Case 1

Acute Appendicitis

A 19 year old female presents to the ED with right lower quadrant abdominal pain. The ED has not done an evaluation and calls you to see the patient. You're in private practice and have a full day of clinic the next day. You also live 40 minutes from the hospital, so since it is 1 AM on day 5 of you being on call. What do you do? a. [[Tell the ED it's probably Gyn related since the patient is a female with RLQ pain. They shoud call ObGyn, since you're too busy to deal with nonsurgical consults]] b. [[Ask for associated symptoms]] c. [[Get labs (CBC, CMP, Pregnacny test, LFTs)]]

Besides the abdominal pain, she reprots having nausea, vomiting, and anorexia that began the previous evening. She describes her abdominal pain as initially periumbilical, but now localized to the right lower quadrant (RLQ). Her temperature is 37.9 C. Her vital signs are otherwise normal. On abdominal exam, her abdomen is soft and nondistended, but tender to palpation over RLQ. She has no signs of peritonitis. What do you do next? a. [[Take to OR for lap appy]] b. You opt to [[Get labs (CBC, CMP, Pregnacny test, LFTs)]] c. You get angry and [[Tell the ED it's probably Gyn related since the patient is a female with RLQ pain. They shoud call ObGyn, since you're too busy to deal with nonsurgical consults]]

Labs: - CBC: WBC of 13,000 cells/µL, H/H normal, Platelet normal - crp: elevated - CMP: WNL - LFTs: WNL - Pregnancy test: negative CT scan shows acute NON-perforated appendicitis. What do you recommend to the patient? a. [[Non-operative management (Antibiotics and close monitoring in the hospital)]]. b. [[Laparoscopic appendectomy]]. c. [[Open appendectomy]].

ObGyn does proper/comlete evaluation and determines this is NOT gynecological pathology. [[ED calls you back]]

It's been 8 hours since the patient initially arrived in the ED. No treatments (Medication, Fluids, Supplemental oxygen or procedures) have been done since she arrived. She remains NPO. Vitals show: Temp: 38.5 C HR: 110 BP: 75/45 RR: 20 O2 Sat: 96% She has not made any urine since arrival. Abdominal exam shows tenderness in the RLQ, but patient does NOT have peritonitis. What next? a. [[Get IV access, administer broad spectrum antibiotics, administer IV fluid bolus, place foley catheter and place her on supplemental oxygen]] b. [[Send to CT scan]] c. [[Admit to ICU before starting any therapy]]

OB Gyn has done a thorough job evaluating the patient so intsead of repeating tests you decide to review the labs and imaging. You go on to review the [[Results]]

Patient codes in CT scan and dies [[Clinical Pearls]]

The patient deteriorates on the way to the ICU. What do you do next? a. [[Get IV access, administer broad spectrum antibiotics, administer IV fluid bolus, place foley catheter and place her on supplemental oxygen]] b. [[Take emergently to OR]] for laparoscopic appendectomy c. [[Call IR for drainage]]

You find perforated appendicitis with abscess and significant inflammation and adhesions. Freeing up the appendix is extremely difficult and you're unable to identify the cecum, colon or terminal ileum. How do you proceed? a. [[You convert to open]] b. You close and -> [[IR for drainage]] together with starting broad spectrum antibiotics c. [[You continue laparoscopic]]

Labs: - CBC: WBC of 13,000 cells/µL, H/H normal, Platelet normal - crp: elevated - CMP: WNL - LFTs: WNL - Pregnancy test: negative CT scan shows perforated appendicitis with an abscess. What do you want to do? a. [[IR for drainage]] b. [[To OR for lap appy]]

IR eventually comes in and places a drain. The patient has a protracted hospital course characterized with an ileus and need for NGT. Finally, drain output resolves, the patient finishes their course of antibiotics. She has return of bowel function, so NGT is removed and diet is advanced. She is ultimately discharged home after 3 weeks in the hospital. You schedule her for an interval appendectomy in 6 - 12 weeks. [[Clinical Pearls]]

The operation continues to be extremely difficult with poor visualization. You notice stool spillage and realize you have perforated the cecum. You then [[You convert to open]].

IR calls you back after several hours and refuses to come because there is no imaging to show anything drainable. So you decide to [[Send to CT scan]].

Even open you find it difficult to tease out the anatomy. Ultimately you perfomr an ileocecetomy and leave a drain. The patient has a protracted hospital course characterized with an ileus and need for NGT. Finally, drain output resolves, the patient finishes their course of antibiotics. She has return of bowel function, so NGT is removed and diet is advanced. She is ultimately discharged home after 3 weeks in the hospital. [[Clinical Pearls]]

The operation continues to be extremely difficult with poor visualization. You notice stool spillage and realize you have perforated the cecum. You then [[You convert to open]].

You find perforated appendicitis with abscess and significant inflammation and adhesions. Freeing up the appendix is extremely difficult and you're unable to identify the cecum, colon or terminal ileum. a. [[You convert to open]] b. You close and -> [[IR for drainage]] together with starting broad spectrum antibiotics c. [[You continue laparoscopic]]

(text-style:"underline")[''NONPERFORATED APPENDICITIS ''] Nonperforated appendicitis (simple appendicitis or uncomplicated appendicitis), refers to acute appendicitis that presents without clinical or radiographic signs of perforation (eg, inflammatory mass, phlegmon, or abscess). Approximately 80% of appendicitis are not perforated at presentation. Traditional therapy comprised appendectomy but, there is mounting evidence that, in many respects, antibiotic therapy is not inferior to surgery for nonperforated appendicitis in healthy patients. Nonoperative management: - Antibiotics with the aim of avoiding surgery. - Appendectomy is reserved for those who do not have a response to antibiotics or have recurrence of appendicitis. Nonoperative management is ideal in patients with localized appendicitis without physical findings of diffuse peritonitis or imaging evidence of large abscess, phlegmon, perforation, or tumor. Relative contraindications: - Appendicolith - Older patients – Antibiotic response may be delayed in patients > 45 years old Absolute contraindications: - Diffuse peritonitis - Hemodynamically instability or severe sepsis - Pregnancy - Immunocompromise - History of inflammatory bowel disease Initial appendicitis - Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission. - The other 10% who fail to respond to antibiotics require a rescue appendectomy. Recurrent appendicitis - 15 to 49% of patients who choose nonoperative treatment may develop recurrent symptoms. - When appendicitis recurs, surgery is commonly performed and may be preferred in adults who are 40 years of age or older given the possibility of a malignancy. - Retreatment with antibiotics is an option in younger patients. - Approximately 70% of those successfully treated with antibiotics during the initial admission are able to avoid surgery during the first year. - The other 30% eventually require appendectomy for recurrent appendicitis or symptoms of abdominal pain. - Long-term the cumulative incidence of recurrent appendicitis was 27.3% at one, 34.0% at two, 35.2% at three, 37.1% at four, and 39.1% at five years and 39% at 7 years in the APAC trial. - In the CODA trial, which included patients with appendicolith, 29% of patients required appendectomy at 90 days (41% with appendicolith versus 25% without appendicolith), 40% at one year, 46% at two years, and 49% at three and four years. (text-style:"underline")[''PERFORATED APPENDICITIS''] Patients with perforated appendicitis may appear acutely ill and have significant dehydration and electrolyte abnormalities, particularly if fever and vomiting have been present for a long time. The pain usually localizes to the right lower quadrant if the perforation has been walled off by surrounding intra-abdominal structures, such as the omentum, but can be diffuse if generalized peritonitis ensues. On imaging studies, appendicitis can present with a contained perforation (an inflammatory mass often referred to as a "phlegmon," or an intra-abdominal or pelvic abscess) or, rarely, a free perforation. Other unusual presentations of appendiceal perforation can occur, such as retroperitoneal abscess formation due to perforation of a retrocecal appendix or liver abscess formation due to hematogenous spread of infection through the portal venous system. An enterocutaneous fistula can result from an intraperitoneal abscess that fistulizes to the skin. Appendiceal perforation can result in a small bowel obstruction, manifested by bilious vomiting and obstipation. High fevers and jaundice can be seen with pylephlebitis (septic portal vein thrombosis) and can be confused with cholangitis. Perforation is found in 13 to 20% of patients who present with acute appendicitis. - The perforation rate is higher among men (18% men versus 13% women) and older adults - Approximately 20% of patients with perforated appendicitis present within 24 hours of the onset of symptoms. The management of perforated appendicitis depends on: - The condition of the patient (stable versus unstable) - The nature of the perforation (contained versus free perforation) - Whether an abscess or phlegmon is present on imaging studies (text-style:"mark")[//''Please see appendicitis flowchart for management algorithm''//] (text-style:"bold","underline")[''OUTCOMES''] Mortality — The mortality associated with appendicitis is low but can vary by geographic locations. In developed countries, the mortality rate is between 0.09 and 0.24%. In resource-limited countries, the mortality rate is higher, between 1 and 4%. Morbidity - For nonperforated appendicitis, the overall risk of antibiotic therapy is not greater than that of upfront appendectomy, and complications that occur with appendectomies performed after trying antibiotics first are not more common than those of upfront appendectomies. - Delaying surgery while taking antibiotics for nonperforated appendicitis does not increase the risk of perforation. - Complications include o Surgical site infection, most of which occur in patients with perforated as opposed to nonperforated appendicitis. o Recurrent or stump appendicitis - Recurrent appendicitis can occur in 15 to 49% of patients who are managed nonoperatively, depending on the study and the length of follow-up. o Stump appendicitis is a form of recurrent appendicitis that is related to incomplete appendectomy that leaves an excessively long stump after open or laparoscopic surgery. - Your Text Here To minimize stump appendicitis, the appendix should be transected no further than 0.5 cm from its junction with the cecum and removed as a whole. - In case stump appendicitis occurs, stump resection can be performed open or laparoscopically. - A perforated appendiceal stump, however, typically requires a more extensive bowel resection to control. (text-style:"underline")[''Laparoscopic appendectomy''] Key Technical Steps 1. Infraumbilical 12-mm incision and abdominal access via Veress needle or open Hasson technique. 2. Insert two 5-mm ports in low midline above pubic symphysis and left lower quadrant. 3. Divide adhesions in RLQ to expose appendix. 4. Create mesenteric window at base of appendix with Maryland dissector. 5. Divide mesoappendix and appendix with endoscopic GIA stapler. 6. Retrieve appendix with Endocatch device. 7. Remove ports, close fascia at infraumbilical incision, and close skin. Potential Pitfalls • Injury to inferior epigastric vessels or abdominal viscera with port placement. • Dense adhesions require conversion to open appendectomy. • Injury to cecum, small bowel, or iliac vessels during dissection. • Division of the appendix with infl ammation at the base, resulting in staple line leak. (text-style:"underline")[''Open appendectomy''] Key Technical Steps 1. Skin incision at McBurney’s point or point of maximal tenderness. 2. Open external oblique aponeurosis and bluntly separate internal oblique and transverse abdominis muscles. 3. Incise peritoneum. 4. Identify appendix and deliver into operative fi eld. 5. Divide mesoappendix. 6. Place purse-string suture around base of appendix. 7. Clamp crush base of appendix and ligate and divide appendix at its base. 8. Invaginate appendiceal stump into base of cecum. 9. Close peritoneum, fascia, and skin in individual layers. Potential Pitfalls • Damage to cecum. • Retrocecal appendix may be diffi cult to expose. • Inability to inspect other abdominal structures with limited incision. References: 1. Clinical Scenarios in Surgery 2. Surgery Algorithm 3. Up-to-date

The patient does well overnight, but during your first case you get a page that your patient now has excrutiating abdominal pain. Since you're in private practice you have no residents who can immediately go to evaluate the patient. You tell the nurse to give the patient some pain medication and you will come as soon as you finish your colectomy. 4 hours later you finally go see the patient. They are writhing in bed and tell you the oxycodone they received did not even touch them. Vitals show: Temp: 38.5 C HR: 110 BP: 75/45 RR: 20 O2 Sat: 96% Abdminal exam: She patient is clearly peritoneal with rebound and guarding. You surmise the patient has now perforated appendicitis. What is your next move? a. You postpone your next case and [[Take emergently to OR]] for laparoscopic appendectomy b. You have another case right now so you [[Send to CT scan]] to get more information

You find simple, nonperforated appendicitis. The operation is uncomplicated. Postoperatively, the patient does well and is discharged home after 24 hours in the hospital. [[Clinical Pearls]]

The patient refuses because they are concerned about cosmesis so they opt for a [[Laparoscopic appendectomy]].