VCU Department of Surgery
Death & Complications Conference
Michelle Hamel, PGY-5
11/13/14
• Operation: Laparoscopic Appendectomy
• Indication: Acute Appendicitis
• Complication: Readmission, pelvic phlegmon
formation, bacteremia
Clavien-Dindo Classification
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.
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
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
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
CT Abd/Pelvis
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
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
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
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.
CT abdomen/pelvis
Case Presentation
• CT abd/pelvis: Developing pelvic abscess with
fluid collections and locules of free air
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
• Our patient received antibiotics just prior to
incision, and no post operative antibiotics
• Should our patient have received postoperative antibiotics in setting of complicated
appendicitis?
• 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
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
• 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
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
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)
• Questions?