Tuesday, September 19, 2006
Tales From the Right Lower Quadrant, Part four
I used to have certain prejudices, one of which was that people who'd attended college were smart. I'd managed to hold onto that one for several years, until I met George, in the emergency room. He'd been sick a few days, getting more feverish, vomiting, suffering increasing pain in his right lower belly, putting up with it long enough for his appendix to rupture and form a quite impressive abscess, easily detectable on exam. That's not the un-smart part; I'll get to that eventually.
There are several ways to handle an appendiceal abscess, most of which don't involve removing the appendix right away. Since the body has, in forming the abscess, managed to keep the infection from spreading all over the place, it's generally a good thing to keep the barriers in place; rooting around within the abscess cavity in order to find and remove the appendix can tear down the wall (Mr Gorbachev) and spread infection around. So quite often, treatment consists of draining the abscess, surgically or by placing drainage catheters into it with Xray guidance. Typically this leads to rapid resolution of the immediate problem, but leaves on the table the question of how -- or whether -- to deal with the offending appendix in the future. But before we get to that, let's talk a bit about draining that abscess.
Mainly risking incredulity and recommending finding another surgeon by the patients' friends, I've on a couple of occasions treated small abscesses only with antibiotics. When a person comes into the office complaining of a month's worth of somewhat annoying illness, and the workup shows mostly swelling in the appendix's homeland with only a small fluid collection, it's seemed reasonable to take a pretty conservative approach. But in most cases, the patient is sicker than that, and the abscess is bigger, so drainage is best. Of course, I've always leaned toward the surgical approach, because it's the most definitive: especially for a large and loculated collection. You can get big drains in there, wiggle your finger around in the hole to break down the septations, and get it done all at once. Radiologists are getting better and braver at approaching intra-abdominal fluid collections, and it's become the preferred approach in lots of situations. The one area that until fairly recently many of them like to avoid, however, is a deep pelvic abscess. I liked it, if the anatomy was just right, because even in busy operating rooms, it seems I could always surprise a person or two with how I did it. Guess it must be an old-timer thing.
When the appendix is long and low-lying, and its tip sits way down in the pelvis, it's not rare for it to rupture by the time its particular form of appendicitis is figured out. That's in large measure because it tends to present with diarrhea, as opposed to most cases, in which bowel shut-down is the norm. The abscess that forms sits on the front of the rectum and bulges inward into it. You can put the victim up in stirrups, spread open the anus, confirm you can reach the abscess, poke a little needle through the rectal wall to prove the pus is there, and then, grossly, ram a clamp through the same point, through the entire thickness of the rectal wall and into the cavity. Pus ensues; fragrant, copious, gratifying pus. Guide a rubber drain into the area, and you're done: no skin incision, no consequences. You'd think poking a hole through the rectal wall into the abdominal cavity would lead to disaster; but it's well walled-off, it drains, it heals, and everyone is happy. The drain falls out in short order.
I drained silly George, and he got well promptly. He followed up as suggested, in the office, and I told him (as I had in the hospital) that I recommended he have his appendix removed after an appropriate amount of time had passed for healing. It's become controversial -- more now than a few years ago. The concern is that left in there, appendicitis will eventually happen again, and it's one of those things passed down from generation to generation of surgeons. It's only quite recently that studies have been done that raise questions about the need (these are all "retrospective" studies, meaning analyses of existing data, rather than "prospective" studies, meaning randomizing current patient to groups who'd have it done and who'd not have it done, and seeing what happens. Prospective studies are better. None have been done; but the papers have, rightly, gotten the attention of surgeons.)
Trained in the dark ages, I've done quite a few "interval appendectomies," and it's interesting how they have varied: in some cases it's as if the person had never had appendicitis. Everything normal, easy as pie. In others, the worm has been plastered to various entrails and exceedingly difficult to remove. Once or twice, it had been so fried by the original infection that there was nothing left but a thread; clearly incapable of causing further trouble. One time the pathology report came back "acute appendicitis with rupture," months after the actual event. But the need for the surgery was not what troubled George. He was worried about having his appendix removed, fearing the loss of it would lead to some sort of future health consequences.
That's not an unreasonable concern, and it's been addressed in many ways. I liked to refer to a study done by the Mayo Clinic (can't find it now. Didn't try real hard.) that compared around 4000 people who'd had appendectomy with the same number of ones that hadn't, similar in all other ways, and found no difference in incidence of health problems over many years of observation. But George brought an article, published in a journal of alternative medicine. It had actual photomicrographs of the appendix, showing lymphoid tissue (well-known.) The article pointed out the appendix's location between the small and large intestine (close enough) and stated that given the location and the lymphoid tissue, it clearly had an immune-surveillance function. There were no data, no studies. Just a conclusion out of thin air. Now this is not really a big deal, and I don't mean to hijack my own post. But it was the first time I'd seen an educated person show a complete lack of ability to judge data. Pretty picture, shiny paper = conclusion must be correct. Imagine. George rejecting reams of scientific and peer-reviewed data in favor of pseudo-data that served his purposes...
I'll finish this series (for now) with another prejudice, for the heck of it: I'm not a big lover of laparoscopic appendectomy. I think laparoscopy is a fabulous innovation, and there are several operations for which the laparoscopic approach is clearly superior to the open one. Appy, in my opinion, ain't one of them. Why? Properly done, an open appy takes fifteen or twenty minutes, uses a small incision that isn't very painful (much less so than the original disease was!) and from which the patient recovers rapidly; often in the hospital only a day or so postop. Admittedly, this isn't always so: appendectomy can be an extremely difficult operation. But we're talking typical, here. Come in to do an appy in the middle of the night, get a crew not so familiar with all the laparoscopic tools of the trade, and you've turned a simple thing into a time- and money-consuming circus. But tool-makers are very talented at marketing (there are some great technologies out there, just waiting for a disease.) High profile, big-ticket lasers gather dust in OR hallways as we speak. But that's for another post, another time.