Non-operative management of rectal cancer: Highlighting the controversies

There remains much ambiguity on what non-operative management(NOM)of rectal cancer truly entails in terms of the methods to be adopted and the best algorithm to follow.This is clearly shown by the discordance between various national and international guidelines on NOM of rectal cancer.The main aim of the NOM strategy is organ preservation and avoiding unnecessary surgical in-tervention,which carries its own risk of morbidity.A highly specific and sensitive surveillance program must be devised to avoid patients undergoing unnecessary surgical interventions.In many studies,NOM,often interchangeably called the Watch and Wait strategy,has been shown as a promising treatment option when undertaken in the appropriate patient population,where a clinical complete res-ponse is achieved.However,there are no clear guidelines on patient selection for NOM along with the optimal method of surveillance.

Predictors for success of non-operative management of adhesive small bowel obstruction

BACKGROUND Majority of adhesive small bowel obstruction(SBO)cases can be managed nonoperatively.However,a proportion of patients failed non-operative management.AIM To evaluate the predictors of successful non-operative management in adhesive SBO.METHODS A retrospective study was performed for all consecutive cases of adhesive SBO from November 2015 to May 2018.Data collated included basic demographics,clinical presentation,biochemistry and imaging results and management outcomes.The imaging studies were independently analyzed by a radiologist who was blinded to the clinical outcomes.The patients were divided into group A operative(including those that failed initial non-operative management)and group B non-operative for analysis.RESULTS Of 252 patients were included in the final analysis;group A(n=90)(35.7%)and group B(n=162)(64.3%).There were no differences in the clinical features between both groups.Laboratory tests of inflammatory markers and lactate levels were similar in both groups.From the imaging findings,the presence of a definitive transition point[odds ratio(OR)=2.67,95%confidence interval(CI):0.98-7.32,P=0.048],presence of free fluid(OR=2.11,95%CI:1.15-3.89,P=0.015)and absence of small bowel faecal signs(OR=1.70,95%CI:1.01-2.88,P=0.047)were predictive of the need of surgical intervention.In patients that received water soluble contrast medium,the evidence of contrast in colon was 3.83 times predictive of successful non-operative management(95%CI:1.79-8.21,P=0.001).CONCLUSION The computed tomography findings can assist clinicians in deciding early surgical intervention in adhesive SBO cases that are unlikely to be successful with non-operative management to prevent associated morbidity and mortality.

Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials

AIM: To perform a systematic review and meta-analysis comparing operative vs non-operative treatment of displaced proximal humerus fractures in elderly patients.METHODS: A systematic literature search was performed using EMBASE and MEDLINE through the OVID interface,CINAHL,the Cochrane Central Register of Controlled Trials(CENTRAL),Proquest,Web of Science,SAE digital library,and Transportation Research Board's TRID database.Searches of conference proceedings were also conducted.All available randomized controlled trials comparing operative vs non-operative management of displaced three- and four-part proximal humerus fractures in elderly patients were included.The primary outcomes measures included physical function,pain,health related quality of life,mortality,and the re-operation rate.RESULTS: Six randomized controlled trials(n = 287) were included.There was no statistically significant difference in function(MD = 1.72,95%CI:-2.90-6.34,P = 0.47),as measured by the Constant score,between the operative and the non-operative treatment groups.There was no statistically significance difference insecondary outcomes of health related quality of life(standardized MD = 0.27,95%CI:-0.05-0.59,P = 0.09),and mortality(relative risk 1.29,95%CI: 0.50-3.35,P = 0.60).Operative treatment had a statistically significant higher re-operation rate(relative risk 4.09,95%CI: 1.50-11.15,P = 0.006),and statistically significant decreased pain(MD = 1.26,95%CI: 0.02-2.49,P = 0.05).CONCLUSION: There is moderate quality evidence to suggest that there is no difference in functional outcomes between the two treatments.Further high quality randomized controlled trials are required to determine if certain subgroup populations benefit from surgical management.

Non-operative management of isolated liver trauma

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, nonoperative management（NOM） is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma.Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2%（70/72）. The success rates of NOM in the patients with grade I-III, IV and V liver trauma were100%, 94.4% and 83.3%. The complication rates were 10.0%and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived.NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

Functional Outcomes for Combined Acute Anterior and Posterior Cruciate Knee Injuries Treated Non-Operatively

Introduction: results after non-operative management for knees sustaining combined acute anterior and posterior cruciate ligament tears were presented. Subjects: 13 patients, 10 with medial, and 3 with lateral ligament injury. Methods: non-operative management consisted of employing a brace to prevent sagittal translation of the tibia. Quadriceps muscle and early passive knee motion exercises in the brace was encouraged immediately after arthroscopy. Weight-bearing was forbidden for 3 weeks. The brace was not removed for 3 months. Follow-up periods ranged from 2 to 6 years (mean, 3 years 2 months). Results: none, but one patient had a slight restriction of knee flexion. Quadriceps muscle strength revealed an average of 89.0% of normal side. The knee score indicated 2 patients rated good, 3 rated fair, and 8 rated poor. The score correlated with measurements of anterior and posterior translation on the stress radiograph significantly. Stress radiography revealed that anterior laxity was reduced better than posterior laxity significantly. Conclusion: non-operative brace therapy can be considered for this combined injury as the initial treatment. A late reconstruction would be performed when the result was not satisfactory. Preserved range of motion and muscle strength after brace therapy had a great advantage to the late reconstructive surgery.

Outcomes following operative vs. non-operative management of blunt traumatic pancreatic injuries: a retrospective multi-institutional study

Background:Traumatic pancreatic injuries are rare,and guidelines specifying management are controversial and difficult to apply in the acute clinical setting.Due to sparse data on these injuries,we carried out a retrospective review to determine outcomes following surgical or non-surgical management of traumatic pancreatic injuries.We hypothesize a higher morbidity and mortality rate in patients treated surgically when compared to patients treated non-surgically.Methods:We performed a retrospective review of data from four trauma centers in New York from 1990–2014,comparing patients who had blunt traumatic pancreatic injuries who were managed operatively to those managed non-operatively.We compared continuous variables using the Mann-Whitney U test and categorical variables using the chi-square and Fisher’s exact tests.Univariate analysis was performed to determine the possible confounding factors associated with mortality in both treatment groups.Results:Twenty nine patients were managed operatively and 32 non-operatively.There was a significant difference between the operative and non-operative groups in median age(37.0 vs.16.2 years,P=0.016),grade of pancreatic injury(grade I;30.8 vs.85.2%,P value for all comparisons<0.0001),median injury severity score(ISS)(16.0 vs.4.0,P=0.002),blood transfusion(55.2 vs.15.6%,P=0.0012),other abdominal injuries(79.3 vs.38.7%,P=0.0014),pelvic fractures(17.2 vs.0.00%,P=0.020),intensive care unit(ICU)admission(86.2 vs.50.0%,P=0.003),median length of stay(LOS)(16.0 vs.4.0 days,P<0.0001),and mortality(27.6 vs.3.1%,P=0.010).Conclusions:Patients with traumatic pancreatic injuries treated operatively were more severely injured and suffered greater complications than those treated non-operatively.The greater morbidity and mortality associated with these patients warrants further study to determine optimal triage strategies and which subset of patients is likely to benefit from surgery.

Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature

Purpose: Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. Methods: A systematic literature review searched "liver trauma" , "hepatic trauma" , "conservative management" , "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs;studies reported NOM complications together with those post-intervention;case reports;studies including less than 5 cases;studies not written in English;and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. Results: A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. Conclusion: NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.

Non-operative management of adult blunt splenic injuries

To investigate the indication of nonoperative management of adult blunt splenic injuries. Methods： A retrospective review was performed on all adult patients （age 〉 15 years ） with blunt splenic injuries admitted to the department of vascular surgery of Pellegrin hospital in France from 1999 to 2003. We managed splenic injuries non-operatively in all appropriate patients without regard to age. Results： During the 4 years, 54 consecutive adult patients with blunt splenic injuries were treated in the hospital. A total of 27 patients with stable hemodynamic status were treated non-operatively at first, of which 2 patients were failed to non-operative treatment. The successful percentage of non-operative management was 92. 6%. In the 54 patients, 7 of 8 patients older than 55 years were treated with non-operative management. Two cases developing postoperatively subphrenic infection were healed by proper treatment. In the series, there was no death. Conclusions： Non-operative management of lowgrade splenic injuries can be accomplished with an acceptable low-failure rate. If the clinical and laboratory parameters difficult for surgeons to make decisions, they can depend on Resciniti＇ s CT （computed tomography） scoring system to select a subset of adults with splenic trauma who are excellent candidates for a trial of nonoperative management. The patients older than 55 years are not absolutely inhibited to receive non-operative management.

Scapula Fracture in a Child: Report of a Rare Injury

Scapular fracture is exceptional in children, mainly occurring after high-energy trauma. Radiologic investigations help its diagnosis and classification, which determines its management. We report the case of a 14-year-old patient admitted for blunt trauma of the left shoulder after falling from a speeding car. The diagnosis of a displaced fracture of the body of the scapula was made, and non-operative treatment was indicated and carried out for four weeks, followed by physiotherapy for another four weeks. Nine weeks after the trauma, the mobility of the affected shoulder was equivalent to that of the contralateral shoulder.

Management of proximal humerus fractures in adults

The majority of proximal humerus fractures are lowenergy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures.Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each indi-vidual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

Therapeutic experience of 289 elderly patients with biliary diseases

AIM To present clinical characteristics, diagnosis and treatment strategies in elderly patients with biliary diseases. METHODS A total of 289 elderly patients with biliary diseases were enrolled in this study. The clinical data relating to these patients were collected in our hospital from June 2013 to May 2016. Patient age, disease type, coexisting diseases, laboratory examinations, surgical methods, postoperative complications and therapeutic outcomes were analyzed. RESULTS The average age of the 289 patients with biliary diseases was 73.9 +/- 8.5 years (range, 60-102 years). One hundred and thirty-one patients (45.3%) had one of 10 different biliary diseases, such as gallbladder stones, common bile duct stones, and cholangiocarcinoma. The remaining patients (54.7%) had two types of biliary diseases. One hundred and seventy-nine patients underwent 9 different surgical treatments, including pancreaticoduodenectomy, radical resection of hilar cholangiocarcinoma and laparoscopic cholecystectomy. Ten postoperative complications occurred with an incidence of 39.3% (68/173), and hypopotassemia showed the highest incidence (33.8%, 23/68). One hundred and sixteen patients underwent non-surgical treatments, including anti-infection, symptomatic and supportive treatments. The cure rate was 97.1% (168/173) in the surgical group and 87.1% (101/116) in the non-surgical group. The difference between these two groups was statistically significant (chi(2) = 17.227, P < 0.05). CONCLUSION Active treatment of coexisting diseases, management of indications and surgical opportunities, appropriate selection of surgical procedures, improvements in perioperative therapy, and timely management of postoperative complications are key factors in enhancing therapeutic efficacy in elderly patients with biliary diseases.

Liver trauma: What current management?

Background: The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years.Methods: The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed.Results: The study involved 83 patients, with a mean age of 33 years and a marked male predominance(85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries(81.9%) were of low severity(grades Ⅰ,Ⅱ,Ⅲ), while 15(18.1%) were of high severity(grade Ⅳ or greater). Fifty-six patients(67.5%) had multiple injuries. Surgical treatment was performed in 26(31.3%) patients. Non-operative management was undertaken in 57 cases(68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group.Conclusions: Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

Current debate in the oncologic management of rectal cancer

Despite the considerable amount of research in the field,the management of locally advanced rectal cancer remains a subject to debate.To date,effective treatment centers on surgical resection with the standard approach of total mesorectal resection.Radiation therapy and chemotherapy have been incorporated in order to decrease local and systemic recurrence.While it is accepted that a multimodality treatment regimen is indicated,there remains significant debate for how best to accomplish this in regards to order,dosing,and choice of agents.Preoperative radiation is the standard of care,yet remains debated with the option for chemoradiation,short course radiation,and even ongoing studies looking at the possibility of leaving radiation out altogether.Chemotherapy was traditionally incorporated in the adjuvant setting,but recent reports suggest the possibility of improved efficacy and tolerance when given upfront.In this review,the major studies in the management of locally advanced rectal cancer will be discussed.In addition,future directions will be considered such as the role of immunotherapy and ongoing trials looking at timing of chemotherapy,inclusion of radiation,and nonoperative management.

Management of complicated acute appendicitis in children:Still an existing controversy

Complicated acute appendicitis(CAA)is a serious condition and carries significant morbidity in children.A strict diagnosis is challenging,as there are many lesions that mimic CAA.The management of CAA is still controversial.There are two options for treatment:Immediate operative management and nonoperative management with antibiotics and/or drainage of any abscess or phlegmon.Each method of treatment has advantages and disadvantages.Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events.In many cases,non-operative management with or without drainage and interval appendectomy is advised.The reasons for this approach include new medications and policies for the use of antibiotic therapy.Furthermore,advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries.However,questions have been raised about the risk of recurrence,prolonged use of antibiotics,lengthened hospital stay and delay in returning to daily activities.Moreover,the need for interval appendectomy is currently under debate because of the low risk of recurrence.Due to the paucity of high-quality studies,more randomized controlled trials to determine the precise management strategy are needed.This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.

Outcome analysis of management of liver trauma: A 10-year experience at a trauma center

AIM: To review the outcomes of liver trauma in patients with hepatic injuries only and in patients with associated injuries outside the liver.METHODS: Data of liver trauma patients presented to our center from January 2003 to October 2013 were reviewed. The patients were divided into two groups. Group 1 consisted of patients who had hepatic injuries only. Group 2 consisted of patients who also had associated injuries outside the liver.RESULTS: Seven(30.4%) patients in group 1 and 10(28.6%) patients in group 2 received non-operative management; the rest underwent operation. Blunt trauma occurred in 82.8%(48/58) of the patients and penetrative trauma in 17.2%(10/58). A higher injury severity score(ISS) was observed in group 2(median 45 vs 25, P < 0.0001). More patients in group 1 were hemodynamically stable(65.2% vs 37.1%, P = 0.036). Other parameters were comparable between groups. Group 1 had better 30-d survival(91.3% vs 71.4%, P = 0.045). On multivariate analysis using the logistic regression model, ISS was found to be associated with mortality(P = 0.004, hazard ratio = 1.035, 95%CI:CONCLUSION: Liver trauma patients with multiple injuries are relatively unstable on presentation. Despite a higher ISS in group 2, non-operative management was possible for selected patients. Associated injuries outside the liver usually account for morbidity and mortality.

Endoscopic drainage for duodenal hematoma following endoscopic retrograde cholangiopancreatography: A case report

Intramural duodenal hematoma (IDH) is a rare complication following endoscopic retrograde cholangiopancreatography (ERCP). Blunt damage caused by the endoscope or an accessory has been suggested as the main reason for IDH. Surgical treatment of isolated duodenal hematoma after blunt trauma is traditionally reserved for rare cases of perforation or persistent symptoms despite conservative management. Typical clinical symptoms of IDH include abdominal pain and vomiting. Diagnosis of IDH can be confirmed by imaging techniques, such as magnetic resonance imaging or computed tomography and upper gastrointestinal endoscopy. Duodenal hematoma is mainly treated by drainage, which includes open surgery drainage and percutaneous transhepatic cholangial drainage, both causing great trauma. Here we present a case of massive IDH following ERCP, which was successfully managed by minimally invasive management: intranasal hematoma aspiration combined with needle knife opening under a duodenoscope.

Penetrating Abdominal Injuries: Pattern and Outcome of Management in Khartoum

Background: The pattern and presentation of penetrating abdominal trauma vary according to places and the structure of the present health system. As well controversies in management exist ranging from mandatory exploration to selective non-operative management. Objectives: To determine the pattern of penetrating abdominal trauma, current management practiced and outcome in Khartoum. Patients and Methods: The study was prospective, descriptive and hospital-based. It was carried out at the main three hospitals in Khartoum State. It was conducted over a period of one year from 2012 Mar to 2013 Mar. All patients who presented penetrating injury to their abdomen were included. Results: The study included 85 patients with a mean age of 28 years (SD ± 10). The male to female ratio was 11:1. Most of the patients (89.4%) were in the first four decades of their life. Twenty-three patients (27.1%) presented shock. Stab wound is the commonest mode of trauma seen in 83.5% of our patients. The majority of our patients were managed by exploratory laparotomy (81.2%), however 16 (18.8%) underwent conservative measures. Of the operated group, solid organ injuries were found in 22.9%, yet hollow viscous injuries were reported in 86.9% of the patients. Registrars operated on 78.26% of the patients. The rate of negative laparotomy of this study was 8.7%. Complications and mortality were encountered in 25.9% and 4.7% respectively. The mean hospital stay was 8.47 days (SD ± 10.6). Conclusion: This study demonstrates no difference in the pattern of intra-abdominal injuries. The rate of operative treatment is acceptable, but more laparotomies can be avoided if the haemodynamic stable patients without features of peritonitis were given a period of observation. The overall outcome was satisfactory.

Has platelet-rich plasma any role in partial tears of the anterior cruciate ligament?Prospective comparative study

BACKGROUND Partial tears of the anterior cruciate ligament(ACL)are frequent,and there is still considerable controversy surrounding their diagnosis,natural history and treatment.AIM To examine patient-reported outcomes,physical examination and magnetic resonance imaging(MRI)findings of partial ACL tears treated with an intraarticular injection of platelet-rich plasma(PRP)compared to a control group.METHODS From January 2015 to November 2017,consecutive patients from a single institution with partial ACL tears treated nonoperatively were prospectively evaluated.Partial tears were defined as a positive Lachman test with a clear endpoint,a negative pivot-shift and less than 3 mm of side-to-side difference using the KT1000 arthrometer.Patients in group 1 were treated with one intraarticular injection of PRP and specific physical therapy protocol.Control group consisted of patients treated only with physical therapy.Prospective analyzed data included physical examination,Tegner activity level and Lysholm and International Knee Documentation Committee scores.Baseline MRI findings and at 6 mo follow-up were reviewed.Failure was defined as those patients with clinical instability at follow-up that required a subsequent ACL reconstruction.RESULTS A total of 40 patients where included,21 treated with PRP injection with a mean follow-up of 25 mo[standard deviation(SD):3.6]and 19 in the control group with a mean follow-up of 25 mo(SD:5.68).Overall failure rate was 32.0%(n=13).No significant differences were observed between groups regarding subjective outcomes,return to sport and failure rate.MRI findings revealed an improvement in the ACL signal in half of the patients of both groups.However,we did not find a significant relationship between MRI findings and clinical outcomes.CONCLUSION Overall,95.0%of patients returned to sports at a mean follow-up of 25 mo.Mean time to return to sports was 4 mo.Out of these patients,almost 30.0%in each group had a new episode of instability and required surgery at a median time of 5 mo in group 1 and 8 mo in group 2.The addition of PRP alone was not sufficient to enhance any of the outcome measures evaluated,including MRI images,clinical evaluation and failure rate.

Conservative management of small bowel perforation in Ehlers-Danlos syndrome type Ⅳ

Ehlers-Danlos syndrome (EDS) is a group of inherited connective tissue disorders caused by collagen synthesis defects. EDS type Ⅳ, or vascular EDS, is caused by loss-of-function mutations in the type Ⅲ pro-collagen gene (COL3A1 ). Common complications of EDS type IV include gastrointestinal bleeding and bowel perforations, posing diagnostic and therapeutic dilemmas for both surgeons and gastroenterologists. Here, we describe a complicated case of EDS type Ⅳ in a 35-year-old caucasian female who presented with overt gastro-intestinal bleeding. The patient had a prior history of spontaneous colonic perforation, and an uncomplicated upper endoscopy was performed. A careful ileoscopy was terminated early due to tachycardia and severe ab-dominal pain, and a subsequent computed tomography scan confirmed the diagnosis of ileal perforation. The patient was managed conservatively, and demonstrated daily improvement. At the time of hospital discharge, no further episodes of gastrointestinal blood loss had occurred. This case highlights the benefit of conservative management for EDS patients with gastrointestinal hemorrhage. It is recommended that surgical treatmentshould be reserved for patients who fail conservative treatment or in cases of hemodynamic instability. Finally, this case demonstrates the necessity for a higher threshold of operative or endoscopic interventions in EDS type Ⅳ patients.

The Presence but not the Location of an Appendicolith Affects the Success of Interval Appendectomy in Children with Ruptured Appendicitis

Purpose: To determine whether the presence and/or location of an appendicolith can predict failure of initial non-operative management in children with ruptured appendicitis. Methods: A retrospective chart review of pediatric patients presenting with ruptured appendicitis was performed. Patients in whom the intent to treat was with initial non-operative management and interval appendectomy (IA) were selected (n = 117). One patient was excluded due to the presence of both intraluminal and extraluminal appendicoliths. Children who failed initial non-operative management were assigned to the “failure” group (n = 22). Children that improved and underwent elective IA were assigned to the “success” group (n = 94). Age, gender, duration of symptoms, presence of an appendicolith, appendicolith location (intraluminal/extraluminal), presence of a drainable abscess, and complications were reviewed. Results: There was an overall 18.8% failure rate for IA. Patients with an appendicolith had a 41.7% failure rate, and patients without an appendicolith had a 13% failure rate (p = 0.003). Patients with intraluminal or extraluminal appendicoliths each had a 41.7% failure rate. The presence or absence of a drainable in-tra-abdominal abscess did not affect the failure rate. Children in the failure group presented to the hospital earlier (6.57 ± 2.59 vs. 10.02 ± 7.21 days;p = 0.030). Conclusions: The presence of an appendicolith increases the likelihood of failure of initial non-operative management of ruptured appendicitis in children;however, the location of the appendicolith is not a predictor of failure.