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It is difficult to differentiate complications of a disease from postoperative complications. As a rule, it concerns the most terrible complications of an acute appendicitis: peritonitis the general and local, pylephlebitis, thrombosis of mezenterialny vessels, etc. At most of patients this complication of the disease if during performance of intervention the gross technical blunder was not made. However if these complications are stated even before operation, then they join in the general main diagnosis and are not postoperative. If during operation only premises to development of complication come to light and the surgeon took measures for the prevention of its development, but it after all arises (for example, drainage of an abdominal cavity and the subsequent development of peritonitis), it should be considered postoperative.
We cannot agree completely with that point of view that many therapeutic diseases should be considered only as associated diseases. Only those which were found in the patient even before operation have to be carried to accompanying (for example, forced urgent appendectomy is carried out against a myocardial infarction). At the same time, development of these diseases in the early postoperative period has to be considered as postoperative complication. At the same time it is necessary to consider that operation, or the operational illness in Lerish's terminology, is deep we will shake it in which are interested all physiological systems. In these conditions emergence of a number of serious general diseases in the postoperative period, even on condition of the heavy previous pathological background, has to be considered as postoperative complication. Let's refer to some own supervision.
Sick Ch., 65 years, is transferred to clinic 17/XII 1971 g from therapeutic department where it was treated concerning chronic bronchitis with an asthmatic component, focal pneumonia of the lower share of the right lung, a diffusion pneumosclerosis, emphysema of lungs.
14/XII 1971 g at the patient appeared dull aches in the right ileal area, temperature to 37,5 ° increased. Objectively: local morbidity in the right ileal area, a positive symptom of Shchetkin — Blyumberg. Diagnosis: acute appendicitis. Operation. Removal flegmonozno the changed worm-shaped shoot.
Postoperative current heavy. The patient is sluggish, adynamic. Language dry. The stomach is blown up, intense. The peristaltics is not listened, symptoms of irritation of a peritoneum are determined by all stomach. In lungs a large number of wet rattles. In the postoperative period dynamic intestinal impassability, frequent attacks of bronchial asthma developed. The intensive care including antibiotics, nystatin, Diaphyllinum, cardiacs, vitamins, prozerin, Galantaminum, intravenous injections of plasma, saline solutions, enemas was carried out.
The wound is opened, widely trained, healed second intention. It is written out in a satisfactory condition.
In this case the patient was operated concerning acute phlegmonous appendicitis which is a basic disease. Operation is performed against serious associated diseases: bronchial asthma, pneumonia. The postoperative period was complicated by dynamic impassability of intestines. Undoubtedly, associated diseases played a role in development of this complication, and nevertheless it has to be considered as postoperative. Our also following supervision where the associated disease was a cause of death of the patient is characteristic.
Sick G., 65 years, is brought by ambulance car of 25/IV 1969 g with suspicion to gastric bleeding. In the evening of 24/IV 1969 g acute abdominal pains and the right hypochondrium, nausea appeared.
In the morning 25/V vomiting and a diarrhea with blood impurity developed. At receipt: complaints to pains in heart, headaches. In 1949 transferred a stomach resection concerning a duodenum ulcer. Cardiac sounds are muffled, arrhythmic, emphasis of the II tone on an aorta, arterial pressure of 220/120 mm of mercury. Pulse of 80 blows 1 minute, with losses. The stomach is soft, participates in the act of breath. Symptoms of irritation of a peritoneum are not defined. It is left for supervision.
28/V 1969 g a condition of the patient sharply worsened. There were abdominal pains, slackness, an adynamia.
The stomach is blown up, tension of a front abdominal wall, reduction of a zone of hepatic dullness. Palpation: pain in the right half of a stomach, Shchetkin's symptom — Blyumberg, morbidity in epigastric area is expressed here. At survey of a rectum it is found tar-like by kcal with impurity of fresh blood. At survey roentgenoscopy of an abdominal cavity of free gas and Kloyber's bowls it is not revealed.
Blood test: N — 78%; Ayr. — 3 360 000; tsv. pok. — 0,88; l. — 14 900; the item — 40%; e — 0; it is young. — 8,5%; page — 30%; limf — 13,7%; Maun — 7%. The anisocytosis is insignificant, a polychromatophilia insignificant. ROE — 38 mm an hour.
Analysis of urine: ud. weight — 1020, protein — 0,66%o, leyk. — 1 — 2 under review. Cylinders of hyalins. — 2 — 3 under review with stratification of granular disintegration.
ECG — a sinoatrial rate, rare single supraventricular extrasystoles. Signs of the expressed diffusion changes in a myocardium.
The serious general condition of the patient was explained by gastrointestinal bleeding, intoxication products of the decayed blood, the accompanying idiopathic hypertensia and the increasing cardiovascular insufficiency. However the symptoms of an acute abdomen which were not allowing to exclude an acute surgical disease of abdominal organs (fibrinferments of mezenterialny vessels? Acute appendicitis?) forced to define indications to an urgent laparotomy, despite the general very serious condition of the patient.
The laparotomy is made by a right-hand pararectal section. Local anesthesia. Gangrenous appendicitis is found. Appendectomy. The considerable serous exudate in an abdominal cavity, change of coloring of a small intestine is at the same time found that induced to carry out broad audit of an abdominal cavity under the general anesthesia. During an anesthesia (the intubation period) there was a cardiac standstill. The indirect cardiac massage, the managed breath and medicamentous actions brought the patient out of a condition of clinical death and recovered normal indicators of activity of cardiovascular system. In 3 hours after intervention of the patient died as a result of a repeated cardiac standstill.
On opening: the stratifying aneurism of a chest and ventral aorta with its gap. Intraparietal thrombosis of vessels of a loop of a small bowel with segmented sites of a necrosis.
In the described supervision in the presurgical period it was not distinguished a serious associated disease: the stratifying aortic aneurysm with the subsequent its gap. Possibly, the gap occurred at the time of manipulations at reanimation of the patient (an indirect cardiac massage). The cardiac standstill at the time of an intubation has to be considered as complication of an anesthesia. Not distinguished there was also intraparietal thrombosis of vessels of intestines. Retrospectively we were inclined to estimate necrosis of a worm-shaped shoot also as display of thrombosis of its vessels. Nevertheless, in this case acute gangrenous appendicitis was the main diagnosis.
As example opposite when the myocardial infarction was considered as postoperative complication, the following supervision can serve.
Sick D., 61 years, is brought to surgical department of 28/IX 1971 g with the diagnosis of an acute appendicitis.
At clinical supervision and inspection of the patient the diagnosis of an acute appendicitis was confirmed and 28/IX 1971 g made appendectomy concerning acute phlegmonous appendicitis.
The first days of the postoperative period were complicated by paralytic intestinal impassability which by 18 o'clock 30/IX
accepted signs of mechanical enteric impassability with sharp colicy pains in a stomach, not passage of flatus and a calla, abdominal distention, desires on vomiting.
Tsianotichna extremities. Pulse of 140 blows 1 minute, rhythmical, satisfactory filling and tension. Cardiac sounds are deaf. Arterial pressure — 110/90 mm of mercury. Language dry. The stomach is blown sharply up also painful at a palpation throughout. Percussion — a high tympanites and obtusion in flanks. A positive symptom of Shchetkin — Blyumberg.
Conservative treatment of impassability of intestines is ineffective.
30/IX 1971 g in 18 hours 10 min. made relaparotomy with elimination of commissural enteric impassability, imposing of a suspended ileostoma and drainage of an abdominal cavity.
In 20 hours 10 min. 30/IX 1971 g there came the sudden cardiac standstill.
The held resuscitation events were ineffective.
At pathoanatomical research — a heart attack of a back wall of a left ventricle of heart with distribution on an interventricular partition and a sidewall.
Conclusion: the death occurred from a myocardial infarction.
For this reason peritonitis can be not always considered as postoperative complication. The following supervision can be an example of development of peritonitis as postoperative complication.
Sick R., 26 years, is operated in one of hospitals of the Lviv region concerning gangrenous appendicitis. Prescription of a disease — 2 days. In an abdominal cavity the serous exudate was found, but the abdominal cavity is sewn up tightly. In the postoperative period peritonitis in this connection for the 7th days it was operated repeatedly developed: the operational wound in the right ileal area is disclosed and counteropening is made at the left, at the same time a large amount of dirty-gray liquid with an unpleasant fecal smell was allocated. The condition of the patient improved a little, but for the 12th day symptoms of impassability of intestines appeared. By the patient it was taken to regional hospital where she is operated repeatedly.
Median laparotomy. At audit in an abdominal cavity a large number of a muddy exudate is revealed, all intestines are covered with fibrinous films, in some places intestinal loops are intimately spliced among themselves. All small intestine to ileocecal department is inflated, thick — in the fallen-down state. In left hypochondrium the limited abscess containing fetid dense pus. In the field of an ileocecal corner the big epiploon which completely peredavlivat terminal department of an ileal gut is soldered, causing impassability. At department of an epiploon the gaping stump of a worm-shaped shoot is revealed. From a caecum gleam through a stump fecal contents are allocated. Appendectomy with drainage of a large and small bowel the rubber tube which is carried out via the ileocecal gate is made. Unions are divided, the careful toilet of an abdominal cavity, novocainic blockade of a root of a mesentery is carried out. Drainage of an abdominal cavity. Recovery.
In the given case history all described complications have to be considered as postoperative. The main diagnosis — acute gangrenous appendicitis. Insolvency of a seam of a stump of a worm-shaped shoot (the main complication caused by a technical error) was a basic reason of diffuse peritonitis.
In other cases development of peritonitis in the postoperative period shall not be considered as complication of the postponed appendectomy.
The patient To., 65 years, it is brought to clinic of 11/XII 1961 g in 12 hours from the beginning of a disease with complaints to sharp pains in the right ileal area, nausea, vomitings.
Objectively: tension of a front abdominal wall in the right ileal area, a positive symptom of Shchetkin — Blyumberg is revealed. Blood test: a moderate leukocytosis with a deviation to the left. The diagnosis — an acute appendicitis. Appendectomy. Histologically — simple appendicitis.
The postoperative period proceeded very hard, the phenomena of dynamic intestinal impassability, then diffuse peritonitis developed. For the 4th days after operation the patient died.
On opening: a partial enterocele of a segment of a fenny gut in an internal ring of the femoral channel (Richter's hernia), acute intestinal impassability, diffuse purulent peritonitis.
Thus, the peritonitis which developed after appendectomy was not postoperative complication, and was a consequence of not recognizable disease: the restrained femoral hernia and acute impassability of intestines. It is impossible to consider as postoperative complication and the peritonitis which developed at the patient even before operation.