Appendiceal stump abscess

Appendiceal

Stump

A REPORT OF STUMP ABSCESS TWENTY-THREE

Abscess YEARS POSTAPPENDECTOMY

SIGMUND A. SIEGEL, M.D.,Diplomate, American Board of Surgery, New York, New York From tbe Surgical Service of tbe New York City Hospital, New York, New York.

S

technic has been considerabIy standardized on anatomic and physiologic principIes. AIthough some new areas are constantIy being probed, in onIy a short time one procedure is evoIved which quickIy becomes the choice of the majority of surgeons. This is aIso true of appendectomy, except for the method of treating the stump, of which the popuIar technics are: (I) simpIe Iigation, (2) simpIe Iigature with purse-string inversion and (3) purse-string inversion (burying), without Iigature. AI1 agree that the stump shouId not be Ionger than 35 inch. Dawbarn3 in 1895, shortly after the first appendectomy, described eIeven methods of treating the appendiceal stump. His preferred technic Ieft the appendicea1 stump never longer than 35 inch, which was then invaginated untied. Goode and Krege14 objected to the simpIe tie because the stump does not have serosa-to-serosa apposition. AIso, the stump sIoughs up to the Iigature. On opening the abdomen of their experimenta animaIs four to five days Iater, very insecure protective adhesions were found over the cecum. The hazard of Ieakage was judged to be greatest at the third day. Burying the stump seemed as undesirabIe. Inversion of a short, untied, carboIized stump was preferred. Yeagerl investigated, in a series of rabbits, the end resuIts of the usual method of treating the appendicea1 stump, with the further variations of catgut, siIk, pheno1 and cautery. No superiority of any method couId be determined. Roses reviewed thirteen cases of recurrent appendicea1 abscesses, two of which were due to incompIete remova1, one at two years and the other at one year. Each had 2 inches of the appendix remaining. Ochsner and LiIIys have written a cIassic articIe concerning treatment of the appendiceal stump. They state that with American Journal of Surgery, Volume 88, October. 1954 630 URGICAL

simpIe Iigature the bowel is inadequateIy cIosed, the stump is a source of infection and adhesions are encouraged. Favoring Iigation and inverting (burying) the stump, they say serosa-to-serosa approximation is secured. However, there is no doubt about the real danger of cecal waI1 abscess deveIoping at the Iigature. An intramura1 vesse1 may be incIuded in the purse-string suture. Since Dawbarn,3 who objected to previous methods and practiced simpIe crushing and inversion of the stump, many minor variations have appeared. aIthough this method has been However, championed by many, by no means may it be considered sufficient to have excIuded others. Serosa-to-serosa apposition is adequateIy secured, obviating or certainIy minimizing the danger of Iater Ieakage. Further, the infected stump is not buried in the cecal wall. Adequate crushing of the stump, absence of infection and carefu1 insertion of the purse-string suture shouId obviate danger of hemorrhage. The appendicea1 artery shouId be ligated adequateIy and carefuIIy. Stratte6 tied the base 35 inch from the cecum. CoIp’ further emphasized the danger to vesseIs in the ceca1 wall with hematoma formation and secondary interference with bIood suppIy. Baumgardnerlo reported a rupture of an appendicea1 stump, treated with simpIe Iigature, three months after appendectomy. A 3 cm. Iinear tear of the cecum was found. In this case a bIowout occurred at the site of an abscess due to persistent infection Iocally. Kross* studied the buried and nonburied stump method in a series of rabbits. He found the most striking feature of the buried stump to be gross hemorrhage, infiltration and uIceration of the ceca1 waI1 dista1 to the pursestring suture, often with direct communication between the Iumen of the bowe1 and the necrotic buried stump. With simple ligation of the stump there was no evidence of hemorrhagic infiltration of the cecum. In both types adhesions were found about the cecum and the

AppendiceaI Stump Abscess surrounding structures, dense and more numerous buried. CASE

which were more where the stump was

REPORT

E. G. (No. 143648), a fifty-one year old white woman, was admitted to the New York City Hospital on JuIy 19, 1946, for pain in the right Iower abdominal quadrant. During October, 1945, she had first become aware of this pain which varied from sharp to duI1 but was constant and non-radiating. Profuse vomiting of a brownish nature occurred periodicaIIy, accompanied by anorexia without distention. She was admitted to the surgica1 service of another hospita1 for eight weeks where she had a septic temperature, finaIIy being discharged as improved without operation. Recurrence of the same pains (and their persistence for two weeks) required her admission to the New York There was again profuse City Hospital. vomiting without any change in the bowel habits or Ioss of appetite. She was para o, having appeared gravida o, her menopause four years previously. Past surgery consisted of appendectomy in 1932 and hemorrhoidectomy in 1938. Examination reveaIed a we11 nourished, we11 deveIoped, white woman in no apparent distress, with heaIthy skin and good coIor. BIood pressure was 105 mm. Hg systolic, 60 mm. Hg diastolic. The teeth were in poor condition, the mucous membrane dry and the tongue coated. Heart sounds were faint but otherwise satisfactory. The abdomen was obese, distended and diffuseIy tympanitic. A we11 heaIed McBurney appendectomy scar was present, beneath which was a firm, irregular, tender there was no rebound abdomina1 mass; tenderness. The patient’s temperature was IO~OF., puIse g6 and respiration 15. On admission the white count was 27,000 per cu. mm., 88 per cent of which were poIymorphonucIear Ieukocytes. The urine was negative, bIood sugar 75 mg. per cent and non-protein nitrogen 29.0 mg. per cent. Mazzini test was negative. On JuIy 21, 1946, a progress note stated that there was a mass in the right Iower quadrant, adherent to skin only and sIightIy movabIe. Temperature and bIood count indicated infection rather than new growth. There was a history of drainage of appendicea1 abscess twenty-five years previousIy. It was con631

sidered that the appendix had been left in and this was an appendiceal abscess. The patient was treated with intravenous Buids, sulfadiazine, suIfaguanidine and peniciIlin. Her temperature varied between 103’ and 102’~. unti1 JuIy 24th, when it became normaI. X-rays of the chest, barium enema and intravenous pyeIogram were negative. The upright abdomina1 flm showed a few ffuid IeveIs. Operation on JuIy 3rst, through a right rectus muscIe-splitting incision, discIosed an appendicea1 abscess containing 3 cc. of fouIsmeIIing pus; the stump of appendix 34 inch Iong contained a fecaIith. No information was avaiIabIe as to the type of treatment given the appendicea1 stump twenty-three years previousIy. The subsequent hospita1 course was uneventfu1, the patient being discharged to cIinic care on August 29th with the drainage sinus aImost cIosed. On foIIow-up in October, 1952, the patient was symptom-free. There had been no recurrence of infection or abdomina1 pain. The abdomina1 waI1 was we11 healed, firm and nontender, with no evidence of mass. COMMENTS

Severe compIications due to the Ieakage of an appendicea1 stump are occasionally being reported. Perhaps the reports do not indicate the true incidence. It is aIso possibIe this compIication is responsibIe for the stormy convaIescence rareIy seen after appendectomy or for the massive postoperative adhesions found in the right Iower quadrant when the abdomen is reopened.2 ObviousIy there is no one method for treating the appendicea1 stump. CompIications have arisen with a11 methods of Iigaturing after remova1. Of major consideration must be the degree to which the base of the appendix and the surrounding cecum is affected by the inff ammation. It has been the author’s observation that the base is not usuaIIy invoIved to a marked or considerabIe degree, if at aI1. Where there is infiammation, it is more often periappendicitis rather than a true process through a11 the coats of the waI1. In the genera1 type the simpIest method of treatment shouId be satisfactory, nameIy, crushing, catgut Iigature and carboIation. Where the base is gangrenous, a ligature may not hoId. For this eventuaIity one may crush and invert a short stump. There is no doubt that serosa-to-serosa cIosure of the bowe1 is highIy desirabie to insure the most

Appendiceal

Stump

Abscess

had been uneventfu1. EtioIogic factors were a stump 34 inch in Iength and a feca1ith. Differentia1 diagnosis was between neopIasm, granuIoma and abscess. FoIlowing simple removal of the stump with ligature and carbolation and abscess drainage, convaIescence and foIIow-up were without incident.

favorable healing, since the mucous membrane is a secreting surface and under conditions found in the gastrointestina1 tract does not sea1 itself without the aid of the peritoneum or serosa. However, the stump of the appendix does not Iend itse1f to true inversion by being turned inside out. In the case presented herein one may inquire why the quiescence of the appendicea1 stump was disturbed. This cannot be answered and should not be attempted here for fear of entering the reaIm of phiIosophy. FactuaIIy, a feca1ith and a ~5 inch stump was found. It seems apparent that the remaining stump shouId be no Ionger than that which is absoIuteIy necessary to hoId a Iigature. Furthermore, thorough carboIation or cauterization shou1d be practiced. To insure this it wouId be better to crush onIy where the Iigature is to be tied and not cut between the cIamps, tying proxima1 to the proximaI c1amp. If one were to cut between cIamp and Iigature, the stump wouId remain open and may be adequately carbohzed. In this manner we may strive toward aseptic necrosis of the remaining portion.

REFERENCES

I. YEAGER, G. H. The appendicea1 stump. Ann. Surg., 126: 814-819, 1947. 2. SIEGEL, S. A. and PLESHETTE, N. IntestinaI obstruction complicating pregnancy. New York State J. Med., 48: 1264-1267, 1948. 3. DAWBARN, R. A study in the technic of operation upon the appendix. Internal. J. Surg., 8: 139, 1895. 4. GOODE, J. V. and KREGEL, L. A. Management of appendiceal stump. Surgery, 13: 956963, 1943. 4. STFCATTE. J. J. Inversion of the appendiceal stump. Am. J. Surg., 68: 91-92, 1945. 6. OCHSNER, A. and LILLY, G. The technic of appendectomy. Surgery, 2: 532-554, 1937. 7. COLP, R. External feca1 fistulae in acute appendicitis. Ann. Surg., 84: 837, 1926. 8, KROSS, I. Appendiceal stump: its manner of heaIing in open and cIosed methods of treatment. Arch. Surg., 39: 101~1027, 1939. 9. ROSE, T. F. Recurrent appendiceal abscess. M. J. Austldlia, 32: 659-662, 1945. IO. BAUMGARDNER,L. 0. Rupture of appendiceal stump three months after uneventfu1 appendectomy with repair and recovery. Obio State M. J.,

SUMMARY

A case is presented in which a periappendicea1 abscess deve1oped twenty-three years after appendectomy. The intervening period

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1949.