Download to read offline
![A COMPLEX DISEASE ENTITY
Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J
Gastrointest Surg 2021; 13(11): 1293-1314 [PMID: 34950421 DOI: 10.4240/wjgs.v13.i11.1293]](https://image.slidesharecdn.com/appendixdraft-230309151956-fb361def/85/APPENDIX-DRAFT-pptx-41-320.jpg)
More Related Content
Similar to APPENDIX DRAFT.pptx
![ONFH[AVN HIP] -TRIPLE REGIME -A NOVAL SURGICAL CONCEPT .pptx](https://cdn.slidesharecdn.com/ss_thumbnails/onfhavnhip2026koaconcalicutdrgokuldevdrmashraf-260210064517-213ec005-thumbnail.jpg?width=640&height=640&fit=bounds)
APPENDIX DRAFT.pptx
- 2. APPENDIX:DISEASE CONDITION & MANAGEMENT PRESENTEDBY JR 2- UNIT II MODERATOR : Lt Col C K Thakur
- 3. SCHEME OF PRESENTATION •Introduction : Dr.Subhashis Sharma • Pathophysiology: Maj Nikhil Singh • Acute uncomplicated/perforated appendix:Dr Anjali Goel • Lap vs Open appendectomy: SLC Mehul Kohli • Neoplasm/recent advances,SLC D J Choudhury
- 4. INTRODUCTION: • Most Commonurgent or emergent general surgical operation performed. • First “Major” case performed by the surgeon in training. • Reminder of the art of surgical diagnosis. • Propensity to the formation of tumors with dramatic clinical consequences Ref: Sabiston Textbook of Surgery
- 5. History: • 1492: Leonardoda Vinci depicted the appendix in his anatomic drawings. • 1544 Jean Fernel described appendiceal disease in a paper published • 1735: First known appendicectomy performed by Claudius Amyand. Ref:A Brief History Of Appendicitis: Medical University of South Carolina
- 6. Cont. • 1886:First formaldescription of the disease process,clinical features by Reginald Herber Fitz. • 1894:McBurney’s description of technique for removal of Appendix. • 1982: Description of Laparoscopic appendectomy by Kurt Semm.
- 7. APPENDIX • A narrow,hollow, blind ended tube. • Large aggregation of lymphoid tissues • Point of attachment to the cecum is consistent. • Suspended by mesoappendix Ref: Gray’s Anatomy
- 8. Cont. • Appendix length:Variable (5 to 15 cm) • Luminal diameter: varies (Approx 5 mm) • Blood Supply: Appendicular artery from the ileocolic artery. • Nerves :Superior mesenteric Plexus • Surface projection of the base is at McBurney's point. • Most Common variety: Retrocecal (60%) Ref: CUNNINGHAM’S MANUAL OF PRACTICAL ANATOMY
- 9. Histology: • The lumenis irregular, being encroached on by multiple longitudinal folds of mucous membrane. • intestinal mucosa of colonic type Ref: Netter’s surgical anatomy & approaches
- 10. ETIOLOGY Ref- Bailey &Love 28th Ed Presentor- Maj Nikhil
- 11. ETIOLOGY- CONT... • Fecolith •Lymphoid Hyperplasia • Parasites Ref- Bailey & Love 28th Ed
- 12.
- 13. BACTERIOLOGY GRAM NEGATIVE BACTERIA •E.Coli- 64.6% •P. Aeruginosa – 16.4% •Klebsiella Pneumonia- 5.3% •Citrobacter species- 2.6 % GRAM- POSITIVE BACTERIA •Enterocoocus species- 3.9% •Streptococcus Species- 2.9% Ref- Sabiston 21st Ed
- 14. CLINICAL PRESENTATION Peri- umblical Pain Nausea Vomiting Anorexia Diarrhoea Constipation Migration of painto RIF Pain in Rt Lumbar region Supra- pubic Pain TYPICAL PRESENTATION ATYPICAL Fever
- 15. PHYSICAL EXAMINATION Ill Appearence Fever Tachycardia Dehydration Rigidity On DRE Tenderness Over McBurney’s Point Guarding Rebound Tenderne ss Flexion of knee and Hip Extension of Hip
- 16. DIFFERENTIAL DIAGNOSIS Gastroenteritis RegionalEnteritis Mittelschmerz Diverticulitis Mesentric Adenitis Ureteric colic PID Intestinal Obstruction Meckel’s Diverticulitis Perforated peptic Ulcer Pyelonephritis Colonic Carcinoma Intussusception Torsion of Testis Ectopic Pregnancy Torsion Appendix epiploicae HSP Pancreatitis Torsion/Rupture of Ovarian cyst Mesentric Infaraction Lobar Pneumonia Rectus sheath haematoma Endometriosis Leaking Aortic Aneurysm Ref- Bailey & Love 28th Ed
- 17. Clinical Diagnosis Symptoms Migratory RIFPain Anorexia Nausea and Vomiting 1 1 1 Signs Tenderness in RIF Rebound Tenderness Elevated temperature 2 1 1 Laboratory Leucocytosis Shift to left 2 1 Total 10 1-4 5/6 7-10
- 18.
- 19. Agenda • Laparoscopic vsOpen Appendectomy • Non operative vs Operative treatment • Management of Delayed presentation • Normal Appearing Appendix
- 22. Patient Related ⚫Lesser wound complications ⚫Reducedpost op pain ⚫Shorter recovery time Procedure Related ⚫Examination of entire peritoneal space ⚫Exclude other intra abdominal diseases Advantages Disadvantage ----------------------> Intra Abdominal Abscess
- 23. NON OPERATIVE VSOPERATIVE APPROACH
- 24. Operative ⚫Lower morbidity ⚫Treats high recurrencerates Non Operative ⚫Preserving appendix ⚫No greater tendency to proceed to complications Advantages
- 26. Delayed Presentation • Definition •Complications • Management • Interval Appendectomy
- 28.
- 29. Normal Appearing Appendix •Advantages • Disadvantages • Incidental Appendectomy
- 31. APPENDICULAR MALIGNANCIES AND SPECIALCONSIDERTIONS IN APPENDICITIS
- 32. APPENDICEAL MALIGNANCIES • Incidentaldetection (0.7 - 1.7%) • 0.4 - 1 % of all GI malignancy • Diverse pathology and biologic behaviour • No consensus of Classification/ Terminology/ Treatment • ANENs (Carcinoid)- M/c (0.2-0.7) • Epithelial Neoplasms • Adenoma , Serrated polyps • AdenoCA (0.08-0.1) • Non Mucinous • Adeno CA with signet ring • Mucinous Tumors (AMNs) • Low grade • High grade • Mucinous adenoCA
- 33. ANENS (Carcinoids) • F>M, ~65% incidence • 2nd/ 3rd decades • Arise from subepithelial NE cells • Mostly located at tip • Acute Appendicitis/ Mass/ Mets • Dx: IHC - • Synaptophisin • CgA WHO CLASSIFICATION based on size (<1, 1-2, >2 cm); Ki- 67 index, Tx invasion 1. NET-G1 (well diff) 2. NET-G2 (intermediatly diff) 3. NEC-G3 (poorly diff) 4. MANECs
- 34. ENETS GUIDELINES :NET APPENDIX CLASSIFICATION
- 35. ENETS GUIDELINES :NET APPENDIX MANAGEMENT
- 36. MUCINOUS APPENDICEAL TUMOURAND PSUEDOMYXOMA PERITONEI • Peritoneal Surface Oncology Group International (PSOGI) + AJCC 8 th classification (2016) • Low grade, High grade, High grade with signet ring • Consensus on pathologic classification • Presentation: Incidental (2/3rd) / Appendicitis (1/3rd) • Surgical excision without capsular disruption • Govaerts K, Lurvink RJ, De Hingh IHJT, Van der Speeten K, Villeneuve L, Kusamura S, Kepenekian V, Deraco M, Glehen O, Moran BJ; PSOGI. Appendiceal tumours and pseudomyxoma peritonei: Literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment. Eur J Surg Oncol. 2021 Jan;47(1):11-35. doi: 10.1016/j.ejso.2020.02.012. Epub 2020 Feb 28. PMID: 32199769. • PMP syndrome: peritoneal dissemination of mucinous neoplasm • Appendiceal/ gastric/ ovarian/ pancreatic/ colorectal primary Tx • Early detection of of limited peritoneal mets is favorable • CRS + HIPEC
- 37. CRS & HIPECIN APPENDICEAL TUMOURS • Perforated epithelial appendiceal tumours are rare • Present unexpectedly at elective or emergency abdominal surgery, often with PMP. • CRS (Cytoreductive Surgery)and HIPEC (hyperthermic intra-peritoneal chemotherapy) results in good long term outcomes in most patients. • Parietal and visceral peritonectomies + intra-peritoneal heated (42℃) Mitomycin • Safe at high volume centres Ansari N, Chandrakumaran K, Dayal S, Mohamed F, Cecil TD, Moran BJ. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1000 patients with perforated appendiceal epithelial tumours. Eur J Surg Oncol. 2016 Jul;42(7):1035-41. doi: 10.1016/j.ejso.2016.03.017. Epub 2016 Apr 9. PMID: 27132072.
- 39. SPECIAL CONSIDERATIONS INAPPENDICITIS PEDIATRIC POPULATION • Perforation in 51-100% in infants/ young children, lower in school age groups • PAS similar to Alvarado Score • RLQ tenderness / pain with cough, hopping: 2 points • Exclusion of DDs • Lap > Open > Conservative (22% recurrence) ELDERLY • Reduced inflammation • Perf/ Abscess ↑ • Complications due to co-morbs • Diagnostic imaging important • Lap > Open
- 40. APPENDICITIS IN PREGNANCY •First/ Second trimester • 1/800 to 1/1000 pregnancies (most common surgical emergency in pregnancy) • C/F include heartburn/ bowel irregularity change in bowel habits • Point of max tenderness: usually displaced • USG (preferred)/ MRI • Risk of fetal loss 36% in perf • Low threshold for exploration (negative exploration 30%) • Lap safe (7% vs 3% fetal loss risk) • Lower pressures (10-12mm Hg) to prevent early labour • Non-op Mx (failure rates ~ 25%) Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management and complications. Acta Obstet Gynecol Scand. 1999 Oct;78(9):758-62. PMID: 10535336.
- 41. A COMPLEX DISEASEENTITY Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J Gastrointest Surg 2021; 13(11): 1293-1314 [PMID: 34950421 DOI: 10.4240/wjgs.v13.i11.1293]
- 42.
Editor's Notes
- #16 “s point
- #20 Open appendectomy has been the gold standard for treating patients with acute appendicitis for more than a century, but the efficiency and superiority of laparoscopic approach compared to the open technique is the subject of much debate nowadays . There is evidence that minimal surgical trauma through laparoscopic approach resulted in significant shorter hospital stay, less postoperative pain, faster return to daily activities related with gastrointestinal surgery. However, several retrospective studies, several randomized trials and meta-analyses comparing laparoscopic with open appendectomy have provided conflicting results. Some of these studies have demonstrated better clinical outcomes with the laparoscopic approach while other studies have shown marginal or no clinical benefits and higher surgical costs
- #21 Retrospectively collected data from 593 consecutive patients with acute appendicitis were studied. These comprised 310 patients who underwent conventional appendectomy and 283 patients treated laparoscopically. The two groups were compared for operative time, length of hospital stay, postoperative pain, complication rate, return to normal activity and cost. Conclusion The laparoscopic approach is a safe and efficient operative procedure in appendectomy and it provides clinically beneficial advantages over open method (including shorter hospital stay, decreased need for postoperative analgesia, early food tolerance, earlier return to work, lower rate of wound infection) against only marginally higher hospital costs.
- #22 This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay. Results: Laparoscopic appendectomy is superior to open appendectomy in terms of wound site infections and operating time. The operating time depends on the surgical skills of the operating surgeon and the magnitude of the condition. With regards to the length of hospital stay, there is no difference between the two techniques
- #24 It is general opinion that the appendix has no significant function in humans. De Coppi et al. in 2006 showed that the vermiform appendix was capable of producing mesenchymal stem cells. They found that appendix-derived mesenchymal stem cells are present in the vermiform appendix. These cells can differentiate into osteoblasts, lipoblasts, and myoblasts, depending on the stimulation. They suggested the possibility that vermiform appendix acts like a reservoir for stem cells capable of bowel repair trough life. Some authors moreover suggested the possibility that appendix serves as a reservoir for bacteria of the gut flora, and it is necessary to recolonize the bowel after bacterial infections. Appendectomy either open either laparoscopic is still associated with a significant morbidity and mort ality despite advances in surgery and care. A 3.5-fold excess mortality after surgical intervention for non-perforated appendicitis and a 6.5-fold excess mortality in perforated ones. In patients with a discharge diagnosis of nonspecific abdominal pain the mortality rate after negative appendectomy was increased by 9.1-fold. This mortality rate may only partially be explained by an underlying condition that was concealed by the appendectomy.
- #27 Previous studies have identified the following factors as being associated with diagnostic errors of acute appendicitis in adults: age >60 years appendicitis in the pelvic region atypical symptoms or inadequate examination poor clinical findings the experience level of the emergency physician female sex the presence of coexisting conditions, constipation, and appendicitis without pain In addition, other physician- and environmental-related factors, such as physician specialty, access to ultrasound, and hospital size, have been reported as factors associated with misdiagnosis in pediatric studies.