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Appendectomy and resection of the terminal ileum with secondary severe necrotic changes in acute perforated appendicitis.

Shiryajev YN, Volkov NN, Kashintsev AA, Chalenko MV, Radionov YV - Am J Case Rep (2015)

Bottom Line: On laparoscopy, a large mass in a right iliac fossa was found.A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis.Postoperative recovery was uneventful.

View Article: PubMed Central - PubMed

Affiliation: Department of Faculty Surgery named after Prof. A.A. Rusanov, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation.

ABSTRACT

Background: Resectional procedures for advanced and complicated appendicitis are performed infrequently. Their extent can vary: cecal resection, ileocecectomy, and even right hemicolectomy. We present a very rare case of appendectomy that was combined with partial ileal resection for severe necrotic changes and small perforation of the ileum.

Case report: A 19-year-old female patient was hospitalized with right iliac fossa pain and fever 10 days after the onset of symptoms. On laparoscopy, a large mass in a right iliac fossa was found. The ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. After conversion using McBurney's incision, acute perforated appendicitis was diagnosed. It was characterized by extension of severe necrotic changes onto the ileal wall and complicated by right iliac fossa abscess. A mass was bluntly divided, and a large amount of pus with fecaliths was discharged and evacuated. Removal of necrotic tissues from the ileal wall led to the appearance of a small defect in the bowel. A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis. We perform a resection of the involved ileum combined with appendectomy and drainage/tamponade of an abscess cavity. Postoperative recovery was uneventful. The patient was discharged on the 15th day.

Conclusions: In advanced appendicitis, the involved bowel resection can prevent possible complications (e.g., ileus, intestinal fistula, peritonitis, and intra-abdominal abscess). Our case may be the first report of an appendectomy combined with an ileal resection for advanced and complicated appendicitis.

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A terminal ileum with severe inflammatory and necrotic changes secondarily to 10-day perforated appendicitis complicated by a large periappendiceal abscess.
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f1-amjcaserep-16-37: A terminal ileum with severe inflammatory and necrotic changes secondarily to 10-day perforated appendicitis complicated by a large periappendiceal abscess.

Mentions: At the laparoscopic revision, pathologic changes of the genitalia were not found. A large mass in the right iliac fossa was diagnosed. Consultation with a surgeon was requested, and indications for laparotomy were established. At that time, the ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. It had been taken into account that the patient was admitted to the hospital complaining on increasing pain and fever. These symptoms were regarded as very dangerous for a potential abscess rupture into a free abdominal cavity. All these circumstances have led us to the decision to choose an open surgery. The abdomen was opened by a McBurney’s incision. A large mass in the right iliac fossa and in the pelvis, including cecum, terminal ileum, and major omentum, was detected. This mass was divided bluntly, and a large amount of pus with fecaliths and tissue debris was discharged and evacuated. Due to large size of fecaliths, we avoided the simple abscess drainage in favor of appendectomy, considering a high risk of the fecal fistula (considering the wide lumen of the appendix). Only a small part of the vermiform appendix was present (about 3.5 cm from its base) and the remainder was completely necrotized. The existing part of the appendix was mobilized and removed. Its stump was peritonized by a fold of the lateral cecal wall because the bowel wall around the appendiceal stump was very hard and rigid and was not suitable for a stump closure. The wall of the ileum and its mesentery about 15 cm from the ileocecal junction was severely inflamed as a result of tight contact with the necrotized appendix, with formation of 5×2 cm necrotic area (Figure 1). On the surface of this area, non-viable tissues were clearly seen. In the process of their separation from the bowel wall, a small all-layer defect of the ileum was formed, despite very careful handling. It was detected by leakage of small air bubbles. Due to severe inflammation of the bowel wall, closure of this defect by single or single-row suture was unreliable and 2-row suture leads to substantial narrowing and obstruction of the intestine. In this situation, we prefer to perform a resection of the part of the ileum with necrotic tissues and perforation. The length of the resected bowel was 7–8 cm. An end-to-end anastomosis was created using 2 rows of 4/0 Vicryl sutures. The right iliac fossa and pelvis were irrigated with antiseptic solution (nitrofural 1:5000). The abscess cavity was drained by 1 tampon and 1 rubber tube, and the pelvis was drained by an additional tube. The wound was closed layer-by-layer, except for the tamponade area.


Appendectomy and resection of the terminal ileum with secondary severe necrotic changes in acute perforated appendicitis.

Shiryajev YN, Volkov NN, Kashintsev AA, Chalenko MV, Radionov YV - Am J Case Rep (2015)

A terminal ileum with severe inflammatory and necrotic changes secondarily to 10-day perforated appendicitis complicated by a large periappendiceal abscess.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4307687&req=5

f1-amjcaserep-16-37: A terminal ileum with severe inflammatory and necrotic changes secondarily to 10-day perforated appendicitis complicated by a large periappendiceal abscess.
Mentions: At the laparoscopic revision, pathologic changes of the genitalia were not found. A large mass in the right iliac fossa was diagnosed. Consultation with a surgeon was requested, and indications for laparotomy were established. At that time, the ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. It had been taken into account that the patient was admitted to the hospital complaining on increasing pain and fever. These symptoms were regarded as very dangerous for a potential abscess rupture into a free abdominal cavity. All these circumstances have led us to the decision to choose an open surgery. The abdomen was opened by a McBurney’s incision. A large mass in the right iliac fossa and in the pelvis, including cecum, terminal ileum, and major omentum, was detected. This mass was divided bluntly, and a large amount of pus with fecaliths and tissue debris was discharged and evacuated. Due to large size of fecaliths, we avoided the simple abscess drainage in favor of appendectomy, considering a high risk of the fecal fistula (considering the wide lumen of the appendix). Only a small part of the vermiform appendix was present (about 3.5 cm from its base) and the remainder was completely necrotized. The existing part of the appendix was mobilized and removed. Its stump was peritonized by a fold of the lateral cecal wall because the bowel wall around the appendiceal stump was very hard and rigid and was not suitable for a stump closure. The wall of the ileum and its mesentery about 15 cm from the ileocecal junction was severely inflamed as a result of tight contact with the necrotized appendix, with formation of 5×2 cm necrotic area (Figure 1). On the surface of this area, non-viable tissues were clearly seen. In the process of their separation from the bowel wall, a small all-layer defect of the ileum was formed, despite very careful handling. It was detected by leakage of small air bubbles. Due to severe inflammation of the bowel wall, closure of this defect by single or single-row suture was unreliable and 2-row suture leads to substantial narrowing and obstruction of the intestine. In this situation, we prefer to perform a resection of the part of the ileum with necrotic tissues and perforation. The length of the resected bowel was 7–8 cm. An end-to-end anastomosis was created using 2 rows of 4/0 Vicryl sutures. The right iliac fossa and pelvis were irrigated with antiseptic solution (nitrofural 1:5000). The abscess cavity was drained by 1 tampon and 1 rubber tube, and the pelvis was drained by an additional tube. The wound was closed layer-by-layer, except for the tamponade area.

Bottom Line: On laparoscopy, a large mass in a right iliac fossa was found.A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis.Postoperative recovery was uneventful.

View Article: PubMed Central - PubMed

Affiliation: Department of Faculty Surgery named after Prof. A.A. Rusanov, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation.

ABSTRACT

Background: Resectional procedures for advanced and complicated appendicitis are performed infrequently. Their extent can vary: cecal resection, ileocecectomy, and even right hemicolectomy. We present a very rare case of appendectomy that was combined with partial ileal resection for severe necrotic changes and small perforation of the ileum.

Case report: A 19-year-old female patient was hospitalized with right iliac fossa pain and fever 10 days after the onset of symptoms. On laparoscopy, a large mass in a right iliac fossa was found. The ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. After conversion using McBurney's incision, acute perforated appendicitis was diagnosed. It was characterized by extension of severe necrotic changes onto the ileal wall and complicated by right iliac fossa abscess. A mass was bluntly divided, and a large amount of pus with fecaliths was discharged and evacuated. Removal of necrotic tissues from the ileal wall led to the appearance of a small defect in the bowel. A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis. We perform a resection of the involved ileum combined with appendectomy and drainage/tamponade of an abscess cavity. Postoperative recovery was uneventful. The patient was discharged on the 15th day.

Conclusions: In advanced appendicitis, the involved bowel resection can prevent possible complications (e.g., ileus, intestinal fistula, peritonitis, and intra-abdominal abscess). Our case may be the first report of an appendectomy combined with an ileal resection for advanced and complicated appendicitis.

Show MeSH
Related in: MedlinePlus