the cause of acute perforated appendicitis as this can rarely be due to a secondary metastatic deposit from a widespread malignant process.
Introduction and Importance: We present a case of extensive stage small cell lung cancer presenting as perforated appendicitis secondary to an appendiceal metastasis. This is a rare presentation with only 6 reported cases in the literature. Surgeons must be aware of unusual causes for perforated appendicitis as in our case the prognosis can be dire. Case Presentation: A 60-year-old man presented with an acute abdomen and septic shock. Computed tomography demonstrated perforated appendicitis and a widespread malignant process initially suspected as colonic origin malignancy. Urgent laparotomy and a subtotal colectomy was performed. Further imaging suggested the malignancy was secondary to a primary lung cancer. Histopathology demonstrated a ruptured small cell neuroendocrine carcinoma in the appendix with TTF1 positive immunohistochemistry. Unfortunately, the patient deteriorated due to respiratory compromise and was palliated on day 6 postoperatively. Discussion: The appendix is a rare site for metastasis of lung cancer and these metastases usually present as acute perforated appendicitis. Distinguishing the site of the primary tumor can be difficult when there is extensive metastatic disease, and this differentiation relies on immunohistochemistry. In our case the patient was managed surgically, however rapidly deteriorated post operatively from multi-organ metastatic disease. This demonstrates the diagnostic challenges in metastatic small cell lung carcinoma presenting as an acute appendicitis as well as the poor prognosis with advanced disease. Conclusion: Surgeons should consider a broad differential diagnosis for the cause of acute perforated appendicitis as this can rarely be due to a secondary metastatic deposit from a widespread malignant process.
At the authors request, the Editor and Publisher of Open Access Surgery are retracting the published article. The author informed the journal that an ethics request to perform the study was submitted to the local ethics committee as per the hospital policy. Unfortunately, the request was not processed, and a misunderstanding led the author to believe the study had been approved, when in fact no approval had been provided. The ethics approval number provided in the article is not an approval number but rather a processing number. As the study did not receive the appropriate ethics approval prior to commencement the author requested to retract the article and the Editor and Publisher agreed with this decision.We have been informed in our decision-making by our editorial policies and the COPE guidelines.The retracted article will remain online to maintain the scholarly record, but it will be digitally watermarked on each page as "Retracted".
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