How To Approach The Patient Suspected Of Having Acute Appendicitis, Introducing New Criteria: (Two Out Of Three)

Background:Acute appendicitis is the most common cause of acute surgical abdomen.Inspite of the introduction of ultrasonography, computed tomography scanning and laparoscopy in the years 1987-1997 the difficulty in accurate diagnosis of acute appendicitis has remained the same.Our way of reaching a decision for operating in a patient suspected of having acute appendicitis(which will follow) has superiority to other introduced so far approaches. Methods:3046 patients suspected of having acute appendicitis were evaluated during the years 2003-2005 at Shohada Medical Center.We have adopted a 3 point system, giving 1 point each to history, physical examination and laboratory tests if they meet the criteria:   1. Typical history gets 1 point if: an abdominal pain shift from epigastrium or periumbilical area to RLQ accompanying anorexia, nausea and vomiting depending on age.  2. Typical physical findings: RLQ tenderness associated with rebound tenderness, 3. Laboratory tests: leukocytosis between 10,500 to 18,000/mm3 along with normal urinalysis or leukocyturia without presence of bacteria. In pregnancy where leukocyteosis exists shift to the left is considered positive. Each of the criteria gets zero or 1 point if it meets that mentioned above and those who get two or three points will be operated on, otherwise the patient will be observed for 12 hours until his symptoms improve or progress to have two or three point criteria when he or she will be operated on. The results of histopathological examination of appendix have been used for the accuracy of this method. Results: Among 3046 patients, 1241 (41%) were operated on rightaway with diagnosis of acute appendicitis since they had 2 or 3 points on arrival. From these 1213 (97/1%) had acute appendicitis. 1805 (59%) patients who didn't get at least 2 points were observed for 12 hours, during this period 115 (6.4%) patients, who got at least two points were operated on, and 92 (80.5%) patients had non-perforated appendicitis;and the others were discharged since their symptoms improved.None of the patients,who were observed,developed perforation of appendix or peritonitis.Sensitivity and specificity of this method was 100% and 97.1% with positive and negative predictive values of 93.3% and 95.5%.So this method is a safe way of approaching patients suspected of having acute appendicitis. Conclusion:The 2 out of 3 points criteria for approaching the patients suspected of having acute appendicitis provide a nonexpensive, noninvasive,simple,rapid and accurate method for diagnosis of acute appendicitis

How To Approach The Patient Suspected Of Having Acute Appendicitis, Introducing New Criteria: (Two Out Of Three)

Background: Acute appendicitis is the most common cause of acute surgical abdomen. Inspite of the introduction of ultrasonography, computed tomography scanning and laparo-scopy in the years 1987-1997 the difficulty in accurate diagnosis of acute appendicitis has remained the same. Our way of reaching a decision for operating in a patient suspected of hav-ing acute appendicitis (which will follow) has superiority to other introduced so far approaches. Methods: 3046 patients suspected of having acute appendicitis were evaluated during the years 2003-2005 at Shohada Medical Center. We have adopted a 3 point system, giving 1 point each to history, physical examination and laboratory tests if they meet the criteria: 1. Typical history gets 1 point if: an abdominal pain shift from epigastrium or periumbilical area to RLQ accompanying anorexia, nausea and vomiting depending on age. 2. Typical physical findings: RLQ tenderness associated with rebound tenderness, 3. Laboratory tests: leukocytosis between 10,500 to 18,000/mm3 along with normal urinaly-sis or leukocyturia without presence of bacteria. In pregnancy where leukocyteosis exists shift to the left is considered positive. Each of the criteria gets zero or 1 point if it meets that mentioned above and those who get two or three points will be operated on, otherwise the patient will be observed for 12 hours until his symptoms improve or progress to have two or three point criteria when he or she will be operated on. The results of histopathological examination of appendix have been used for the accuracy of this method. Results: Among 3046 patients, 1241 (41%) were operated on rightaway with diagnosis of acute appendicitis since they had 2 or 3 points on arrival. From these 1213 (97/1%) had acute appendicitis. 1805 (59%) patients who didn't get at least 2 points were observed for 12 hours, during this period 115 (6.4%) patients, who got at least two points were operated on, and 92 (80.5%) patients had non-perforated appendicitis; and the others were dis-charged since their symptoms improved. None of the patients, who were observed, devel-oped perforation of appendix or peritonitis. Sensitivity and specificity of this method was 100% and 97.1% with positive and negative predictive values of 93.3% and 95.5%. So this method is a safe way of approaching patients suspected of having acute appendicitis. Conclusion: The 2 out of 3 points criteria for approaching the patients suspected of hav-ing acute appendicitis provide a nonexpensive, noninvasive, simple, rapid and accurate method for diagnosis of acute appendicitis

An Easy Solution For The Diverting Loop Colostomy: Our Technique

Background: The loop colostomy is one of the most popular techniques used as a protective maneuver for a distal anastomosis and/or temporary fecal diversion. We are introducing the use of a full thickness skin bridge under the large bowel instead of a glass rod which alleviates problems such as protrusion of the large bowel, retraction of the bowel into the abdomen after removing the rod and hindering proper application of a colostomy bag over the stoma. Methods: Seventeen patients needing double barrel colostomy for complete diversion of fecal material were selected using loop colostomy with skin bridge. Three patients had Fournier's gangrene and 14 had penetrating rectal injury. Omega loop colostomy with a full thickness skin bridge was performed for fecal diversion. Results: All of the 17 patients had gas passing and full passage of fecal material within 3 days postoperatively. No case of skin necrosis and stitch abscess was encountered. No parastomal hernia or large prolapse was noted until healing was completed and patients were discharged and after at least 8 weeks and in Fournier's gangrene somewhat longer, the loop colostomy was closed without the need for formal laparotomy and without any case of anastomotic leak. Conclusion: In this study we confirmed that diverting loop colostomy using a skin bridge is a safe, rapid and easy to manage colostomy technique which gives complete diversion similar to double barrel colostomy without the need of performing a laparotomy for closure of the colostomy

Cosmetic Surgical Repair of Contaminated Wounds Versus Traditional Loose Approximation: Does It Increase the Rate of Wound Infections?

Background:The cosmetic result of the surgical scar has long been considered by surgeons as an important factor for patient satisfaction.On the other hand,there has been an old teaching that perfect closure of contaminated wounds increases the rate of infection. We decided to look into this matter and see if this is a fact or a myth. Methods: In this prospective randomized study conducted on 200 patients with suppurative or gangrenous appendicitis,we closed the wounds with a cosmetic subcuticular suture of 4/0 nylon in 100 patients and in the other 100 patients the wound was approximated loosely with a few stitches of 3/0 nylon in vertical mattress fashion during a 14-month period.Results:There was no significant difference in the rate of wound infection between these two groups.Conclusions:This study shows that perfect closure of the wound with subcuticular closure,which gives a very good cosmetic result in comparison with traditional loose closure, does not increase the rate of wound infection