SURGERYFinals - 1. the Appendix

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Dr. Nelson Ayson | September 11, 2015 | SURGERY

THE APPENDIX o

HISTORICAL BACKGROUND Claudius Amyand (1736) – unknowingly did the first ever appendectomy  He was doing a surgery on an 11-year old boy who had an inguino-scrotal hernia with fistula.  Upon operation, he found out that there was a perforation on the appendix (but didn’t know that it was the appendix) and pierced it with a needle.  Due to the hernia and perforated appendix, he developed a fistula.  Typhlitis or perityphlitis – term used to describe right lower quadrant inflammation in the 19th century Reginald Fitz – coined the term appendicitis Fergus, in Canada – first elective appendectomy in 1883 Charles McBurney – published New York State Medical Journal describing the indications for early laparotomy for the treatment of appendicitis; in this paper he described McBurney point (point of maximal tenderness)  Later on, he acknowledged McArthur as the one who first described McBurney’s incision. Semm – first successful laparoscopic appendectomy in 1982

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ANATOMY

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The THREE TAENIAE COLI converge at the junction of the cecum with the appendix and can be a useful landmark to identify the appendix  Taenia libera – prominent taenia coli Normally located retrocecally, on a posteromedial orientation at the right iliac fossa (where the sacrum lies) The appendix can vary in length from 30 cm; most appendices are 6-9 cm long Luminal capacity of the normal appendix: 0.1 mL Secretion of as little as 0.5 mL of fluid distal to an obstruction raises the intraluminal pressure to 60 cm H20 The APPENDICEAL ARTERY, a branch of the ileocolic artery (which comes from the superior mesenteric artery), supplies the appendix  Important in surgeons, especially when doing resection of the intestines McBurney’s Point: point of maximum tenderness, when one examines with the fingertips is, in adults, one half to two inches inside the right anterior spinous process of the ilium on a line drawn to the umbilicus “Good morning appendix” (meaning, voila! Nakatayo na kaagad!) – All you have to do is to cut/ligate the mesoappendix to the base of the appendix. There are cases when > 1cm is adherent to the cecum, so you leave > 1cm of the appendix knowing that you are already at the base (kahit wala pa naman). That is why the critical view is very important (“funneling effect”). Because if not, you might still be leaving a considerable length and after a few years, patient might be returning to you complaining of signs and symptoms of appendicitis. Drop method – double-ligating the base Sometimes, the obstruction is near the base, so there is a poor tissue quality and you are in doubt that the patient will hold the suture. What is done, aside from ligating it, is that a purse-string suture is applied and the stump is embedded.

The appendix, ileum, and ascending colon are all derived from the MIDGUT The appendix first appears at the EIGHTH WEEK of gestation as an outpouching of the cecum and gradually rotates to a more medial location as the gut rotates and the cecum becomes fixed in the right lower quadrant Lymphoid tissues appears at 2 weeks AOG The relationship of the base of the appendix to the cecum REMAINS CONSTANT, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal, or right pericolic position

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PATHOPHYSIOLOGY Obstruction of the lumen is the dominant etiologic factor in acute appendicitis Fecaliths are the most common cause of appendicieal obstruction  Lymphoid hyperplasia in the younger population The proximal obstruction of the appendiceal lumen (due to bacterial overgrowth) produces a closedloop obstruction, and continuing normal secretion by the appendiceal mucosa rapidly produces distention Distention of the appendix stimulates the nerve endings of visceral afferent stretch fibers, producing vague, dull, diffuse pain in the midabdomen or lower epigstrium – 1st symptom that the patient would experience  Continuous secretion would cause a shift of the pain to the right side Peristalsis also is stimulated by the rather sudden distention, so that some cramping may be superimposed on the visceral pain early in the course of appendicitis As pressure in the organ increases, venous pressure is exceeded Capillaries and venules are occluded, but arteriolar inflow continues, resulting in engorgement and vascular congestion  Disruption of the normal blood flow would lose the normal barrier against microorganisms The inflammatory process soon involves the serosa of the appendix and in turn parietal peritoneum in the region, which produces the characteristics shift in pain to the right lower quadrant Extensive distention causes reflex nausea and vomiting, and the diffuse visceral pain becomes more severe Progression of infection and inflammation would lead to liquefactive necrosis usually to the least supplied area which is distal to the obstruction and the antimesenteric border of the appendix How do we differentiate a phlegmon from a periappendiceal abscess?  Both are complications.  Phlegmon is the matting of the intestines and fats. The purpose is to form a barrier.  Before the appendix ruptures, the body tries to suppress generalized peritonitis.  Once there is pus, and an abscess wall is present, that is what we call a periappendiceal abscess. The only management is appendectomy.

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SCORING SYSTEMS Several scoring systems were devised in order to determine the probability that a patient presenting with acute or surgical abdomen is a case of appendicitis. The most commonly used is the ALVARADO SCALE. A better, but more expensive scoring system used is the AIRS or Appendicitis Inflammatory Response Score, which uses CRP evaluation as one of its parameters. ALVARADO SCORE Findings Points Migratory Right Iliac Fossa Pain 1 Anorexia 1 Nausea or Vomiting 1 Tenderness: Right Iliac Fossa 2 Rebound Tenderness: Right Iliac Fossa 1 Fever ≥ 36.3oC 1 Leukocytosis ≥ 10x109 cells/L 2 Shift to the Left of Neutrophils 1 INTERPRETATION 6mm in diameter and lacks peristalsis.

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In an uncomplicated appendicitis, what type of surgical wound do you have? Clean contaminated. Therefore, treat prophylactically for an average of24 hours (48 hours at the most).Start antibiotics at least an hour prior to cutting.

4) What is the appropriate treatment for appendicitis? o Appendectomy is the appropriate treatment for acute appendicitis. [II, A] There are now breakthroughs in medicine, particularly the emergence of nonsurgical manage-ment of appendicitis; however, consider this only if it is an uncomplicated type that is confirmed by CT scan with presence of fecalith ruled out. Consider cautiously a nonsurgical approach in the event of Ascaris lumbroicoides parasitism inhabiting the appendix (Ultrasound reveals a double lumen, one for the appendix, the other for the Ascaris).

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YES, antibiotic prophylaxis is effective in the prevention of surgical site infection for patients who undergo appendectomy and should be considered for routine use Treatment is giving the full course (5-7 days)

B. What antibiotic is/are recommended for prophylaxis in uncomplicated appendicitis and what is the appropriate dose & route of administration? (MEMORIZE) o o o

Cefoxitin 2g IV single dose (adults); 40mg/kg IV single dose (children) Alternative agents:  Ampicillin-Sulbactam 1.5-3g IV single dose (adults); 75mg/kg IV single dose (children) For patients w/ allergy to beta-lactam antibiotics:  Gentamycin 80-120mg IV single dose + Clindamycin 600mg IV single dose (adults)  Gentamycin 2.5mg/kg IV single dose + Clindamycin 7.5-10mg/kg IV single dose (children)

History and physical examination are still the best assessment techniques to rule out other pathologies.

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C. What antibiotic is/are recommended for the treatment of COMPLICATED APPENDICITIS & what is the appropriate dose, route & duration of administration? (MEMORIZE)

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Adult Patients: o Ertapenem 1g IV q 24hrs or o Tazobactam-Piperacillin 2.25g IV q 6hrs or 4.5g IV q 8hrs o Adults w/ Beta-Lactam Allergy:  Ciprofloxacin 400mg IV q 12hrs + Metronidazole 500mg IV q 6hrs

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Pediatric Patients: o Ticarcillin-Clavulanic acid 75mg/kg IV q 6hrs o Alternative: Imipenem-Cilastatin 15-25mg/kg IV q 6hrs o Pediatric Patients w/ Beta-Lactam Allergy:  Gentamycin 5mg/kg q 24hrs + Clindamycin 7.510mg/kg IV q 6hrs o o

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For gangrenous appendicitis, the recommended form of management is to treat in the same manner as uncomplicated appendicitis (Level I, Category A) The duration of therapy may vary depending on the clinician’s assessment after the operation. The therapy may be maintained for 5-7days. For complicated appendicitis, treatment should be the full course.(5-7 days) Sequential therapy: from IV to oral antibiotics may be considered when gastrointestinal function has returned (Level I, Category A) Better if you have an IV preparation with an oral counterpart.

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The absence of fever for 24hrs (temp vomiting

PICTURE 3 (not actual picture) -

Gangrenous appendix with perforation

PICTURE 8 (MEMORIZE THIS PICTURE)

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Tinea liberia Double ligation Depends on the quality of the tissue -

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Gangrenous appendix with localized collection of pus

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PICTURE 9

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Same manifestations with appendicitis due to its location Management is as the same as appendicitis Segmentally resect the ileum and then perform an end-to-end anastomosis

PICTURE 13 (not actual picture)

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“Longganisa”-looking appendix

PICTURE 10 (not actual picture) -

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Fecalith

Diagnosis: Volvulus A very long Meckel’s diverticulum with a long fibrous band connected retroperitoneally  can rotate  wil lead to gangrene Management is resection and end-to-end anastomosis If diagnosed early, the fibrous band may be removed and observed for the viability of the intestine

PICTURE 14 (not actual picture)

PICTURE 11

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Pediatric appendicitis

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PICTURE 12

Another management is wedge resection Acquired Diverticulum – contains only one layer of the intestinal wall True Diverticulum – contains all layers of the intestinal wall

PICTURE 15 (not actual picture)

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Outbudding Diagnosis: Meckel’s Diverticulum A true diverticulum Congenital anomaly that can only be ruled out intra-operatively

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Diagnosis: Cholecystitis If this perforates, this condition can mimic an acute appendicitis Cholecystitis is one of the differentials for acute appendicitis Bile can gravitate into the right iliac fossa leading to the migration of pain in the right lower quadrant

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Upon opening up, check for the fluid in the peritoneum; if the fluid is bilious, consider a ruptured cholecystitis or a ruptured ulcer

PICTURE 16 (not actual picture)

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Presented also as an acute abdomen

PICTURE 19 Intraoperatively, if the intestines contract when they are squeezed or stimulated, the intestines are still viable PICTURE 20 Diagnosis: Inguinal Hernia PICTURE 21 (not actual photo)

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Diagnosis: Perforated Cecal Mass Grossly, the perforated mass is red in color The appendix is normal This condition also mimics acute appendicitis

PICTURE 17 (not actual picture)

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Diagnosis: Twisted Ovarian Mass

VALENTINO’S APPENDICITIS Valentino's syndrome is pain presenting in the right lower quadrant of the abdomen caused by a duodenal ulcer with perforation through the retroperitoneum.

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Diagnosis: Inguinal Hernia Presented as an acute abdomen Upon opening up, the area shows fatty tissue: omentum that is necrotic The appendix is normal Upon history and PE, it was revealed that the patient has inguinal hernia The herniated structure was not a part of the small intestine, rather, a part of the omentum Management: Resection of the necrotic tissue In the actual picture, you will be able to visualize the omentum entering the INTERNAL INGUINAL RING

It is named after Rudolph Valentino who presented with right lower quadrant pain which turned out to be perforated peptic ulcer. He subsequently died from an infection resulting from surgery attempting to repair the perforation. The pain is caused by gastric and duodenal fluids that tend to settle in the right paracolic gutter causing peritonitis and RLQ pain (Achacoso, et al. 2012).

PICTURE 18 (not actual photo)

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Diagnosis: Inguinoscrotal Mass

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PARAMETER

Suspicion of Acute Appendicitis Pertinent Clinical Findings

Diagnostics and Laboratory

Treatment Approach to Surgical Management Laparoscopic Appendectomy for children Antibiotics

COMMITTEE RECOMMENDATION

Allergy to Beta-Lactam Antibiotics Gentamycin 80-120mg IV single dose + Clindamycin 600mg IV single dose (ADULT)

LEVEL OF EVIDENCE AND CATEGORY OF RECOMMENDATION

EXECUTIVE SUMMARY OF THE CPG ON ACUTE APPENDICITIS

Any patient with RLQ pain

III, A

High Intensity Abdominal Pain  7 to 12 hours duration  Migration to RLQ  Followed by vomiting Guarding Rebound Tenderness Other signs of Peritoneal Irritation ALL CASES  White Blood Cell with differential count

I, A

EQUIVOCAL APPENDICITIS (ADULT)  CT Scan preferred  Ultrasound

I, A

EQUIVOCAL APPENDICITIS (PEDIA)  Ultrasound preferred  CT Scan

II, A

SELECTED CASES  Diagnostic Laparoscopy

III, A

The following are generally not useful: Plain Abdominal X-Ray; Barium Enema; and Scintigraphy Appendectomy Open Appendectomy preferred; Therapeutic laparoscopic appendectomy as alternative Alternative to open appendectomy in children

II, A

ANTIBIOTIC PROPHYLAXIS  Must be considered for routine use to prevent surgical site infection

I, A

I, A

Gentamycin 2.5mg/kg IV single dose + Clindamycin 7.5-10mg/kg IV single dose(PEDIA) TREATMENT OF COMPLICATED APPENDICITIS (ADULT)  Ertrapenem 1g IV OD  Tazobactam-piperacillin 3.375g IV QID  Tazobactam-piperacillin 4.5g IV TID  Ciprofloxacin 400mg BID + Metronidazole 500mg IV QID if with allergy to Beta Lactam antibiotics

I, A

I, A (PEDIA)  Ticarcillin-clavulanic acid 75mg/kg IV QID  Imipenem-Cilastatin 1525mg/kg IV QID as alternative  Gentamycin 5mg/kg IV OD + Clindamycin 7.5-10mg/kg IV QID if with allergy to Beta Lactam antibiotics

II, A I, A

I, A

Gram Stain & Culture Localized Peritonitis

Wound Closure PROPHYLAXIS FOR UNCOMPLICATED APPENDICITIS

Optimal Timing of Surgery

Recommended Cefoxitin 2g IV single dose (ADULT) Cefoxitin 40mg/kg IV (PEDIA)

I, A

Alternative Ampicillin-Sulbactam 1.5-3g IV single dose (ADULT)

I, A

GANGRENOUS APPENDICITIS – Treat as uncomplicated

II, A

DURATION varies on clinician; maintain for 5-7 days. Shift to oral therapy with return of GIT function may be considered

I, A

DISCONTINUE THERAPY if with absence of fever (T