Mark C. Horattas

A reappraisal of appendicitis in the elderly

Historically, appendicitis in the elderly is associated with higher morbidity and mortality. Ninety-six patients over 60 years of age with appendicitis treated over a 10-year period were reviewed. Only 20% presented classically with anorexia, fever, right lower quadrant pain, and an elevated white blood cell count. One third of the patients had greater than 48 hours delay to admission. Objective diagnostic testing was often confusing and unreliable. At the time of admission, only 51% were diagnosed as having possible appendicitis. Eighty-three percent of our patients underwent surgery within 24 hours, and 72% had frank perforation. Thirty-two percent of those surviving developed complications, and 83% of these patients had perforated appendicitis. Complications were twice as likely in patients with perforation. Despite the relatively high morbidity, there were only four deaths in patients with coexistent carcinoma. Because of the later and atypical presentation of appendicitis in this age group, a high index of suspicion and early operation are important in avoiding perforation and subsequent morbidity.

What have we learned over the past 20 years about appendicitis in the elderly

BACKGROUND This study evaluates appendicitis in the elderly, comparing our findings to those previously published a decade earlier. METHODS Comparison of appendicitis in the elderly (aged 60 years and older) from 1978 to 1988 with the following 10 years, 1988 to 1998. RESULTS Overall (1978-1998) 26% of patients presented typically, one third delayed seeking care, with only half diagnosed correctly on admission. Computed tomography (CT) use increased (44% versus rarely in the previous decade). Perforation rates declined (72% first group versus 51% second group) with a concomitant drop in complications from 32% to 21% respectively. Overall, three fourths of complications occurred in patients with perforated appendicitis. Mortality rates remained constant. CONCLUSIONS Appendicitis in the elderly is a difficult problem with delays in medical care, non-typical presentation resulting in incorrect diagnosis, relatively high rates of perforation often with associated postoperative complications and mortality. A higher index of suspicion with liberal early utilization of CT in uncertain cases may result in more appropriate management.

Does pneumoperitoneum during laparoscopy increase bacterial translocation

AbstractBackground: To evaluate the impact of laparoscopy in the presence of peritonitis, this study was designed to assess bacteremia caused by E. coli–induced peritonitis with a carbon dioxide pneumoperitoneum in a rat model. Methods: Sixty Sprague-Dawley rats were divided into inoculum groups (no E. coli, 106 colony-forming units [CFU] E. coli, and 108 CFU E. coli), followed by induction of a carbon dioxide pneumoperitoneum or no pneumoperitoneum. Fifteen-minute-interval blood cultures were obtained to determine time of bacteremia development. Statistical assessment to determine significant differences among groups was done using ANOVA and t-test analysis. Results: A total of 20 animals with E. coli introduced into the peritoneum and a carbon-dioxide-induced pneumoperitoneum had more frequent positive blood cultures at all time intervals compared to identical inoculum subgroups without a pneumoperitoneum. ANOVA revealed a significant difference in bacteremia within the same concentration inoculum groups in animals receiving a pneumoperitoneum vs none (p < 0.01). Bacteremia increased significantly as inoculum concentrations increased (25% with 106E. coli inoculum vs 80% with 108E. coli), especially among the insufflated subgroups (45% with 106E. coli vs 100% with 108E. coli) over 180 min (p < 0.01). Conclusion: Carbon dioxide pneumoperitoneum increases the incidence of E. coli bacterial translocation from the peritoneum into the bloodstream in this rat model.

Metastatic renal cell carcinoma to the thyroid gland.

OBJECTIVE To examine the presentation, diagnosis, and appropriate management of renal clear cell carcinoma metastasis to the thyroid gland. METHODS We describe a clinical case of solitary thyroid metastasis from renal clear cell carcinoma and present a comprehensive review of the related English-language literature. Common patterns of presentation and generalized overall management recommendations are evaluated and summarized. RESULTS Eight years after nephrectomy for renal carcinoma at age 61 years, a man presented with a thyroid mass. Cytology and histopathologic surgical findings were consistent with a solitary metastasis most compatible with metastatic clear cell carcinoma from his previous renal carcinoma. After left thyroid lobectomy and isthmusectomy, the patient remains disease-free 5 years later. Although uncommon, nearly 150 cases of clinically recognized metastatic renal cell carcinoma to the thyroid have been reported in the English-language literature. Metastatic disease from the kidney to the thyroid gland can occur more than 20 years after nephrectomy with the average time interval being 7.5 years. Obtaining a full clinical history in any patient who presents with a thyroid nodule is essential to allow consideration of possible metastatic disease from previous primary tumor. Metastatic disease to the thyroid gland can be correctly diagnosed preoperatively. If metastatic renal cancer is limited to the thyroid gland only, prompt, appropriate surgical intervention can be curative. CONCLUSION Metastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of renal cell carcinoma.

Increased transperitoneal bacterial translocation in laparoscopic surgery

Background: The indications for laparoscopic surgery have expanded to include diseases possibly associated with peritonitis such as appendicitis, perforated peptic ulcers, and diverticulitis. The safety of carbon dioxide (CO2) pneumoperitoneum in the presence of peritonitis has not been proved. Our previous investigations demonstrated increased bacteremia associated with CO2 insufflation. In effort to clarify the relative effects of intraabdominal pressure and type of gas, this study was designed to measure bacterial translocation with different gases at different pressures of pneumoperitoneum. Methods: For this study, 110 rats were given intraperitoneal bacterial innoculations with Escherichia coli and equally divided into five groups of 20 animals each. The study groups included a control group with no pneumoperitoneum administered (n = 30), insufflation at a commonly used pressure of 14 mmHg with helium (n = 20) and CO2 (n = 20), and low insufflation at 3 mmHg with helium (n = 20) and CO2 (n = 20) in an effort to minimize influences related to pressure. Blood cultures were checked at 15-min intervals for the first 45 min, then hourly thereafter for a total of 165 min after peritoneal inoculation with 2 × 107E. coli. Results: There is increased risk of bacterial translocation in comparing groups that underwent pneumoperitoneum with those that did not in the rat peritonitis model. Furthermore, these findings are dependent on the presence or absence of gas, but not necessarily on the type of gas used for insufflation. In the low-pressure groups of both gases (helium and CO2), bacterial translocation was significantly increased, as compared with the control group. Low pressure also was associated with increased bacterial translocation, as compared with high pressure, but beyond 30 min of insufflation, no significant differences were apparent. Conclusions: The risk of bacterial translocation in the E. coli rat peritonitis model is increased with insufflation using CO2 or helium, and this effect is more significant at lower pressures (3 mmHg) than at higher pressures (14 mmHg). However, no clinically applicable conclusions regarding the relative effects from type of gas or insufflation pressures could be confirmed.

Hickman Catheter Dislodgement Due to Pendulous Breasts

Dislodgement of Hickman, Broviac, and Mediport catheters is a rare but recognized complication. To date, no specific etiology for this has been cited. We present five cases of dislodgement due to positional changes in large-breasted women and one man with gynecomastia. Apparently, motion in the subcutaneous tissue secondary to gravitational forces on large breasts causes downward and outward traction on the subcutaneous portion of the catheter. Variations in placement technique to help avoid this complication are described.

Cardiopulmonary needle embolization: A complication of central venous drug abuse

A great variety of complications secondary to drug abuse have been reported in the literature. We report a case of multiple cardiopulmonary needle embolization. A drug addict who had resorted to central venous drug abuse was found on chest roentgenograms to have multiple asymptomatic needle fragments within her chest. In this instance chest roentgenograms and tomographs were more helpful in needle localization than computed tomography. Complications of intracardiac foreign bodies are also briefly reviewed. In attempts to diagnose this complication, a high index of suspicion is necessary as central venous drug abuse becomes increasingly more prevalent.

Concepts in Hernia Repair, Surgery for Necrotizing Fasciitis, and Drainage of Subphrenic Abscess

We begin with a perspective on one of surgery’s most ancient and vexing problems in adults. Inguinal hernia repair now constitutes 35% of all abdominal surgeries submitted to the American Board of Surgery by general surgeons applying for recertification [1]. Rutkow et al., who have a keen interest in socioeconomic issues, reported that nearly 700,000 operations are performed annually [2]. Clearly, this mechanical problem has vast associated medical and economic costs that fuel an interest in this operation that has not abated. Moreover, Smith found 3,100 published citations in the MEDLINE literature search over a 10-year period at the end of the twentieth century dedicated to one aspect or another of groin hernia repair [3]. No wonder surgeons remain bemused and skeptical when a new technique is acclaimed as the ultimate solution. Finally, and again drawing from the American Board of Surgery recertification database, the average number of inguinal hernia repairs performed annually by an individual surgeon was only 35 [1]. This simple fact is important to bear in mind when discussing multiple new and vastly different operative approaches, each of which may have a different learning curve.