1. O.O.Bogomolets National Medical University Department of Faculty Surgery #1 “Approved” at the Methodist Faculty Surgery Department # 1 Council “__”_____2008, protocol #_____ Head of Faculty Surgery Department # 1 Professor _______ M.P.ZakharashStudy Guide for Practical Work for Teachers and Students Topic: “Complications of appendicitis”. Course 4 Foreign Students’ Medical Faculty Duration of the lesson – 45 min. Worked out by Assistant T.Kravchenko Kyiv 2008
2. I. The theme actuality.Despite diagnostic and therapeutic advancement in medicine, appendicitis remains aclinical emergency. In fact, this illness is one of the more common causes of acuteabdominal pain. Left untreated, appendicitis has the potential for severecomplications, including perforation or sepsis, and may even cause death.II. Startup aims of the study. To teach students major methods of appendicitis complications diagnosis andtreatment.Student should have knowledge: 1. Definition and prevalence of appendicitis complications. 2. Classification of appendicitis complications. 3. Clinical manifestations (features) of appendicitis complications. 4. Pathogenesis of appendicitis complications 5. Methods of diagnosis. 6. Treatment of appendicitis complications. 7. Prevention of appendicitis complications.Student should be able to: 1. Correctly gather an anamnesis. 2. Compose adequate examination plan for patient with appendicitis complications. 3. Interpret received results of examinations. 4. Interpret data of x-ray, ultrasound scan, CT, endoscopy. 5. Determine the type of complications basing on investigations’ data. 6. Determine the severity of appendicitis complications. 7. Compose plan for treatment of patient with appendicitis complications. 8. Treat patient with complication of appendicitis.
3. III. Educative aims of the study. 1. To acquire the skills of psychological contact establishment and creation of trusting relations between the doctor and the patient. 2. The development of insight of ecological and socio-economic factors’ influence on health condition. 3. The formation of deontology concepts and practical skills related to patients with complication of appendicitis. 4. The development of responsibility sense for timeliness and completeness of patient’s investigation, as well as for patient awareness about possible methods of treatment and adverse effects which are concerned with them. 5. To develop deontology presentations, be able to carry out deontology approach to the patientIV. The content of the theme.IntroductionSevere and untreared cases of acute appendicitis may lead to a numbers ofcomplications.Classification1. Complication of appendicitis– Perforation– Peritonitis (local, spread, total)– Appendix mass– Appendix abscess– Pylephlebitis– Sepsis2. Morbidity (complications after appendectomy) Early (up to 1week)
4. – Wound infection, hematoma, evisceration– Intraabdominal bleeding– Abdominal mass /abscess– Intestinal obstruction– peritonitis Late (after 2weeks)– Wound fistula, mass– p/o hernia– Abdominal mass /abscess (right iliac fossa, pelvic, subphrenic)– Fecal fistulaPerforated AppendicitisPatients with perforation of the appendix may be very ill and require several hours offluid resuscitation before safe induction of general anesthesia. Broad-spectrumantibiotics directed against gut aerobes and anaerobes are initiated early in theevaluation and resuscitation phase. In children, a laparoscopic approach to theperforated appendix appears to reduce the incidence of postoperative woundinfections and ileus and is associated with shorter hospital stays and lower costs.Recent studies in adults suggest that patients successfully treated laparoscopicallyrealize similar benefits, albeit with a higher risk for conversion to an open procedurethan for patients with simple appendicitis. We usually begin with a diagnosticlaparoscopy and use a rolled gauze to gently sweep adherent loops of small bowelaway from the cecum, thereby exposing the appendix. Depending on the ease ofcompleting that task, a decision is made whether or not to convert to an openappendectomy. Any pus encountered during the dissection is aspirated and sent forGram stain and culture. Oozing from the severely inflamed retroperitoneum is easilycontrolled with argon beam coagulation, if available. The inflamed, indurated
5. mesoappendix is divided using the LigaSure or harmonic scalpel. The taeniae of thececum are followed onto the base of the appendix, and the stump is divided eitherbetween Endoloops or with a stapler, depending on the integrity of the tissues. Whenthe mesoappendix is densely adherent to the cecum or retroperitoneum, it may behelpful to divide the stump of the appendix with the stapler before dividing themesoappendix. The abdomen and pelvis are irrigated and the fluid aspirated. Weleave a closed-suction drain in place only if a well-defined residual abscess cavityexists after reflection of the small bowel away from the appendiceal bed. Antibioticsmay be altered, if necessary, based on the culture results and are continued until thepatient is afebrile postoperatively.Appendiceal AbscessPatients who present late in the course of appendicitis with a mass and fever maybenefit from a period of nonoperative management, which reduces complicationsand overall hospital stay. Imaging studies are useful both in confirming the diagnosisand in evaluating the size of any abscess present. Patients with large abscesses,greater than 4 to 6 cm in size, and especially those patients with abscess and highfever, benefit from abscess drainage. This may be accomplished via the transrectalor transvaginal route using ultrasound guidance if the abscess is suitably located, orby a percutaneous image-guided approach. Those patients with smaller abscesses orphlegmon and who are not sick may be successfully managed initially withantibiotics alone. Patients who continue to have fever and leukocytosis after severaldays of nonoperative treatment are likely to require appendectomy during the samehospitalization, whereas those who improve promptly may be considered for intervalappendectomy.After nonoperative treatment of suspected late appendicitis, adults undergocolonoscopy or barium enema because colon cancer is detected in about 5% of
6. cases. The risk for recurrent appendicitis is about 15% to 25% after nonoperativetreatment and warrants consideration of interval appendectomy. We typicallyperform this procedure laparoscopically about 6 weeks after the initial bout ofappendicitis. Interval appendectomy is associated with low morbidity and a shorthospital stay. The procedure is routinely performed in children. The decision aboutwhether to proceed with interval appendectomy for adult patients includes factorssuch as patient age, comorbid conditions, and prior abdominal surgery.Chronic or Recurrent AppendicitisA small number of patients report episodic bouts of right lower abdominal pain inthe absence of an acute febrile illness. Some are found to have appendicoliths on CTor sonographic evidence of an enlarged appendiceal diameter; most of these willhave both surgical and pathologic evidence of chronic inflammation of the appendixand relief of symptoms after appendectomy. These findings support the notion thatappendicitis represents a spectrum of inflammatory changes that may, in rare cases,wax and wane.Normal-Appearing AppendixIf a normal-appearing appendix is identified at the time of surgery, should it beremoved? This question has been raised again after the introduction of thelaparoscopic approach; consensus is lacking on this point. Although it is difficult toknow how many patients benefit from this practice, removal of the appendix addslittle morbidity to the procedure. In some cases, pathologic abnormalities that werenot apparent on visual inspection are identified.[37–39] Our practice is to removethe appendix and perform a thorough search for other causes of the patientssymptoms. We specifically examine the small intestine for Meckels diverticulum
7. and Crohns disease, the mesentery for lymphadenopathy, and the pelvis forabscesses, ovarian torsion, and hernias.Treatment AlgorithmPatients are considered to have so-called simple appendicitis if the duration ofsymptoms is less than 48 hours or imaging studies show the absence of a largeabscess or phlegmon. These patients typically undergo appendectomy. For patientswith an atypical or long history and those who present during the recovery phase,imaging studies are obtained. CT is typically selected for nonpregnant adults andultrasound for pregnant women and children. Occasionally, these patients are foundto have radiographic features of simple appendicitis and undergo appendectomy.More commonly, a phlegmon is found. An associated large abscess (>4-6 cm) isdrained either percutaneously, if it is located in the iliac fossa, or transrectally, if it isin the lower pelvis. Patients who are systemically ill are treated with antibiotics andbowel rest and re-evaluated. If they do not improve, we perform an openappendectomy. Similarly, sick patients with a phlegmon or a small abscess aretreated with antibiotics and bowel rest and re-evaluated for signs of improvement asdescribed earlier. Some patients present during the recovery phase from the acuteillness and may be managed as outpatients. Adults who are managed nonoperativelyduring their initial presentation undergo colonoscopy 2 to 4 weeks after their acuteillness to exclude colitis or neoplasms. We typically remove the appendix in thesepatients 6 to 8 weeks after the initial presentation. The procedure is performedlaparoscopically as an outpatient.OutcomesThe mortality rate after appendectomy is less than 1%. The morbidity of perforatedappendicitis is higher than that of nonperforated cases and is related to increased
8. rates of wound infection, intra-abdominal abscess formation, increased hospital stay,and delayed return to full activity.Surgical site infections are the most common complications seen afterappendectomy. About 5% of patients with uncomplicated appendicitis developwound infections after open appendectomy. Laparoscopic appendectomy isassociated with a lower incidence of wound infections; this difference is magnifiedamong groups of patients with perforated appendicitis (14% versus 26%). Patientswith a fever and leukocytosis and a normal-appearing wound after appendectomyundergo CT or ultrasonography to exclude an intra-abdominal abscess. Similarly, ifpus emanates from a fascial opening during wound inspection, an imaging study isobtained to identify any undrained intra-abdominal fluid collections. In thissituation, we place a percutaneous drain into the collection to divert the infectedmaterial away from the fascia and facilitate wound healing. For pelvic abscesses thatare located in proximity to the rectum or vagina, we prefer ultrasound-guidedtransrectal or transvaginal drainage, thereby avoiding the discomfort of apercutaneous perineal drain.Small bowel obstruction occurs in less than 1% of patients after appendectomy foruncomplicated appendicitis and in 3% of patients with perforated appendicitis whoare followed for 30 years. About one half of these patients present with bowelobstruction during the first year.The risk for infertility following appendectomy in childhood appears to be small. Ahistory of either simple or perforated appendicitis was sought in a large cohort ofinfertile patients and compared with the frequency of appendicitis in pregnantwomen; no significant differences were found.
9. There are rare reports of appendicocutaneous or appendicovesical fistulas after appendectomy, typically for perforated appendicitis. Fistulas to the skin generally close after any local infection is treated. Fistulas to the bladder have been successfully diagnosed and treated laparoscopically in recent years. V. Lesson topic control questions. Key points:• Severe cases of acute appendicitis and delay of treatment may lead to a number of complications• Complications of acute appendicitis are numerous and correlate well with the severity of the inflammatory process.• Diagnosis is not easy and includes Contrast-enhanced CT, endoscopy, ultrasound, plain abdominal films or CT, laboratory tests Cases A 65-year-old female comes to the ER with a complain of mild abdominal pain in the right, lower abdomen. She describes the pain now as 7/10 in intensity, with no exacerbating or alleviating factors. She admits to a 4-days history of constipation, as well as nausea and vomiting. Lab reveals WBC 10,000; UA shows Escherichia coli 50,000. The patient had a Foley catheter placed, yielding dark concentrated urine. A mass was palpated in the RLQ. CT of the abdomen and pelvis showed an enlarge appendix. The patient was taken to the operation room where a Rocky-Davis incision was used and the tip of appendix appeared to be neoplastic. Frozen section comes back as adenocarcinoma. What operative procedure is warranted? 1. Appendectomy with culture and stain of peritoneal fluid 2. Appendectomy with frozen section
10. 3. Create a midline incision to check for intraabdominal metastasis and perform appendectomy 4. Rerform a Fowler-Weir incision and perform right hemicolectomy and ileocolic anastamosisAnswer is 4Primary adenocarcinoma of the appendix is rare and encompasses threetypes:mucinous adenocarcinoma, colonic adenocarcinoma, and adenocarcinoid.Typical presentation is that of appendicitis which may also present with ascites orpalpable mass. Recommended treatment is right hemicolectomy, which can beperformed with medial extension of a Rocky-Davis incision throught the anteriorand posterior rectus sheaths. 5-year survival is 60% after a righy hemicolectomy and20% for appendectomy alone.VI. Supporting materials required for teaching1. Participation in clinical duties on admission2. Working in libraryVII. Literature1. Townsend CM, Harris JW. Sabiston’s Textbook of Surgery, 16th ed. Philadelphia, PA: W.B. Saunders Co, 2001, vol.442. Schwartz SI, Schires GT, Spencer FC, Daly JM, Fischer JE, Galloway AC. Principles of Surgery, 7th ed. New York: McGraw-Hill, 1999, vol.273. Bruce E. Jarrell, R.Antthony Carabasi. Surgery, 3rd ed. Williams & Wilkins, 1998