Right thigh necrotizing fasciitis induced by perforated appendicitis

Acute appendicitis is one of the most common surgical diseases. However, diagnosis is often delayed due to atypical manifestations of appendicitis. Delayed diagnosis causes complications such as perforation, wound infection, abscess, and peritonitis. Necrotizing fasciitis (NF) complicated by perforated appendicitis is extremely rare and can be fatal. Herein, we report the case of an elderly woman presenting with NF of the right leg due to hidden perforated appendicitis. She had multiple medical diseases and initially complained of right leg pain for 3 days without any abdominal symptoms or signs. Her vital signs became unstable on the second day after admission. Computed tomography showed deep NF of the right leg extending from the perforated appendicitis. Emergency surgery was performed after appropriate resuscitation, but she failed to recover from sepsis and died 42 days after surgery.

Therapeutic Consideration of Periappendiceal Abscess: an Evaluation of Non-surgical Treatment Followed by Minimally Invasive Interval Appendectomy

PURPOSE: Periappendiceal abscess (PAA) is a severe complicated appendicitis with high morbidity. Non-surgical treatment followed by interval appendectomy (IA) is associated with lower complication rate compared with emergency surgery (ES) and minimally invasive surgery (MIS) can be done more often. The purpose of this study is to assess the incidence and factors predictive of complications of surgery for PAA and to evaluate the clinical effectiveness of IA as a treatment policy to increase MIS. METHODS: Retrospectively, we reviewed 171 patients undergoing surgery for PAA between 2011 and 2016 at Ulsan University Hospital. The incidence and influence of different factors were assessed by univariate and multivariate analyses. RESULTS: In 171 patients, 28 (16.4%) developed postoperative complications, which included; wound complications (7.6%), intra-abdominal abscess (4.1%) and ileus (2.9%). In both analyses, only ES was independently associated with postoperative complications; (Relative risk, 15.0; 95% Confidence interval, 2.4~92.5). Comparing the IA and ES groups revealed that operative time, complication rate, laparoscopic approach, postoperative hospitalization, postoperative antibiotic use and bowel resection rate were significantly different. The postoperative complication rate of patients with PAA in ES group was 28.7%, which was statistically higher than that of IA group (3.6%). Especially, MIS rate was more than 9-times greater in the IA group (98.8% vs. 10.3%, p<0.001). Although the IA group required additional hospitalization, there was no statistical difference between the two groups in total length of hospital stay. CONCLUSION: Morbidity was high for patients who had emergency surgery for PAA. ES was the only factor associated with postoperative morbidity. IA can reduce the postoperative complication rate and allowed MIS to be used more often as a useful treatment policy for PAA.

Advantages of Interval Laparoscopic Appendectomy for Periappendiceal Abscess

PURPOSE: Laparoscopic appendectomy is a common procedure for treatment of appendicitis. However, in some complicated cases, like periappendiceal abscess, deciding on treatment options is very challenging. Early appendectomy or interval appendectomy may be possible, but remains controversial. METHODS: We prospectively studied the advantages of interval appendectomy in 21 patients with periappendiceal abscess using a laparoscopic method versus 14 patients with immediate initial laparotomy. RESULTS: In the interval appendectomy group (INT group), in periappendiceal abscess, use of a laparoscopic method was advantageous in terms of operation time (p<0.001), less fasting time (p<0.001), and fewer postoperative complications (p=0.032). However, the total cost in the INT group was 1,686,000+/-940,000 South Korean won (KRW) compared with 1,506,000+/-322,000 KRW in the early appendectomy group (EAR group) (p=0.007) because patients in the INT group required two hospital visits. The total length of hospital stay postoperatively, was 7.31+/-2.726 days in the INT group, compared with 9.21+/-3.378 days in the EAR group (p=0.537). CONCLUSION: We recommend interval appendectomy as the preferable approach for the periappendiceal abscess, as it can result in more favorable postoperative surgical outcomes, fewer complications, and less antibiotic usage.

Advantages of Interval Laparoscopic Appendectomy for Periappendiceal Abscess

PURPOSE: Laparoscopic appendectomy is a common procedure for treatment of appendicitis. However, in some complicated cases, like periappendiceal abscess, deciding on treatment options is very challenging. Early appendectomy or interval appendectomy may be possible, but remains controversial. METHODS: We prospectively studied the advantages of interval appendectomy in 21 patients with periappendiceal abscess using a laparoscopic method versus 14 patients with immediate initial laparotomy. RESULTS: In the interval appendectomy group (INT group), in periappendiceal abscess, use of a laparoscopic method was advantageous in terms of operation time (p<0.001), less fasting time (p<0.001), and fewer postoperative complications (p=0.032). However, the total cost in the INT group was 1,686,000+/-940,000 South Korean won (KRW) compared with 1,506,000+/-322,000 KRW in the early appendectomy group (EAR group) (p=0.007) because patients in the INT group required two hospital visits. The total length of hospital stay postoperatively, was 7.31+/-2.726 days in the INT group, compared with 9.21+/-3.378 days in the EAR group (p=0.537). CONCLUSION: We recommend interval appendectomy as the preferable approach for the periappendiceal abscess, as it can result in more favorable postoperative surgical outcomes, fewer complications, and less antibiotic usage.

The Necessity of a Routine Interval Appendectomy Necessary in Adults?: Initial Experience

PURPOSE: The traditional management of a periappendiceal abscess or a perforated appendicitis has been initial conservative treatment, followed by an interval appendectomy (IA). However, the necessity of the interval appendectomy has been questioned by an increasing number of studies recently. The purpose of this study was to clarify the role of conservative treatment, instead of IA, in managing a perforated appendicitis or a periappendiceal abscess after successful initial conservative treatment. METHODS: We prospectively studied 26 out of 80 patients who had been admitted for a perforated appendicitis or a periappendiceal abscess to Chonbuk National University Hospital from March 2005 to December 2007. These 26 patients were initially treated by using conservative treatment instead of surgery. We analyzed these 26 patients' progression and prognosis after treatment. The IAs were conducted at intervals of 6 to 12 wk after colonoscopy when the patient wanted an operation. RESULTS: Twenty-three out of 26 (88.5%, 23/26) patients were improved after initial conservative treatment. Only 3 patients who were not improved were managed surgically. Four out of 23 patients who were relieved by conservative treatment underwent an IA voluntarily at intervals of 6 to 12 wk. Of the remaining 19 patients without IA, 1 patient (5%, 1/19) suffered a recurrence after 6 mo, and an appendectomy was performed. Eighteen (78%, 18/23) patients without an IA have shown no recurrence for 15 mo, and they are still being followed up. CONCLUSION: We conclude that a routine IA after successful initial conservative treatment for a perforated appendicitis or a periappendiceal abscess seems unnecessary. Those patients should undergo colonoscopy to detect any underlying diseases and to rule out coexistent colorectal cancer.

Abdominal Actinomycosis Presented as a Periappendiceal Abscess

The anaerobic gram-positive bands, Actinomycosis israelii, are normal inhabitants of the oral cavity but upper intestinal tract of humans and rarely cause disease. Actinomycosis is an infrequent chronic suppurative infection which usually manifests as fistulas and sinuses or as a mass that simulates a pseudo-neoplastic formation. The cervicofacial region is the most common site of the disease, and the abdomen is the second. Abdominal involvement is traditionally often associated with right-sided infection. Herein, two cases of abdominal actinomycosis detected by the pathologist after a surgical operation, are reported. Before the operation, both patients presented with right lower quadrant pain, a palpable mass and leukocytosis. Preoperative abdominal computerized tomography (CT) was performed, followed by surgical intervention under the impression of a periappendiceal abscess. These cases demonstrate that abdominal actinomys should be included in the differential diagnosis when CT shows an infiltrative and inflammatory intraabdominal mass with localized tenderness.

Abdominal Actinomycosis Initially Diagnosed As a Colorectal Cancer or Periappendiceal Abscess / 대한소화기내시경학회지

BACKGROUND/AIMS: Colonic actinomycosis is a rare disease with clinical and radiographic findings that overlap those of other inflammatory and neoplastic conditions. We performed this study to analyze clinical manifestation, characteristic radiologic findings of 5 cases of abdominal actinomycosis, which was initially diagnosed as a colorectal cancer or periappendiceal abscess. METHODS: We analyzed chief complaint, predisposing factor, presence of leukocytosis and sulfur granule, involved site, presence of LN involvement and abdominal CT findings, retrospectively. RESULTS: The most common clinical manifestation was abdominal pain. In 3 cases, predisposing factors were identifiable, which were intrauterine contraceptive device (IUD), previous appendectomy, and diabetes mellitus (DM) respectively. Leukocytosis was noted in 4 cases (80%) and sulfur granule in all 5 cases. Sigmoid colon was the most common involved site (4 cases) followed by appendix and rectum. On computed tomography, inhomogeneous mass or severe inflammation along the bowel wall or serosa was noted. Explorations were performed in 4 cases. Preoperative diagnosis was a colorectal cancer in 3 cases and periappendiceal abscess in 1 case. CONCLUSIONS: Actinomycosis should be born in mind in the differential diagnosis of patients with IUD, previous appendectomy and DM, presenting leukocytosis and CT finding of inhomogeneous mass and relatively uncommon LN involvement to eliminate unnecessary explorations.

A Clinical Study of Periappendiceal Abscess

This is a clinical analysis and review of one-hundred ninety-four patients with periappendiceal abscesses who were treated at the Departmeat of Surgery, Masan Samsung Hospital over a ten year period from January 1985 to December 1994. The following results were obtained. The incidence of periappendiceal abscesses was 7.24% of the total cases of appendicitis operated on during the same period, and most of the patients(43.8%) were over fifty years old. The male to female ratio was 1:1.02. 41.2% of the patients had operations within four days after their symptoms occurred. On admission, the most common physical finding was tenderness on the right lower quadrant of the abdomen (92.9%) and leukocytosis(> OR = 10,000/mm3) was noted on CBC in 82% of the patients. Abdominal sonograms revealed periappendiceal abscesses in 88% of the patients, 83% were revealed with barium enema and 88% with abdominal CT scan. Many patients(75.5%) visited the local clinic and were treated under the diagnosis of gastritis or enteritis instead of appendicitis. One-hundred eighty-three patients(94.3%) had appendectomies with drainages(94.3%), two patients had drainages of abscesses without appendectomy, six patients had ileocecal resections and three patients had right hemicolectomies. Microbiologically, E. coli was the most frequently cultured species(63%) from abscess, and Klebsiella, Enterococcus and Proteus were isolated in some cases. Postoperative complication occurred in seventy-five patients(38.6%) and the most frequent complication was wound infection(28.8%). There was no mortality and the mean hospital stay was fifteen days.

The Hemolytic Uremic Syndrome Associated with Periappendiceal Abscess / 대한신장학회잡지

The hemolytic uremic syndrome (HUS) is clinically characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. The unique cause has not been determined but some bacteria such as E. coli was regarded as the causative agent of HUS in infant. A 30-year-old male patient was admitted due to acute abdomen. In operating field, the periappendiceal abscess was found, so the appendectomy with the drainage of abscess was performed. Initial hemoglobin level was 16.2g/dL but abruptly developed anemia (12.6g/dL) and thrombocytopenia (27000/mm3) was detected at hospital day 3. The urinary outflow was totally absent, the serum creatinine was 12.8mg/dL and the LDH was 3,650IU/L. The peripheral blood smear showed strong evidence of microangiopathic hemolysis. We performed total plasma exchange and hemodialysis under the diagnosis of HUS. The patient's renal function was markedly improved and the last creatinine was 1.9mg/dl. To our knowledge, this is the first report of HUS associated with periappendiceal abscess in Korea. We present a case and the review of literature.