25. 1 Acute pancreatitis
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If the appendicular abscess is situated more medially the same incision for appendicectomy is made. When after opening the peritoneum one sees appendicular abscess, it is better to drain the abscess and come out.
Appendicectomy is usually avoided during draining of the abscess, lest a faecal fistula may result due to injury to the inflamed caecum and inflamed coils of small intestine. Appendicectomy is only performed in case of infants, if it becomes very easy, as there is a chance of continued drainage of faeces from caecum through perforation of the appendix due to broad lumen of the appendix in infant.
A sump drainage tube should be inserted into the appendix cavity. The subcutaneous tissue and skin incision are kept open as should be done in case ofgangrenousappendicectomyto avoid wound infection. So long as the drainage continues the tube is kept in position. When the drainage has been stopped a sinogram may be performed to know that the abscess cavity has been obliterated. The drainage tube is removed. Systemic antibiotics are continued for 5 days postoperatively. Rectal examination should be made almost daily to detect developing pelvic abscess.
A pelvic abscess may be drained in the female into the vagina and in the male into the rectum.
If the appendix is not removed when the abscess is drained, interval appendicectomy should be done 6 to 8 weeks after the wound has healed.
Management of subacute, recurrent and chronic appendicitis.— The treatment of choice is early appendicectomy.
COMPLICATIONS OF APPENDICECTOMY— 1. Wound infection— Infection of the subcutaneous tissue is the most common complication following appendicectomy.
2. Pelvic, Subphrenic or intra-abdominal abscess—may occur following gangrenous or perforated appendicitis.
3. Faecal fistula may occur if a ligature slips from a tied but noninverted appendiceal stump, too tight suturing of the base of the appendix or purse string suture, necrosis from a periappendiceal mass encroaching on to the caecum, erosion of the wall of caecum by drain, Crohn's disease etc. Faecal fistulas usually close spontaneously. All that is required is to ensure that the tract remains open until the drainage ceases, (i) If the bowel beyond the fistula is obstructed or (ii) the mucous membrane of the gut is continuous with the skin, closure of the fistula will require an operation.
4. Pylephlebitis or portal pyemia may result which is characterised by jaundice, high fever and chills.
5. Intestinal obstruction, initially paralytic but occasionally may go on to true mechanical obstruction may occur with slowly resolving peritonitis. Intestinal obstruction due to adhesion formation is not uncommon after 2 months of operation.
NEOPLASMS
Neoplasms of the appendix are extremely uncommon and are usually diagnosed at operation or autopsy. MALIGNANT tumours are: (i) Carcinoid tumour; (ii) Adenocarcinoma; (iii) Malignant mucocele.
Carcinoid.— About 40% of all carcinoid tumours of G.I. tract have been reported to be found in appendix. But true incidence is more as majority of these tumours are without symptoms.
Carcinoids of appendix are typically small, firm, yellowish brown tumours. Majority of these tumours occur at the distal third of the appendix and only less than 10% occur at the base. These are without symptoms and are usually discovered at the time of operation. Only less than 3% of appendiceal carcinoids metastasise.
Treatment is appendicectomy with excision of mesoappendix. If nodal metastasis is demonstrated, right hemicolectomy with excision of the nodes bearing mesentery is indicated.
Adenocarcinoma.— By all means this is similar to colonic adenocarcinoma. Preoperative diagnosis can only be confirmed by visualisation ofextra-caecal mass on barium enema. Majority of these cases are diagnosed during appendicectomy. In a few instances the lesion is even missed during appendicectomy and is only detected on histopathological report of the appendicectomy specimen. Treatment is right hemicolectomy.
Malignant mucocele.— Benign mucocele may occur in the process of acute appendicitis and has been described in section of 'Pathology' of acute appendicitis. Malignant mucocele is a mucous papillary adenocarcinoma (Grade I). This is a cystic dilatation of the appendix containing mucoid material.
Treatment is simple appendicectomy. Care must be taken to avoid rupture of mucous-filled appendix, as there is a chance of pseudomyxoma peritonei to develop.