MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENSE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES TRAN HUNG DAO DIAGNOSIS AND TREATMENT LIVER TRAUMA AT THE NORTHERN MOUNTAINOUS HOSP[.]
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENSE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES TRAN HUNG DAO DIAGNOSIS AND TREATMENT LIVER TRAUMA AT THE NORTHERN MOUNTAINOUS HOSPITALS Speciality : Gastroenterology surgery Code : 62720125 PhD THESIS ABSTRACT HANOI - 2022 THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Scientific Supervisors: Professor TRINH HONG SON Reviewer 1: Reviewer 2: Reviewer 3: The thesis is presented at the Council of 108 Institute of Clinical Medical and Pharmaceutical Sciences: Date The thesis can be founded at: Vietnam National Library Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences INTRODUCTION Appendiceal peritonitis is an inflammation of the peritoneum caused by late appendicitis with perforation complicated Diagnosis and treatment of patients with appendiceal peritonitis is often difficult and expensive, in many cases, if patients did not treat promptly, patients may die from infection and toxicity Trinh Hong Son’s study performed at 12 general hospitals in the northern mountainous provinces (2010-2011) found the rate of appendiceal peritonitis 19.2% Studies on laparoscopic surgery treated appendiceal peritonitis have shown that this method is a safe, effective and has many advantages compared to open surgery Some domestic authors reported the success rate of laparoscopic surgery was 84-96.3% Northern mountainous provinces have slow economic development, difficult living conditions, underdeveloped health system, limited and uneven qualifications human resources, lack of modern medical equipment, this condition make the diagnosis and treatment of surgical diseases, including appendicitis peritonitis, become difficult Nowadays, there has not been a study on laparoscopic surgery treat appendicitis peritonitis in the Northern mountainous provinces, so to evaluate the status of diagnosis and treatment of appendiceal peritonitis in order to improve the quality of treatment, we carry out the project with goals: Commenting on the diagnosis of appendiceal peritonitis at some general hospitals in the Northern mountainous provinces from 2015 to 2017 Evaluating of early laparoscopic surgery results for appendiceal peritonitis at some general hospitals in the Northern mountainous provinces NEW CONTRIBUTIONS OF THE THESIS Research on 468 appendiceal peritonitis patients treated with laparoscopic surgery at northern mountainous province hospitals from January 2015 to the end of September 2017 Diagnostic status of appendiceal peritonitis Status of clinical examination: patients had fever 68.2%, abdominal pain, abdominal wall reaction 100%, the rate of peritoneal palpation was 41.9% Status of subclinical examination: blood count with leukocytes >10G/L is 79.3%; the rate of neutrophils ≥ 70% is 88.0%; Ultrasound has a sensitivity and accuracy of 47.0%, computed tomography has a sensitivity and accuracy of 44.2% Diagnostic status: the diagnosis accurate rate of appendiceal peritonitis compared with surgery reached 50.4% Evaluation of early laparoscopic surgery results treated appendiceal peritonitis: normal appendix position 86.8%; clamp the appendix root by Hemolock/Clip 54.9%; average laparoscopic surgery time was 50.35 minutes; the success rate of laparoscopic surgery is 97.6%; early complications was 1.3%; average hospital stay time was 7.13 days; overall results: good (98.7%), moderate (1.3%) The thesis contributions are practical, contributing to show the current situation, thereby improving the efficiency of appendiceal peritonitis diagnosis and treatment at the Northern mountainous province general hospitals STRUCTURE OF THE THESIS The thesis consists of 144 pages: pages introduction, 40 pages literature review, 28 pages study subjects and research methods, 29 pages research results, 42 pages discussion, pages of conclusion, page recommendations, articles, 46 tables, 07 charts, 12 images, 120 references Chapter LITERATURE REVIEW 1.1 Physiology, anatomy, pathology and pathophysiology of the appendix and peritoneum 1.1.1 Anatomy and physiology 1.1.2 Pathology and pathophysiology 1.2 Diagnosis of appendiceal peritonitis 1.2.1 Clinical symptoms Systemic symptoms: Pay attention to infection and fever Functional symptoms: Assess abdominal pain, nausea and vomiting, bowel obstruction Physical symptoms: Assess abdominal distension, palpation, pain throughout the abdomen, especially the right iliac fossa, sometimes abdominal wall rigidity, signs of peritoneal palpation 1.2.2 Subclinical 1.2.2.1 Blood tests Complete blood count: white blood cell count and percentage of neutrophils 1.2.2.2 Methods to assist in the diagnosis - Unprepared abdominal X-ray - Supersonic - Take a CT scan 1.2.3 Bacterial and pathophysiology of appendicitis peritonitis 1.2.3.1 Pathology - Peritonitis due to appendicitis - Peritonitis due to necrotic appendix 1.2.3.2 Bacteria Bacterial culture test from the peritoneal fluid to isolate bacterial strains for antibiotic use to help post-operative treatment achieve better results 1.3 Diagnosis of appendicitis peritonitis - Diffuse peritonitis - Regional peritonitis 1.4 Differential diagnosis 1.4.1 Differentiate from diseases other than peritonitis 1.4.2 Differentiate from other peritonitis 1.5 Treatment of appendicitis peritonitis 1.5.1 Method Treatment methods include: medical treatment and surgical treatment - Medical treatment: use broad-spectrum antibiotics - Surgical treatment includes open surgery and laparoscopic surgery 1.5.2 History, indications and contraindications of laparoscopic surgery 1.5.2.1 History of laparoscopic surgery for appendiceal peritonitis 1.5.2.2 Indications and contraindications Indication Laparoscopic appendectomy is indicated in most cases of appendiceal peritonitis, however, it depends on surgeon experience and laparoscopic surgical equipment Contraindications Do not apply laparoscopic surgery in the following cases: + Blastron appendicitis Contraindications to anesthesia and peritoneal inflation: - Pneumothorax - Hypovolemic shock - Increased intracranial pressure - Angle-closure glaucoma does not respond to treatment - Body temperature drops below 35.5 degrees - Blood clotting disorders - History: many times abdominal surgery - Severe congenital heart diseases 1.5.3 Studies on laparoscopic surgery for appendicitis peritonitis Most authors found that laparoscopic surgery had a high success rate, low complication rate, and shorter hospital stay and recovery time than open surgery The authors found that the success rate of laparoscopic surgery ranged from 81.4% to 97%; the average rate of abdominal abscess 8%; the average rate of surgical site infection was 6.7% 1.6 Current status of appendiceal peritonitis diagnosis in some northern mountainous province hospitals 1.6.1 Geographical, economic and social characteristics The northern mountainous provinces still face many socioeconomic difficulties: they have a large area, complex topography, many high mountain ranges, steep slopes, limited traffic, far from Hanoi capital mainly forests and mountains with few advantages in terms of resources and trade, the population is mainly ethnic minorities, the main economy is still agriculture, and per capita income is still very low It greatly affects the diagnosis and treatment of appendiceal peritonitis in particular and surgical diseases in general 1.6.2 Current status of treatment of appendicitis peritonitis in northern mountainous province hospitals The lack of human resources for surgery, anesthesia resuscitation, imaging diagnostics as well as equipment systems limits the development of diagnostic techniques such as CT scan with limited indications, so some diseases are incompletely diagnosed, especially in cases of regional peritonitis 1.6.3 Diagnosis of appendiceal peritonitis in the Northern mountainous provinces Trinh Hong Son's study on 3594 appendicitis patients were diagnosed appendicitis and treated at 12 general hospitals in the northern mountainous provinces: the rate of patients admitting the hospital after 24 hours was high, accounting for 38.8%; Diagnosis symptoms are mainly based on clinical right iliac fossa pain, fever, abdominal wall reaction Ultrasound has 85% sensitivity and 90% specificity; CT has a sensitivity of 90% and a specificity of 95% The majority of diagnoses before surgery were appendicitis accounted for 79.49% or focal peritonitis 14.36% or diffuse appendicitis 4.86% 1.7 Results of appendiceal peritonitis treatment in northern mountainous province hospitals Although there is a shortage of human resources specialized in laparoscopic surgery, and the equipment is not synchronized, the success rate of laparoscopic surgery in the Northern mountainous provinces is quite high due to the application of surgical procedures by Trinh Hong Son’s study (2012) Trinh Hong Son published a study on appendicitis treatment in 12 northern mountainous provinces, studied on 3594 patients, the rate of appendiceal peritonitis was 19.22%, of which the breakthrough was 1643 patients underwent laparoscopy surgery accounted for 45.7% The results showed that in the laparoscopic surgery group, the rate of regional peritonitis was 115 patients, accounting for 14.36%; 21 patients diffuse peritonitis accounted for 4.86%, the author concluded that all provinces have well implemented laparoscopic appendectomy technique Chapter STUDY SUBJECTS AND RESEARCH METHODS 2.1 Study subjects All patients diagnosed with appendiceal peritonitis were indicated to laparoscopic surgery from January 1, 2015 to September 31, 2017 at general hospitals in the northern mountainous province (Dien Bien, Son La, Hoa Binh, Cao Bang, Tuyen Quang, Bac Kan, Ha Giang, Bac Giang) 2.1.1 Selection criteria - Including all patients indicated for laparoscopic treatment with a confirmed surgical diagnosis of appendiceal peritonitis (the surgeon described the ruptured appendix) performed at northern mountainous province hospitals - Pathological results: Macroscopic and microscopic images of the appendix concluded that the appendix was perforated or necrotizing inflammation divided into groups of patients: + Generalized appendicitis peritonitis: pain increases, then pain all over the abdomen, collapsed body, emaciated face; temperature 39 40°C; chills may be present; abdominal distension, bowel obstruction or diarrhea Examination revealed increased abdominal skin sensation, peritoneal palpation throughout the abdomen, but if careful examination, the most pain was found in the right iliac fossa Intraoperative assessment, appendix has purulent ruptured or necrosis, abdominal cavity has purulent, pseudomembranous spread in many areas of the abdomen + Localized appendicitis: Pain increases but is localized in the right iliac fossa with fever, but defecation is still possible Examination revealed a pelvic mass, sharp pain, and unclear boundaries Localized peritonitis will progress to an appendix abscess Intraoperative evaluation, appendix was purulent ruptured or necrotic, but purulent fluid, pseudomembranous was only in one area of the appendix site, the inflammatory process was localized by the great omentum, mesentery, and bowel loops - Patients are investigated according to the uniform research case form - Patient and family agreed to participate in the study 2.1.2 Exclusion criteria - Information on the sample medical record is not fully recorded in the original medical record - The postoperative diagnosis was peritonitis due to other causes 2.2 Research Methods 2.2.1 Research design Descriptive, retrospective study Research period: from January 1, 2015 to September 31, 2017 2.2.2 Sample size and sample selection: Convenient sample selection During the study period, 468 eligible patients were selected 2.2.3 Research media 2.2.3.1 Equipment for diagnosis 2.2.3.2 Equipment for laparoscopic surgery a Laparoscopic surgery system b Instruments for laparoscopic surgery 2.2.4 Procedure for diagnosis and treatment of appendiceal peritonitis: according to the State-level Science and Technology project have code ĐTĐL.2009G/49 2.2.4.1 Diagnostic protocol (1) Clinical and subclinical diagnosis of appendicitis peritonitis (2) Confirmed diagnosis of appendicitis peritonitis (3) Diagnosis of treatment possibility 2.2.4.2 Laparoscopic surgery Laparoscopic surgery steps a Prepare the patient before surgery * Patient's pose After endotracheal intubation - long muscle relaxant, or spinal anaesthesia, the patient is placed on a 30° incline and 30° left side * Surgeon and assistant stand to the left of the patient The accessory assistant stands to the right of the patient The instrument table is at the patient's foot The screen is on the right side of the patient If a second monitor is available, place it behind the surgeon b Inflate the peritoneum and place the trocar + The technique of inflating the abdomen (using the open technique) + Laparoscopic appendectomy usually uses trocars Technique for cutting appendix in the abdomen: The most common techniques include the following steps: appendix mesenteric resection; appendectomy; bring the appendix out; clean the abdomen; put drainage; deflate the abdomen and close the incisions d Place abdominal drainage A douglas drainage or right iliac fossa should be placed, with a small or large plastic tube, depending on the case e Handling complex situations f Switch to open surgery In case the prognosis cannot be resolved by laparoscopic surgery, such as: complications during surgery, complicated lesions that cannot be treated through laparoscopic surgery, the location of the appendix is difficult to cut through laparoscopic surgery, and cannot be cleaned abdomen cavity, … the surgeons will switch to open surgery to ensure patient safety g Technological changes in laparoscopic surgery h Complications * Complications during surgery: bleeding, damage to the abdominal wall, in the cecum due to heat, damage to surrounding organs during surgery, intestinal perforation during place trocar or electrocautery, CO2 embolism, pneumothorax, cardiovascular collapse due to the influence of pneumoperitoneum * Post-operative complications: hernia through trocar hole, abdominal wall hematoma, infection or wound abscess, incisional fistula, douglas abscess, intestinal obstruction due to postoperative adhesions 2.2.5 Research targets 2.2.5.1 General features 11 3.2.1.2 Physical symptoms All patients had abdominal pain in which right iliac fossa pain accounted for the highest rate of 92.3% 3.2.1.3 Physical signs Table 3.7 Physical signs Number of Signs patients Percentage (n=468) (%) A lot 11 2,4 Distention Moderate 18 3,8 A little 132 28,2 Right iliac fossa abdominal tenderness 468 100,0 Right iliac fossa abdominal wall reaction 468 100,0 Rebound tenderness 196 41,9 Rigidity 1,1 Palpable mass in the abdomen 11 2,4 Comment: All patients have right iliac fossa tenderness and wall reaction 3.2.2 Subclinical 3.2.2.1 Blood count test: The rate of leukocytosis over 10G/L accounts for 79.3% The rate of neutrophil ≥ 70% accounting for 88.0% 3.2.2.2 Abdominal ultrasound Ultrasound has a sensitivity and accuracy of 47% 3.2.2.3 Abdominal computed tomography scan Abdominal computed tomography has a sensitivity and accuracy of 44.2% 3.2.2.4 Bacteria and pathology Bacteria: The percentage of culture with E Coli bacteria was 73.2% Pathology: Most of the appendix was distended with pus and perforated 56.8%; Microscopic is purulent appendicitis accounting for 63.5% 3.2.3 Risk factors for appendiceal peritonitis complications 3.2.3.1 Including diseases The rate of patients with previous abdominal surgery was 3.8% 12 3.2.3.3 Geographical distance Patients live in less than 30 km distance from a provincial hospital area accounted for 50.4% 3.2.3.4 Time the patient has pain until hospital admission Patients have pain from 24 to less than 48 hours accounted for 38.9%; patients have pain less than hours had 3.2% 3.2.3.5 Taking medication before diagnosing appendicitis Prevalence of antibiotic use before diagnosis 5.3% Prevalence of pain medication before diagnosis is 5.1% 3.2.3.6 Time from hospital admission to surgery The time from hospital admission to surgery is less than hours is 53.4% 3.2.3.7 Hospitalization in the right department The rate of patients admitting the wrong department was 3.7% 3.2.4 Diagnosis Table 3.17 Comparison of diagnosis before and during surgery During surgery Regional Diffuse peritonitis peritonitis (n=359) Before surgery (n=109) Appendiceal peritonitis 206 (57,4%) 30 (27,5%) (n=236) Acute appendicitis 152 (42,3%) 79 (72,5%) (n=231) Bowel obtruction (n=1) (0,3%) p < 0,001 Correct diagnosis rate 50,4% Comment: The correct diagnosis rate of appendiceal peritonitis is 50.4% 3.3 Results of laparoscopic surgery for appendiceal peritonitis at Northern mountainous province general hospitals 3.3.1 Results in surgery 3.3.1.1 The emotionless method The rate of endotracheal anesthesia accounted for 87.7% 3.3.1.2 Number and positions of trocar Most of the patients were placed trocar, accounting for 99.1% 3.3.1.3 Assess the abdomen condition Patients without peritoneal fluid accounted for 1.5% 13 3.3.1.4 Locating and lesions of appendix in surgery The majority of appendix in the normal position in the right iliac fossa accounted for 86.8% The majority of perforation was in the trunk area, accounting for 41.0% 3.3.1.5 Surgical handling techniques Cutting appendix root technique - The cutting appendix root technique downstream accounts for 96.9% - Tie the appendix root 34.8%; appendix root clamp with Hemolock/Clip 54.9% Take the appendix out, peritoneal cleaning and drainage Taking appendix through plastic bags accounts for 70.7%; The main peritoneal cleaning technique is washing the peritoneum with 0,9% NaCl solution accounts for 70.5% Drain placement The majority of drainages were located in Douglas, accounting for 93.1% There were 50 patients who did not receive an abdominal drainage 3.3.1.6 Surgery time The average surgical time was 50.35 ± 17.87 minutes 3.3.1.7 Catastrophe During surgery, there was patient with small bowel perforation, patient with bleed 3.3.1.8 Causes and factors associated with conversion to open surgery Table 3.27 Reasons for switching to open surgery Number of Diffuse Regional Reason patient peritonitis peritonitis (n=468) Small bowel perforation (0,27) (0,2) in surgery Can't handle appendix (0,27) (0,2) root Inability to clean the abdominal cavity after (0,27) (0,9) (0,4) cutting appendix Can’t cut appendix (1,7) (0,9) (1,5) Total (2,5) (1,8) 11 (2,4) p 0,598 14 Comment: The most common switch to open surgery reason is abdominal adhesions that cannot be removed appendix, accounting for 1.5% Table 3.28 Univariate correlation of factors with conversion to open surgery CI Các yếu tố p OR Min Max Pain time to hospital admission (over 48 hours versus less than 48 hours and abnormal appendix position are independent predictive factors for conversion to open surgery with p