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General complications of appendectomies
COMPLICATIONS FROM CORDIAL AND VASCULAR SYSTEM
Functional frustration of cardiovascular system after appendectomy are not a rarity. Most often they arise at development of various complications, especially pyoinflammatory character. The death of patients after the complicated appendectomy in most cases occurs at the phenomena of increase of cardiovascular insufficiency that is explained by rough dystrophic changes in this system. Heart and vascular failure develops at such complications as peritonitis, pancreatitis, a thrombembolia, bleeding. We will investigate only some complications from cardiovascular system which emergence comes out on top in a clinical picture of the postoperative period, considerably burdening it and worsening the forecast.
Recently significant increase in tromboembolic episodes after operation on abdominal organs is noted. According to N. M. Melman, the number of thromboses and embolisms from 1948 to 1959 increased by 5,5 times. Similar data give Kunz, Domanig, Howanietz (1962), Schmutzler (1970).
Their frequency among total quantity operated not high (0,55%) that there corresponds to data G. K. Shveychuk (1966), M. P. Postolov with coauthors (1972) and other researchers. However among causes of death tromboembolic episodes are on the second place, reaching 16,5%, and concede only to peritonitis. In literature also higher rates — 29,4% (G. K. Shveychuk, 1966), 37,7% meet (D.P. Pavlovsky, 1967).
Influence of an acute appendicitis and appendectomy on a condition of coagulant and anticoagulative systems is insufficiently reflected in modern literature, and some provisions are inconsistent. M. I. Bystritsky (1954), S. P. Belkaniya (1958), M. M. Abdullaev (1962) point to decrease of the activity of coagulant system of blood after appendectomy. Other researchers, in particular Ya. P. Yurchishin (1970), E. I. Petrik (1972), M. P. Postolov with coauthors (1972), on the contrary, note increase of coagulative potential as during operation, and in the next few days after it.
Activation of coagulant system of blood after operation is promoted by such factors as diseases of a vascular wall (varicosity, atherosclerosis), disturbance of a hemodynamics, decrease of the activity of patients, increase in maintenance of coarse-dispersion fractions of protein, shift of acid-base equilibrium, a hypoxia.
In recent years the big place in an intravascular blood coagulation and a thrombogenesis after operation is allocated to the fabric pro-coagulants resulting from an injury of fabrics and absorption of products of an aseptic necrosis (B. T. Savkiv, 1964; F. A. Efendiyev, 1963; Gaston, 1964). Hit in a blood stream of a large amount of these substances leads to increase of thromboplastic activity of blood and increase in danger of tromboembolic episodes (I. G. Turovets, 1970).
Frequency them among patients till 60 flyings made 0,43%, and after 60 — 3,8% or almost in 9 times more. It should be noted that at all patients 60 years which died from tromboembolic episodes are more senior the accompanying cardiovascular diseases are noted.
Thrombophlebitises and phlebothromboses
Thrombophlebitises and phlebothromboses are the most frequent tromboembolic episodes. According to our data, they were observed at 14 patients (0,27% operated). Development of this type of complications comes on 3 more often — the 5th day of the postoperative period, at sick senior age groups at destructive changes in a worm-shaped shoot.
Localization of process was mainly in the lower extremities. Only one patient had a thrombosis of veniplexes of a basin and at one patient — pubis veins. At retrocecal appendicitis development of lumbar thrombophlebitises is possible (Altschuler, 1938).
Thrombophlebitis of superficial veins does not present great difficulties in diagnosis. With hypostasis, a hyperemia, a cyanochroic shade of skin complication allows to distinguish the affected extremity pains amplifying when walking, palpation of dense, sharply painful tyazh in hypodermic cellulose, involvement in process of surrounding fabrics timely. Often body temperature to 38 ° increases, there are oznoba. In blood the moderate neutrophylic leukocytosis is found, and when studying a koagulogramma — hypercoagulation.
In clinic active surgical tactics at acute superficial thrombophlebitises is accepted. Timely excision of the thrombosed vein allows to cure considerably in shorter terms patients. At emergence of contraindications conservative therapy is applied to intervention: the rest, sublime position of an extremity, anticoagulants, proteolytic enzymes, physiotherapeutic methods of treatment (warming a compress, UVCh, an ionophoresis with heparin).
The clinical picture of deep thrombophlebitis of a shin is characterized by emergence of the dull ache amplifying when lowering an extremity and walking, spasms, paresthesias, feeling of a raspiraniye and weight, sometimes only fast fatigue at the movement. Pain and hypostasis of an extremity amplify by the evening. At objective research the first revealed symptom is extremity hypostasis. The palpation of a gastrocnemius muscle is sharply painful, sometimes it is possible to probe consolidations around the thrombosed veins. Especially often pain arises at a palpation of a neurovascular bunch in an interval between bones of a shin and the place of transition to an Achilles tendon (Oliver, 1957). Gomans's symptom — emergence or strengthening of pain in a gastrocnemius muscle at fast bending of foot, and also "a cuff symptom" has clinical value (Opitz — Kamines, 1956). It is defined by forcing of air to 40 — 50 mm of mercury. in the sphygmomanometer cuff imposed above a knee. Increase of venous pressure leads to emergence of a sharp pain syndrome. Reflex spasms of peripheral arteries are sometimes observed. The disease often is followed by temperature increase to 38 °, in a koagulogramma hypercoagulation comes to light.
Damage of deep veins of a hip has more difficult character. Pain is localized on the course of the main venous trunks, amplifies at a palpation of a skarpovsky triangle, a gunterov of the channel, muscular arrays. Hypostasis of an extremity can be sharply expressed at fibrinferments of large veins. The joining reflex spasm of arteries leads to development of flegmasia alba dolens ("white painful hypostasis") that dictates need of carrying out the differential diagnosis with fibrinferments of arterial system.
Thrombophlebitis of deep veins of a hip, especially with thrombosis of an ileofemoralny segment, belongs to heavy complications of appendectomy. Except possibility of a fatal embolism, the disease often passes into a chronic form with an invalidism of patients. Our following supervision is indicative.
Sick L., 24 years, repeatedly came to clinic 31/03 1971 with complaints to the pains in the left shin which are amplifying when walking and followed by considerable hypostasis, existence is long not healing ulcers on internal surfaces of the lower third of both shins, temperature increase to 39 °.
In February, 1969 in clinic appendectomy concerning phlegmonous appendicitis is made. For the 5th days after operation at the patient heavy deep thrombophlebitis of the right lower extremity developed. Under the influence of conservative therapy the condition of the patient improved and he was written out. In the subsequent there was a secondary expansion of superficial veins of the lower extremities with distribution on a front abdominal wall, trophic ulcers of both shins developed. Clinical and X-ray inspection revealed impassability of deep veins of extremities. Conservative therapy brings only temporary improvement.
Development of thrombophlebitises after appendectomy needs to be considered first of all as a dangerous source of a thromboembolism. Phlebothromboses which are characterized by thrombosing of not changed veins in this respect are especially artful. Elderly, corpulent persons with disturbance of cordial activity and atherosclerosis of vessels are subject to this complication. Local signs are almost not expressed and come to light only at a careful palpation of venous trunks of the lower extremities in the form of small consolidations without the periphlebitis phenomenon. Often there is tachycardia, sensation of fear, nervousness without the visible reasons (A. Ochner, J. Ochner, N. Sanders, 1970). Diagnosis of this complication presents considerable difficulties. At 4 of 5 patients with phlebothromboses the diagnosis is established only retrospectively at emergence of thromboembolisms of branches of a pulmonary artery.
Thrombophlebitises and phlebothromboses have to be considered as the most probable sources of embolic complications. It dictates need of fast identification and acceptance of preventive and medical measures.