Dissertations / Theses on the topic 'Appendectomy'

Апендектомія – залишається найбільш частою ургентною абдомінальною операцією. Не зважаючи на більш ніж сторічну історію хірургічного лікування всі питання діагностики гострого апендициту остаточно не вияснені. До невирішених проблем ГА належить не тільки пізня діагностика з розвитком тяжких ускладнень але і необгруновані (не терапевтичні) апендектомії з видаленням морфологічно незмінених червоподібних відростків, частота яких досягає 20-40 % (в середньому 30%). При цитуванні документа, використовуйте посилання http://essuir.sumdu.edu.ua/handle/123456789/32594

Objetivo: Una tasa de apendicectomía negativa (AN) entre 10-15% es considerada aceptable. Sin embargo, a nivel internacional el rango va entre 2-9%. El presente estudio busca identificar la TAN y los factores asociados a esta. Métodos: Estudio retrospectivo de todas las apendicectomías realizadas entre los años 2012 y 2013 en una clínica privada de Lima-Perú. Se revisó las historias clínicas de pacientes apendicectomizados que contaron con historia clínica de emergencia e informe quirúrgico. Se excluyó a aquellos que no contaban con informe anatomopatológico del apéndice. Se calculó los OR ajustados con un modelo de regresión logística para identificar los factores asociados con AN. Resultados: Se realizaron 376 apendicectomías durante el periodo 2012-2013. Se excluyeron 13 casos por no contar con registro de historia clínica. La población femenina fue de 55,9%. La media de edad del paciente fue 33,4 años ± 17,6. En 28 de 363 pacientes (7,7%) se registró una AN. Se encontró que el dolor en flanco derecho (OR: 5,44 P=0,013), Mc Burney negativo (OR: 3,63 P=0,017), dolor en hipogastrio (OR: 3,05 P=0,030),) y no leucocitosis (OR: 2,85 P=0,015) son factores asociados a una AN. Las patologías más frecuentemente implicadas en el caso de una AN fueron las de causa ginecológica (53,6%) seguida de enfermedad diverticular complicada (14,3%). Conclusión: Los resultados obtenidos indican que la presencia de dolor en hipogastrio, dolor en flanco derecho, Mc Burney negativo y no leucocitosis son factores diagnósticos que se pueden tener en cuenta para prevenir apendicectomías negativas.
Background: A negative appendectomy rate (NAR) between 10-15% is considered acceptable. Nevertheless, internationally the range is between 2-9%. This study seeks to find factors associated with a negative appendectomy (NA) and the NAR. Methods: Retrospective study of all appendectomies performed between 2012 and 2013 at a private hospital of Lima-Perú. We reviewed the medical records of patients who underwent appendectomy and had a medical report of emergency. We excluded the ones whithout pathology reports. Adjusted ORs were calculated with a logistic regression model to identify factors associated with AN. Results: Three hundred seventy-six appendectomies were performed for suspected appendicitis 55.9% in women). The average patient age was 33.4 ± 17.6 years. A NA was found in 28 of 363 patients (7,7%). We found that pain in right flank (OR: 5,44 P=0,013), negative Mc Burney (OR: 3,63 P=0,017), pain in hypogastrium (OR: 3,05 P=0,030),) and no leucocitosis (OR: 2,85 P=0,015) were associated factors to AN. Gynecologic conditions (53,6%) and intestinal diseases (14.3%) are the most common to be misdiagnosed as appendiceal disease. Conclusion: The obtained results indicate that the presence of pain in the right flank, negative Mc Burney, pain in hypogastrium and no leukocytosis are diagnostic factors that can be taken into account to prevent negative appendectomy.

Objective: To retrospectively evaluate antibiotic use in pediatric appendectomy procedures following an educational intervention in December 2001. Methodology: Demographic, clinical, and prescribing data was collected for all the patients <18 years old who have had undergone non-perforated appendectomy procedures at Princess Margaret Hospital for Children, WA. Data collection and analysis were divided into three groups. Group-I involved patients from May 2002 to April 2004 (which followed the post-intervention follow-up conducted from December 2001-April 2002 by Mallik et al.1). In May 2004, the Western Australian Therapeutic Advisory Group (WATAG) sent an advisory note which recommended a change from the use of cefotetan for surgical prophylaxis to cephazolin plus metronidazole. Group-II of the study involved patients between May 2004 (when the WATAG note was released) and June 2004; while Group-III involved patients from July 2004 to April 2005 (when the hospital issued the new guidelines and withdrawn cefotetan).Patient records were randomly selected for Group I & III and all the records were evaluated for Group III. Results: Records for 408 patients were evaluated across the three groups of the study. There no significant difference (p>0.05) between gender and age across the three groups. An appropriate prophylactic drug regimen was prescribed in 68.5%, 66.7% and 39.8% of patients in Groups I, II and III respectively, with a significant difference in appropriate drug choice between Groups I and III (p <0.05). There was no significant difference between the groups with respect to appropriate prophylactic drug dose (p>0.05). Appropriateness rates for antibiotic choices for ward treatment were high at 91.0%, 92.0% and 92.7%, with no significant differences (p>0.05).There was a significant difference (p<0.05) between the three groups regarding the number of doses for ward treatment, with inappropriateness rates of 29.9%, 40% and 16.4%. The total appropriateness rates (drug choice plus dose in theatre and ward) across the study were 54.7%, 54.2% and 31.5%, with a significant difference (p <0.05) between Groups I and III. Conclusion: This study has identified deficiencies related to the prescribing of antibiotics for prophylaxis. There was a varied level of prescribing appropriateness in terms of antibiotic choice for prophylaxis with an increasing trend for inappropriateness towards the end of the study period. This would indicate that issuing of changed guidelines and withdrawal of the drug being replaced did not positively influence appropriate prescribing. Further interventions are required to improve compliance with hospital prescribing guidelines.

Objective: To retrospectively evaluate antibiotic use in pediatric appendectomy procedures following an educational intervention in December 2001. Methodology: Demographic, clinical, and prescribing data was collected for all the patients <18 years old who have had undergone non-perforated appendectomy procedures at Princess Margaret Hospital for Children, WA. Data collection and analysis were divided into three groups. Group-I involved patients from May 2002 to April 2004 (which followed the post-intervention follow-up conducted from December 2001-April 2002 by Mallik et al.1). In May 2004, the Western Australian Therapeutic Advisory Group (WATAG) sent an advisory note which recommended a change from the use of cefotetan for surgical prophylaxis to cephazolin plus metronidazole. Group-II of the study involved patients between May 2004 (when the WATAG note was released) and June 2004; while Group-III involved patients from July 2004 to April 2005 (when the hospital issued the new guidelines and withdrawn cefotetan).Patient records were randomly selected for Group I & III and all the records were evaluated for Group III. Results: Records for 408 patients were evaluated across the three groups of the study. There no significant difference (p>0.05) between gender and age across the three groups. An appropriate prophylactic drug regimen was prescribed in 68.5%, 66.7% and 39.8% of patients in Groups I, II and III respectively, with a significant difference in appropriate drug choice between Groups I and III (p <0.05). There was no significant difference between the groups with respect to appropriate prophylactic drug dose (p>0.05). Appropriateness rates for antibiotic choices for ward treatment were high at 91.0%, 92.0% and 92.7%, with no significant differences (p>0.05).
There was a significant difference (p<0.05) between the three groups regarding the number of doses for ward treatment, with inappropriateness rates of 29.9%, 40% and 16.4%. The total appropriateness rates (drug choice plus dose in theatre and ward) across the study were 54.7%, 54.2% and 31.5%, with a significant difference (p <0.05) between Groups I and III. Conclusion: This study has identified deficiencies related to the prescribing of antibiotics for prophylaxis. There was a varied level of prescribing appropriateness in terms of antibiotic choice for prophylaxis with an increasing trend for inappropriateness towards the end of the study period. This would indicate that issuing of changed guidelines and withdrawal of the drug being replaced did not positively influence appropriate prescribing. Further interventions are required to improve compliance with hospital prescribing guidelines.

Within the last decade there has been a shift away from the traditional on-call model towards an Acute Surgical Unit (ASU) model for managing patients who present with acute general surgical conditions. This shift has been driven by results from multiple studies showing improved clinical and non-clinical outcomes with the ASU model of care. Nepean Hospital is a large tertiary referral centre in Western Sydney. The hospital adopted the ASU model in November 2006 and since then the consultant driven, protocol based model has been used for patients presenting with a wide variety of general surgical problems. To date there has been no analysis of appendicectomy outcomes for patients presenting to Nepean Hospital with acute appendicitis. Furthermore there is a paucity of evidence in the literature looking at whether or not ‘established’ ASU departments maintain positive outcomes, with the majority of studies comparing the period immediately before and after implementation of the ASU model. Over time, factors such as increasing workload, staffing and theatre access may limit the effectiveness of the ASU model. It is therefore important to evaluate how the ASU model has functioned over time. Four papers are presented within this thesis by publication. The first two papers specifically assess outcomes for patients who underwent an appendicectomy for suspected acute appendicitis treated within ‘pre’, ‘early’ and ‘established’ ASU groups. These papers demonstrate many of the improvements in clinical and non-clinical outcomes for patients treated in the ‘established’ ASU. Results from these papers did reveal a gradual increase in the rate of negative appendicectomy; this issue is addressed in detail in paper three. Finally, paper four specifically focuses on the ASU's use of laparoscopic washout as a novel approach for managing persistent sepsis or collections following appendicectomy.

Background: The high prevalence of Human Immunodeficiency Virus (HIV) has added a new dimension to the management and outcomes of many general surgical conditions in South Africa. However, there is a paucity of data describing the impact of HIV status on surgical outcomes in our setting. Appendicitis is the most common gastrointestinal emergency, and its surgical outcomes in areas of high HIV prevalence are poorly described in the literature. Thus, the aim of this study is to describe and compare the outcomes of appendectomy between HIV-infected (HIV+) and HIV-negative (HIV-) patients. Methods: This is a retrospective study of patients undergoing appendectomy at a large regional hospital over a 12-month period. Demographic data, duration of pre-hospital symptoms, HIV status, surgical approach, operative findings, histopathology reports, hospital stay and complications were recorded. Data for the HIV+ and HIV-patient cohorts were then described, analysed and compared. Statistical analysis was performed using the Chi-Squared or Fisher's exact test for non-continuous variables, and non- parametric ANOVA and Wilcoxon ranked sum test for continuous variables. A P-value less than 0·05 was considered statistically significant. Results: The study group comprised 134 patients; 18 (13.4 %) tested positive for HIV. HIV+ patients were significantly older (mean age of 29.3 vs. 20.3 years, P= 0.002) and had longer duration of pre-hospital symptoms (mean of 3.94 vs. 2.57 days, P= 0.03). Postoperative complications (44.4 % vs. 17.2 %, P= 0.03) and lengthier hospital stays (7.28 days vs. 5.95 days, P= 0.004) were also more frequently seen in the HIV+ patients. There were no differences in appendiceal rupture rates, histopathological findings and mortality. Conclusion: HIV infection is common in patients admitted with clinical features of acute appendicitis in South Africa. Presentation in HIV+ patients was delayed, and surgery was associated with significant postoperative morbidity and longer hospital stay.

gcpriale@hotmail.com
Objective: Identify the frequency of negative appendectomy (NA) and associated factors associated in a private hospital in Lima. Methods: Retrospective study of all appendectomies performed between 2012 and 2013 at a private hospital of Lima-Peru. We reviewed the medical records of patients who underwent appendectomy and had a medical report of emergency. We excluded the ones without pathology reports. Adjusted ORs were calculated with a logistic regression model to identify factors associated with AN. Results: Three hundred seventy-six appendectomies were performed for suspected appendicitis 55.9% in women). The average patient age was 33.4 ± 17.6 years. We identified 28 AN cases of 363 patients (7.7%). We found that pain in right flank (aOR: 5.4; 95%CI: 1.4-20.8), negative Mc Burney (aOR: 3.6; 95%CI: 1.3- 10.5), pain in hypogastrium (aOR: 3.1; 95%CI: 1.1-8.4) and no leucocitosis (aOR: 2.9; 95%CI: 1.2-6.7) were associated factors to AN. Gynecologic conditions (53.6%) and complicated diverticular disease (14.3%) are the most common diagnosis in AN cases. Conclusion: The obtained results indicate that the presence of pain in the right flank, negative Mc Burney, pain in hypogastrium and no leukocytosis are factors that can be taken into account to prevent negative appendectomy.
Objetivo: Identificar la frecuencia de apendicectomías negativas (AN) y los factores asociados en una clínica privada de Lima. Métodos: Estudio retrospectivo de todas las apendicectomías realizadas entre los años 2012 y 2013 en una clínica privada de Lima-Perú. Se revisó las historias clínicas de pacientes apendicectomizados que contaron con historia clínica de emergencia e informe quirúrgico. Se excluyó a aquellos que no contaban con informe anatomopatológico del apéndice. Se calculó los OR ajustados con un modelo de regresión logística para identificar los factores asociados con AN. Resultados: Se realizaron 376 apendicectomías durante el periodo 2012-2013. Se excluyó 13 casos por no contar con registro de historia clínica. La población femenina fue de 55.9%. La media de edad del paciente fue 33.4 ± 17.6 años. En 28 de 363 pacientes (7.7%) se registró una AN. Se encontró que el dolor en flanco derecho (ORa: 5.4; IC95%: 1.4-20.8), Mc Burney negativo (ORa: 3.6; IC95%: 1.3-10.5), dolor en hipogastrio (ORa: 3.1; IC95%: 1.1-8.4), y no leucocitosis (ORa: 2.9; IC95%: 1.2-6.7) son factores asociados a una AN. Las patologías más frecuentemente implicadas en el caso de una AN fueron las de causa ginecológica (53.6%) seguida de enfermedad diverticular complicada (14.3%). Conclusión: Los resultados obtenidos indican que la presencia de dolor en hipogastrio, dolor en flanco derecho, Mc Burney negativo y no leucocitosis son factores que se pueden tener en cuenta para prevenir apendicectomías negativas.

Acute appendicitis is a common cause of abdominal surgery in children, and is the result of appendiceal luminal obstruction and subsequent inflammation. The clinical presentation is often variable, allowing imaging to play a central role in disease identification and characterization. Ultrasound is often the modality of choice for diagnosis of appendicitis in children. Ready availability and lack of ionizing radiation are attractive features of sonography, though operator dependence is a potential barrier. Computed tomography (CT) was historically the preferred modality in children, as in adults, but recent awareness of the risks of radiation has reduced its usage. The purpose of this article is to detail the imaging findings of appendicitis in children. The discussion will focus on typical signs of appendicitis seen on ultrasound, CT, and magnetic resonance imaging. Considerations for percutaneous drainage by interventional radiology will also be presented. Finally, the evolution of imaging algorithms for appendicitis will be discussed.

El adenocarcinoma mucinoso de apéndice es una neoplasia poco frecuente con una tasa de incidencia de 0,08% de todas las neoplasias. El diagnóstico suele hacerse por biopsia ya que por su presentación clínica puede simular otras patologías de estructuras localizadas en cuadrante abdominal inferior derecho. Actualmente el tratamiento aún es controversial siendo la cirugía la mejor opción. El presente reporte describe un paciente con antecedentes de apendicectomía hace 27 años que actualmente acude con una tumoración dolorosa en fosa ilíaca derecha asociada a un antígeno carcinoembrionario de 138 ng/dl.
Mucinous adenocarcinoma of the appendix is a rare neoplasm with an incidence rate of 0.08% of all malignancies. The diagnosis is usually made by biopsy because its clinical presentation may mimic other diseases of structures located in the right lower quadrant. Currently, the treatment is still controversial, being surgery the best option. This report describes a patient with a history of appendectomy 27 years ago that is hospitalized for a painful mass in the lower abdomen associated with carcinoembryonic antigen of 138 ng/dl.

Der chronische Unterbauchschmerz stellt den behandelnden Arzt vor erhebliche differentialdiagnostische Probleme. Die vorgestellte Studie soll den Wert der Laparoskopie im diagnostischen Konzept aufzeigen. Dazu führten wir zwischen Oktober 1993 und Juni 1998 bei 100 Patienten mit der klinischen Diagnose «chronischer Unterbauchschmerz» eine Laparoskopie durch. Bei 14 Patienten ließ sich ein morphologisches Korrelat unabhängig von der Appendix finden. 86 Patienten wurden appendektomiert, wobei die histologische Untersuchung des Präparats in 82 Fällen (95,3%) einen pathologischen Befund aufwies. 80 Patienten (93%) blieben auch während der Nachuntersuchungen beschwerdefrei. Die Laparoskopie stellt ein sicheres Verfahren zur Diagnostik und Behandlung chronischer Unterbauchschmerzen dar. Bei fehlendem Korrelat für die Beschwerden sollte in gleicher Sitzung die laparoskopische Appendektomie durchgeführt werden
The differential diagnosis chronic lower abdominal pain can be problematic, and this symptom may lead to several diagnostic procedures. The purpose of this study was to evaluate the usefulness of laparoscopy in the diagnostic concept. From October 1993 to June 1998 we performed 100 laparoscopies in patients with chronic or recurrent lower abdominal pain. In 14 patients we found a substrate for the reported pain, which was independent of the appendix. In 86 patients we performed an appendectomy. In 62 of the specimens (95.3%) the histological study showed pathological findings. 80 patients (93%) reported no further complaints during follow-up. Laparoscopy is a safe procedure for diagnostics and treatment of patients with chronic lower abdominal pain. If no other explanation for the symptoms is found, laparoscopic appendectomy should be performed
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich

The theoretical part of the diploma thesis explains terms as management, managers, managerial roles, process, costing method, process management, process analysis and its tools. In the practical part a chosen in-patient department and its surgical department are characterized. The general and the supportive processes are mapped and analyzed. In conclusion both economical and medical aspects of appendectomy carried out in classical and laparoscopic way are compared.

Abstract Epidemiological and clinical data suggest that acute appendicitis might have two different forms with different disease severities. Uncomplicated and complicated acute appendicitis appear to be distinct entities instead of consecutive events. Appendicitis does not always inevitably progress to perforation and most cases are uncomplicated by nature. This supports the importance of an accurate differential diagnosis between uncomplicated and complicated acute appendicitis enabling treatment optimization. This thesis consists of three studies. The first study evaluated the possibility to differentiate between uncomplicated and complicated appendicitis using only clinical symptoms and laboratory markers with a special focus on predicting the presence of an appendicolith without the use of modern imaging. We found neither sufficiently reliable to accurately estimate the severity of acute appendicitis or to determine the presence of an appendicolith, supporting the use of computed tomography imaging to assess the disease. The second study focused on clarifying the histopathological differences between uncomplicated acute appendicitis and acute appendicitis presenting with an appendicolith; a calcified deposit of faecal material in the appendiceal lumen. It’s presence has been shown to predict perforation and failure of conservative treatment. This study evaluated the histopathological findings of computed tomography diagnosed uncomplicated acute appendicitis and appendicolith appendicitis without perforation. Acute appendicitis presenting with an appendicolith was histopathologically different from uncomplicated acute appendicitis on all the assessed histological parameters, indicating the potentially complicated nature of appendicolith appendicitis. The third study was a randomized, multicentre clinical trial comparing interval appendectomy with follow-up with magnetic resonance imaging after successful initial non-operative treatment of complicated acute appendicitis presenting with a periappendicular abscess. The study hypothesis was that an interval appendectomy might not be necessary based on the previously reported low appendicitis recurrence rate after a periappendicular abscess. The original study hypothesis was left unresolved, as an unexpectedly high rate of appendiceal neoplasms was detected in the study population and the study was prematurely terminated. The neoplasm rate after a periappendicular abscess in this prematurely terminated study was high (20%). All the neoplasms were detected in patients over 40 years of age, strongly supporting an interval appendectomy for all patients over 40 years of age if this rate of neoplasms is validated in future studies
Tiivistelmä Aiemmat tutkimukset viittaavat siihen, että on olemassa kaksi erillistä akuutin umpilisäkkeen tulehduksen muotoa: komplisoitumaton ja komplisoitunut. Nämä muodot eivät ole toistensa jatkumo: umpilisäkkeen tulehdus ei aina johda umpilisäkkeen puhkeamiseen, vaan valtaosa umpilisäkkeen tulehdustapauksista on komplisoitumattomia. Oikean hoitotavan valinta edellyttää tarkkaa erotusdiagnostiikkaa tautimuotojen välillä Tämä väitöskirjatyö koostuu kolmesta osatyöstä. Ensimmäisen osatyö selvitti, onko komplisoitumaton ja komplisoitunut umpilisäkkeen tulehdus mahdollista erottaa ilman kuvantamista kliinisin löydöksin ja laboratoriokokein painottaen ulostekiven olemassaolon ennustamista. Umpilisäkkeen tulehduksen vaikeusasteen tai ulostekiven olemassaolon ennustaminen ei ollut mahdollista pelkästään kliinisten löydösten tai laboratoriokokeiden perusteella. Tämä korostaa tietokonetomografian merkitystä taudin vaikeusasteen arvioinnissa. Toinen osatyö selvitti histologisia eroja komplisoitumattoman umpilisäkkeen tulehduksen ja ulostekiven sisältävän äkillisen umpilisäkkeen tulehduksen välillä. Ulostekiven tiedetään ennustavan umpilisäkkeen puhkeamaa ja konservatiivisen hoidon epäonnistumista. Tutkimuksessa selvitettiin histologisia löydöksiä potilailla, joilla oli tietokonetomografiatutkimuksella varmistettu komplisoitumaton äkillinen umpilisäkkeen tulehdus tai ulostekiven sisältävä äkillinen umpilisäkkeen tulehdus ilman puhkeamaa. Tutkimuksessa todettiin, että ulostekiven sisältävät tulehtuneet umpilisäkkeet poikkeavat kaikkien tutkittujen parametrien osalta komplisoitumattomasta umpilisäkkeen tulehduksesta. Tämä tukee käsitystä ulostekiven sisältävän umpilisäkkeen tulehduksen komplisoituneesta luonteesta. Kolmas osatyö oli randomoitu monikeskustutkimus, jossa verrattiin toisiinsa rauhallisessa vaiheessa tehtyä umpilisäkkeen poistoa ja seurantaa magneettiresonanssikuvauksella potilailla, joilla oli onnistuneesti hoidettu konservatiivisesti umpilisäkkeen ympäryskudoksen paise. Hypoteesina oli, että myöhempi umpilisäkkeen poisto ei ole tarpeen, koska tulehduksen uusiutumisen riski umpilisäkkeen vieruskudoksen paiseen hoidon jälkeen on aiemmin raportoitu matalaksi. Tutkimushypoteesi jäi avoimeksi, koska tutkimuksen aikana havaittiin runsaasti umpilisäkkeen kasvaimia, mikä johti tutkimuksen ennenaikaiseen keskeyttämiseen. Umpilisäkkeen kasvainten ilmaantuvuus oli 20 %, kaikki yli 40-vuotiailla potilailla. Mikäli tutkimuksen tulokset vahvistuvat tulevissa tutkimuksissa, kaikille yli 40-vuotiaille potilaille tulisi suositella umpilisäkkeen poistoa sairastetun umpilisäkkeen vieruskudoksen paiseen jälkeen

Der chronische Unterbauchschmerz stellt den behandelnden Arzt vor erhebliche differentialdiagnostische Probleme. Die vorgestellte Studie soll den Wert der Laparoskopie im diagnostischen Konzept aufzeigen. Dazu führten wir zwischen Oktober 1993 und Juni 1998 bei 100 Patienten mit der klinischen Diagnose «chronischer Unterbauchschmerz» eine Laparoskopie durch. Bei 14 Patienten ließ sich ein morphologisches Korrelat unabhängig von der Appendix finden. 86 Patienten wurden appendektomiert, wobei die histologische Untersuchung des Präparats in 82 Fällen (95,3%) einen pathologischen Befund aufwies. 80 Patienten (93%) blieben auch während der Nachuntersuchungen beschwerdefrei. Die Laparoskopie stellt ein sicheres Verfahren zur Diagnostik und Behandlung chronischer Unterbauchschmerzen dar. Bei fehlendem Korrelat für die Beschwerden sollte in gleicher Sitzung die laparoskopische Appendektomie durchgeführt werden.
The differential diagnosis chronic lower abdominal pain can be problematic, and this symptom may lead to several diagnostic procedures. The purpose of this study was to evaluate the usefulness of laparoscopy in the diagnostic concept. From October 1993 to June 1998 we performed 100 laparoscopies in patients with chronic or recurrent lower abdominal pain. In 14 patients we found a substrate for the reported pain, which was independent of the appendix. In 86 patients we performed an appendectomy. In 62 of the specimens (95.3%) the histological study showed pathological findings. 80 patients (93%) reported no further complaints during follow-up. Laparoscopy is a safe procedure for diagnostics and treatment of patients with chronic lower abdominal pain. If no other explanation for the symptoms is found, laparoscopic appendectomy should be performed.
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Uvod:Apendicitis je oboljenje, koje se najčešće javlja u dečjem uzrastu. Poslednjih godina se laparoskopska apendektomija sprovodi sve češće u ovom uzrastu, međutim ne postoji jasan konsenzus o optimalnom izboru anestetika za održavanje opšte anestezije u toku ove hirurške metode u dečjem uzrastu. Cilj istraživanja: Utvrditi uticaj vrste anestezije i vrste hirurške procedure na odgovor organizma na hirurški stres tokom operacije crvuljka. Metodologija: Klinički prospektivno istraživanje je sprovedeno na Klinici za dečiju hirurgiju, na Institutu za zdravstvenu zaštitu dece i omladine Vojvodine. Istraživanjem je obuhvaćeno 120 dece, uzrasta od 7 do 17 godina, bez postojećih komorbiditeta, koji su operisani zbog zapaljenja crvuljka. U zavisnosti od vrste operativnog zahvata i vrste primenjene anestezije deca su podeljena u četiri grupe bolesnika. Kod sve četiri ispitivane grupe uzimana je venska i kapilarna krv, nekoliko minuta nakon uvoda u anesteziju, u momentu vađenja crvuljka iz trbuha i 12 časova nakon kraja hirurške intervencije. Laboratorijski su određeni markeri oksidativnog stresa (TBARS), metaboličkog odgovora na hirurški stres (laktat, glikemija), inflamatornog odgovora organizma (IL-6, leukociti), gasne analize, parametri oksigenacije i ventilacije, i hemodinamski parametri ispitanika. Rezultati:U istraživanju je dobijen rezultat da je zapaljenje crvuljka oboljenje koje se češće javlja kod dečaka. Tokom apendektomije u dečjem uzrastu, sevofluran je bolje kontrolisao arterijsku tenziju, dok na srčanu frekvencu vrsta anestezije nije imala uticaja. Sevofluran je anestetik tokom čije primene je manji inflamatorni odgovor tokom laparoskospske apendektomije. Propofol deluje suprimirajuće na oksidativni stres, ali nije nađena statistička značajnost u odnosu na vrednosti dobijene analizom uticaja sevoflurana na parametre oksidativnog stresa. Zaključak: Laparoskopska apendektomija u odnosu na laparotomiju nije praćena većim stepenom hirurškog stresa, a sevofluran je anestetik koji tokom anestezije za laparoskopsku apendektomiju u dečijem uzrastu daje bolju kontrolu kliničkog, metaboličkog i inflamatornog odgovora.
Introduction: Appendicitis is a disease which appears most commonly in children. In recent years appendectomy in children is performed by laparoscopy, but there is no consensus yet on the optimal choice of anesthetics during general anesthesia for this procedure. Aim: To determine the influence of type of anesthesia and type of surgical procedure for appendectomy, on surgical stress in children. Methodology: A prospective clinical trial in Clinic of pediatric surgery in Novi Sad, Vojvodina. The study included 120 children aged from 7 to 17 years, with no commorbidities, who underwent appendectomy. Children were divided in four groups based on the type of anesthesia and type of surgery they received. In all participants, venous and capillary blood was sampled for analyzis 10 minutes after induction of anesthesia, at the moment of appendix removal and 12 hours after the procedure. The laboratory analysis included markers of oxidative stress (TBARS), metabolic response to surgical stress (lactate, blood glucose), inflammatory response (IL-6, leucocites), bloodgas analyses, parameters of oxygentation and ventilation and haemodynamic parameters of the participants. Results: In the study appendicitis was more common in boys. During laparoscopic appendectomy sevoflurane controlled better the blood pressure, but not the heart rate. Sevoflurane maintained a better control of parameters of the inflammatory response. Propofol decreased the oxidative stress, but there was no statistical difference compared to the effects of sevoflurane on oxidative stress. Conclusion: Laparoscopic appendectomy shoved no difference in the level of surgical stress compared to laparotomy, and sevoflurane appeared as an anaesthetic which had a better control of the metabolic, clinical and inflammatory response.

Uvod: Akutni apendicitis predstavlja jedno od najčešćih abdominalnih hirurških oboljenja u dečjem uzrastu. Lečenje je operativno, primenom otvorene hirurgije ili primenom minimalno invazivne hirurgije tj. laparoskopske apendektomije. Iako je laparoskopska apendektomija, zbog svojih prednosti, stekla popularnost kod mnogih hirurga, još uvek nije široko primenjena metoda na našim prostorima. Prednost izvođenja laparoskopske apendektomije u odnosu na otvorenu metodu u dečjem uzrastu je i dalje nedovoljno definisana i predmet je mnogih istraživanja. Cilj istraživanja je da se utvrdi da li je dužina hospitalizacije kod dece operisane laparoskopski zbog akutnog apendicitisa kraća u odnosu na otvorenu metodu, kao i da se utvrdi da li postoji razlika u pojavi postoperativnih komplikacija između ove dve hirurške metode. Pored toga, cilj istraživanja je i da se utvrdi uticaj obe metode lečenja na kvalitet života i brzinu uspostavljanja svakodnevnih aktivnosti. Metodologija: Na Klinici za dečju hirurgiju, Instituta za zdravstvenu zaštitu dece i omladine Vojvodine, sprovedena je prospektivna, kontrolisana randomizirana studija, u trajanju od deset meseci, u koju su bili uključeni svi pacijenti sa akutnim apendicitisom, kod kojih je planirana apendektomija, a čiji roditelji su dali pismeni pristanak za učešće u istraživanju. Svi ispitanici su podeljeni u dve osnovne grupe u odnosu na operativnu tehniku: otvorena i laparoskopska apendektomija. Potom su svi ispitanici podeljeni u tri podgrupe, u zavisnosti od stepena upaljenosti crvuljka (negativni, nekomplikovani i komplikovani apendicitis). Svaki ispitanik je imao svoj individualni protokol istraživanja gde su preoperativno zabeleženi: uzrast, pol, simptomi (vrsta i dužina), fizikalni pregled, laboratorijske analize (broj leukocita, hematokrit), ultrazvučni nalaz, procena opšteg stanja, udružena oboljenja, vreme od prijema do operacije, preoperativna antibiotska terapija. Intraoperativno je analizirano: vrsta hirurgije, nalaz na apendiksu, prisustvo peritonitisa, udružena patologija, dužina operacije i trajanje pneumoperitoneuma (kod laparoskopske apendektomije), patohistološki nalaz apendiksa, bakteriološki bris abdomena. Postoperativno su analizirani: antibiotska terapija (vrsta i dužina), započinjanje peroralnog unosa, utvrđivanje postoperativnog bola, febrilnost, uspostavljanje peristaltike creva, izgled rane, postoperativne komplikacije (infekcija rane, intraabdominalni apscesi, ileus) i dužina hospitalizacije. Posebno su analizirani kvalitet života pacijenata nakon operacije pomoću modifikovanog upitnika SF 10 za dečji uzrast, kao i uspostavljanje svakodnevnih aktivnosti pomoću Activity Assessment Scale (AAS), modifikovane za dečji uzrast, nakon svakog postoperativnog dana, prvih sedam dana, nakon mesec dana, tri i šest meseci od operacije. Svi pacijenti su operisani u uslovima opšte anestezije. Klasična, otvorena apendektomija je vršena kroz naizmenični rez u desnoj ilijačnoj jami. Po otvaranju peritoneuma, cekum je izvučen i načinjena je klasična apendektomija. Laparoskopska apendektomija je vršena kroz tri 5 mm porta. Pneumoperitoneum je kreiran otvorenom metodom po Hasson-u, kroz infraumbilikalnu inciziju, a preostala dva porta su postavljena desno i levo ilijačno. Mezenteriolum je zbrinut pomoću ultrazvučnih makaza. Postavljene su intrakorporalne ligature i apendiks je odstranjen kroz desni port. Rezultati: Tokom perioda od deset meseci operisano je ukupno 125 pacijenata uzrasta od 2 do 18 godina, zbog akutnog apendicitisa. Laparoskopskom tehnikom je operisano 60 pacijenata (48%), a otvorenom metodom 61 (48,8%). Kod 4 pacijenta je načinjena konverzija, tj. promena operativne tehnike iz laparoskopske u otvorenu metodu. Nije bilo statistički značajne razlike između terapijskih grupa u odnosu na stepen upaljenosti apendiksa, vrstu i dužinu trajanja simptoma, u dijagnostičkim procedurama, kao ni u vremenu proteklom od prijema u bolnicu do operacije. Srednje operativno vreme je iznosilo 65 minuta (25-185 min) za laparoskopsku grupu i 45,49 minuta (25-90 min) za otvorene apendektomije (razlika je statistički značajna, p<0,001). Crevna peristaltika, kao i započinjanje peroralnog unosa, se statistički značajno ranije uspostavljaju u grupi laparoskopsko operisanih. U grupi laparoskopskih apendektomija, postoperativne komplikacije (infekcija rana i formiranje intraabdominalnih apscesa) su se javile kod 8,33% ispitanika (5/60), a u otvorenoj grupi kod 4.91%, (3/61), što nije bilo statistički značajno (c2 = 0,152; df = 1; p = 0,696). Dužina hospitalizacije kod dece operisane laparoskopski je iznosila 5,95 } 1,21 dana, a otvoreno 6,43 } 1,09 dana, što je statistički značajna razlika (t = -2,206; p = 0,029). Rezultati Man-Vitnijevog U testa su pokazali statistički značajno bolji ukupni skor svakodnevnih aktivnosti za grupu laparoskopskih apendektomija (Z = -7,608; p = 0,000). U svim ispitivanim indikatorima kvaliteta života, deca laparoskopske grupe su imala veći skor. Deca sa akutnim apendicitisom operisana laparoskopski značajno ranije postižu visok stepen kvaliteta života (t = 2,407; p = 0,018). Zaključak: Prednost minimalno invazivne hirurgije u terapiji akutnog apendicitisa u dečjem uzrastu ogleda se u bržem uspostavljanju ponovnog funkcionisanja gastrointestinalnog trakta, kraćoj hospitalizaciji, a samim tim i bržem sveukupnom oporavku, vraćanju svakodnevnim aktivnostima i dobrom kvalitetu života. Postoperativne komplikacije se podjednako javljaju, kako kod otvorene, tako i kod laparoskopske operativne tehnike.
Introduction: Acute appendicitis is one of the most common abdominal surgical diseases in children. Operative treatment means open surgery or minimally invasive surgery (laparoscopic appendectomy). Although laparoscopic appendectomy, gained popularity among many surgeons, it is still not widely accepted in our region. The advantage of laparoscopic appendectomy compared to the open method in children is still not sufficiently defined and is the subject of further research. The aim of the research was to determine whether the length of hospital stay after laparoscopic surgery in children with acute appendicitis is shorter compared to the open method, as well as to determine whether there is a difference in the occurrence of postoperative complications after these two operative techniques. In addition, the aim of the research was to determine the effect of both methods of treatment on quality of life and everyday functioning. Methodology: This prospective, randomized controlled study was performed at the Clinic for Pediatric Surgery, Institute of Children and Youth Healthcare of Vojvodina, during a period of ten months. All patients with acute appendicitis, whose parents have given written consent, were included in research. All patients were divided into two basic groups, in relation to the surgical technique: open or laparoscopic appendectomy. Then, all of them were divided into three groups, depending on the degree of appendicitis (negative, uncomplicated and complicated appendicitis). Each participant had their own individual research protocol where we recorded preoperatively: age, sex, symptoms (type and length), physical examination, laboratory tests (white blood cell count, hematocrit), ultrasound finding, general state (ASA classification), associated diseases, time from admission to surgery, preoperative antibiotic therapy. During the operation we analyzed: type of surgery, degree of the appendicitis, the presence of peritonitis, associated pathology, length of surgery and duration of pneumoperitoneum (in laparoscopic appendectomy), hystopathologic findings of the appendix, a bacteriology. Postoperatively we analyzed: antibiotic therapy (type and length), oral intake, postoperative pain, fever, establishing peristalsis, the appearance of postoperative complications (wound infections, intra-abdominal abscesses, ileus) and length of hospitalization. Especially, we analyzed the quality of life of patients after surgery using the modified questionnaire SF 10 for children; and the establishment of daily activities using Activity Assessment Scale (AAS), modified for children; after each postoperative day, the first seven days, one month, three and six months after surgery. All patients were operated under general anesthesia. Open appendectomy was performed through incision in the right iliac fossa. Peritoneum was opened, the cecum was pulled out and classic appendectomy was made. Laparoscopic appendectomy is performed through three 5 mm ports. Pneumoperitoneum was created by the Hasson techique, through the infraumbilical incision, and the remaining two ports are set at right and left iliac region. Mezenteriolum was ligated by ultrasonic scissors. After putting intracorporal ligature, appendix was removed through the right port. Results: Over a period of ten months we operated 125 patients , aged 2 to 18 years, due to acute appendicitis. Laparoscopic technique was performed in 60 patients (48%), and the open method in 61 (48,8%). In 4 patients the conversion was made (operative technique changed from laparoscopic to open method). There were no statistically significant differences between the treatment groups with respect to the degree of appendix inflammation, the type and duration of symptoms, the diagnostic procedures, as well as the time from hospital admission to the surgery. Medium operative time was 65 minutes (25-185 min.) for laparoscopic group and 45,49 minutes (25-90 min.) for open appendectomy (the difference is statistically significant, p<0,001). Intestinal peristalsis, as well as the initiation of oral intake was significantly sooner established in the laparoscopic group. Postoperative complications (wound infections and intra-abdominal abscess formation In laparoscopic appendectomy) occurred after laparoscopy in 8,33% of patients (5/60), and in the open group in 4,91% (3/61), which was not statistically significant (c2 = 0,152, df = 1; p = 0,696). Length of hospital stay in children operated by laparoscopy was 5,95 } 1,21 days and by open technique 6,43 } 1,09 days, which is significantly longer (t = -2,206; p = 0,029). Results of the Mann-Whitney U test showed significantly better overall record of daily activities for a group of laparoscopic appendectomy (Z = -7,608; p = 0,000). In all tested indicators of quality of life, children from laparoscopic group had a higher score. Children with acute appendicitis treated by laparoscopic surgery achieved a high level of quality of life, significantly earlier (t = 2,407; p = 0,018). Conclusion: The advantage of minimally invasive surgery in the treatment of acute appendicitis in children is reflected in the faster re-establishment of functioning of the gastrointestinal tract, shorter hospitalization and therefore, a faster overall recovery, resuming normal activities and a good quality of life. Postoperative complications occur equally in both, open as well as in laparoscopic operative techniques.

Advances in medical technology have altered the need for certain types of surgery to be performed in traditional inpatient hospital settings. Less invasive surgical procedures allow a growing number of medical treatments to take place on an outpatient basis. Hospitals face growing competition from ambulatory surgery centers (ASCs). The competitive threats posed by ASCs are important, given that inpatient surgery has been the cornerstone of hospital services for over a century. Additional research is needed to understand how surgical volume shifts between and within acute care general hospitals (ACGHs) and ASCs. This study investigates how medical technology within the hospital industry is changing medical services delivery. The main purposes of this study are to (1) test Clayton M. Christensen’s theory of disruptive innovation in health care, and (2) examine the effects of disruptive innovation on appendectomy, cholecystectomy, and bariatric surgery (ACBS) utilization. Disruptive innovation theory contends that advanced technology combined with innovative business models—located outside of traditional product markets or delivery systems—will produce simplified, quality products and services at lower costs with broader accessibility. Consequently, new markets will emerge, and conventional industry leaders will experience a loss of market share to “non-traditional” new entrants into the marketplace. The underlying assumption of this work is that ASCs (innovative business models) have adopted laparoscopy (innovative technology) and their unification has initiated disruptive innovation within the hospital industry. The disruptive effects have spawned shifts in surgical volumes from open to laparoscopic procedures, from inpatient to ambulatory settings, and from hospitals to ASCs. The research hypothesizes that: (1) there will be larger increases in the percentage of laparoscopic ACBS performed than open ACBS procedures; (2) ambulatory ACBS will experience larger percent increases than inpatient ACBS procedures; and (3) ASCs will experience larger percent increases than ACGHs. The study tracks the utilization of open, laparoscopic, inpatient and ambulatory ACBS. The research questions that guide the inquiry are: 1. How has ACBS utilization changed over this time? 2. Do ACGHs and ASCs differ in the utilization of ACBS? 3. How do states differ in the utilization of ACBS? 4. Do study findings support disruptive innovation theory in the hospital industry? The quantitative study employs a panel design using hospital discharge data from 2004 and 2009. The unit of analysis is the facility. The sampling frame is comprised of ACGHs and ASCs in Florida and Wisconsin. The study employs exploratory and confirmatory data analysis. This work finds that disruptive innovation theory is an effective model for assessing the hospital industry. The model provides a useful framework for analyzing the interplay between ACGHs and ASCs. While study findings did not support the stated hypotheses, the impact of government interventions into the competitive marketplace supports the claims of disruptive innovation theory. Regulations that intervened in the hospital industry facilitated interactions between ASCs and ACGHs, reducing the number of ASCs performing ACBS and altering the trajectory of ACBS volume by shifting surgeries from ASCs to ACGHs.

碩士
國立中山大學
醫務管理研究所
97
Abstract Background and Objectives: Since 1894, open appendectomy (OA) has been the treatment of choice for acute appendicitis. In 1981 Semm performed the first laparoscopic appendectomy (LA). More than 2 decades later, the benefits of LA are still controversial. The goal of the present investigation was to compare the effectiveness of LA and OA based on a large administrative (The Bureau of National Health Insurance, BNHI) Research Database. The source of data analyzed was the administrative claims data from the BNHI Research Database. Methods: The objective of this retrospective study was based on the ICD-9-CM procedure code of 4701 (Laparoscopic appendectomy, LA) and 4709 (Open appendectomy, OA) respectively from a database of 20 million insurance population, Separate analyses were performed for uncomplicated (ICD-9-CM, 540.9) and complicated (presence of appendiceal perforation or abscess; ICD-9-CM 540.0 and 540.1) appendicitis. Exclusive criteria were: (1) Average length of stay exceeds 3 S.D. (n=1,262). (2) Gender unmentioned (n=243). All these data will analyze in multiple dimensions including length of hospital stay, in-hospital complications, in-hospital mortality, and rate of routine discharge between laparoscopic (LA) and open appendectomy (OA) based on The Bureau of National Health Insurance (BNHI) database. Results: We enrolled 11,118 patients underwent LA and 47,725 patients underwent OA during 2004 to 2007. The prevalence of LA increases gradually from 6.97 per 100,000 populations in 2004 to 21 per 100,000 populations in 2007. The prevalence of OA decreases gradually from 57.5 per 100,000 populations in 2004 to 44.86 per 100,000 populations in 2007. Patients underwent LA (3.25±1.51day) have significant lower length of hospital stay than OA (3.57±1.49 day) (p<0.001). We also found the trend that the annual medical expenditure of LA increases gradually but OA decreases gradually. In general, LA spends higher medical expenditure than OA. With respect to medical expenditure, higher length of hospital stay and co-morbidity are associated with more medical expenditure significantly. Conclusions: LA is the current developing trend of surgical treatments for appendicitis. LA can reduce length of hospital stay significantly. OA can reduce the medical expenditure in Taiwan. In our opinion, the results represent the native data in Taiwan and are very important for a good administration of public resources distribution.

碩士
國立中山大學
醫務管理碩士學位學程
101
Objectives: The aim of this study is to compare the difference of hospitalized costs between open appendectomy (OA) and laparoscopic appendectomy (LA). We will evaluated the influence of hospitalized costs among the patients who had received appendectomy after Tw-DRGs was apply. We were also exploring the impact of medical payment system on declaration of expense differences in our study at the same time. Methods: This is a cross-sectional study design. The patient’s data was retrospectives collection by chart review from a general teaching hospital in the Kaohsiung city. Between January 1, 2008 and December 31, 2011, 1100 patients were received with appendectomy. We defined the year of case payment from 2008 to 2009, and the Tw-DRGs from 2010 to 2011. After exclude 53 patients who had uncompleted data or repeated cases. Of these, 1047 patients met the inclusion criteria and we analyzed the patient’s clinical data, hospitalized costs, and hospital declaration of expense differences. Results: All of the 1047 patients, there were 555 male (53.0%) and 492 female (47.0) and with a mean age of 41.4 (17.3) years. Of these, 431 patients had LA and the remaining 616 had OA. The mean length of stay was relatively shorter for LA (3.37+/-1.60 days) compare to OA (5.18+/-3.88 days; p<0.001). But the complication within 14 days (LA 0.9% vs. OA 1.3%) and death within 30 days (no case occur in LA or OA) after surgery was no significant differences between LA and OA. The mean of hospitalized costs was significant lower for LA (35347.3+/-8544.7 dollars) compare to OA (39042.4+/-19716.3 dollars; p<0.001). The total patient’s mean hospital declaration of expense differences was 886.5+/15769.6 dollars, but divided into 2 types of appendectomy were different (LA 3674.1+/- 7503.6 dollars vs. OA -1064.0+/-19772.6 dollars; p<0.001). When we used the multiple regression models that were control other factors which were associated with hospitalized costs, hospital declaration of expense differences, and case profit. The mean hospitalized costs on LA 3574.2 dollars were more expensive than OA (increase 12.1%). The effect size of LA compare to OA was lower degree level (0.23 to 0.24). We founded that years of Tw-DRGs compare to case payment was not significant decreased the patient’s hospitalized costs. But in each type of appendectomy groups, the patient’s hospitalized costs were both decreased (LA was -2987.1 dollars, decreased 7.6% and OA was -2493.3 dollars, decreased 4.5%) after Tw-DRGs system was apply in Taiwan. Based on year of 2008, the hospital declaration of expense differences were decreased 177.2 dollars in year of 2009, and both increased 9082.8 dollars and 10880.9 dollars in year of 2010 and 2011. In the multiple linear regression model, the hospital declaration of expense differences was decreased 1142.4 dollars when LA compare to OA, but no statistically significant (p=0.184). In the multiple logistical regression model, compare the OR of case profit between LA and OA was decrease (crude OR was 0.505 and adjusted OR was 0.019). Conclusion: In our study shows that the Tw-DRGs system compared with case payment system will be increases the hospital profit when treatment patients who received appendectomy. But we suggested that choice LA compare to OA will increase patient’s hospitalized cost. Surgeons selective LA or OA to treatment acute appendicitis will no significant influences on hospital declaration of expense differences.

碩士
國立陽明大學
急重症醫學研究所
103
Background: This study investigated whether the time from emergency room registration to appendectomy (ETA) would affect the incidence of perforation and post-operative complications in patients with acute appendicitis. Methods: Patients who underwent an appendectomy at the Ren-Ai branch of Taipei City Hospital between Jan. 2010 and Oct. 2012 were retrospectively reviewed. Patients’ demographics, white blood cell count (WBC), C-reactive protein (CRP), body temperature, CT scan usage, operation method, pathology report, post-operative complication and length of hospital stay, and ETA were abstracted. Multivariate analysis was performed to search the predictors, including ETA, of outcomes for the perforation and post-operative complication rates. Results: There were 236 patients included. Perforation occurred in 12.7% (30/236) and post-operative complications developed in 24.1% (57/236) of these patients. There were 121 patients with ETA < 8 hours; 88 with 8-24 hours, and 27 > 24 hours; patients with ETA > 24 hours had significantly longer hospital stay. Univariate analysis showed perforated patients had significant older age, higher CRP, longer stay and higher complication rate. Patients who developed postoperative complications had significantly older age, higher neutrophil count, less use of CT and open appendectomy. After multivariate analysis, age 55 years or older was the only predictor for perforation (OR: 3.65; CI: 1.54-8.68); for postoperative complications, age 55 years or older (OR: 1.65; CI: 1.84-3.25), perforated appendicitis (OR: 3.17; 1.28-7.85) and open appendectomy (OR: 3.21; 1.36-7.58) were associated. ETA was not a significant predictor in both analyses. Conclusion: From our study, although longer ETA had a longer hospitalization, ETA was not correlated with postoperative complications. Our results incline toward the position that appendectomy can be performed as a semi-elective surgery.

M.Tech.
Iridology is defined as a science that identifies pathological and functional changes within organs via assessing the iris for aberrant lines, spots, and discolourations (Medow, 2000). According to iridology, the iris does not reflect changes during anaesthesia, due to its inhibitory effect on nerves impulses, and in cases of organ removal, it reflects the pre-surgical condition (Jensen, 1986). The Homoeopathic profession is frequently associated with iridology and in a recent survey by Rostovsky et al. (2009) investigating the perceptions of Masters of Technology graduates in Homoeopathy on the existing programme offered by the University of Johannesburg, iridology was highly regarded as a potential additional skill requirement for assessing the health status of the patient. This was a randomized and controlled quantitative study. The study aimed to assess the reliability of iridology in the diagnosis of previous acute appendicitis, as evidenced by appendectomy. A total of 60 participants took part in the study. Of the 60 participants, 30 had had an appendectomy due to acute appendicitis, and 30 with their appendix intact with no prior history of appendicitis. All participants were recruited on the premises of Rita Frank Optometrists. Each participant signed a Participant Information and Consent Form (Appendix E) and a Consent Form to Photograph the iris (Appendix F). Thereafter the researcher obtained the information required in a private setting (Appendix G). Afterwards each participant’s right iris was documented by photograph with the use of a specialist non-mydriatic retinal camera (Canon EOS-20D), reset for the iris, by the researcher. The photographs were then randomized by an external person and no identifying data made available to the three raters. The raters included the researcher and two practising iridologists. Data was obtained from the analyses of the photographs wherein the presence or absence of lesions (implying acute appendicitis) was indicated by the raters. All the data was captured into an Excel spreadsheet (Appendix H) and sent for statistical analysis. vi None of the three raters showed a significant success rate in determining correctly who had had acute appendicitis and resultant appendectomies and who had not. The outcome of this study indicated an outcome that was subject to chance. The null hypothesis that states that appendectomy due to acute appendicitis does not manifest in a corresponding lesion in the typical organ area of the eye, is supported. It is in the opinion of the researcher that the association of iridology with homoeopathic practice may harm the credibility of the profession and that further research on iridology is needed to disprove this conviction.

BACKRGOUND: Appendicitis is the condition in which the appendix, a finger-length appendage located in the right lower quadrant (RLQ) of the abdomen, becomes inflamed due to a bacterial infection. Every year, nearly 300,000 cases of appendicitis are diagnosed at hospitals and clinics throughout the United States. In the U.S., the current standard of care for appendicitis is an appendectomy; surgery that completely removes the appendix from the body. Numerous studies in Europe, however, have demonstrated that antibiotics can be an equally safe and effective treatment for treating appendicitis. This clinical research study hypothesizes that antibiotics for intra-abdominal infections like appendicitis can be an effective treatment. METHODS: Patients that met eligibility were randomized to either antibiotic treatment or appendectomy treatment. If patients decided not to randomize, they had the option to join the Electronic Medical Record (EMR) cohort in which they could choose the treatment that they received. Patients in both cohorts were followed along via EMRs for the span of two years after initial treatment. Individuals who consented to the randomization group also received follow-up phone calls at specified points in time. RESULTS: A total of 374 patients were approached between March 2016 – March 2018. 100 patients consented to the randomization group and 118 patients elected into the EMR group. In the randomization group, 49 patients were randomized to appendectomy and 51 were randomized to antibiotic treatment. 21 patients in the antibiotic treatment group (41.1%) returned back to the hospital within two years of their index visit for an appendectomy. From the EMR cohort, 109 patients chose to receive appendectomies, and 9 patients received antibiotics. CONCLUSION: Treatment with antibiotics can serve as an alternative to surgery. However, due to the recurrence rate of 41% after two years, antibiotics should only be used as a means to delay permanent treatment. If a patient’s current situation is not immediately life-threatening, they should be granted the option to decide whether they would prefer to take antibiotics or elect into surgery.
2021-06-14T00:00:00Z

碩士
國立臺灣大學
藥學研究所
84
The enforcement of National Health Insurance（NHI）, especially the case payment has great influence on the medical provider. How to utilize the limited medical resource efficiently is important to all the members of the health-care system. system. The standard medication procedure was made. The medication procedure, patient''s severity of illness, average hospitalization fee and the drug cost of 25 uncomplicated appendectomy cases studied in 1996 were compared retrospectly with 33 cases in 1993. The average hospitalization fees are 35,291 NT dollars in retrospective study（Group A）and 17,266 NT dollars in prospective study（Group B）. The average hospitalization days are 5.6 in Group A and 3.1 in Group B. The percentages of drug cost are 31% in Group A and 22% in Group B. The average hospitalization fees, average hospitalization days and the percentages of drug cost are all significantly different between Group A and Group B. The wound infection rates are 3% in Group A, in which the correct a antibiotics were used at the right time, and 0% in Group C, in which the antibiotics were administered at all the hospitalization days without concerning the antimicrobial activities, safety, and cost of these agents. The results show that the "single dose" prophylactic antibiotic is practical. The clinical path system is one of National Taiwan University Hospital''s policies of quality assurance.We hope the pharmacy can contribute to reduce the cost and enhance the quality of medical care by participating in the formation of standard medication procedure in clinical path.

碩士
國立中正大學
資訊管理所
94
The Bureau of National Health Insurance (NHI) in Taiwan has endeavored for decades in the preparation of carrying out DRGs payment system, bringing case-payment system with more than 50 items into action and issuing three versions of DRG classification, TDRG-I、TDRG-II and TDRG-III. Once NHI puts DRG payment system into practice, the hospitals will face a serious condition that they will not know the reimbursement of inpatients until the patients discharge. Since of the uncertainty of payment, such a condition will cause the hospitals to over-utilize medical resources or to reduce the necessary exams or the length of stay for saving costs. In this thesis, we predict the DRG of an inpatient with appendectomy through the models constructed by C4.5 algorithm and back-propagation neural network (BPN) before they discharge. Instead of the information, such as ICD-9, complication, and comorbidity, which can be got only when the inpatient discharges, we utilize the tests of an inpatient which can be got while he gets the admission note. After implementing the above two models, we conduct the experiments with the data from two hospitals. The results showed that the accuracies of the two classification models constructed by C4.5 and BPN can be up to 97.84% and 98.70%, respectively. The results imply that the hospital can estimate the reimbursement of appendectomy patients accurately. According to the predicted DRG code, the hospitals can know how many the medical expenses they can acquire. Thus, the hospitals can effectively arrange the medical resources with certainty in payment and quality. Finally, this method is expected to improve the medical quality of patients and create a win-win situation between hospitals and patients.

Introdução: A abordagem cirúrgica da apendicite aguda na população pediátrica é ainda um assunto controverso. Objetivos: Este trabalho pretende comparar os resultados de duas técnicas cirúrgicas utilizadas no tratamento da apendicite aguda em crianças. Foram comparadas a apendicectomia transumbilical laparo-assistida e a apendicectomia convencional. Métodos: Entre janeiro de 2009 e dezembro de 2010, foram avaliados, retrospectivamente, todos os doentes pediátricos submetidos a apendicectomia num hospital universitário. Os doentes foram classificados em diferentes grupos: apendicites não complicadas operadas por cirurgia convencional (ANC-CC), apendicites não complicadas operadas por cirurgia laparoscópica (ANC-CL), apendicites complicadas operadas por cirurgia convencional (AC-CC), apendicites complicadas operadas por cirurgia laparoscópica (AC-CL), apendicites operadas por cirurgia convencional (CC) e apendicites operadas por cirurgia laparoscópica (CL), independentemente da severidade. Os parâmetros avaliados foram: i) duração da cirurgia; ii) complicações intraoperatórias; iii) tempo de internamento; iv) taxa de readmissão; v) taxa de reoperação; e vi) complicações pós-operatórias major e minor. A analise estatística foi realizada com o teste Two Way ANOVA para as variáveis continuas e o teste Qui-quadrado, com a correção de Yates, para as variáveis categóricas. Resultados: Foram analisadas um total de 691 apendicectomias (ANC-CC, n=397, ANC-CL, n=90; AC-CC, n=156, AC-CL, n=48). A duração da cirurgia foi superior nos grupos ANC-CL (57±22min) e AC-CL (75±22min) , quando comparados com os grupos ANC-CC (43±15min) e AC-CC (57±34min), respetivamente. O tempo de internamento foi inferior no grupo ANC-CL (1.8±1.0days) quando comparado com o grupo ANC-CC (3.3±1.2days. Não se encontraram diferenças entre os grupos CL e CC relativamente á taxa de readmissão e ás complicações major. No que respeita as complicações minor, os grupos ANC-CL e AC-CL apresentaram uma taxa superior de granuloma da sutura quando comparado com os grupos ANC-CC e AC-CC, respetivamente. Conclusões: A apendicectomia transumbilical laparo-assistida deve ser considerada uma opção válida no tratamento cirúrgico da apendicite aguda, tanto complicada como não complicada. Esta técnica apresenta como vantagens um melhor resultado estético e um menor tempo de internamento no caso das apendicites não complicadas.

碩士
國立臺灣大學
衛生政策與管理研究所
94
Objective: Using prophylactic antibiotics before surgery to prevent post-operative wound infection and reduce medical cost was widely acknowledged. The objectives of this study were: to describe the use of prophylactic antibiotics in appendectomy in Taiwan and its adherence to the clinical guidelines; and to investigate the treatment results of appendectomy associated with guideline adherences of prophylactic antibiotics. Method: This study employed data concerning inpatient expenses and medical orders from 2003 and 2004 National Health Insurance Research Database. Guidelines for the use of prophylactic antibiotics in surgery was obtained from “Infectious Diseases Society of the Republic of China” and “Taiwan Surgical Association”. This study constructed guidelines adherences into four models—Rigid model, Mild model 1, Mild model 2 and Loose model to analyze guideline adherences of prophylactic antibiotics in appendectomy. Results: The number of appendectomy due to acute appendicitis coded as ICD-9-CM 540.9 and 470 in DRG in 2003 and 2004 was 29,830 patients. The guideline adherences rates among patients receiving antibiotics were 1.07% in Rigid model, 15.68% in Mild model 1, 14.80% in Mild model 2 and 19.02% in Loose model. Patients treated by doctors with fewer practice years or higher service volume in Mild model 1, Mild model 2 and Loose model were more likely to received antibiotics adherenced to the guidelines. Guideline adherences of prophylactic antibiotics was one of the important factors that affected length of stay and medical cost. Suspected postoperative wound infection rate for appendectomy was 1.46% nationwide. Conclusion: This study showed that guideline adherences of prophylactic antibiotics might reduce length of stay and cost; however this study also found guideline adherences of prophylactic antibiotics in appendectomy was smaller than 20%. Therefore health authorities should pursue strategies to improve the guideline adherences of prophylactic antibiotics usage.

碩士
中國醫藥學院
醫務管理研究所
91
In the beginning practice of universal health insurance, the fee for service depends on the quantity performed. This system leads the medical institutes to induce the need of the medic care which caused the waste of medical resources. The medical expense goes up every year. In order to stop the growing of expense, policies like Case payment, Capitation, Per Diem are implemented continually; after that, the Health Department launched the Global Budget System. It used fixed annual medical budget to force the institutes to increase the control on the cost to create earning. After implementation of universal health insurance, medical institutions begin to increase investment of computer hardware and software to co-operate with the reporting of medical expenses. Various clinical medical behavior and prescription drugs could also be entered into computer more completely. However, most of these behaviors are in order to co-operate with needs of reporting medical expenses of Health Insurance. From the accumulated medical records in the medical database, we can analyze and extract those worthy phenomenon and number by the technique of Data Mining. General speaking, this method will generate useful information for the management of medical institutes. This research mainly focuses on the experiment of Data Mining technique applying on Evidence-Based Medicine. By means of Algorithm of Data Mining from a medical institute’s database, we can present the information in some sort of order so that they can become useful references for the management of the medical institutes. This paper uses medical records in a medical institute’s database as sample, and then takes Clinical Pathway and the cost of prescription as examples. By using the Association Rule and Bayesian Network of Data Mining technologies, we are able to establish a learning information database prototype. After the history data training and the expert’s advice, we can find medical behavior models of the same disease from historical data that could be the references of research or clinician. We also expect that classification of Clinical Pathway would be more efficient and flexible than that of manual practice, costs of prescription drugs become more reasonable, and medical resource wasting becomes fewer and fewer. This will assist to increase management efficiency in medical institutes and reduce operation costs eventually

INTRODUCTION: There currently exists a wide variation in anesthesia perioperative management for pediatric patients undergoing laparoscopic appendectomy. The purpose of this retrospective chart review is to compare outcome indicators by using patient demographics. This study aims to establish evidence based guidelines for safe, efficient and effective anesthetic management for patients undergoing laparoscopic appendectomies by analyzing selected outcome indicators and metrics in relation to Surgical-End-to-Transport (SET) time: defined as the time from the end of surgical time until the patient is ready to exit the operating room. METHODS: After institutional review board approval, all laparoscopic appendectomies performed from 2012 through 2014 (n=790) were queried. Using the median SET time of 14 minutes, two groups were established as follows: Group A (n=431), SET time between 0 and 14 minutes, and Group B (n=338), SET time of 14 minutes and longer. Bivariate and multivariate logistic regression models were used to compare readmissions by American Society of Anesthesiologists (ASA) status and reports of high pain with PACU (Post-Anesthesia Care Unit) duration, gender, age, and surgical duration using IBM SPSS Statistics (version 21.0, IBM, Armonk, NY). RESULTS: To limit confounding variables, patients over the age of 21 and those assigned an ASA Physical Status Classification 3 or 4 were excluded. Remaining cases (n=769) were then used to calculate readmission incidence. The median SET time for the study population was 14 minutes, while the median surgical and PACU durations were 58 minutes and 59 minutes, respectively. The readmission incidence rate was 300 per 10,000 (n=23, 3%). The study population consisted of 56% males and 44% females. Females had a higher incidence of readmission (n=13, 3.8%) than males (n=10, 2.3%), while males had longer SET times than females (Group A Males 52.33% vs. Group B Males 60.30%, p=0.0276). There was no difference in readmission incidence rates between ASA I (n=473) and ASA II (n=296) patients (ASA I readmits 3.2 % vs. ASA II readmits 2.7%, p=.711). Patients who reported high postoperative pain (n=75) were more than twice as likely to be readmitted than patients who did not report high pain (p=.071). Ethnicity frequencies were collected as follows: 60.3% White, 6.8% Black or African American, 3.6% Asian, and 29.1% Other. DISCUSSION: Males had significantly longer durations in SET times, and they experienced fewer readmissions than females. There were no significant findings related to the ethnic demographics. Further analysis identifying intraoperative and postoperative anesthesia management for both groups will be performed. This study was subject to the following limitations: retrospective design, incomplete data acquisition, and inconsistent EMR documentation. The correlations and results are preliminary in nature and will serve as a framework for future analyses.

碩士
南台科技大學
企業管理系
92
Large-scale hospitals are setup one after another; however, the sources of the invalids are the same. As a result, the competition among hospitals is intense. In order to attract the patients to take medical advice, many hospitals improve their medical treatments to higher qualities, meanwhile, hospitals confront with the pressure to increase financial income and reduce the costs. Among the great deal of health insurance expenses, the ratio of hospitalization is 32%, and above 50% of hospitalization fee is related to days to hospital stay. Because of the reason why budget of hospitalization is pruned off is often due to the long days to hospital stay, each hospital devotes itself to manage patients’ stay length reducing the costs and promoting doctors’ service to higher qualities. We take an investigation of the medical center in south Taiwan, and discover that it only uses the days of hospital stay to remind doctors of patients’ recovery conditions. But it’s not helpful to improve doctors’ medical services and make the patients’ quick recovery nor to reduce the days which patients have to stay in hospital. Therefore we use the past appendectomy data of the medical center, applying C4.5-based data mining and neural network technologies to establish the predict model and to detect if the patients’ stay length exceed in the upper bound for which the hospital allow. That can help doctors to understand the patients’ recovery and provide suitable medical care. Because there is an asymmetric distribution within the classification of appendectomy data set, we prefer using asymmetric methods to solve the problem and revise the bias to improve the efficiency of classifier. Besides, we also adopt attribute selective procedures to reduce unnecessary properties, making the model construction more efficient and to figure out the simplified classification rules. Now that some properties are reduced, we should estimate the influence of reduction on model efficiency. The result of our study implies that if we use the methods of over-sampling for expanding minority data to reduce the asymmetric of data set, it will obviously improve the efficiency of prediction model which is established by the C4.5-based model and neural network. Besides, if we reduce the numbers of the attributes in a right way, it will not only improve C4.5-based model efficiency but also simplify the classification rules of decision tree at the same time. However, the reduction of attribute numbers will decrease the efficiency of the neural network. Although neural network is a better classification method, we recommend that using a suitable attribute selective procedure first to figure out some important attributes and then applying the C4.5-based data mining technology to setup the predictive model will be a more efficient way to set up a model and to generate the classification rules.

碩士
高雄醫學院
公共衛生學研究所
87
The rise of medical expenses is a common problem of the whole world. All those countries implementing National Health Insurance have been anxiously looking for solutions. And it has been a long time that Taiwan adopts a system of fee-for-service (FFS) to pay for medical expenses, but cannot effectively control the growth of expenses. According to the experiences of different countries, payment system is one of the major factors determining the growth of expenses. Therefore, in the very beginning of the plan for National Health Insurance, the part of inpatient medical expense was prepared to adopt case payment to replace the original fee-for-service system. Eventually, it adopts Perspective Payment System (PPS), which takes Diagnosis Related Groups (DRGs) as the standard, to pay the expenses expecting to release the threatening rise of expenses. Nevertheless, since the implementation of case payment in Taiwan, there lacked the relevant studies of actual evidences for reference. And this system was soon replaced by DRGs System. Therefore, this study focuses on appendectomy, as this disease is simple in treatment protocal and has less variation among the case payment items implemented by National Health Insurance, to investigate the effects of “case payment system of appendectomy” on the use of health re-sources, and take them as a reference for the implementation of DRGs/PPS in the future. This study extracts the data from the outpatient and inpatient claim files of Kao- Ping branch, Bureau of National Health Insurance. The patients of appendectomy before implementation (February to April 1997) and after implementation (February to April 1998) are taken as the targets of this study. After those of unknown sexes are eliminated, there are 1,788 patients collected as samples. Below are the important findings of the research results: 1. Effects of Demographic Features on the Use of Health Resources Generally speaking, sex does not affect the use of health resources much. And age has obvious positive relation with the situation of the use of health resources (except anesthesia expense). 2. Effects of Hospital Features on the Use of Health Resources Hospitals of different grades have different situations of the use of health resources. The reason for and the cause of this difference are that the points of items paid by different grades of hospitals are different and that there is an intervention of payment system. 3. Effects of Case Payment on the Use of Health Resources (1) Regarding the Length of Stay: After the implementation of case payment, the length of stay is obviously shortened (by 1.18 days). Similar phenomenon can lso be found in various grades of hospitals. This is just meeting the assumption of this study. (2) Regarding the Inpatient Expenses: After the implementation of case payment, no matter in the general hospitals or individual grade of hospital, the inpatient expenses and operation fees are obviously increased. This is different from the original assumption of this study. Perhaps one of the main reasons is that the adjustment of payment standard has reflected the increase of expenses. (3) Various Items of Expenses: Apart from operation fee, after the implementation of case payment, most of the various items of expenses are lower than those when fee-for-service is implemented. 4. Situation of Readmission within 14 Days after Operation This research result shows that after implementation of case payment, the situation of re-admission has not been increased . 5. Situation of Cost-Shifting From the results of outpatient and inpatient medical expenses, it shows that after implementation of case payment, there is a situation of cost-shifting, but mostly found in academic medical center.