Sunday, September 7, 2014

Night of the Appendix


It started at 4:30 pm. Another night on call, only today I was covering two busy emergency rooms. It was like that, back in those days, years ago. Our group provided emergency care at four different hospitals and sometimes we covered all of them. Tonight it was two. I wasn’t really concerned. There was another surgeon on back-up call and in all the years I’d been in practice there had only been a single episode of simultaneous life threatening emergencies which would have required me to be in two different places at the same time. Luckily, the back-up surgeon came to the rescue in that instance.
But, back to today. This first call from hospital A was about Lester, 55 years old with abdominal pain for two days. The pain started in the mid abdomen and then moved to the right lower quadrant. His white blood cell count was sixteen thousand and CT Scan of the abdomen and pelvis revealed acute appendicitis.
A no brainer.
I called the OR and told them to crank up the laparoscope as I made my way to the ER to see Lester. He was the manager of a well known used car dealership. His story and exam were textbook, he had an IV, antibiotics were flowing and the OR crew was ready to take him away.
I commented on the steady beeping of the OR monitors as he drifted off to sleep. The surgery went off without a hitch as I encountered a straightforward inflamed appendix which I deftly liberated with my trusty Endo GIA stapler, popped into an endopouch and pulled it out in all of twelve minutes.
As I placed the last stitch my phone went off again. The ER from hospital B was calling. Dr. P was on the other end of the call.
“I’ve got a nine year old girl with belly pain for four days, temp is 102 and CT shows appendicitis, possibly with an abscess. Do you do kids?”
I answered in the affirmative.
“Does she look very sick?”
“A little flushed, but her heart rate is around a hundred, BP is OK.”
“Does she have diffuse tenderness or is it localized?”
“Seems to only in the right lower quadrant.”
“I think we can do her surgery there. I’ll call the OR and I’ll be there in a little bit,” I informed Dr. P.
I tucked Lester away in the Hospital A PACU and made the fifteen minute drive to Hospital B. It was now 6:15 pm.
Luisa was a skinny nine year old. She smiled at me when I walked in the ER room and winced when I lightly tapped on her RLQ. Her pain had started four days previously, she’d had nausea and vomited about ten times and also had diarrhea. Her primary care doctor had diagnosed her with gastroenteritis and prescribed Pedialyte and Bactrim. It’s pretty common for appendicitis to be misdiagnosed and present late in its clinical course. Conditions such as gastroenteritis are very common and, as we are taught, common things occur commonly and gastroenteritis is more common than appendicitis.
She was wheeled off to surgery at 7:12.
She was asleep by 7:35. I put the scope in through her belly button and was greeted by a mass of inflamed bowel and omentum which was oozing pus. It wasn’t very attractive and it presented a bit of a challenge. Luisa was not going to be a twelve minute appendectomy.
I started to gingerly dissect. First the omentum. I could see the plane and gently pulled on the tissue. The “watchdog” peeled away so that I could now see a fat, grayish black appendix nesting against the small bowel, which was my next target. Carefully, carefully I separated the appendix from the small bowel. A well of brownish pus poured out and a large brown “fecalith” rolled down.
“Pac Man,” I requested.
The surgical tech rummaged around on her back table and produced the desired instrument, a device which opens and closes its jaws just like the creatures which race around the maze in the Pac Man video game. I’m not sure what this instrument’s proper name is.
I scooped up the fecalith and whisked it away, deposited it in the basin which was awaiting the offending (and offensive) appendix. Back to the task at hand, I finally had all the bowel and omentum away from the appendix and was able to proceed with what was now a “routine” appendectomy. Once the appendix gone, the final task was irrigating, washing, irrigating and more washing until the peritoneum was clean.
With the final steri placed my phone chimed again. Hospital A ER was calling.
“This is Dr. T. I’ve got a 22 year old male with two days of right lower quadrant abdominal pain, White blood count 22,000, CT shows appendicitis.”
Back I went to hospital A. It was now 8:52.
When I arrived in the ER at Hospital A I met Esteban. He had been having pain for about a day and half. He was lying motionless on the stretcher, his face was slightly flushed. He was thin with a black moustache and he only spoke Spanish.
“Tiene dolor en el estomago?” I asked reaching the limits of my Spanish.
“Cuando empezado el dolor?”
And so it went. I can take a reasonable history in Spanish as long as the patient’s symptoms are limited to the abdomen and their answers are limited to yes or no. Esteban reminded me of one of the rules I learned during residency:

If a young Latino male comes to the ER complaining of right lower quadrant abdominal pain you can schedule him for appendectomy without seeing him. You will make the proper diagnosis almost one hundred per cent of the time.

This was true because it was not considered “macho” to go to the doctor. In my experience, in the 1980’s, this rule held true. Esteban fell into this category, but he still had been evaluated with the requisite CT Scan which confirmed the obvious diagnosis of acute appendicitis.
He was in the OR by 9:45 and underwent a straightforward “lap appy,” which I finished just in time to get paged to the ER at hospital B.
“Mary Rogers, 59 years old, right lower abdominal pain for two days, White count is 12,000, CT shows a retrocecal appendicitis,” reported the familiar voice of Dr. M.
“Isn’t it early for you to call?” I asked Dr. M. “It’s usually two am when I get to hear your voice.”
“Be thankful you get an early start tonight,” she advised. “Oh and there may be another appendix brewing.”
“I’ll be there shortly,” I answered.
Luckily, the OR crew had not gone home yet. Mary was waiting in the OR holding area when I arrived. I did a quick history and physical and explained the surgery and they whisked her away to OR five. It was now 11:10.
The CT scan was one hundred per cent accurate in this case. Mary’s appendix was very retrocecal, which means it was hiding behind the Cecum (the first part of the colon which is where the appendix is attached to the colon), and behind the ascending colon, which is the next part of the colon.
I started by picking up the cecum and identifying the tenia coli, which are bands of muscular tissue in the wall of the colon. There are three tenia on the colon and they meet at the base of the appendix. Following these tenia coli allows the surgeon to find the appendix, which occasionally can be a difficult task. Using this technique I found the base of the appendix, but that was the only portion I could identify. The rest disappeared behind the colon, heading north towards the liver. In order to see what I needed to see I had to mobilize the right colon, which means divide the peritoneal attachments which keep the colon from flopping around.
This done I now could see the appendix, at least see where it was going. And so I began the tedious task of step by step clipping of the “mesoappendix” which contains the blood vessels going into the appendix. Normally I would take a stapling device and simply divide and staple this mesoappendix with one squeeze, but there was nothing easy about Mary.
Finally, the end was in sight as the inferior edge of the liver came into view. The appendix was inflamed over the distal half, not ruptured and it was finally completely free. Once it was out of the abdomen I measure it at eight inches in length, probably more than twice the norm.
Finally done.
No such luck. The phone went off again.
At least it was Hospital B again. Dr. M greeted me.
“Megan Bartlett is sixteen years old, right lower quadrant abdominal pain for eight hours, White Blood cell count is ten and her CT is normal. She is pretty tender, however.”
“OK, I’m still here. I’ll come take a look at her,” I replied.
Megan was there with two very worried parents, but it soon became obvious that the parents were no longer together and didn’t agree on much. Daddy wanted to take his little girl downtown to “World Famous Medical Center.” Mommy thought she could stay at Hospital B. I did my usual history and physical exam, reviewed the CT Scan and then sat down to talk to all the partied involved.
“Megan’s history and exam are strongly suggestive of appendicitis,” I began, “but the CT looks normal. She’s only been sick for eight hours and sometimes the CT won’t show any of the usual changes we see with appendicitis if her pain hasn’t been going on very long.”
I recommended she stay in the hospital to be examined later and if her pain and tenderness persisted then operate at that time. Mommy was in agreement, but Daddy was still skeptical. I left them alone for a few minutes to hash it out and, in the end, Mommy won out. Daddy was not there when I returned.
Megan was admitted to the Pediatric floor and I went home. It was two am.
I reevaluated Megan in the morning. She was still tender and subsequently underwent an uncomplicated appendectomy.
This night confirmed the old medical adage: “Common things occur commonly.”
Appendicitis is one of the most common maladies General Surgeons are called upon to treat. Most of the time this means surgery, although there have been recent efforts made to treat appendicitis nonoperatively with antibiotics. In the end, removal of this offending organ seems to be the best approach. Most patients with uncomplicated appendicitis are discharged within twenty four hours and are back to normal activity in a few days.
The advent of CT Scanning to evaluate possible appendicitis has made my life much easier. When I started in the surgery business (too many years ago) the diagnosis and treatment of appendicitis usually took three hours. Appendicitis was diagnosed based on history, physical exam and labs. I would drive to the hospital, do my H&P, then call the OR crew, wait for them to arrive and set up, do the surgery and then go home. Total time: three hours. Now, the ER physician presents the patient, tells me the CT Scan result, I call the OR crew from home, arrive just before the surgery, perform the operation and go home. Total time: one hour.
But, I still have to come and evaluate the patient in cases like Megan. Watchful waiting sometimes prevents unnecessary surgery. It is not unusual for the pain to fade away and the patient discharged without any surgical intervention. Often we never find out what caused the pain. Presumably it is a virus or some other self limiting condition.
Five appendectomies in twenty four hours is a bit unusual. Recently, I broke this record by doing seven laparoscopic appendectomies in a twenty four hour period. Maybe this disease is becoming more common. When I was in medical school Denis Burkitt,  a durgeon who lived in Africa, famous for describing Burkitt’s Lymphoma, spoke at one of my classes. He said that appendicitis, among several other diseases like hemorrhoids and colon cancer, was almost never seen in Africa. He chalked it up to Americans being “constipated society,” one where the highly processed, low fiber diet caused these colonic maladies. I don’t know if he is correct. I do know that that appendicitis is very common and seems to becoming even more prevalent.
Patients will sometimes ask: “What is the purpose of the appendix?”
I answer: “It gives General Surgeons something to do when we are bored or need to make a car payment.”