Case of perforated appendicitis
I was called to the ER to see a 28 YO male-insulin dependent diabetic- patient who presented with RUQ pain, chills and high fever. He gave a history of a laparoscopic cholecystectomy a year ago- elsewhere; during the year which followed he was admitted 7 times with RUQ pain and temperature, each episode responding to a short course of IV antibiotics; CT- guided percutaneous drainage of “something” was performed on 2 occasions.
On examination the patient was febrile; his RUQ was tender and guarding with percussion tenderness over the liver and right loin; the rest of the abdomen was innocent. White cell count was elevated; absence of clinical jaundice and normal LFT excluded more or less ascending cholangitis. We admitted him and started IV antibiotics. We went then to study his obese hospital chart- learning the following:
The lap chole was performed for “acute cholecystitits” and “multiple gallstones”. The pathology report- “acute cholecystitits- no stones submitted”. (the patient and family denies receiving any gallstones). On the subsequent re-admissions- CT was done -reporting an “effusion in the Morrison pouch (hepatorenal fossa) and a soft tissue phlegmon at that region. On all admissions the patient responded to a brief IV antibiotic course. A month ago, a PC drainage was performed, obtaining clear fluid which grew S.fecalis (?).
We CT scanned the patient again- some fluid in the Morrison pouch and a large, soft tissue density just below (the same as at the time of the previous PC drainage). Liver and bile ducts-normal. My initial diagnosis was “lost” or “dropped” gallstones-forming a chronic abscess. The radiologist did not know that gallstones may be “dropped” during 85. I booked the patient for a laparotomy pn Saturday morning- telling the PGY -IV to start writing another case report -level 5- paper.
We explored him through a 12 cm’ transverse RUQ incision; dissecting dense adhesions between the transverse colon and liver, the LC clips at the porta-hepatic were identified- nothing there. Nothing at the right gutter or on the kidney; the retroperitoneal overlying the duodenum-shining and healthy. The tissue plans exposed above the colon were hard and inflamed; we dissected the colon from above, exposing the base of the mesocolon- and found -stuck on the retroperitoneum just below the portal hepatis, a 2 X3 cm’ inflamed tip of a chronically perforated appendicitis – very long retrocolic APPENDIX. Appendectomy was uneventful.
So the acute cholecystitis was in fact perforated appendicitis “treated” with LC – the histological changes on the GB were caused by the nearby appendicitis. Further re-activation of the resulting- partially treated by antibiotics appendicular abscess- were again masked by more antibiotics.
Ten years ago all the above would have never occured- as during the open cholecystectomy for “acute cholecystitis ” the surgeon would have identified the real problem. And then there is the issue of over-reliance on modern imaging methods and non-invasive therapies.
If the surgeon was still doing the old fashioned incidental appy as a lap incidental appy (don’t know if this patient would have been a good candidate with his diabetes, but maybe his diabetes isn’t so bad now that he has his perforated appendix out and even I probably would not take out a retrocecal appendix strictly as an incidental lap appy), this problem would have been solved at the first op also.
Or if the surgeon had noticed the difference between the patient’s presentation and what he found, he might have looked around and found and removed the appy.
(The point is that just because you have a laparoscope, you don’t have to be a dummy.)
Or if the Radiologist had thought of the appy (after all, they are touting CT for diagnosis of acute appendicitis), perhaps they would have discovered the perforated appy.
As Level 8 evidence of a completely unrelated problem (but kind of interesting), I was asked to see a middle-aged (to me, old to Eric) lady with RUQ pain last year. Gallbladder sonogram was normal. Her RLQ felt normal, but her RUQ was quite tender and she looked ill (she is successfully self-employed and the successfully self-employed don’t usually come in unless they are sick).
I knew it was not her gallbladder, so made a RLQ incision (over the appendix) and found instead a perforated transverse colon diverticulum with abscess sitting next to her gallbladder. I extended the RLQ Rocky-Davis incision just a little and did a right hemicolectomy with primary anastomosis and she did well.
Technology is wonderful as long as you know what you are looking for. Last year, a 24 year old female was referred to me for persistent “jaundice of pregnancy” even up to one year post partum. She was otherwise quite asymptomatic except for jaundiced sclerae and persistently elevated enzymes but negative for hapatitis. She had been seen by about 16 doctors in three diferrent hospitals ranging from surgeons, internists, pediatricians, OB’s and has had two ultrasounds of the HBT done months apart with unremarkable findings except for a slightly enlarged liver. She developed quite a dossier with her workups with nothing to show for it except continuous treatment with vitamins. Her personal and social history was very unremarkable. She remained a medical enigma but which was quite disturbing to the hospital staff because she was also employed as the admitting clerk in a hospital and she had to see all admissions and interview them prior to admission. So all the patients had to see her jaundiced sclera.
When she was referred to me, I borrowed a portable ultrasound machine from a radiologist on the excuse on the excuse that I wanted to look at somebody’s gall bladder but I did not tell her that I also do ultrasounds on the HBT and pancreas. Please don’t tell the other radiologists that I do ultrasound of the HBT just for fun. Ultrasound finding’s were as follow’s, diffusely enlarged liver with lacey-like echopatttern, GB normal in size, CBD normal. The echopattern was characteristic of liver cirrhosis from Schistosoma japonica infestation. Repeat history revealed a travel to an endemic area for about two weeks when she was 4-5 years old. Repeat repeat (nth) fecalysis revealed schistosoma ova (when the med tech was really looking for it). Schistosomiasis is really something you see only in textbooks in our place. But maybe Moshe, you are right, an ultrasound would not have been necessary if someone would have bothered to ask if she had ever travelled to a certain province in her lifetime. There’s nothing like a good ‘ol history.
I just finished the Selected Readings in General Surgery (Parkland Dallas TX) Continuing Ed on Portal Hypertension and they mentioned that the number 1 cause of portal hypertension in the world is schistosomiasis.
How many surgeons have performed laparoscopic cholecystecomy for what was presumed biliary disease (and possibly did have biliary disease) and later found out that the symptoms were do to some other source? We have had a couple including a carcinoma of the fourth portion of the duodenum found when the patient continued to have symptoms (lap GB performed “elsewhere” of course).
Your post is an interesting anecdote, but one that in no way invalidates laparoscopic surgery. It is simply a tale of a misdiagnosis, an inadequate laparoscopic operation, and several subsequent botched diagnostic investigations. I’ve been faced with “acute cholecystitis” like this twice in the last 2 years. Both times I found an inflamed appendix in the right up per quadrant and removed it laparoscopically. Both of those operations were kind of challenging, but I remember driving home from the hospital, elated, (a less spectacular drive than your’s–just pine trees and lakes) thinking of that t I think you’re reaching on this one.
BTW, you made mention that “the patient and family denies receiving any gallstones”. Does this mean that surgeons in your part of the world give their patients their stones to take home? We have patients ask for their stones here, but I’ve been told that OSHA prohibits that because of infection concerns.
The abdomen remains the temple of mystery.
I hope you do write it up, as there is a lesson there that must constantly be re-learned- quit relying so much on shadows on a piece of celluloid and get back to common sense and the patient to answer your questions and to solve the patient’s problems.
He was not indicting “laparoscopic surgery”, but just how easy it is for us to get a little lazy and fall into the trap of relying more on pictures than common sense, because the former is so much easier–we are all human, and have the same weaknesses as the rest of our race. You can’t deny it happens every day, unless you are living in a vacuum–I certainly see it all the time–do you really think the case was an outlier??? Of course not–it was just a piece of the tip of the iceberg that he happened upon.
I would like to add intraoperatory judgement(source & damage control) plus clinical history&judgement, I think, they are the ABC of the surgeon at the present and I hope in the future also (but I am a human been, therefore I do mistakes every day..)
I wouldn’t deny a certain amount of paranoia. I’ve elected to take the other end of the rope.
Laparoscopic surgery demands different skills, different judgement, but it’s still surgery. Racial weaknesses notwithstanding, relying on pictures to perform surgery does not preclude using common sense or applying basic surgical principles. Certainly I have seen the results of poor surgical judgement in laparoscopic cases as well as classic open cases. You’re right, of course. The basic fact is that this patient had poor surgical treatment. A poor laparoscopic surgeon is in reality just a poor surgeon.
Have you seen somebody dieing due to LC? What about M&M during the former years of the LC era? What you are telling is in an anecdotic way? or you are wanting to tell us the open cholecystectomy is safer than LC? Is better to do open? Cause, with the open system I can also tell you some histories, and I guess every one of us can. So, my friend your case teach us that we must take care of LC, but I remember that from the first LC I did, I am listening to the same advice, and now I give the same to the younger surgeons as well. Last week I operated a young woman, she had cholelithiasis demonstrated by US, we offered LC, she insisted in opened, we insisted in LC, at last, we didn’t insist anymore. I said to the resident, that it’s not good to try to force the patient to change her/his mind, for if something happens, it’ll be hard to defend. Well, we operated her opened, we found an “easy” gallbladder, but as a rutinary maneuver in OC, I touched the CBD, and EUREKA!, one stone, so we did the cholecystectomy, plus choledochostomy with T-tube, like old times. On the other hand, I don’t know what is your experience, but I feel that LC has taught me many things, such as: early discharge, no drains, no suture to the cistic bed. Common regime a week after the op, no unneccessary antibiotics, summing up, to be SIMPLER, and this is for me an added value of LC.
With cholecystectomy for simptomatic and asimptomatics patients,we usualy give the stone to patients.If no simptoms,is necessary a physical sign for the patient.
This however was not “just an anecdote”; the case I presented was seen and managed over a year by not a few physicians- a few of whom I know and respect. It suggests that all the “recent advances in surgery” brought upon us new problems.
After reading the pre-LC imaging report that “multiple stones were seen” and noting that the pathology report mentions that no GS were received I asked the patient whether, maybe, he got the stones. I know that this is not the practice around here, but this was the practice in the few countries I worked before landing in North America. Anyway, I noticed that patients were satisfied to observe their stones in a small jar by their bed- showing it to the visitors. The latter loved to shake the jar-obviously multiple small stones were more impressive than one stone.
Try giving the stones to your patient- it will make them happy . I do not know what OSHA is but the “infection concerns” sound a major B.S to me.
They told us that too – that the stones were “biohazardous waste.” The OR Administrator then threw in an anecdote about a case where a hospital had lost a large sum of money for giving the biohazardous gallstones to a patient, after which the stones were found and consumed by a child in the family.
Being a skeptic to begin with I guffawed at this one, and promised to stop giving my patients their gallstones if they could show me the case.
“No problem,” they said. And I didn’t let it pass. I asked every day until they admitted there was no such case.
I guess I’m as much of a crusader on this issue on minimal surgery. I can’t count the times I’ve been told there is a “policy” forbidding something, only to leave everyone astounded when I demand they show me the policy and they can’t find it.
In our part of the world, the patient’s relatives measure the success of cholecystectomy by the number of stones they are given to take home. More and bigger the better! Just to add, the complexity of the operation is measured by the number of skin sutures!
For years we have been doing open cholecystectomy without drains, without suturing the GB bed and with one dose of AB. These favorable changes in your practice should not be attributed to LC but to a drastic advance in your surgical thinking!
It appears that you misunderstood somehow the intended message of my banal case report. My intention was not to claim that LC is “bad”; I do it routinely although all evidence points to the truth that “small incision open cholecystectomy” is as good, safer, and cheaper. All I wanted is to point out the extreme potential pitfalls associated with the “new technology”.
I’d like to see some of this evidence. And please don’t quote from the article in Annals of Surgery published by my colleague about “Microceliotomy cholecystectomy.” He claims to have good results using a small incision in the “Minimal Stress Triangle” which minimizes post-op pain. It also minimizes your ability to see what you are doing. He’s had terrible complications and poor follow-up. The residents named as co-authors had no knowledge that they were named in the paper because they wanted to have nothing to do with it. The paper had no data and no basis from which to draw any conclusions. I suppose I should have written to the editors to ask how they could have published such a paper; I thought Annals of Surgery was supposed to be peer-reviewed. But I digress. Laparoscopic surgery is safe if you know your limitations. It is also cheap if you don’t use disposable instruments.
I agree with you about the Hungarian paper you mentioned. I also thougth that it cannot be true- a “mini-cholecystectomy in 12 minutes…”
However, there are at least 4-5 randomised studies comparing mini-open cholecystectomy to open conventional operation (one of the study ours- World J Surg) and mini to LC -one from Canada published in the Lancet.
Overall- mini is better than the conventional and LC very minimally better or not better than mini. “Better” I mean less pain and shorter hospital stay. No doubt= a good mini in good hands is a safe operation.
Now, I do did not intend to say that LC is “not good” -I just say that LC is not a gift from God and a good surgeon can or could produce as good results without all these instruments that make companies rich.
Now, you want references- go to the MEDLINE and click the words “mini” or “minimal” and combine it with cholecystectomy.
I am sure about one thing: we can meet in your town and take 10 patients: 5 will undergo LC by you, 5 “mini”-cholecystectomy by me. Both groups will receive similar abdominal dressings and will be blinded to what procedure they underwent. They will be assessed by persons also blinded to the proocedure. I can ensure you that neither the patinets, nor the “judges” will know who underwent which operation.
I am sure that you are a leading laparoscopic surgeon but, please ,do not be blinded to the real value of laparoscopic surgery.
All I have to say is that again Dr. puts emphasis and stresses a particular situation that may happen anywhere, anyday to somebody, specially to those surgeons who are not well awared with all the steps that must be observed when you are entering the abdomen via laparoscopic approach. So it seems that in the case of the reference, the surgeon didn’t do any exploration at all. He went directly and full of energy to the GB (with ot without stones, who knows?) and misregarding the rest of the viscerae,he did his operation, he took out the GB and then he went happy driving home, a little elated…also. He had done his job and he believed he had done it right.What a hell of mistake…He was wrong. But such a misfortune can’t be charged to the laparoscopic procedure.Only to the unskillfull operator, isn’t so, Dr. ?
Doesn’t all laparoscopic surgeons perform a thoroughfull general inspection of the abdo cavity once they have entered?
Would such an acute process affecting the appendix, even in an abnormal location, be misregarded to an exploration done by an experienced lap surgeon?
Does that mean that laparoscopic cholecystectomy is a fountain of multiple complications, misdiagnoses,iatrogenic injuries,choleperitonitis,etc. when the cause of the situation reported by Dr. is fully awarded to the surgeon who performed the first op?
Of course,not.
In his own speech, Dr. states that 10 years ago,in an open cho, this would have never happened and gives us the impression that one of the weakness of lap chole is that things like these might take place during the procedure.
Worse things have happened during open Chole everywhere and, almost all of it, could be awarded to the surgeon in action, not to the procedure itself. And Dr. knows that perfectly well.
I don’t know why Dr. , in a “coup de folie”, attacks again the laparoscopic procedure when there’s enough evidence level 1 that it’s good, safe and low cost.
Is it that he has nostalgia and he is looking backwards to the past? Who knows…
Then he embarks against imagenologic procedures, stating that ,even though they represent a real and effective progress in supporting diagnoses, they might take us by mistaken paths, like what happened in the case he reports.
Doesn’t everybody know that these radiological actions are complements to the clinical data and they must always be analysed by the clinician in view of the clinical picture the pt presents?
Age gives us perspective. We age and we mellow. You now notice the clouds and take pleasure in an appendicectomy. Like the philosophers of my continent said: to be in the world, not of the world.
Would you -after an emergency laparoscopic cholecystectomy-for what appears to be acute cholecystitits- routinely mobilise he right and left colon to look for a retrocolic high appendix? I doubt it. I do not wish to bore the members and myself with further arguments.
Please, forgive for being a pain in the ass. You know, I know….that I am, you are some sort of ” contestataires”. Undoubtedly, you do better than me, as your knowledge and wisdom in surgical sciences is, by far, more than mine.