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Inflammatory "tumors" of an abdominal cavity - appendectomy Complications

Table of contents
Appendectomy complications
Reasons of postoperative complications 2
Reasons of postoperative complications 3
Reasons of postoperative complications 4
Indications to appendectomy
Indications to appendectomy - appendicular infiltrate
Indications to appendectomy at not changed shoot
Indications to appendectomy at an appendicism
Indications to appendectomy - postoperative supervision
Complications from a wound
Complications from a wound, the choice of methods of treatment
Complications from a wound - the general treatment
Complications from a wound - eventration
Complications from a wound - use of antibiotics for prevention of early complications
Early complications from an abdominal cavity
Peritonitis
Diffuse peritonitis
Diffuse peritonitis - a peritoneal dialysis
Diffuse peritonitis - an intestines peristaltics
Infiltrates and abscesses of an abdominal cavity
Abscesses of an abdominal cavity
Abscesses interloopy and right ileal area
Subphrenic abscesses
Phlegmons of retroperitoneal cellulose
Acute intestinal impassability
Acute postoperative pancreatitis
Complications from cardiovascular system
Thromboembolism of a pulmonary artery
Myocardial infarction, pylephlebitis
Fibrinferments and embolisms of mesenteric vessels
Prevention of tromboembolic episodes
Complications from a respiratory organs
Complications from an urinary system
Late complications from an abdominal wall
Recognition of inflammatory "tumors" of a front abdominal wall
Origins of postoperative hernias
Late complications from an abdominal wall - keloid cicatrixes
Late complications from abdominal organs
Infiltrates and abscesses of an abdominal cavity
Inflammatory "tumors" of an abdominal cavity
Intestinal fistulas
Adhesive desease
The recommended literature

Nonspecific inflammatory "tumor" was for the first time described by Muller in 1874, and soon after it on the congress of the German surgeons of Gussenbauer showed the patient operated concerning inflammatory "tumor" of the sigmoid gut which developed because of a diverticulum. In 1888 Mr. of Mauo publishes article with the description of series of observations of nonspecific "tumors", and at the beginning of the 20th century works of Reynes (1902), Schloffer (1907), Braun (1909) appear. Provided the most considerable number of supervision (14) in the same 1908 of Korte. From domestic scientists on this matter acted I. G. Kulikovsky (1911), S. M. Kalmanovsky (1924), A.     A. Chaika (1927), S. L. Feldman (1927), A. A. Fedorovsky (1930). The disease is described under various names: inflammatory "tumor", pseudocarcinoma, chronic nonspecific granuloma, granuloma of a foreign body, fibroplastic appendicitis and nonspecific periappendikulyarny granuloma.
We observed 52 patients with inflammatory nonspecific "tumors" of ileocecal department of intestines (tab. 9).
Apparently from these tab. 9, at our patients inflammatory "tumors" most often arose in connection with the postponed appendectomy (33 patients).

TABLE 9. Reasons of formation of inflammatory "tumors"


Probable causes

Number
patients

1. Appendectomy including

33

1) acute appendicitis

23

from them

 

a) idle time

3

b) phlegmonous

6

c) gangrenous

5

d) perforative

9

2) Appendicism

10

2. Unextracted worm-shaped shoot

9

3. Herniotomy

1

4. Stupid injury

1

5. Other reasons (actinomycosis, tuberculosis, anomaly of development, etc.)

8

In total

52

The most part of patients (33) with inflammatory "tumors" of ileocecal area in the past are operated concerning acute (23 persons) and chronic (10 people) appendicitis. At 20 of urgently operated patients destructive forms of appendicitis, part — with a retrocecal arrangement of a worm-shaped shoot were found; perforative appendicitis (9 people), gangrenous (5 people), phlegmonous (6 people). Only at 3 patients the simple form of an acute appendicitis is established. The postoperative period proceeded hard and was followed by a number of complications (intraperitoneal abscesses, fecal and alloyed fistulas, etc.). At the patient operated concerning an acute appendicitis we give one of our supervision as an example of formation of inflammatory "tumor".
Sick S., 50 years, came to clinic in January, 1964 with complaints to the aching pain in the right ileal area amplifying at an easy exercise stress, the speeded-up urination with impurity of blood and existence of tumorous education. In November, 1963 the patient underwent an operation for acute phlegmonous appendicitis. The postoperative period proceeded without complications. In 1,5 months the above described symptoms suddenly appeared. At the time of survey in the right ileal area the tumor of 9X10 cm in size, moderately painful, motionless was palpated. Surface its hilly, very dense consistence. At X-ray inspection of 14/01 1964 small deformation of a contour of a caecum with indistinct drawing of a relief of a mucous membrane in this department after emptying is noted. Against a diagnostic pneumoperitoneum and a retropneumoperitoneum at a medial and back wall of a caecum the shadow of a wrong and oval form, inseparable from a gut wall, is defined by the sizes of 3,5X2,5 cm.
It is suggested about caecum cancer.
23/01 1964 the patient is operated. The caecum tumor with transition to retroperitoneal space to which loops of an ileal gut are intimately soldered is found. The outside surface of a tumor is connected with a sidewall of an abdominal cavity. The right-hand hemicolectomy is made.
Macroscopically: tumorous education is located out of a caecum gleam the sizes of 10X12 cm, a dense consistence, places softer. Dense homogeneous sites of yellowish color. Mucous guts it is a little maleficiated. On a section the tumor dense, represents growth of connecting fabric. On a caecum top, according to the mouth of a worm-shaped shoot, the silk ligature is found.
Microscopic examination: a chronic inflammation with growth of fibrous connecting fabric. In fatty tissue a chronic inflammation with growth of fibrous connecting fabric. In a gut wall sharply expressed chronic inflammation from a plentiful infiltratsiy mucous membrane polymorphic cells, mainly one-nuclear, with impurity of eosinophils, a sharp sclerosis and lipomatoz a submucosal layer, a plentiful infiltration of a muscular layer.
The appendectomy postponed in the past served in the given example as the reason of development of inflammatory "tumor". The role of the infectious beginning or an irritant was executed by the ligature imposed on a shoot stump.
The main microscopic changes in inflammatory "tumor" after appendectomy are found in serous, subserous, muscular layers and surrounding cellulose of a caecum with the phenomena of a chronic inflammation and growth of fibrous connecting fabric, with polymorphocellular infiltrates. The mucous membrane is involved in inflammatory process for the second time.
Destructive changes of a worm-shaped shoot were followed by development of the limited peritonitis expressed in a varying degree. The operations in the conditions of infection which are followed by implementation of foreign bodys (ligature) are that favorable background on which inflammatory "tumors" as expression of a productive inflammation develop. It is promoted by existence of a cul-de-sac and the closed cavity which is formed at immersion of the alloyed infected stump of a worm-shaped shoot in a caecum wall.
The infection which acts into the forefront at destructive forms of appendicitis is the main origin of inflammatory "tumors" after appendectomy. Further, as showed A. Mayer (1897), Ts. Vilyamson (1923), G. G. Yaure (1924) researches, microorganisms for a long time remain in his mesentery, lymph nodes, commissures and are, across Pribram and Lyuzyu, depot of the masked infection. The disturbances of balance in an organism coming under various influences, decrease in reactivity of the patient is followed by a powerful productive inflammation.
In certain cases inflammatory "tumors" develop after appendectomies concerning so-called simple forms of an acute appendicitis. We observed 3 such patients. We give our following supervision as an example.
Sick M., 28 years, came to clinic of 23/1 1962 with the diagnosis of cancer of a caecum. In February, 1961 it is operated concerning acute simple appendicitis. After an extract from hospital there was a discrepancy of edges of a wound, was treated within 1 month. In April, 1962 noted strengthening of pain, nausea. At survey in right the hypochondrium and the right ileal area decides dense, painful, on a smooth surface a tumor by the Blood test sizes of 4X2 cm: N of 77%, Ayr. 4 020 000, l. 7900, page of 58%, item of 4%, aa. 5%, limf. 26%, Maun. 7%. ROE of 16 mm/hour.
7/VI 1962 g of the patient it is operated. In a stump of a worm-shaped shoot the dense hilly tumor up to 8 cm in size in the diameter is found. On a. ileocolica course dense lymph nodes. The resection of an ileocecal node with imposing of an invaginatsionny ileal and colonic anastomosis across Kimbarovsky is made.
Drug: a dense, hilly, fungoid tumor the sizes to 8 cm in the diameter. It was located on a mucous membrane according to the mouth of the amputated shoot.
Microscopic examination: a diffusion chronic purulent inflammation with plentiful quantity of eosinophils in exudate, growth of the hyalinized connecting fabric in a submucosal layer. Signs of malignant growth are not revealed.
In the given example during operation we did not find the reason of development of so-called inflammatory "tumor" and stopped on the diagnosis of cancer of a caecum. However the tumor arrangement according to the mouth of the amputated shoot could help with statement of the diagnosis. Its establishment was promoted by microscopic examination of remote drug.
The long stump of a worm-shaped shoot left after appendectomy can serve as other origin of inflammatory "tumors". We observed this complication twice.
It is necessary to believe that process of healing of the invaginated shoot stump almost always passes through a stage of development of abscess. Chronic inflammatory process in the form of a nonspecific pseudoneoplasm can develop in this period in the presence of an irritant. At our 7 patients the role of such irritant was carried out by the ligature imposed on a stump of a shoot or its mesentery. Around it there is a reactive chronically proceeding inflammation to a hypertrophy of a muscular layer and fibrous deposits on a serous cover.
At 9 patients the tumor developed at an unextracted shoot which was a source of a productive inflammation. This group included 7 patients at whom intervention (laparotomy) was made, but the inflamed worm-shaped shoot was not removed, in the subsequent at all 7 patients inflammatory "tumor" developed.
Education it at an inflammation of a stump of a shoot and in cases of an unextracted shoot emphasizes a genetic linkage of pseudoneoplasms of a caecum with an appendix. V. F. Bobrov (1898), G. I. Baradulin (1903), N. I. Rostovtsev (1909) hold the same opinion,
A. A. Nemilov (1928), Yu. A. Ratner (1962), Yu. V. Astrozhnikov, A. M. Volkova (1963).
Every time at patients with inflammatory "tumor" we aimed to establish a proximate cause of its emergence, subjecting to careful macroscopic research remote drug. Searches of "provoker" of a productive inflammation were successful at 12 patients. Finds were the most various: the silk ligature, at 6 — the inflamed shoot stump was found in 8 patients in the center, 2 patients have foreign bodys of an abdominal cavity.
2 patients at whom "tumor" developed in connection with leaving during the previous operation of a gauze napkin and a tupfer are of special interest.
Sick B., 55 years, came to clinic in January, 1968 with complaints to pain in the right ileal area, the dense hilly mobile tumor to 10 cm in the diameter is defined here. From the anamnesis it is known that 8 months ago the patient is operated concerning an acute appendicitis. The tumor noticed 3 months later.
воспалительная «опухоль»
Fig. 26. Macrodrug of inflammatory "tumor". In the center — a gauze tupfer.
On the roentgenogram by a medial and back surface roughness of contours and polymorphic defects of a mucous membrane is defined on the area of 4X5 cm. Conclusion: caecum cancer.
Operation: excision of a tumor. During it the "tumour" 6X6X8 cm in size connected with a front abdominal wall is found, consists of a thick-walled capsule in which gleam sliming the gauze tupfer who is intimately connected with a wall of a cyst (fig. 26).
Histologic research: inflammatory "tumor" of a caecum around a foreign body; in a wall its chronic purulent inflammation with growth of fibrous connecting fabric. Postoperative current smooth.
For developing of inflammatory "tumor" of a caecum there are necessary some accessory factors among which the accompanying appendicitis a typhlitis, traumatic manipulations on a gut wall when overlaying a purse-string seam matter, and also possibility of the closed cavity under a purse-string seam.
Development of this "tumor" is regarded as the peculiar plastic process which is characterized by the expressed tendency to high-quality proliferation of connective tissue elements. Usually malovirulent Nye the purulent infection has only character of a releaser. With the big basis we can say that inflammatory "tumor" is reaction rather to a foreign body, than on an infection which is of little importance in this process. That is it is possible to assume that inflammatory "tumor" is manifestation of the productive inflammation which developed in response to implementation of the foreign body which does not have tendency to implantation. This steady tendency to high-quality proliferation stated by us it becomes frequent a source of serious diagnostic mistakes when high-quality process is regarded as a malignant tumor in this connection are undertaken radical, justified at cancer, but inadmissible at inflammatory process, operative measures. It sets big tasks for establishment of accurate diagnostic criteria at recognition of a disease and elaboration of surgical tactics.
All specified "tumors", irrespective of the reasons of their emergence, are macroscopically very similar to malignant new growths. They a dense consistence, had most often a hilly surface of grayish-white color. On a section we often found the small purulent cavity which is quite often containing silk ligatures or other foreign bodys in the center of such "tumor". Considerable development of fatty and fibrous connecting tissue in the form of tyazhy was found. Expanding, they squeeze muscle fibers, guts, causing their atrophy. Microscopic changes in "tumors" represented various degrees of an acute, subacute and chronic inflammation. We found the main morphological changes in them in serous, subserous and muscular layers of a wall of a caecum.
The mucous membrane is almost not involved in inflammatory process, and in most cases there are only phenomena of a moderate chronic inflammation. The bulk of "tumours" consisted of dense fibrous or fibrous connecting fabric of different degree of a maturity. Along with cicatricial we found layers of young granulyatsionny fabric, infiltrirovanny a large number of various forms of cells. In all drugs there were sites with chronic inflammatory infiltrates in which lymphocytes, monocytes, and in some supervision — plasmocytes and eosinophils were found.
Data on terms of emergence of inflammatory "tumors" from the moment of the postponed operative measure are of practical interest. At most of our patients the tumor arose within the first year (26 people), however also later development of a disease is possible (till 24 flyings). Emergence of a tumor in later terms complicates the correct recognition of a disease as both the patient and the doctor quite often forget about the postponed intervention or do not attach it significance and do not find communication of the developed tumor with this intervention.
The clinical course of inflammatory "tumor" is characterized by a number of subjective and objective symptoms. The most frequent is pain in the right ileal area which we noted at all patients observed by us. It was more often constant, stupid (20 people), but at the same time at some patients it was noted also sharp skhvatkoobrazny, periodically amplifying.
Quite often at patients temperature increase (16 people) to subfebrile level, but in some cases and to higher figures was noticed. As a rule, it was followed by strengthening of pain.
From other symptoms loss of weight from 2 to 5 kg (10 people), lack of appetite (7 people), the general weakness (20 people), disorder of activity of intestines (19 people) in the form of locks, abdominal distention, the complicated passage of flatus, sometimes the ponos which are replaced locks were noted.
The most characteristic objective symptom is existence of the palpated tumor that is revealed us at 30 patients. Characterizing features of the palpated tumor, it is necessary to specify that in most cases it was motionless and slow-moving. According to our data, inflammatory "tumors" are inclined to growth and by the sizes the majority of them (21 persons) there were more than 4 cm in the diameter.
The aspiration to find signs, pathognomonic for this "tumor", induced V. M. Mysh (1948) to offer a so-called symptom of an accordion which is characterized by periodic increase and reduction of "tumour". We found this symptom in 21 patients. Two other signs which are also offered by V. M. Mysh (strengthening of pain and temperature increase after long research of a tumor and a symptom of a palpatorny leukocytosis), we did not manage to establish. At the same time we found change of "tumour" under the influence of a roentgenotherapy (3 persons) or physical therapy (18 people). Both of these symptoms bring closer establishment of the correct diagnosis. At a blood analysis at 8 patients we noted moderate anemia, at 2 — an anisocytosis and poykilitsitoz, at 17 — changes of a leukocytic formula, including towards increase in quantity of leukocytes from 9600 to 18 150 at 12 patients. Acceleration of ROE which we defined at 29 patients is the most typical. Any other pathological changes from a blood count us are noted.
In the course of recognition of tumors of intestines the leading place is allocated to a radiological method in this connection deserve attention of the data on our radiological finds. At this research defect of filling was found only at 10 patients, at 7 of them it had indistinct contours with the break of folds typical for a malignant tumor. Other radiological signs — change of contours of a caecum without destruction of a mucous membrane (7 people), restriction of mobility of a caecum (3 persons), existence of "tumour" out of a gut shadow (4 persons) and other — with a high probability testify to the inflammatory nature of a disease.
We established the correct diagnosis before operation only at 9 patients and radiological is suspected at 8, in the course of operation at 20 patients, nevertheless in all cases we considered necessary urgently to confirm it histologically. Possibly, it is necessary to recognize correct such approach to business when the doctor, suspecting inflammatory "tumor", uses all opportunities for a final exception of its zlokachestvennost, including a biopsy on the operating table.
Operative measures at inflammatory "tumors" of ileocecal department of intestines can be the most various — from a section and its excision before the expanded and combined operations including removal of the right half of a large intestine and a resection of adjacent bodies. Nature of the made surgeries is defined by many factors, and first of all reliability of the established diagnosis.
According to our data, more expanded operations were executed at 11 of 33 operated patients at whom "tumor" arose after appendectomy. Generally it were patients at whom we with a bigger share of probability suspected a malignant tumor and the correct diagnosis was established only in the course of histologic research and the retrospective analysis of clinical data. At sufficient confidence in the inflammatory nature of a disease the volume of operation was respectively reduced. In these cases we were guided by situation Yu. Yu. Dzhanelidze which for us became the rule: it is necessary to remove only epicenter of inflammatory "tumor" with a possible source of a productive inflammation (more often a ligature). In most cases it happens enough for its regression and recovery of the patient.
The result of surgeries concerning inflammatory "tumors" generally favorable. Among complications we noted secondary healing (3 persons), wound suppuration (4 persons), formation of fecal fistula (1 person) and abscess of the right ileal area (1 person). Died 1 sick after a right-hand hemicolectomy. Insolvency of an ileal and colonic anastomosis was a basic reason of death.



 
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