P. J. Schmit

Surgical approach to cecal diverticulitis

BACKGROUND Cecal diverticulitis is a rare condition in the Western world, with a higher incidence in people of Asian descent. The treatment for cecal diverticulitis has ranged from expectant medical management, which is similar to uncomplicated left-sided diverticulitis, to right hemicolectomy. STUDY DESIGN A retrospective chart review was conducted of the 49 patients treated for cecal diverticulitis at Olive View-UCLA Medical Center from 1976 to 1998. This was the largest-ever single-institution review of cecal diverticulitis reported in the mainland US. RESULTS The clinical presentation was similar to that of acute appendicitis, with abdominal pain, low-grade fever, nausea/vomiting, abdominal tenderness, and leukocytosis. Operations performed included right hemicolectomy in 39 patients (80%), diverticulectomy in 7 patients (14%), and appendectomy with drainage of intraabdominal abscess in 3 patients (6%). Of the 7 patients who had diverticulectomy, 1 required right hemicolectomy at 6 months followup for continued symptoms. Of the three patients who underwent appendectomy with drainage, all required subsequent hemicolectomy for continued inflammation. Of the 39 patients who received immediate hemicolectomies, there were complications in 7 (18%), with no mortality. CONCLUSIONS We endorse an aggressive operative approach to the management of cecal diverticulitis, with the resection of all clinically apparent disease at the time of the initial operation. In cases of a solitary diverticulum, we recommend the use of diverticulectomy when it is technically feasible. When confronted with multiple diverticuli and cecal phlegmon, or when neoplastic disease cannot be excluded, we advocate immediate right hemicolectomy. This procedure can be safely performed in the unprepared colon with few complications. Excisional treatment for cecal diverticulitis prevents the recurrence of symptoms, which may be more common in the Western population.

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management

Study objective Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics‐first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics‐first, including outpatient management, with appendectomy. Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics‐first‐treated participants older than 13 years could be discharged after greater than or equal to 6‐hour emergency department (ED) observation with next‐day follow‐up. Outcomes included 1‐month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics‐first appendectomy rate. Results Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics‐first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/&mgr;L (range 6,200 to 23,100/&mgr;L), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic‐treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics‐first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics‐first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics‐first‐treated participants had less pain and disability. During median 12‐month follow‐up, 2 of 15 antibiotics‐first‐treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. Conclusion A multicenter US trial comparing antibiotics‐first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.

The Use of Single-Agent Antibacterial Regimens in the Treatment of Advanced Appendicitis with Peritonitis

SummaryThe optimal antibacterial regimen for the treatment of patients with mixed intra-abdominal infections remains to be established. Since advanced (gangrenous and perforated) appendicitis with peritonitis probably represents the most reproducible clinical model of this disease process, we performed a randomised double-blind study comparing 2 single-agent regimens (ceftizoxime 2g every 12 hours and cefoxitin 2g every 6 hours) in the treatment of advanced appendicitis with peritonitis. 109 evaluable patients (84 male, 25 female) aged 12 to 70 (mean 28) years were randomised, 53 to ceftizoxime and 56 to cefoxitin. 75 patients (69%) had perforation and 34 (31%) exhibited gangrene, with the mean duration of abdominal pain and mean white blood cell (WBC) count on admission being significantly greater in the group with perforation [71 vs 46 hours and 16.9 vs 14.8 ×109/L, respectively (p < 0.05)]. Bacteria were recovered from the peritoneal cultures of all patients, with a mean of 3.3 aerobes and 8.8 anaerobes per specimen, representing a 600% increase in bacterial recovery compared with previous reports. The clinical cure rate was 51 of 53 (96%) for ceftizoxime vs 47 of 56 (84%) for cefoxitin (p = 0.06), or 90% overall. We conclude that single-agent antibacterial therapy with either of these 2 drugs is safe and very effective in patients with advanced appendicitis with peritonitis, and that the number of bacteria associated with this condition is much greater than previously believed.

Biliary disease during pregnancy

BACKGROUND Biliary disease during pregnancy is rare and the need for surgery in these cases is controversial. We evaluated our experience with biliary disease during pregnancy with regard to outcome and cost containment. PATIENTS AND METHODS We reviewed the clinical course of pregnant women with biliary disease at the University of California at Los Angeles and Olive View-UCLA Medical Centers from 1988 to 1993. RESULTS Seventy-two of 46,075 pregnant women presented with biliary disease (incidence 0.16%). Sixteen underwent surgery while pregnant, 5 in the first and 11 in the second trimester. No maternal or fetal deaths occurred secondary to medical or surgical management of biliary disease. Patients who were treated medically at initial presentation had a 69% rate of relapse prior to delivery, compared to no relapses in those treated surgically (P < 0.01). Patients who experienced relapse spent an average of 3.0 additional days in hospital. CONCLUSION Surgical therapy for biliary disease performed in the second trimester of pregnancy does not increase morbidity and may help reduce relapses and additional days in hospital.