Saturday, December 20, 2008
Cranial Burr Holes and Emergency Craniotomy: Review of Indications and Technique
Introduction
Traumatic head injury causes primary injury to the brain itself, but may also result in intracranial hematoma (ICH) formation. ICH can cause compression of the brain, resulting in a shift of intracranial structures, cerebral herniation, coma, and death. It can be located in either the intra-axial compartment (within the brain itself) or extra-axial, as either an epidural hematoma (EDH) or subdural hematoma (SDH). EDH occurs in 0.5 to 12.3% of patients with moderate to severe head injury and SDH in 12 to 18%.6-8 The incidence of both is even higher in those with brainstem dysfunction or a skull fracture and ICH occurs frequently in patients with penetrating injuries. The clinical outcome depends on many factors, including the type, location, and size of ICH, as well as the severity of the associated primary brain injury. Some authors have proposed that a shorter duration of time between injury and hematoma evacuation improves ultimate outcome, but other series have not confirmed this result. The overall morbidity and mortality ranges from 12 to 41% with EDH to 57 to 90% with SDH. SDH is associated with worse outcome because it generally is caused by high-velocity injuries, resulting in more primary brain injury. Since EDH is usually associated with low-velocity injury, it results in little primary injury to the brain and causes poor outcome only if the expanding hematoma is allowed to compress the brain. Combinations of EDH and SDH in the same patient may occur. It is evident although that the patient's preoperative neurological function correlates highly with outcome, and that early recognition and prompt surgical evacuation of ICH avoids preventable death and dysfunction, especially in those patients who "talk and deteriorate."
Burr hole craniotomy, or trephination, may be the earliest form of surgical procedure ever performed. Archeological studies of ancient skulls show it was performed in various ways on several different continents before the dawn of written history and confirm that many patients survived the procedure. It has been practiced extensively throughout the history of medicine, particularly in military conflicts, and the fascinating history of this procedure has been reviewed in detail elsewhere. The procedure was expanded, refined, and standardized throughout World Wars I and II and in civilian practice thereafter. With the arrival of computerized tomography (CT) in the 1970s, the indications for burr holes quickly dwindled. CT is rapid, noninvasive, and provides much more information about the location and nature of the brain injury than burr holes.
Since the development of trauma management and evacuation systems in the United States, the situation is rarely encountered where a patient with acute neurological deterioration is unable to undergo CT. In certain rare circumstances, burr hole craniotomy remains a relatively rapid and frequently effective treatment for patients who otherwise will likely die. These situations are much more common in combat health support operations, particularly at echelons II and III. For example, a patient injured in a remote area may require burr holes if there is no access to immediate evacuation or CT, or a multitrauma patient who develops a unilaterally dilated pupil while under anesthesia for non-neurological surgery may not be stable for immediate transport to CT. Because many general surgeons or other nonneurosurgeons in the military are deployed to remote areas of the world without the availability of CT or a neurosurgeon, the authors have occasionally advised such surgeons (via telephone or radio link) to perform burr holes as a lifesaving measure. Successful cases have also been reported in the literature. Such experiences from Operations Enduring Freedom and Iraqi Freedom have especially spurred renewed interest in reviewing the anatomy, technique, and indications for this procedure. However, it must be strongly emphasized that this procedure should not be performed randomly for all comatose patients, nor should it be undertaken without contacting a neurosurgeon first, except in the most dire circumstances.
Methods
Initial Assessment and Stabilization
The injured patient must undergo general resuscitative measures first, in accordance with a standard trauma protocol such as that taught by the American College of Surgeons in the Advanced Trauma Life Support course.47 It must be ensured that the patient has a patent airway and is breathing, the blood pressure and pulse are stabilized, and at least a primary survey is conducted before any consideration of burr holes. A critically important factor in the outcome for patients with ICH is avoidance of hypoxemia and hypotension. Improved oxygenation and blood pressure often improve a patient's altered mental status and may even normalize dilated or asymmetric pupils. A rapid neurological assessment is performed and the Glasgow Coma Scale score is determined. A detailed secondary survey is then performed to identify other possible causes of deterioration and to look for any secondary complications of head injury. Of paramount importance is maintenance of spinal immobilization precautions and assessment with a lateral cervical spine X-ray if available, since 5 to 10% of head-injured patients also have an associated cervical spine fracture.
If the patient exhibits signs of increased intracranial pressure, nonsurgical treatment is first delivered. This includes endotracheal intubation, assisted ventilation, elevation of the head, and administration of osmotic agents such as 0.5 to 1.0 g/kg of a 25% intravenous mannitol solution or a bolus of hypertonic saline. The patient is then reassessed, since these measures alone may adequately reduce intracranial pressure and potentially mitigate the need for surgery. An intravenous anticonvulsant agent such as fosphenytoin (18 mg/kg) is given to reduce the incidence of early seizures. Assessment of coagulation function is extremely helpful if available, since brain injury may cause coagulopathy, and administration of clotting factors may be required before surgery. Burr holes should only be considered when all other supportive measures have been taken, and yet the patient continues to decline. Every reasonable attempt should be made to contact a neurosurgeon for consultation.
Any patient who has sustained a traumatic injury and presents with the classic clinical triad of altered mental status, asymmetric or poorly reactive pupils, and hemiparesis must be deemed to have ICH until proven otherwise. These findings can be mimicked by brain contusion, which will not benefit from burr holes, but ICH must be ruled out. The "classic" clinical presentation of EDH is an immediate alteration of sensorium punctuated by a lucid interval, which is then followed by progressive neurological decline. A lucid interval can also occur with either SDH or cerebral contusion although, and less than one-third of patients with EDH demonstrate such a pattern. Most simply decline continuously from the time of injury.
Localization
Penetrating injuries and open, depressed skull fractures are often readily apparent and may guide the surgeon rapidly to the location of ICH. Not all fractures have associated ICH however, and ICH may also be located opposite to the point of impact, especially where penetrating fragments have exited or come to rest near the brain surface. Lateralizing findings such as pupillary abnormalities and hemiparesis are useful indicators, found in more than one-half of the patients with ICH, and 85% are located ipsilateral to the larger pupil and contralateral to the hemiparesis. These occur when ICH shifts the brain medially and downward, forcing the temporal lobe against the cerebral peduncle and the third cranial nerve. Since the third nerve remains ipsilateral and the corticospinal tract crosses over to the contralateral side of the body, the dilated pupil and hemiparesis occur on opposite sides of the body. The remaining 15% of patients have "false" localizing signs, such as hemiparesis ipsilateral to the dilated pupil. These findings are caused when the brainstem is shifted over with the temporal lobe and the contralateral peduncle is compressed against the rigid edge of the dural partition called the tentorium cerebelli, creating "Kernohan's notch". It must be emphasized that the presence of these physical findings does not mean that ICH is always present, since they can also occur with direct injury to the brainstem or cranial nerves.
Adjuncts
The best and most rapid method of establishing the diagnosis of ICH is CT. The wealth of information collected by CT includes not only the presence of ICH, but also its location, size, presence of multiple ICH, cerebral contusion, skull fracture, etc. In the absence of CT however, a simple X-ray of the skull may provide important clues to the diagnosis. It should always be used for deteriorating patients when CT is unavailable, especially to visualize foreign bodies in penetrating injuries . If patients with the appropriate clinical findings have a skull fracture, especially near the middle meningeal artery or the durai venous sinuses, ICH is likely present. In >85% of the patients who have both a skull fracture and EDH, the clot is located immediately beneath the fracture site. Although a skull fracture may indicate a possible EDH, it does not confirm it, nor does it mitigate the possibility of coexisting injuries such as brain contusion or SDH. The injury causing SDH is more likely to be diffuse, involving a larger area than that causing EDH; therefore, the hematoma in SDH may not be located directly underneath the fracture as in EDH. In addition, an expanding blood clot in the subdural space is not restricted by any barriers and can extend from one end of the hemisphere to the other. The expansion of EDH may be limited by the cranial sutures, where the dura mater is particularly adherent to the inner table of the skull.
Technique
Burr holes are ideally performed in the operating room to minimize infectious risks and to provide proper lighting and equipment. Electrocautery, suction, irrigation, headlamp illumination, and loupe magnification are helpful. Since the patient has already been intubated, anesthesia and antibiotics are now administered. General anesthesia is preferred, but hypotension must be avoided. Local anesthesia may be used alone, but coughing or other movement during the procedure can be troublesome. The patient should be placed in the supine position with a shoulder roll ipsilateral to the suspected side of ICH and the head turned so that the surgical side is facing upward. The head should be supported with a padded gel roll or horseshoeshaped head holder, if available. A rapid shave of the involved scalp will facilitate surgical prep and visualization. A more extensive shave (i.e., the entire head) is recommended for patients with penetrating injuries or scalp lacerations, but a prolonged period of time should not be wasted on this task.
In the absence of CT or other localization as described above, burr holes are initially placed on the side ipsilateral to the larger pupil. If the pupils are equal or there is no hemiparesis, the side of obvious external trauma should be chosen and the burr hole should be placed next to, not within, a skull fracture. This allows exposure of uninjured dura so that bone fragments can be removed from the area of normal anatomy toward the injured area with a rongeur. Except in cases with obvious localization, the temporal burr hole should be performed first, since temporal lobe decompression is usually the most urgent priority in acute cerebral herniation. This site is also the most common location of EDH and allows access to the area of the middle meningeal vessels. The skin incision should begin just above the root of the zygoma, coursing 1 cm anterior to the tragus and about 5 cm in length, continuing just over the top of the ear. This avoids injuring the superficial temporal artery posteriorly and the temporal branch of the facial nerve anteriorly. If present, a scalp laceration overlying the injured skull may be used to create an incision. The temporalis fascia is sharply incised and monopolar cautery is used to divide the temporalis muscle. Significant bleeding may occur here, but can often be controlled by distracting the tissue with a self-retaining retractor. Persistent bleeding can be controlled with electrocautery or hemostats, and even severe bleeding can be tamponaded temporarily with digital pressure and a sponge until controlled. The periosteum is then dissected away using a periosteal elevator or the handle of the scalpel. The self-retaining retractor should be left in place, but should not interfere with making the burr hole.
A high-speed pneumatic drill will rapidly create a burr hole if available and even a dental drill has been improvised to perform this procedure.44 A handheld drill such as a Hudson brace was used extensively before the invention of motorized drills and remains extremely useful. It is attached to a perforating bit, which is held perpendicular to the skull and turned rapidly. Initially it may be difficult to turn the drill until the outer cortex is penetrated, but the cancellous bone is softer and more easily penetrated, producing more bleeding. As the inner cortex is engaged, there is initially a feeling of cogwheel-type resistance, and then the drill feels almost as if it is being pulled into the skull with every turn. The burr hole should be visually inspected frequently to assess whether the inner cortex has been breached, otherwise the drill may penetrate all the way through the inner cortex and plunge into the brain. When 5 to 10 mm of dura are seen, the drill is removed and a sharp bone curette is used to remove the remaining lip of bone. If the Hudson brace is used, the perforating bit can be exchanged for a rounded burr at this point, which will more safely enlarge the hole without penetrating as deeply toward the brain. There may be bleeding from the bone which obscures the dura, and bone wax is applied to the edges of the burr hole. It is important to differentiate this normal liquid bleeding from the coagulum of an epidural hematoma.
If there is EDH present, it will be encountered now, and the hole should be enlarged with a rongeur to allow removal of additional clot, but great care should be taken not to tear the dura. As the clot is removed with irrigation and suction, vigorous bleeding from the middle meningeal artery can occur, which may be very difficult to control and requires persistent effort with bipolar cautery or suture ligation through the dura. The hemorrhage may be especially difficult if it arises in the proximal portion of the artery near the foramen spinosum of the skull, and cautery may be useless if the artery retracts into the foramen. Placing the wooden end of a cotton tip applicator into the foramen and breaking it off is a desperate measure that may staunch the bleeding.
If there is no EDH encountered, the blue-white dura is seen. Since the temporal area is the most likely area to contain ICH, the burr hole can be widened when exploration is initially negative. ICH may be located anywhere, including immediately adjacent to a burr hole that appears to be negative for ICH; therefore, enlarging the hole improves diagnostic accuracy. If durai pulsations are not visualized after EDH evacuation, consideration should be given to opening the dura to look for coexisting SDH, and the decision to proceed should be weighed against the risk of causing brain injury. The surface of the dura should be cauterized first under low power with bipolar cautery. The dura is then grasped with small-toothed forceps and opened with two perpendicular incisions, using a no. 11 blade. Great care is required because the incision may cause injury to the cortical brain vessels. The edges of the dura are carefully cauterized and will shrink to expose the underlying brain. SDH can now be removed if present using saline irrigation to lift the clot and gentle suction to aspirate it.
If the temporal burr hole is negative, a sponge soaked in antibacterial solution should be placed in the wound and then a frontal burr hole placed. The incision should be placed immediately anterior to the coronal suture. This suture is palpable in most patients and should lie approximately 13 cm posterior to the root of the nose in the average adult. It is imperative that the incision be at least 3 cm lateral to the midline of the skull, at approximately the mid-pupillary line. If the skull is penetrated near the midline, there is risk of injury to the underlying superior sagittal sinus, which may result in exsanguination of the patient. If the burr hole is made more posterior than the coronal suture, there is risk of injury to the motor cortex of the brain and resulting paralysis. The technique for the skull and durai opening are the same as that described for the temporal approach. If the frontal burr hole is also negative for ICH, then a parietal one should be performed in the same fashion. The incision is 3 cm posterior to the external auditory meatus and 5 cm lateral to the midline, made in a vertical fashion.
Removal of a small amount of acute blood clot through a burr hole may provide enough temporary decompression to allow evacuation of the patient to a neurosurgeon. Acute clot is thick and tenacious however and usually extends beyond the exposed area, such that <10%>
If all three burr holes are negative, then the same procedure is performed on the contralateral side, proceeding in order from temporal to frontal to parietal burr holes. This sequence provides the most efficient method of finding and treating ICH, and a complete exploration on both sides reduces the chance of a falsely negative exploration. Even if ICH was present on the initial side, the surgeon must decide whether the clinical situation warrants exploring the contralateral side, depending on the patient's response to initial decompression as well as clinical and radiographie indicators that bilateral hemorrhage may be present.
If all six burr holes are negative despite strong suspicion of ICH, a posterior cranial fossa burr hole may be considered. ICH is rare here, comprising only 4 to 13% of acute EDH58,59,60 and <1%>
At wound closure, a drain should be left in the epidural space if EDH was evacuated. A 10-mm Jackson-Pratt drain is ideal, since it was originally designed for use in the subdural space, However, if SDH is encountered, the inexperienced surgeon placing a drain into the subdural space may disrupt the cerebral cortical vessels and cause further bleeding. It should be emphasized that meticulous hemostasis, especially of scalp bleeding, is essential before drain placement and closure, or else ICH can recur postoperatively. When decompression is complete, all scalp incisions should be closed in two layers, with absorbable suture in the galeal layer and staples or monofilament suture for the skin, unless the patient has a penetrating injury with gross contamination or regions of poorly vascularized scalp. For these patients, closure of the temporalis muscle or galea should be performed to cover the exposed brain and the wound is dressed with the skin open. Scalp flaps will be rotated to provide appropriate coverage later.
Postoperatively, the patient should remain intubated to ensure proper ventilation and careful attention to the vital signs and to supportive care should continue. Worsening brain edema may occur for several days after the injury and may cause increased ICP, but recurrent hemorrhage is always possible and should be considered when increasing ICP or clinical deterioration occurs. Transfer to a neurosurgical facility should be accomplished as rapidly as possible to provide the best possible care for these and other complications of head injury.
Results
In the most modern series, Andrews et al. in 1986 investigated 100 consecutive patients with acute cerebral herniation after blunt trauma. They were taken immediately to the operating room for burr holes without prior CT, and if ICH was found a craniotomy flap was turned to allow complete evacuation. All patients underwent postoperative CT. ICH was found in 56 patients and 86% of ICH was detected on the initial side of exploration. The need for bilateral exploration was apparent, since 14% required bilateral burr holes to find the clot. ICH was missed in six patients because an incomplete procedure was performed, including four who had ICH located very close to a single negative burr hole. No extra-axial hematoma was missed in any patient who underwent a complete bilateral procedure. No posterior fossa burr holes were performed, and no ICH for any patient was visualized there on CT.
All patients who presented with bilaterally enlarged, unreactive pupils and flaccid extremities died, whether or not ICH was present. The poor outcome for these most severely injured patients has been corroborated by numerous other clinical series. Patients with a Glasgow Coma Scale of 3, 4, or 5 and/or bilaterally dilated pupils after resuscitation are thus unlikely to benefit from burr holes, especially if they have been dilated for several hours or if the patient has sustained a through and through gunshot wound.
The results cited above show the outcomes for patients treated by experienced neurosurgeons under the best of conditions. Procedures performed by inexperienced surgeons may be expected to have worse outcomes and, in some cases, only delay transfer to an appropriate neurosurgical facility. It should also be noted that some authors have reported excellent success with a simple twist drill rather than using burr holes. The supposed advantage over burr holes is speed and simplicity of use. However, the twist drill hole is quite small and therefore less likely to allow sufficient evacuation of an acute clot.
Discussion
Posttraumatic ICH is associated with great morbidity and mortality. It is best treated by experienced neurosurgeons in a medical facility equipped with a CT scanner. In the rare instance that CT is not available, burr holes may be performed to diagnose and treat this condition. If CT is available and confirms the diagnosis, even the non-neurosurgeon may be required to perform decompressive burr holes or craniotomy in dire circumstances. It cannot be condoned as a routine practice by inexperienced surgeons however, since even in the hands of an experienced neurosurgeon burr holes are a substantially suboptimal method of diagnosis compared with CT imaging. The decision itself whether to perform this procedure or not is at least as important as the technique, since nonsurgical interventions alone may mitigate the need for burr holes, and burr holes placed by the inexperienced surgeon may exacerbate the injury. Consultation with a neurosurgeon is recommended in all cases, if possible, to determine whether the patient may be transferred to a neurosurgeon for the procedure. If the patient is rapidly deteriorating and cannot await transfer, careful attention to detail by the non-neurosurgeon is required to prevent a difficult situation from becoming even worse. The patient must be transferred rapidly to the neurosurgeon when stabilized after the procedure, since worsening brain edema and/or recurrent hemorrhage will exacerbate the clinical condition and require longterm follow-up care at an appropriate facility.
Urethral Trauma
Introduction
Trauma to the male urethra must be efficiently diagnosed and effectively treated to prevent serious long-term sequelae. Patients with urethral stricture disease from poorly managed traumatic events are likely to have significant voiding problems and recurring need for further interventions. Many of these men have significant orthopedic and neurologic injuries as well. Rehabilitation requires reconstruction of the urinary tract in a manner that does not interfere with the healing process.
History of the Procedure
Most urethral injuries are associated with well-defined events, including major blunt trauma such as caused by motor vehicle accidents or falls. Penetrating injuries in the area of the urethra may also cause urethral trauma. Straddle injuries may cause both short- and long-term problems. Iatrogenic injury to the urethra from traumatic catheter placement, transurethral procedures, or dilation is not uncommon.
Problem
Urethral injuries can be classified into 2 broad categories based on the anatomical site of the trauma. Posterior urethral injuries are located in the membranous and prostatic urethra. These injuries are most commonly related to major blunt trauma such as motor vehicle accidents and major falls. They are most commonly associated with pelvic fractures. Injuries to the anterior urethra are located distal to the membranous urethra. Most anterior urethral injuries come from blunt trauma to the perineum (straddle injuries), and many have delayed manifestation, appearing years later as a stricture.
External penetrating trauma to the urethra is rare, but iatrogenic injuries are quite common in both segments of the urethra. Most are related to difficult urethral catheterizations.
Frequency
Posterior urethral injuries are most commonly associated with pelvic fracture, with an incidence of 5-10%. With an annual rate of 20 pelvic fractures per 100,000 population, these injuries are not unusual occurrences. Anterior urethral injuries are less commonly diagnosed emergently, thus the actual incidence is difficult to determine. However, many men with bulbar urethral strictures recall an antecedent perineal blunt injury or straddle injury, making the true frequency of anterior injury much higher. Penetrating injury to the urethra is rare, with major trauma centers only reporting a few per year.
Etiology
As with many traumatic events, the etiology of a urethral injury can be classified as blunt or penetrating. In the posterior urethra, blunt injuries are almost always related to massive deceleration events such as falls from some distance or vehicular accidents. These patients most often have a pelvic fracture involving the anterior pelvis. Blunt injury to the anterior urethra most often occurs from a blow to the bulbar segment such as occurs when straddling an object or from direct strikes or kicks to the perineum. Blunt anterior urethral trauma is sometimes observed in the penile urethra in the setting of penile fracture.
Penetrating trauma most often occurs to the penile urethra. Etiologies include gunshot and stab wounds. Iatrogenic injuries to the urethra occur when difficult urethral catheterization leads to mucosal injury with subsequent scarring and stricture formation. Transurethral procedures such as prostate and tumor resections and ureteroscopy can also lead to urethral injury.
Pathophysiology
Injury to the posterior urethra occurs when a shearing force is applied at the prostatomembranous junction in blunt pelvic trauma. The prostatic urethra is fixed in position because of the attachments of the puboprostatic ligaments. Displacement of the bony pelvis from a fracture type injury thus leads to either tearing or stretching of the membranous urethra.
Anterior urethral injury most often results from a blunt force blow to the perineum, producing a crushing effect on the tissues of the urethra. The initial injuries are often ignored by the patient, and urethral injury manifests years later as a stricture. The stricture results from scarring induced by ischemia at the site of the injury. Penetrating injuries also occur in the anterior urethra as a result of external violence.
Presentation
Diagnosis of urethral injuries requires a reasonably high index of suspicion. Urethral injury should be suspected in the setting of pelvic fracture, traumatic catheterization, straddle injuries, or any penetrating injury near the urethra. Symptoms include hematuria or inability to void. Physical examination may reveal blood at the meatus or a high-riding prostate gland upon rectal examination. Extravasation of blood along the fascial planes of the perineum is another indication of injury to the urethra. "Pie in the sky" findings revealed by cystogram usually indicate urethral disruption.
The diagnosis is made by performance of a retrograde urethrogram, which must be performed prior to insertion of a urethral catheter to avoid further injury to the urethra. Extravasation of contrast demonstrates the location of the tear. Further management is predicated on the findings of urethrography in combination with the patient's overall condition.
Relevant Anatomy
The male urethra may be divided into 2 portions. The posterior urethra includes the prostatic urethra, which extends from the bladder neck through the prostate gland. It then joins the membranous urethra, which lies between the prostatic apex and the perineal membrane. The anterior urethra begins at that point and includes 3 segments. The bulbar urethra courses through the proximal corpus spongiosum and ischial cavernosus-bulbospongiosus muscles to reach the penile urethra. The penile urethra then extends through the pendulous portion of the penis to the final segment, the fossa navicularis. The fossa navicularis is invested by the spongy tissue of the glans penis.
Potential areas for injury can be deduced from further study of the urethral anatomy. The membranous urethra is prone to injury from pelvic fracture because the puboprostatic ligaments fix the apex of the prostate gland to the bony pelvis and thus cause shearing of the urethra when the pelvis is displaced. The bulbar urethra is susceptible to blunt force injuries because of its path along the perineum. Straddle-type injuries from falls or kicks to the perineal area can result in bulbar trauma. Conversely, the penile urethra is less likely to be injured from external violence because of its mobility, but iatrogenic injury from catheterization or manipulation can occur, which is also possible in the fossa navicularis.
Contraindications
In cases of urethral trauma, patients often have multiple injuries. Immediate urethral repair is contraindicated because life-threatening injuries must be corrected first in any trauma algorithm. Urethral repair must be delayed until the pelvic hematoma has stabilized and hemorrhage is less of a concern.
Penetrating anterior urethral injuries should be explored; however, defects longer than 2 cm in the bulbar urethra and longer than 1.5 cm in the penile urethra should never be emergently repaired. They should be reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue transfers required for the repair.
Weight Loss: Gastric Bypass Operations
Introduction
Gastric bypass operations combine the creation of a small stomach pouch to restrict food intake and construction of bypasses of the duodenum and other segments of the small intestine to cause malabsorption (decreased ability to absorb nutrients from food).
What Types of Gastric Bypass Operations Are There?
- Roux-e-Y gastric bypass (RGB). This operation is the most common gastric bypass procedure performed in the U.S. First, a small stomach pouch is created by stapling part of the stomach together or by vertical banding. This limits how much food you can eat. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the duodenum as well as the first portion of the jejunum. This causes reduced calorie and nutrient absorption. This procedure can now be done with a laparoscope (a thin telescope-like instrument for viewing inside the abdomen) in some people. This involves using small incisions and generally has a more rapid recovery time.
- Extensive gastric bypass (biliopancreatic diversion). In this more complicated gastric bypass operation, the lower portion of the stomach is removed. The small pouch that remains is connected directly to the final segment of the small intestine, thus completely bypassing both the duodenum and jejunum. Although this procedure successfully promotes weight loss, it is not as widely used because of the high risk for nutritional deficiencies.
Are There Risks Associated With Gastric Bypass Surgery?
Yes. People who undergo this procedure are at risk for:
- Pouch stretching (stomach gets bigger overtime, stretching back to its normal size before surgery).
- Band erosion (the band closing off part of the stomach disintegrates).
- Breakdown of staple lines (band and staples fall apart, reversing procedure).
- Leakage of stomach contents into the abdomen (this is dangerous because the acid can eat away other organs).
- Nutritional deficiencies causing health problems.
Gastric bypass operations also may cause "dumping syndrome", whereby stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and, occasionally, diarrhea after eating, as well as the inability to eat sweets without becoming extremely weak. Gallstones can occur in response to rapid weight loss. They can be dissolved with medication taken after the surgery.
What Health Problems Can Nutritional Deficiencies Cause?
The limited absorption ofvitamin B-12 and iron can cause anemia. The lack of calcium absorption can cause osteoporosis and metabolic bone disease. People who undergo this procedure are required to take nutritional supplements that usually prevent these deficiencies.
The more extensive the bypass operation, the greater is the risk for complications and nutritional deficiencies. People who undergo extensive bypasses of the normal digestive process require not only close monitoring, but also lifelong use of special foods and medications.
Stress fracture of the distal tibia secondary to severe knee osteoarthritis: a case report
INTRODUCTIONStress fracture is caused by either abnormal stress placed on a normal bone (fatigue fracture) or normal stress placed on an abnormal bone (insufficiency fracture). Both are due to the exertion of cumulative and repetitive low intensity forces on the bone for a period of time. The tibia is the most common site for a stress fracture, accounting for 50% of such fractures. Stress fractures of the tibia secondary to sports-related activities are relatively common but stress fractures of the distal tibial shaft secondary to osteoarthritis of the knee are rare. Such fractures usually involve the proximal tibia.
CASE REPORT
A 61-year-old heavily built woman with a 10-year history of painful osteoarthritis associated with severe varus deformity of both knees had declined total knee replacement for fear of surgery. She was able to walk but with severely deformed varus knees.
In October 2004, she slipped and twisted her left foot. She complained of pain over the distal left shin that did not resolve after 2 weeks of self-medication, and consulted her family physician who arranged for radiographs to be taken. No abnormalities were revealed and she continued to walk on the left foot. The pain gradually worsened over the next 6 months, and she was eventually confined to a wheelchair. The patient noticed a progressive angulated deformity in the left ankle and repeated radiographs demonstrated a malunited fracture at the distal third of the left tibial and fibular shafts. She was promptly referred to the Singapore General Hospital for further management.
Correction of the malunion using an interlocking nail was performed. The patient was discharged uneventfully, but her knee pain persisted due to severe osteoarthritis. Partial weight-bearing was recommended as the underlying varus deformity of the knee had not been corrected and there was a risk that abnormal stress would break the nail. Full weight-bearing was started once the fracture united. Ten months later, the patient underwent a left total knee replacement with simultaneous removal of the interlocking nail and made an uneventful recovery.
DISCUSSION
Stress fractures occur as a result of repetitive abnormal mechanical loading on the bone. The insults are usually chronic and of low intensity such that the fracture is not acute. Risk factors include repetitive activity (as in sports or marching), abnormal biomechanical forces (such as those that occur in hallux valgus, genu varum or valgus, and limb length discrepancy), and systemic diseases that weaken the bone (rheumatoid arthritis, osteoarthritis, osteoporosis, and renal osteodystrophy).
In our patient, the severe varus deformity of the knee imposed considerable stress on the tibia and shifted the mechanical axis of the left foot to the knee and tibia. Stress fractures have been reported to occur in the tibia, metatarsal shafts, fibula, tarsal navicular, lumbar, humerus, femoral neck, femoral shaft, and pubic ramus, with the tibia being the most common site. The junction of the middle and distal third of the tibial shaft-where the greatest curvature occurs-bears the greatest stress. Studies of the strength distribution in the tibia reveal that fracture is more likely to occur where the curvature is large." According to the mechanism of her fall, our patient sustained a rotational force along the long axis of the left tibia. As long bones do not withstand rotational forces very well, this accident was probably a sentinel event, causing the stress fracture to become symptomatic (the patient had a pre-existing stress fracture in the left distal tibia not visible on radiograph).
Physical signs of a stress fracture include tenderness on palpation and localised pain as a result of compression. In the early stages, plain radiographs may reveal no abnormality,12 as in our patient. If a stress fracture is suspected, a technetium -99m bone scan should be performed because it is more sensitive than a plain radiograph.
There are several treatment options for correction of malunion at the left distal tibial and fibular shafts and treatment of osteoarthritis and severe varus deformity of the left knee. The first option is a single-stage total knee replacement with a long stem extension of the tibial component to bypass the fracture site.13 This would have been feasible in our patient if the fracture had occurred in the proximal shaft,14 but standard modular implants with a stem long enough to bypass a fracture in the distal tibia are not available. The second option is a one-stage total knee replacement with correction of the malunion of the distal tibia. This has the advantage of being one procedure with a single anaesthetic and surgical risk. Nonetheless, the procedure would be more extensive and require separate incisions. In addition, the implant used to stabilise the malunion would have to be a plate as an intramedullary nail would interfere with placement of the tibial component. The dissection at the malunion would be extensive, and the plate would be configured to a 'wave' pattern to accommodate the exuberant callus at the malunion. There is a risk of skin breakdown with such extensive dissection and the need to accommodate a plate with a wave configuration. Wound breakdown would put the total knee arthroplasty at risk of developing infection. The third option is a 2-stage procedure. In stage one, malunion of the distal tibial shaft is corrected using an interlocking nail. The procedure is minimally invasive and dissection around the callus is avoided. The nail is a load-sharing device and the risk of refracture is minimal once the fracture has consolidated. A plate is not used as it must be configured to a wave pattern to accommodate the exuberant callus at the malunion. In stage 2, following union of the tibial fracture, total knee replacement is performed with simultaneous removal of the nail. This is less technically demanding, but requires 2 operations, and leaves the varus knee and abnormal mechanical axis untreated initially, which may lead to implant failure. We decided that this last option was the safest for our patient. Manipulation was performed to correct the malunion as the fracture callus was not consolidated. An interlocking nail was then used to maintain the reduction.
Bone mineral density evaluation was not performed in our patient, thus osteoporosis as a contributory cause of the fracture could not be excluded. Stress fractures in patients with osteoarthritis are rare and usually occur in the proximal tibia. Our patient was unusual as the stress fracture occurred in the distal tibia. A 2-stage procedure using interlocking nailing for the distal tibial fracture, and a total knee replacement for the osteoarthritis and varus deformity was performed because it was the safest option.
Tennison Triangular Flap (Randall Modification)
Tennison Triangular Flap (Randall Modification)The triangular flap is but one of several methods of creating a flap in an otherwise straight line closure of the lip closure may be high or low and various surgeons promote their specific choice of location.
Although the rotation advancement technique of Millard has the greatest number of followers and is recognized as a simple method once experience is obtained, a number of surgeons prever a triangular technique, since it seems simpler to lay out and perform and is less of a “cut as you go” free hand performance. For some surgeons it seems simpler and easier to teach and possibly more reliable for those performing and teaching a small number of cases.
The Tennison triangular flap technique described by Randall demonstrates that the medial lip element contains the essential landmarks for Cupid’s bow. The triangular flap technique recognizes that Cupid’s bow is high on the cleft side. The technique plans for a diagonal incision directly above the raised lateral peak into the philtrum. When the lip element is lowered, a triangular defect is created by incision, which is filled upon closure with the triangular flap from the cleft side. Thus tissue is added to the noncleft side of the lip in the lower one third. This is in contrast to the Millard rotation advancement technique, which advance a triangle of tissue in the upper one third. A distinct difference is that the philtrum is not cut across by the Millard rotation incision. The triangular flap is in the lower one third of the lip and contains full thickness of the lip consisting of skin, muscle, and mucosa.
Advantages of the triangular flap are that it adds length to the medial lip element, rebuilds a good floor of the nostril, preserves Cupid’s bow, and adds tissue in the lower one third of the lip, where it is needed most. Furthermore, it gives dependable results.
The disadvantages are that the Z in the lip crosses the philtral line. It is a confusing technique to explain, especially the height adjustment and placement of the triangle in the lateral lip element. Furthermore, the vermilion countour is deficient in the midline and there is a tendency to get an increase in lip height on the repaired side. It is not clear how long to construct the lateral lip element, thus increasing the discrepancy in lip length.
Colostomy
What Is A Colostomy
In simple terms, a colostomy is when the colon is cut in half and the end leading to the stomach is brought through the wall of the abdomen and attached to the skin. The end of the colon that leads to the rectum is closed off and becomes dormant. This is known as a "Hartmann's Colostomy". There are other types of colostomy procedures, but this one is the most common.
Usually a colostomy is performed for infection, blockage, or in rare instances, severe trauma of the colon. This is not an operation to be taken lightly. It is truly quite serious and demands the close attention of both patient and doctor. A colostomy is often performed so that an infection can be stopped and/or the affected colon tissues can heal. The alternative to the colostomy is often pretty grim, death. Just be glad you are here. It is important realize that, with a few exceptions, you can look forward to having the colostomy reversed.
The Operation
The operation usually takes between two and four hours depending on difficulty, infection, and the severity of trauma if that is the case. Most of the reasons for a colostomy are: diverticulitis, other inflammatory bowel conditions, or cancer.
Since you are having the operation, you should discuss with your doctor whether or not you should have the appendix removed at the same time, since they are going to be in there anyway. It is not a necessary organ and, if removed, it can never cause you problems in the future.
It is normal practice to open the abdomen with an incision from just below belt line to just below the sternum. This gives open access to the internal organs. If you have infection, the doctor will suction and flush out the contaminates until you are clean.
Your colon is retrieved and inspected to locate the bad area. The bad area is then removed and the rectal end of the colon is sealed off. The end of the colon that comes from the stomach is cleaned and brought through the abdominal wall through another incision to provide an opening for the colon to expel gas and stool. After the colon is sutured in place, the first incision is either sutured or stapled together and the entire area is taped to protect the sutures or staples. A colostomy bag is applied to the area where the colon comes through the abdomen. This area is called a stoma.
During the operation there will be a catheter installed to drain the urine. This usually stays in for a couple of days. You will also have an intravenous (IV) line for medication and fluids. This will stay in for several days.
Recovery
The recovery process is, in large part, what you make of it. You can lie around feeling bad, which will slow or stall your recovery, or you can begin the process that will get you up and out of the hospital. It is perfectly normal to feel badly about being in the hospital and about your condition, but it beats the alternatives. You will adapt and you will get along and enjoy life in a reasonably normal manner if you want to. While I had my colostomy bag I found I could still ride my motorcycle, still hike in the woods, still go swimming, still go boating and camping, I even was able to hang around with my friends and do frivolous things and enjoy myself. The point I really want to make is that just because you are wearing a colostomy bag is no reason to give up the things you like to do or to become a hermit. Enjoy the life that this operation has allowed you to live and look forward to the future. KEEP YOUR SENSE OF HUMOR! There are many operations that are worse and there are many diseases that are worse.
Step one of recovery is to follow your doctors recommendations to the letter. Your first phase will be to walk and cough. Walking and coughing help to settle your stomach and clear your lungs. I found that I could force myself to walk a lot because I knew that I had to build up my muscles. You will probably start out with short trips from your bed and in a day or two you should be able to walk for 10 to 15 minutes at a time (more is better). Take it easy and don't overexert at first. During my first operation it took me two days before I could walk for 10 minutes, and during my last operation I was walking 9 hours after my operation. Keep trying.
Getting out of the bed is half the battle. I found that if I lifted the top of the bed straight up and lowered the bottom of the bed all the way down, I could swing out and slide off the edge of the bed. The first couple of days this is really uncomfortable but remember, your abdomen -or you- has been cut open, your insides have been moved all around, your abdominal muscles seem useless, and you probably just want to lie down and be left alone. Sorry, but you must force yourself to get up if you want to get better.
After a couple of days, walking will become easier but don't be afraid to ask for pain medication if you feel you need it. About day five you will find that it isn't quite so hard to get out of bed and your walks last a lot longer. Recovery from this point is just determination. Be determined.
Once you are reasonably mobile and pass a little gas you are starting to fall into a routine and recovering well enough that the nurses will want to wean you from some or all of your medication and remove IV's. This is good, don't feel that you are dependent upon them or that form of pain control. Pain can be successfully controlled with pills and it is during this weaning process that you will find out what type of pills work best for you. Don't be shy, tell the nurses and your doctor if the pills you are using don't work and give them the opportunity to try something else to ease your pain.
The most important thing now is to get out of the hospital and back home where you can be around your family and/or your stuff.
So You Made It Home
Now that you are home keep walking regularly (often). It is just as important to walk at home as it was in the hospital. The more walking that you do the sooner you get to feeling better. Take any medications when you are supposed to, the doctor didn't prescribe them as an exercise, he prescribed them because they are part of your recovery therapy and he expects you to take them.
Once you start feeling a little stronger you might try backing off the pain pills a little so you don't become too dependent on them. You will find that after a few weeks you won't need them and if you have been doing your exercises, you are getting around pretty well. It seems to take about six weeks for everything to feel OK. I have my own business and I didn't have the luxury of taking time off of work so I had to work lightly after I had been home for about a week. After two and a half weeks I was working at about 80% and after five weeks I was working normally. Again it is important to not over exert yourself and when you get tired, take a rest or a nap. Your recovery attitude will dictate your recovery speed for the most part. It seems like it was about 2 1/2 months before I went through the whole day and didn't think about any aches and pains. After about 4 months I felt really good (normal). I understand that with such a serious operation it probably takes about a year to really recover and for everything to be normal.
You may notice that your incisions leak or bleed a little. This is not unusual and it should not last long, but always consult your doctor if you are not sure or you are uncomfortable about it. Always keep your incisions clean.
By couple of weeks after your operation your doctor will remove your sutures or staples. You may notice that the area around the incision is hard and irregular. Don't worry about this, time will take care of it. After a few months, the lumps and irregularities will even out and the hard area will become less hard. Like the saying goes "Time Heals All Wounds", there is a lot of truth to it. You can try a lotion with vitamin E and lanolin to help soften the skin and reduce itching.
How To Deal With Your Colostomy Bag
There are different types of colostomy bags. Some strap on, some stick on. I preferred the stick on type because they required less fussing with. I tried the strap on type and it was uncomfortable around my abdomen. You may not agree. The strap on bag fits over the stoma and a belt goes around you to hold it in place. The stick on bag fits over the stoma and is held on by a wax that adheres to you. The stick on bag requires more attention during installation. Both bags require that you shave the area of the skin around the stoma. I shaved about two inches around the stoma. The reason you have to shave this area is twofold. One is for sanitary purposes and the other is, if you use the stick on bag, so you don't feel as if you are pulling the hairs out when you remove the bag after a few days. It is bad enough after a few days when the hairs have had a chance to grow a little and attach themselves to the wax. You can't stop this, you can only minimize it. In the process of shaving around the stoma, you may touch the stoma with the razor unit and the stoma may begin to bleed. This may also occur if you wash the stoma a little too aggressively. Don't worry, the stoma is very sensitive and bleeds easily if scrapped or nicked. The stoma does not have pain sensors for this so you must be careful and watchful of what you are doing. If the bleeding is severe or won't stop, call your doctor or get medical assistance. Most of the time when you have bleeding it will be minimal and stop rather quickly.
After you have shaved and washed the stoma area you are ready to install a new bag. If you choose the strap on style, strap it on and you are done. If you choose the stick on style you will need to cut the wax area to fit your stoma size. Fitting the stoma is not very hard. The box that the bag came in will have a cardboard piece with a series of holes in it. Find the hole that most closely fits your stoma, but does not pinch the edges of the stoma. Place the hole selected over the back of the bag and note the area that has to be removed. Remove with scissors. Peel the protective cover off the wax and put a thin bead of stoma paste around the very edge of the hole you just cut. This acts as a seal and a fluid barrier. Don't use too much as the more paste you use the less wax you will have sticking to you. Apply the bag to clean, dry skin so that the opening for draining the bag hangs straight down, this makes it easier to clean out between changes. Clamp the bottom of either bag and you are done. This sounds complicated but it isn't after you have done it a few times. You should be able to change the bag in about 5 to 7 minutes. Always carry an extra bag with you, JUST IN CASE. They fit easily into a back pocket or purse and in an emergency you will be glad you have it.
Now the hard part - cleaning out the bag. This is not a pleasant task at first. If you are sensitive you will not like it but you will get used to it. When I changed my first bag I thought I would gag from the smell. You are closer to the stomach and the smell isn't good. I got a swimming nose plug from the sporting goods store so I didn't have to smell it. After a couple of weeks you get used to it and it won't bother you. First you may need to bleed gas off from the bag. You still pass gas, but now it goes into the bag and slowly inflates it like a balloon. To bleed the gas off tip the bottom of the bag up to provide an air passage to release the gas but not the stool, if there is any, and press gently on the bag until it deflates. If there is enough stool to require emptying, use the gas to your advantage. I sat backwards on the toilet so that I had a better shot at the bowl. Open the clamp on the bottom of the bag, hold the bag downward, apply light pressure to the top of the bag and let the gas push the stool down and out. After this you can use a good spray bottle to clean out the bag. wipe off the bottom with a piece of toilet paper, install the clamp and you're done. It may sound difficult but it isn't and you'll get the hang of it after a couple of times. You'll be amazed at how long a roll of toilet paper will last.
Sometimes you will notice that the area under the wax on your bag itches. There isn't a lot you can do about this short of removing the bag and scratching it. One way to ease this is to apply pressure to the spot that itches, this will help.
Another thought about changing your bag is to do it before you have a meal or well afterwards. The reason for this is when your stomach is full it expands your belly. If you apply the bag under this condition you may find that when this expansion is gone, your skin wants to be smaller and the bag wont let it, thus being a little uncomfortable. Also, when you install the bag, be sure to stand up straight so you don't fold the skin. Standing and sitting flex the bag enough without these extra dimensions coming into play.
Straight Talk About Daily Life And Events
You will likely encounter a number of situations that you may not foresee and I will try to recall as many of them as I can remember having and tell you how I managed or overcame them.
Bag Blowout:
The first clue is a telltale odor - don't dismiss it. Check it out and replace the bag if necessary. Earlier, I suggested that you carry a spare bag, this is why. In almost a year I only had this happen twice but the spare was a real lifesaver. A note - the bag you carry as a spare should already have the hole cut to fit so you don't have to mess with it in some rest room.
Passing Gas:
Beware it isn't always silent. You will get a funny feeling in your stomach, learn to recognize it, and this can give you as much as 15 seconds notice, not very much, then sometimes you get no advance notice. I handled this with a sense of humor and no-one was ever offended, here's how. Simply smile and say "excuse me but I recently had an operation and I don't have very much control over that yet". I suppose you could stick a pin into the top of the bag to relieve the gas but I never tried it, you might give it a shot.
Swimming and Showering With The Bag On:
Water is not the bags best friend. What happens is that the wax absorbs the water from the side and if exposed to enough water for long enough the wax sort of turns to a soft putty-like substance. It wont stay on for long. If you go swimming, keep it to about 45 minutes and have a spare bag ready to install when you are done. REMEMBER: The stoma and your incisions are not able to deal with sunlight like your skin so you don't want to expose these areas to direct sunlight any more than necessary. I never experienced it, but, I think it might be pretty painful to get a sunburn on these areas and it could cause other problems. I used a baggy swimsuit and pulled it up over the stoma and bag. That seemed to do the trick plus it covered the area so it wouldn't bother anyone else.
Stool size:
I found that roughage, salads and the like, are among the most efficient foods and produce the least amount of stool while fast food restaurant fare produces the most stool in relation to intake. You can watch what you eat and keep an eye on how long different foods take to process and how efficient they are and keep your own mental notes. This may not seem important but it is. You don't want to eat pork and beans 5 hours before you go to a quiet church service. Neither would you want to eat a fast food lunch if you were planning a long trip. You can regulate your food to compliment the activity you have planned and thus keep embarrassing situations and inconveniences to a minimum.
$5.00 Per Bag:
With tax, colostomy bags cost just under $5.00 each. This can get expensive if you change them too often. About every 3 to 5 days is the useful life of a bag if you are careful. Keep the bag clean and watch for flexing of the wax along skin folds or the beltline area. If flexing is occurring it will soften the wax to the point where it will blow out. Don't let the bag get over half full of stool, and don't let the bag balloon over half full from gas. When it gets to these points, empty it. (Since the publication of this article, the price of bags has risen to over $30.00!)
Bag Cleaning Adapter For Your Sink:
You can buy an adapter for your sink faucet that allows you to attach a garden hose to it. Waterbed stores have plastic ones hardware stores have more durable metal ones. You can than adapt a small hose to the faucet which will help you clean the bag out but don't use too much pressure. I was able to adapt a kitchen sink sprayer for rinsing dishes to my bathroom sink and this gave me an on/off handle to better control the water flow. When I was done cleaning the bag I would remove the hose from the sink, clean it, and store it. Except for the 1/4" adapter on the faucet no one was the wiser. I found everything I needed at a local hardware store and it cost well under $20.00.
Your Rectum:
You will find that you may still want to eliminate rectally. I questioned this at first. How can the rectum function if it is essentially "out of the loop". I learned that the rectum still produces mucus and at a certain point it needs to eliminate what it has accumulated. It usually isn't very much but it is normal. On my first colostomy I eliminated mucus four or five times in the first month then nothing after that. On my second colostomy it occurred about every 7 or 8 days regularly. I would suppose that either is normal. Just don't be alarmed if it happens. Ask your doctor if you're not sure.
What About A Colostomy Reversal
This is a decision that is for you and your doctor to make. If you decide to have a reversal you will find the operation and recovery to be very similar to the first. Lots of walking but generally less hospital and recovery time. I noticed less pain and better mobility from the beginning. If your doctor will do this, it is well worth the trouble, but remember it is not a piece of cake. Prepare yourself for this operation by exercising and getting your weight to a good level (ask your doctor). Be as physically fit and as mentally prepared as you can. This makes the operation easier and the recovery quicker and to some degree less painful.
Conclusion
Just a few thoughts in conclusion. You have had a serious operation, listen to your doctor. This is not the end of the world, but you will have to deal with it. Treat your recovery seriously and be determined. Whenever you are feeling badly, think back a week and you won't feel so badly. You don't have to tough out the pain, that is why your doctor gave you a prescription. Time and exercise can become your best friends. Finally, and perhaps most importantly, KEEP YOUR SENSE OF HUMOR. There may be days that a sense of humor is all you have.
Good luck on your speedy recovery and bright future!
Appendicitis and Appendectomy
What is the appendix?The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed.
What is appendicitis and what causes appendicitis?
Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool). At other times, the lymphatic tissue in the appendix may swell and block the appendix. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside the appendix.. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for example, inflammation, that line the wall of the appendix.)
If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).
Sometimes, the body is successful in containing ("healing") the appendicitis without surgical treatment if the infection and accompanying inflammation do not spread throughout the abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and when antibiotics are used. The patients then may come to the doctor long after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs during healing. This lump might raise the suspicion of cancer.
What are the complications of appendicitis?
The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.
A less common complication of appendicitis is blockage of the intestine. Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the nose and esophagus and into the stomach and intestine.
A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.
What are the symptoms of appendicitis?
The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and poorly localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a problem is confined to the small intestine or colon, including the appendix.) The pain is so difficult to pinpoint that when asked to point to the area of the pain, most people indicate the location of the pain with a circular motion of their hand around the central part of their abdomen. A second, common, early symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. Nausea and vomiting also may occur later due to intestinal obstruction.
As appendiceal inflammation increases, it extends through the appendix to its outer covering and then to the lining of the abdomen, a thin membrane called the peritoneum. Once the peritoneum becomes inflamed, the pain changes and then can be localized clearly to one small area. Generally, this area is between the front of the right hip bone and the belly button. The exact point is named after Dr. Charles McBurney--McBurney's point. If the appendix ruptures and infection spreads throughout the abdomen, the pain becomes diffuse again as the entire lining of the abdomen becomes inflamed.
How is appendicitis diagnosed?The diagnosis of appendicitis begins with a thorough history and physical examination. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his hand after gently pressing on the abdomen over the area of tenderness.
White Blood Cell Count
The white blood cell count in the blood usually becomes elevated with infection. In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early. Unfortunately, appendicitis is not the only condition that causes elevated white blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used as a sign of appendicitis.
Urinalysis
Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract problem.
Abdominal X-Ray
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.
UltrasoundAn ultrasound is a painless procedure that uses sound waves to identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can exclude the presence of conditions involving the ovaries, fallopian tubes and uterus that can mimic appendicitis.
Barium Enema
A barium enema is an x-ray test where liquid barium is inserted into the colon from the anus to fill the colon. This test can, at times, show an impression on the colon in the area of the appendix where the inflammation from the adjacent inflammation impinges on the colon. Barium enema also can exclude other intestinal problems that mimic appendicitis, for example Crohn's disease.
Computerized tomography (CT) Scan
In patients who are not pregnant, a CT Scan of the area of the appendix is useful in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis.
Laparoscopy
Laparoscopy is a surgical procedure in which a small fiberoptic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anestetic.
There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to suspected appendicitis may include a period of observation, tests as previously discussed, or surgery.
Why can it be difficult to diagnose appendicitis?It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other parts of the intestine, has a mesentery. This mesentery is a sheet-like membrane that attaches the appendix to other structures within the abdomen. If the mesentery is large, it allows the appendix to move around. In addition, the appendix may be longer than normal. The combination of a large mesentery and a long appendix allows the appendix to dip down into the pelvis (among the pelvic organs in women). It also may allow the appendix to move behind the colon (called a retro-colic appendix). In either case, inflammation of the appendix may act more like the inflammation of other organs, for example, a woman's pelvic organs.
The diagnosis of appendicitis also can be difficult because other inflammatory problems may mimic appendicitis. Therefore, it is common to observe patients with suspected appendicitis for a period of time to see if the problem will resolve on its own or develop characteristics that more strongly suggest appendicitis or, perhaps, another condition.
What other conditions can mimic appendicitis?The surgeon faced with a patient suspected of having appendicitis always must consider and look for other conditions that can mimic appendicitis. Among the conditions that mimic appendicitis are:
- Meckel's diverticulitis. A Meckel's diverticulum is a small outpouching of the small intestine which usually is located in the right lower abdomen near the appendix. The diverticulum may become inflamed or even perforate (break open or rupture). If inflamed and/or perforated, it usually is removed surgically.
- Pelvic inflammatory disease. The right fallopian tube and ovary lie near the appendix. Sexually active women may contract infectious diseases that involve the tube and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal of the tube and ovary are not necessary.
- Inflammatory diseases of the right upper abdomen. Fluids from the right upper abdomen may drain into the lower abdomen where they stimulate inflammation and mimic appendicitis. Such fluids may come from a perforated duodenal ulcer,gallbladder disease, or inflammatory diseases of the liver, e.g., a liver abscess.
- Right-sided diverticulitis. Although most diverticuli are located on the left side of the colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures it can provoke inflammation they mimics appendicitis.
- Kidney diseases. The right kidney is close enough to the appendix that inflammatory problems in the kidney-for example, an abscess-can mimic appendicitis.
How is appendicitis treated?
Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected.
There is a small group of patients in whom the inflammation and infection of appendicitis remain mild and localized to a small area. The body is able not only to contain the inflammation and infection but to resolve it as well. These patients usually are not very ill and improve during several days of observation. This type of appendicitis is referred to as "confined appendicitis" and may be treated with antibiotics alone. The appendix may or may not be removed at a later time.
On occasion, a person may not see their doctor until appendicitis with rupture has been present for many days or even weeks. In this situation, an abscess usually has formed, and the appendiceal perforation may have closed over. If the abscess is small, it initially can be treated with antibiotics; however, the abscess usually requires drainage. A drain (a small plastic or rubber tube) usually is inserted through the skin and into the abscess with the aid of an ultrasound or CT scan that can determine the exact location of the abscess. The drain allows pus to flow from the abscess out of the body. The appendix may be removed several weeks or months after the abscess has resolved. This is called an interval appendectomy and is done to prevent a second attack of appendicitis.
How is an appendectomy done?
During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an abscess is present, the pus can be drained with drains that pass from the abscess and out through the skin. The abdominal incision then is closed.
Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). If appendicitis is found, the appendix can be removed with special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique include less post-operative pain (since much of the post-surgery pain comes from incisions) and a speedier return to normal activities. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. For example, laparoscopy is especially helpful in menstruating women in whom a rupture of anovarian cyst may mimic appendicitis.
If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent home from the hospital after surgery in one or two days. Patients whose appendix has perforated are sicker than patients without perforation, and their hospital stay often is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital to fight infection and assist in resolving any abscess.
Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in these cases is that it is better to remove a normal-appearing appendix than to miss and not treat appropriately an early or mild case of appendicitis.
What are the complications of appendectomy?
The most common complication of appendectomy is infection of the wound, that is, of the surgical incision. Such infections vary in severity from mild, with only redness and perhaps some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis are so severe that the surgeon will not close the incision at the end of the surgery because of concern that the wound is already infected. Instead, the surgical closing is postponed for several days to allow the infection to subside with antibiotic therapy and make it less likely for infection to occur within the incision. Wound infections are less common with laparoscopic surgery.
Another complication of appendectomy is an abscess, a collection of pus in the area of the appendix. Although abscesses can be drained of their pus surgically, there are also non-surgical techniques, as previously discussed.
Are there long-term consequences of appendectomy?
It is not clear if the appendix has an important role in the body in older children and adults. There are no major, long-term health problems resulting from removing the appendix although a slight increase in some diseases has been noted, for example, Crohn's disease.
What is new about appendicitis?
Recently it has been hypothesized that some episodes of appendicitis-like symptoms, especially recurrent symptoms, may be due to an increased sensitivity of the intestine and appendix from a prior episode of inflammation. That is, the recurrent symptoms are not due to recurrent episodes of inflammation. Rather, prior inflammation has made the nerves of the intestines and appendix or the central nervous system that innervate them more sensitive to normal stimuli, that is, with stimuli other than inflammation. This will be a difficult, if not impossible, hypothesis to confirm.
