1. VCU Department of Surgery Death & Complications Conference
Michelle Hamel, PGY-5
11/13/14

2. Operation: Laparoscopic Appendectomy
Indication: Acute Appendicitis
Complication: Readmission, pelvic phlegmon formation, bacteremia

3. Clavien-Dindo Classification

4. Case Presentation
HPI: 44 y/o AA male presented to ED c/o 1 day h/o bilateral LQ abdominal pain, urinary urgency and tenesmus. Associated with nausea and emesis, which started at the same time as the pain. No fevers. Currently hungry. Normal BM yesterday and still passing flatus.

5. Case Presentation
PMH: DM, HTN, CKD, Sleep apnea, obesity, gout, diabetic retinopathy
PSH: none
SH: Denies tob, EtOH or illicits. Married. Works as a restaurant manager.
FH: DM, HTN, kidney disease

6. Case Presentation
Medications: Glipizide, ASA, atorvastatin, allopurinol, amlodipine, gabapentin
PE:
Vitals: T 37.5; HR 79; BP 174/103; Sats 99%RA
BMI 40
GEN: NAD, non-toxic
RESP: CTAB
CV:RRR
ABD: soft, obese, tender in RLQ/suprapubic region, non-distended. +Rovsing’s sign, Voluntary guarding in RLQ

7. Case Presentation Labs: WBC 8.4 / Hgb 11 / Plt 293
Na 135 / K 4.7 / Cl 104 / Bicarb 22 / BUN 61 / Creat 3.93 / Glucose 109
LFTs, Amylase, Lipase WNL

8. CT Abd/Pelvis

13. Case Presentation
CT abd/pelvis: Calcification within the base of the cecum with fat stranding distal to this and a non-visualized appendix; findings concerning for a ruptured appendix with associated appendicolith

14. Case Presentation
Patient taken to OR and underwent laparoscopic appendectomy
Appendix gangrenous in midportion with tip scarred to the bladder, indicating possible longstanding inflammation
Midportion of appendix broke and appendix was removed piecemeal after stapling base of appendix
No associated abscess or gross spillage

15. Case Presentation
On POD 1, WBC was 10.1, pt was afebrile and tolerating diet
Pt was d/c home
Pathology: Acute necrotizing appendicitis with serositis

16. Case Presentation
Pt returned to ED on POD 7 c/o bilateral LQ abdominal pain and nausea. Subjective fevers at home. Normal BM that am. No emesis.
Febrile to 102, WBC 11.5
Non-toxic appearing and abdomen tender in bilat LQ with no peritoneal signs.

17. CT abdomen/pelvis

21. Case Presentation
CT abd/pelvis: Developing pelvic abscess with fluid collections and locules of free air

22. Case Presentation Patient was admitted and started on IV zosyn.
No drainable fluid collections
Clinical improvement with antibiotics and WBC normalized, inpatient for additional 5 days
Blood cultures positive for bacteroides
Sensitivities demonstrated bacteria resistant to zosyn, sensitive to flagyl
Per ID recommendations, pt d/c home on 2 week course of cipro/flagyl

23. Our patient received antibiotics just prior to incision, and no post operative antibiotics
Should our patient have received post-operative antibiotics in setting of complicated appendicitis?

25. 45 randomized controlled trials including 9,576 adult & pediatric patients comparing effect of antibiotic treatment vs placebo for appendectomy, including wound infection and intraabdominal abscess
Preoperative or postoperative antibiotic treatment significantly decreased the wound infection and intraabdominal abscess formation

26. Weaknesses of study Many studies from 70s and 80s
Definition of intraabdominal abscess = persistent fever with no source, palpable mass in RLQ, purulent rectal drainage
No comparison of preoperative vs postoperative antibiotics
Included adults and children
No recommendations for type or length of course of antibiotics
Smaller number of patients with complicated appendicitis
*Has been standard of care to treat patients with complicated appendicitis with postoperative antibiotics

27. Retrospective review of 52 patients from 2007-2012 at EVMS
No significant difference in postoperative abscess formation in patients receiving <24H or >24H of antibiotics in complicated appendicitis
Small, retrospective study

28. Conclusions
Current standard of care to give postoperative antibiotics for complicated (perforated, gangrenous appendicitis or with associated abscess)
Course and optimal regimen remain to be defined

29. Analysis of Complication
Was the complication avoidable?
Yes, patient did not receive postoperative antibiotics
Would avoiding the complication change the outcome?
Yes, patient would avoid readmission and prolonged antibiotic course
What factors contributed to the complication?
Lack of postoperative antibiotic treatment in a patient at high risk for infectious complications (DM, CKD)

30. Questions?