Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
.pdf
inthisgroup ofpatientstherearemany withperforationsoIwould
startantibiotictreatmentandarrangeforanoperationwithoutundue
delay,especiallyifthepatientisseptic(rapidrespirationorpulse,or
leukopenia).Imagingisnotindicated,asanegativeexaminationwill
probably not change this decision. If I am in doubt about the
diagnosis I startthe operation laparoscopically — for many of
youthisisprobablyaroutineanyway.
•
Patients with an indeterminate presentation (score 5-8) are
admitted to hospital and re-examined after 6-8 hours. The
clinicalpictureoftheAApatientwillbythenunfoldwithasignificant
increaseinclinicalsymptomsand inflammation. If still atypical you
may order a CT or proceed with laparoscopy.If there isa marked
decrease in inflammation at re-examination (especially fever,WBC
count,proportionofneutrophils),butthesuspicionof AAremains, I
plan another re-examination after 6-8 hours. As I will not operate
duringthat timeI allowthe patientto haveameal andthen tofast
again. I often find further improvement after asecond observation
period and sometimes thepatient can be senthome. I have seen
thismanytimes,eveninpatientswithCT-verifiedappendicitis.
•
Small children, the fragile elderly — yes, beware the old
patients in whom presentation of perforated appendicitis is
oftenatypicalanddelayscanbelethal—andpatientswithan
atypical presentation (>3 days’ duration of symptoms, recurrent
episodes of abdominalpain, a palpable mass or if the intensity of
painisdisproportionatetoweakclinicalorlaboratoryfindings)need
specialconsiderationasdescribedabove.InthissituationIhavea
lowthresholdforimaging.
Dr.AnderssonofSweden—whomwe considertobetheultimateinternationalguruonAA—
preaches a selective use of abdominal imaging. However, in the USA, where I
practice,thedecisionwhomandwhentoscanisnolongerinour
surgicalhands.ThefactofthematteristhatmostpatientshavealreadyundergoneaCT
scan, before we, surgeons, arecalled to assess them. Typically, these scans are orderedby
emergencyroomphysicians,orfamilydocs,beforeconsultingthesurgeon.Inmosthospitalsin
the USA, even the tiny rural ones, high-tech CT images are much easier to obtain than a
gourmet meal or even a cup of good coffee.And radiologists are always readily available to
interprettheimagesonline.It’snowonderthenthatphysiciansconfronted
withapotentiallyacuteabdomenfeelcompelledtogetaCTwhen
itisaseasilyprocuredasjunkfood.
Issuchapracticeof(almost)routineCTscanning,imposedonus
byothers,‘good’or‘bad’forourpatients?Itisverydifficult,ifnotunfeasible,
toprovescientificallythattheincreaseduseofCTscanningisbeneficialoverall.Butwhatabout
theindividualpatient?
Theadvantagesof‘liberalscanning’arefamiliartothoseofus who use it ( Chapter5) and
include:
A large number of patients with ‘non-specific abdominal
pain’ can be discharged safely after a normal CT scan;
hospital admission for clinical observation is thus rendered
obsolete.
Greateraccuracyinthediagnosis— gone are the days
whena15-20%rateof‘lily-white’appendiceswasconsideredan
acceptablepricetopayfornotdelayinganoperationinacaseof
genuineappendicitis.
Other diagnoses are readily diagnosed and treated
correctly. Dr. Andersson claims that patients with a ‘typical
presentation’(score>8)donot needimaging. However, patients
withacutediverticulitisofthececumorsigmoidmaypresentwith
typicalfeaturesof AA.Here,age andsexmatters:a17-year-old
male with typical features is much more likely to suffer from AA
thanafertile womanoranelderlypatient —thetypeofpatients
whotendtobenefitfromimaging.
Avoidanceofunnecessaryoperations—CTissaferand
more cost effective in excluding AA in a lady with a ruptured
ovariancystthandiagnosticlaparoscopy.
Many small hospitals do not have an experienced
general surgeon readily available to evaluate each and
everypatient‘àlaDr.Andersson’.AnegativeCTallowstherural
surgeontosleepbetteratnightandavoidsunnecessary‘shipping
out’(transferofpatientstoanotherinstitution).
Legalconsiderations:juriesintheUSAhavebeenawarding
almostamilliondollarsfora“failuretoobtainimaging”andthus,
allegedly, causing a delay in diagnosis of AA — with resulting
morbidity. While not advocating ‘defensive medicine’ it is
impossibletoignoresuchharshrealities.
No, we do not support routine CT scanning. But its liberal use undoubtedly makes for better
clinical management. And anyway, the train has already left the station — we have a useful
diagnostictool,which will improve(becomefasterandemitsmallerdoses ofradiation)—and
thereisnowayback.AndBTW:inpregnantwomen—considerMRI.
Finally, for those of you who like to use ‘scores’: I repeat what Dr.
Andersson said, that scores are only an adjunct to clinical judgment. While statistically solid
theycan‘misfire’intheindividualpatient.Justrecently I reviewed acaseofanelderlypatient
presentingwithlowerabdominalpainandanelevatedWBCcountandCRPlevel. HisAIR
scorewouldhavebeen5.Hewasadmittedforobservation.PerforatedAAwasfound
at laparotomy the next day; he died from overwhelming sepsis. A CT on admission
mayhavesavedhim!SuchapatientfallsintotheuncertaincategorydescribedbyDr.
Andersson.Moshe
Treatment
Antibiotics
Judicious administration of antibiotics, to cover Gram-negative and
anaerobicbacteria,willminimizetheincidenceofpostoperativewound
(common)andintra-abdominal(rare)infectivecomplications( Chapter
13). In simple AAthe antibiotics are considered prophylactic, while in
complicatedAAtheyaretherapeutic( Chapter7).Weencourageyou
to administer the first dose of antibiotics just before you scrub. If the
patientappears‘septic’withsignificantperitonitisandyoususpect
perforated appendicitis, you should start antibiotics immediately
whenyoudecideonanoperation.
IfatsurgerytheAAprovestobesimpleandthereisnovisiblepus,no
postoperative administration is necessary. Should you, on the other
hand,discovercomplicatedAA,additionalpostoperativedosesare
indicated.Wesuggestthatyoutailorthedurationofadministration
totheoperativefindings.GangrenousAA,withoutanypusformation,is
a‘resectableinfection’,whichdoesnotrequireprolongedpostoperative
antibiotics.Whenpusisfoundortheappendixisperforated,youshould
probably give atleast 5 days of treatment ( Chapters 7,13 and 44).
Please note howeverthat iatrogenic perforation of the appendix may
occur during laparoscopic appendectomy. This may result in significant
contaminationoftheperitonealcavity.Addtothis,unwarrantedperitoneal
lavage — which is not completely evacuated (see the laparoscopic
sectionbelow)—andyougettheidealrecipeforpostoperativeinfected
ascites! In these circumstances consider prolonging the postop
courseofantibiotics.
Non-operativemanagementofacuteappendicitis
As already said, simple AA can frequentlyresolve without treatment.
Nowonderthatreportshaveshownthat‘assumed’orimage-proven
simple AA can respond to non-operative management with
intravenous broad-spectrum antibiotics. However, I believe that in
the majority of patients the symptoms resolvespontaneously and
not because of the antibiotics. This parallels recent findings that
patients with uncomplicated acute diverticulitis have identical healing
rateswhethertheyreceiveantibioticsornot.
Ithinkthereareproblemswithgivingantibioticstoapatientwith
assumedAA.Oneisthatifthepatientgetsbetteryoudonotknowifhe
had AAin the firstplace and you do notknow ifthe improvementwas
spontaneousorduetotheantibiotics.Soyouareforcedto‘complete’the
treatment, which may prolong the hospital stay.A second is that if the
patienthascomplicatedAAyoumay seeonlya partialresponse, which
willalso prolongthe suffering.Thisiswhy Ido notsupport non-surgical
managementwithantibioticsfor‘everyone’.
However,non-operativemanagementofAAcanbereasonablein
thefollowingcategoriesofpatients:
•
Patients with a prohibitive surgical-anesthetic risk (e.g. postmyocardialinfarction).
•
Patientswhorefuseanoperation.
•
Patients in the middle of the Pacific Ocean or on a nuclear
submarine, or in rural locations whereno surgeonisavailable.
OronaspaceshiptoMars.
•
Morbidlyobesepatients.
•
Pregnantwomen(1sttrimester)withmildAA,whereanyoperation
mayinduceabortion.(However,thismaybecontroversialassome,
includingmyself,thinkthatthisisamyth.)
•
Obviously,patientswithanappendicealmassorphlegmonshould
be managed non-operatively. This is accepted by most surgeons
andisnolongercontroversial(seebelow)!
Careful clinical assessment, augmented by scoring systems
and/orimaging,shoulddistinguishbetweenthe mild cases, which
arebestamenabletonon-operativetreatmentandthegangrenous
or perforated ones which are not likely to resolve and probably
mandateanoperation.
Communicating with surgeons all over the world (on SURGINET —
http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm) we realize that although non-surgical
treatmentisacceptableinsomesettings,thevastmajorityofsurgeonsarestronglyaddictedto
thepolicyof “alwaysanappendectomy—the soonerthebetter”.Thereasons forthisattitude
are numerous and include: deeply entrenched dogmas and teaching; (unfounded) fear of
progression of mild appendicitis to perforation; fear of litigation, perceiving that non-operative
management is not the accepted standard of care in their communities; the perception that
appendectomy (particularly laparoscopic) offers an instant remedy with minimal morbidity;
reluctanceto subject patients to aprolonged hospitalization and antibiotic treatment,whereas
following an uneventful appendectomy for mild AA they usually go home within 24 hours.
Moreover, many surgeons find it difficult, if not impossible, to
convince patients and their physicians that not all forms of AA
need an appendectomy and that avoiding an operation won’t
endangertheir patients’ lives. And, as always, there are the financial aspects to
considerincountrieswheresurgeonsworkona‘feeforservice’basis:whenthesurgeonispaid
forappendectomytentimestheamounthe receives for non-operativemanagement there will
bealwaystheconsciousorsubconsciousdrivetooperateratherthannot.Evenstrictlysalaried
surgeons often suffer from the syndrome of funktionslust: isn’t operating more fun than
observingorprescribingantibiotics?
ItshouldbeclearthatwebelievethatAAisnotasinglediseasethatneedsonetreatment,but
has a spectrum of presentations and pathologies that can be treated in different ways —
including without an operation. We wish we knew how to modulate the
prevailing educational, cultural, economic and legal components
which still influence mostsurgeons to believe that any diseased
appendixbelongsintheformalinjar.Moshe
Theoperation
The point of greatest tenderness is, in the average adult,
almost exactly 2 inches from the anterior iliac spine, ona
linedrawnfromthisprocessthroughtheumbilicus.
CharlesMcBurney
Theappendixisgenerallyattachedtothececum.
MarkM.Ravitch
Whentooperate?
Youdon’thavetorushtotheoperatingroomassoonaspossible
with each patient diagnosed with AA. Obviously, if your patient is
septicwithrapidrespirationandtachycardiaorhasimpressiveabdominal
findings (suggesting a perforation), then the patient should receive
optimal resuscitation while you start antibiotic treatment, and then you
should operate without delay. Otherwise, you can safely defer an
operationtodaytime—Idonotrecallhavingremovedanon-perforated
appendixafter midnight;except inyoung childrenof course.Youdonot
rush to the operating room with acute diverticulitis ( Chapter 28), so
what’sthedifference?
Thisisyetanotherexampleofthe‘workingenvironmentbias’thatsomuchaffectstheapproach
toAA(andothersurgicalconditions)indifferent,‘realworld’situations.Whenourchiefresident
has to deal with 3-5 cases of AA per night, most of the activity, even for non-perforated
appendicitis, will take place after midnight — but before 8am when the elective list starts.
Danny
Openversuslaparoscopicapproach
As pointed out above, the liberal use of diagnostic laparoscopy for
suspected AA leads to a high incidence of unnecessary, invasive and
non-therapeuticabdominalexploration—proceduresthatarenotfreeof
complications—whichcommonlyendwithanappendectomyevenifthe
appendix is ‘normal’. But what about laparoscopic appendectomy
(LA) if the diagnosis has been established? The voluminous
literature on this controversy can be summarized like this:
compared to the open procedure, LA is associated with better
cosmesis,some reductioninpostoperativepain, marginally earlier
dischargeandalowerincidenceofwoundinfection.However,LAis
associated with a higher risk of postoperative intra-abdominal
collections/abscesses and other rare, but serious, complications like
intestinalandvascularinjuries.Concerningcosts,themoneysavedbyan
earlier discharge after LA is spent on a more expensive and longer
procedure. We cannot therefore declare a winner between these
methods,sothechoicedependsonthepreferencesofthesurgeonand
the patient and the local situation. LA may, however, have a clear
advantageintheveryobesepatient,byavoidingalargeincision. For
details about LA and another perspective see thesection at the end of
thischapter.
Technicalpointsforopenappendectomy
Didanybodyeverteachyouhowtodoanopen‘appy’?Evenifyou
are a ‘lap-appy’ afficionado do not deprive yourself of the skills (and
pleasures)ofbeingabletoremoveadiseasedappendixthroughasmall
right lower quadrant incision. Such skills may be useful when
‘converting’adifficultLA—andno,amidlineincisionisusuallynot
necessaryinthatsituation!
Itispossible thatyouhavedoneyour shareofopenappendectomies
alreadyasan intern.However,havingseenmanysurgeonstransforma
routineappendectomytoanelaborateoperationresemblingaWhipple’s
procedure,weremindyouoftheKISSprinciple—keepitsimple,stupid!
Hereareafewtips:
•
Incision: you do not need the long unsightly oblique incision —
except in the muscular young man whose possible retrocecal
appendix may be unreachable through a transverse hole. Use a
transverseone!Acommonerroristoplaceittoomediallyoverthe
rectussheath.Ifyoucentertheincisionslightlylateraltothepointof
McBurneyyou willin mostcases getitright.Incisethe fascia,split
themusclesandopentheperitoneum.Startwithasmallincision
about 4-5cm long;it can bealways extended to each sideby
cuttingthelateraledgeoftherectusfasciaand/ormuscle.
•
Appendectomy:you can remove the appendixinanantegrade or
retrograde fashion but there is no need to invertthe stump unless
youarehookedonuselessrituals.Just ligateor suture-transfixthe
appendixatitsbaseandchopofftherest.Whenthetissueisfriable,
overrun the divided meso-appendix with a running suture. The
commonfetishesofpaintingthestumpwithBetadine®orburningit
withdiathermyareridiculous.Iftheappendixhasperforatedjust
at its base you have to include some healthy cecal wall to
securethestumpsafely—justplacealinearstapleracrossthe
cecumproximaltotheperforationandfire.Ifyoudonothavea
staplerthen do it by hand—closethe cecal defect withyourbest
anastomotictechnique!
•
Peritonealtoilet: justaspirateandmopthe fluid(do notforget the
pelvis).Peritoneallavageisuselessorevenharmful—responsible
forthosefluidcollectionsthatyouseeonpost-opimaging.
•
Hemostasis:bemeticulous!Thepartialeviscerationofthececum
placesthe blood supplyundertension and mayinterrupt the blood
flow,thusconcealingbleeding.Whenthececum isrepositioned,its
circulation recovers and bleeding from the divided artery or the
meso-appendixmaydeclareitself.Thus,alwayscheckthestump
of the meso-appendixafter returning thececum to its natural
position. Place some gauze into the depths of the wound: if it
comesoutpink,youhavetorecheckthehemostasis.
•
Microbiologicalculture: taking itin this case isunnecessary and
wasteful unless the operation is after failedantibiotic treatment (
Chapter13).
•
Drains:are very(very!)seldomnecessaryafter appendectomy
(no,Iam notkidding)and havealsobeen showntobe harmful(
Chapter39).
•
Closure: theoretically, closing the peritoneum is unnecessary
because it adds no strength to the repair, and we know that the
peritoneumrepairsitselfwithin48hours.However,thisstep‘covers’
thebulgingviscera,facilitatingcarefulclosureoftheabdominalwall
layers and may thus help prevent interstitial hernias. Next the
muscles are approximated loosely with a few sutures to obliterate
dead space; the fascia is closed with a running suture. The
subcutaneous layer,if thick, may be approximated with a fewfine
sutures.Close the skin in continuous subcuticular fashion, even in
complicatedcases.Useabsorbablesuturesandavoidincludingtoo
much tissue, as this may cause necrosis and infection. Some still
advocate secondary wound closure in complicated appendicitis.
This may prevent afew woundinfections atthe cost of prolonged
sufferingfrom changes of dressings and further manipulations and
anuglyscarforallpatients.Thisisnotworththecostasexplained
in Chapters40and50.
Thesurgeonwhocandescribetheextentofanappendiceal
peritonitishasconvictedhimself ofperformingan improper
operation.
MarkM.Ravitch
(If you do not understand this aphorismplease feel freeto email the
Editors.)
Specialconsiderations
The‘white’appendix
What should you do when the appendix proves to be pristine?
Well, you can rub it allowing the pathologist to diagnose mild acute
inflammation (just kidding). The classic dictum is that whenever an
abdominal appendectomy incision exists the appendix should be
removed in order not to confuse matters in the future. What about a
normal appendix visualized at laparoscopy? Should it also be
removed? The emerging consensus is to leave it alone, informing the
patient or the parents that the appendix has been left in situ. As we
mentioned above, the problem is that most surgeons are reluctant to
followsuchan(alleged)consensus.Whataboutyou?
Obviously, when the appendix appears normal (very unlikelyif you
havefollowedourdiagnosticapproachorobtainedaCTscan) you
shouldsearchforalternativediagnosessuchasMeckel’sdiverticulitis(
Chapter 36), adnexal pathology ( Chapter 35), perforated cecal
diverticulitis( Chapter28), ormesenteric lymphadenitis(whatever that
is).Inmostinstances,however,you’llfindnothing.Whatshouldyoudoif
foul-smelling, murky, or bile-stained peritoneal fluid is encountered,
suggesting a serious alternative pathology elsewhere? If the source of
the pathology is not evident you could do a diagnostic laparoscopy
throughthepartly closed gridiron incision. If it is evident then close the
incisionandplaceanewonewheretheactionis.Donottrytodoacolon
resectionthroughanextendedtransverseincision.Bileshouldguideyou
into the upper abdomen. Feces or its odor direct you towards the
sigmoid.Thinkofperforatedduodenalulcerandintestinalperforation.
Соседние файлы в папке Библиотека им академика М.И. Перельмана