appendicular mass.pptx

appendicular mass

1. Regarding Appendicular Mass And Pelvic Abscess M ORBIDITY MEETING Unit B2 Dr Bakri Hassan D r Nabeel Riadh

2. overview C ase Presentation The Details Of Workup And Process Accordingly. Sequence of events leading to m orbidity Sequencial M anagement of related morbidity events L iterature Review related to Appendicular mass + Abscess management T ake Home Message

3. HISTORY A 46-year-old Mrs Eliza presented to the emergency room on 06-10-2023 at 03:24 am with chief complaints of abdominal pain that was vague, Diffused and more pronounced in the hypogastric ,right iliac fossa region for the last week or a bit more. Its associated with fever ,nausea ,vomiting and loss of appetite. She had TWO consecutive visits for the same complaints but was being discharged undiagnosed on oral medications probably by the on-call emergency physicians. She was presented to us by an emergency on-call physician on our khafara early morning on her THIRD visit. She had no significant past medical history e.g. non-diabetic and non-HTNsive. Past surgical Hx had TWO C-suction.

4. The Details Of assessment. Clinical examination On observation, she was Apparently ill-looking with a sluggish verbal response. Mild Guarding and rigidity with somewhat marked Tender and rebound tenderness were noted at the Right iliac fossa and suprapubic region. Digital Rectal Examination postponed due to anorectal pain with anal skin tag secondary to long-standing Fissure in Ano. Vitals Labs WBC-17.91,HB-118,PLTS-338,NEUT-80%,D-Dimers-1605,Urine Shows RBC and WBC X-ray chest showed Falls Situs Inversus on Flipped and Incorrectly labelled chest X-ray but later on, the correction was done after having a CT chest & abdomen.

5. cT aBDOMEN

6. interventional radiology (06-10-2023) 1st POD on 07-10-2023 interventional radiology intervention by PEGTAIL insertion was vitally stable and the PEGTAIL drainage around more 1000 ml/24 hours noted post. FOLLOWED BY CHECK ULTRASOUND ON 08-10-2023

7. F ollowed by repeat CT Abdomen 10-10-23 T ransverse section C oronal section

8. On the 5th PAD decision is TAKEN TO FOR DEFINATINATIVE INTERVENTION. On 5th Post Pigtail Insertion/Admission Day the decision for definative intervention is taken by acute care team since, T he post pegtail recovery of patient wasn’t satifactory e.g. Persistantly increasing WBC count leukocytosis (19.80). Pyrexia. Vomited many times. PEG tail drainage is no longer well-functional since no additional drainage accumulated in the drain bag. Repeat CT abdomen shows cleracut Ficolith. markedly thickened enhanced wall likely probability of underlying MASS should be R/O by histopathology.

9. PER OPEARATIVE FINDINGS Operatuve Findings :- Markedly Distended Proximal Small Bowels Loops e.g. Jejunum ilium up to the level 2 1/2 feet proximal from ICJ Dist al third Ileal Bowels Loops Amalgamated With Proximal Cecum, Mid Of Sigmoid Colon, Caecum and Frozen Pouch Of Douglas. Coiled Tip Of Pigtail Catheter Found In The Centre Of Pelvic Abscess. Appendix Was Retrocaecal Markedly Fibrosed And Mixed With Gangrenous Surrounding Tissues. Post Adhesive-lysis Of Mentioned Gut Found two Likely iatrogenic Ileal Perforation 12cm Proximal To ICJ (Ileocecal Junction). Around 30 Ml. Turbid Fluid Found In Abscess Cavity Mixed With Necrotic Tissue. Procedure:- Diagnostic Lap converted To Exploratory Laparotomy Through Infra-umbilical Midline Incision Slightly Extended Above The Umbilicus And Up To Pubic Symphysis. Peritoneal Cavity Approached. Finding Mention Above Noted Compromised And Perforated Part Of Ileal Portion About 15cm In Length Excised And Side To Side Anastomosis Done To Linear Stapler. Gynaecologists On Table Opinion Taken About The Frozen Pelvic And Made Clear By Them. Peritoneal Cavity Washed Thoroughly With Saline And Mopped. Two Drain Place One On Left Side Draining The Pelvic Cavity And The Other On Right Side Draining The Anastomotic Area Haemostasis Secured Followed By Abdominal Closure With PDS 0 And Skin Stapler Applied To Skin For Closure.

10. Diagnostic lap. Followed by exp. laparotomy on (11-10-2023)

11. 2ND RE-LOOK SURGERY on 15-10-2023 FOR BLEEDING FROM SURGICAL INCISION SITE

12. SEQUENCE OF EVENT LEADING TO M orbidity It is possible that a patient may have been discharged with acute appendicitis without a diagnosis during the first two consecutive emergency visits (delayed presentation). Initial Pigtail insertion by intervention radiology might delayed the definitive , curative surgical intervention e.g. Diagnostic Laparoscopy and proceed accordingly. Per-operative iatrogenic bowels injury lead to resection and anastomosis of distal ilium. 2nd Re-look surgery e.g bleeding from Surgical site incison.

13. H ow we successfully manage these EVENT of morbidiy factor no#1 ? It is possible that a patient may have been discharged with acute appendicitis without a diagnosis during the first two consecutive emergency visits (delayed presentation). Quick identification of patient is purely surgical. Straight CT abdomen with IV contrast instead of USG (Radiologist informed) Informed 2 nd on call and the patient is stratified as may need an emergency surgical intervention. Detail clerking , Hand over , Caprini scoring and Drug Reconciliation , I/V fluid (4/2/1 rule ),antibiotics and analgesia. Endorsed to the morning ACU according to CT findings for Early possible PEG tail insertion by IR to reduce the septic Burdon and it was done on the same day of patient admission. Initially, more than 1000 ml pus was drained which was sent for c/s for antibiotics specification. 4.5 g piperacillin /tazobactam IV every eight hours. 50 mg Caspofungin Injection IV OD

14. H ow we successfully manage these EVENT of morbidiy factor no#2 ? Initial Pigtail Insertion By Intervention Radiology Might Delayed The Definitive , Curative Surgical Intervention e.g. Diagnostic Laparoscopy And Proceed Accordingly. Due To Kinking Or Obstruction Of The Catheter. ​ Accidental Withdrawal/ Displacement Of The Catheter Tip. Very small calibre of PEG tail Drain unable for thick pus of abscess cavity. A s we realised On the 5th post pigtail insertion patient's condition is still deteriorating. The decision for definitive intervention was taken out.

15. H ow we successfully manage these EVENT of morbidiy ? On 5th Post Pigtail Insertion/Admission Day the decision for definative intervention is taken by acute care team since, T he post pegtail recovery of patient wasn’t satifactory e.g. Persistantly increasing WBC count leukocytosis (19.80). Pyrexia. Vomited many times. PEG tail drainage is no longer well-functional since no additional drainage accumulated in the drain bag. Repeat CT abdomen shows cleracut Ficolith. markedly thickened enhanced wall likely probability of underlying MASS should be R/O by histopathology.

16. H ow we successfully manage these EVENT of morbidiy factor no# 3 ? Per-operative iatrogenic bowels injury lead to resection and anastomosis of distal ilium Since intraoperative iatrogenic bowel injury is considered a nightmare by all general surgeons around the world and it commonly happens due to tissue fragility. When the surgeon has to perform an exploratory laparotomy, such as in this patient. So our Operative team members were fully prepared mentally and physically for such an accident. And, unfortunately, it happened in the form of two perforations proximal to ICJ, although the way of our adhesive-lysis of small bowels was very meticulous. Affected part of ileal part resection and anastomosis done with Linear Stapler successfully.

17. H ow we successfully manage these EVENT of morbidiy factor no# 4 ? 2nd Re-look surgery for bleeding from Surgical site incison. It was 5th post op day of exploratory laprotomy. B leeding from incison sited noted P atient taken to OT and bleeding from rectus muscle secured successfully.

18. CURRENT CONDITION OF PATIENT Vitally normal. Well oriented Afebrile. Mobilised. Orally taking food is well tolerating. Normal bowels habits.

19. literature review Aims and Objectives To study the safety and feasibility of emergency appendicectomy in appendicular mass. To compare the complications, morbidity and mortality in emergency appendicectomy and conservatively treated appendicular mass.

20. Abstracts:- Traditionally, these patients are managed conservatively followed by interval appendicectomy 4-6 weeks later (Ochsner Sherren Regime i.e. bedrest, antibiotics and intravenous fluids.[2-11]) Advocates of initial conservative approach claim lower rate of complications compared to early operative approach. The studies favouring immediate appendicectomy claim an early recovery and complete cure during the same admission. Conclusions:- There is no significant difference in the operative problems faced between the two lines of management studied here. There was a significant difference in the complications between the two groups with more complications occurring in the group of patients treated by Ochsner Sherren regimen followed by interval appendicectomy and hence these patients had more morbidity. The duration of parenteral medications and total duration of hospital stay was more in group II patients than in group I hence increasing the economic burden on the patient. Early appendicectomy obviates the need for a second admission and provides curative treatment during the 1st admission whereby minimizing total expenses. Early appendicectomy may also avoid the consequences of the misdiagnosis and mistreatment of other surgical pathologies. Early appendicectomy in appendicular mass is safe owing to the improvements in surgical skills and better post-operative care. Low morbidity, reduced hospital stay, low cost and patient compliance favour operative management of appendicular mass by experienced surgeons thus obviating the old practice of conservative treatment followed by interval appendicectomy.

21. literature review The Points Given Below Are Exactly 100% Matching With Our Case Taken From This Article 15.1% of pc drainage patients needed surgery either laparoscopic or open surgery. F ailure of interventional radiology drainage does not mean, radiologists were not experienced, as there are many causes of failure like, Multiloculated abscess, cases associated with pelvic abscess also, Thick pus and can't be come out through the drain, Tip of drain was blocked by necrotic tissue or omentum and distended surrounding bowel. S o failed interventional radiology drainage is not dangerous and can be well treated by surgery either open or laparoscopy- this is an important part of the message. Conclusion Laparoscopic management of appendicular abscess can be safely applied in a good experienced hand with no mortality & morbidity, without the need for interval appendectomy.

22. T ake home message There are 3 methods for treatment of appendiceal mass: emergency surgery, conservative management followed by interval surgery, and totally conservative management without interval surgery. Misdiagnosis of appendiceal tumour or colonic tumour can be disastrous in patients with appendiceal mass so we should exercise caution during surgical management of appendicular mass. There is no hard and fast or well established management plan for appendicular mass management as it varies from patient to patient. Don't rely on one-way treatment get into a multidisciplinary approach.

23. Thanks