Pediatric appendicitis is one of the most common diseases among pediatric acute abdominal conditions and ranks first. It can occur at any age, with different physiological and anatomical characteristics and different clinical manifestations, and is often prone to misdiagnosis and delayed treatment, resulting in perforation, diffuse peritonitis, complications and even endangering the life of the child.
Therefore, early diagnosis and timely surgical treatment are important to reduce complications and morbidity and mortality.
In recent years, due to advances in diagnostic tools, improved surgical and anesthetic techniques, and the use of effective antibiotics, the mortality rate of pediatric acute appendicitis is about 0.1%, and postoperative complications have been significantly reduced.
However, postoperative complications still occur because appendicitis surgery is considered a “minor operation” and is treated in rural hospitals; in large urban hospitals, it is mostly handled by junior doctors, who inevitably perform improper and inappropriate surgical treatment.
Zhao Yuyuan (2003) reported 1,472 pediatric appendectomies with 83 cases of incisional infection, 11 cases of adhesive intestinal obstruction, 3 cases of appendiceal stump fistula, 1 case of iliac fossa abscess, 2 cases of pelvic abscess, and 1 case of acute pulmonary edema, with a total of 101 cases (6.8%) and 1 case of death.
In order to improve the cure rate and reduce the occurrence of complications, each treating physician should treat “minor surgery” seriously, master the timing of surgery and treatment principles, and not engage in rashness. The possibility of various complications should be considered during each operation, and measures should be taken to reduce or prevent the occurrence of complications. The postoperative complications that can be seen clinically are as follows.
I. Postoperative bleeding
Serious bleeding occurs after surgery, including intestinal bleeding and intra-abdominal bleeding. The former is mainly manifested as blood in the stool, and large amounts may have rapid blood clotting. The former is mainly manifested as blood in the stool, and the large amount of blood may be accompanied by rapid hemagglutination. It mostly occurs in those with imperfect tethering of the appendiceal stump and incomplete suturing of the purse, and the blood still exudes from the appendiceal stump, which can be cured spontaneously with the application of hemostatic drugs.
Intra-abdominal hemorrhage is usually due to poorly ligated appendiceal vessels, incomplete ligation or detachment of the ligature. Most of them occur within 24 h after surgery.
The child presents with abdominal distension, abdominal pain, anemia, rapid pulse, decreased blood pressure, irritability and even shock. The diagnosis can be made by drawing fresh blood by laparotomy. After diagnosis, aggressive antibodies to grams are treated along with surgical hemostasis.
Therefore, thorough freeing and firm ligation of the appendiceal tract and good purse-string suturing during surgery are the keys to prevent bleeding. This complication is rare due to the attention given to it. As for appendiceal incision bleeding and hematoma formation, they are mostly related to muscle tear bleeding or imperfect local hemostasis, which can be avoided by paying attention to them.
Second, postoperative infectious complications
Postoperative incision and abdominal cavity infection are the most frequent complications after appendectomy. Since removal of appendix itself is a bacterial surgery, coupled with acute appendicitis, there are different degrees of inflammation or necrosis, perforation, peritonitis and other changes, causing contamination of the abdominal cavity and incision, postoperative incisional infection, abdominal residual abscess and even subphrenic infection, portal vein infection and liver abscess can occur.
Incisional infection is the most common. It is manifested by persistent postoperative temperature increase, pain, swelling and pressure pain in the incision with a wide range and local redness. Local fluctuations may occur after abscess formation. Once the incision is infected, some sutures should be removed early to facilitate drainage. Inflammation subsides after clear drainage and eventually heals on its own.
Intra-abdominal infections are mostly due to incomplete drainage of pus in the abdominal cavity due to extensive or diffuse peritonitis. Abscess formation can occur in the pelvis, intestinal space or subdiaphragmatic space. Children with abdominal infection present with persistent high fever, abdominal pain, abdominal distention, and signs of systemic toxicity.
Pelvic abscesses have urinary disturbances, urgency, and mucus stools. Ultrasound is valuable for determining the size and location of abscesses in the abdominal cavity and is non-invasive, allowing repeated dynamic observation of changes in intra-abdominal infection and guiding puncture for pus aspiration.
To prevent incisional and intra-abdominal infection, protection of the incision should be enhanced to reduce pus contamination of the incision. For perforation with diffuse peritonitis, intraoperative saline or a solution containing antibiotics should be applied to thoroughly flush the abdominal cavity and incision, and drainage should be placed if necessary. Postoperatively, effective antibiotics should be applied to prevent the occurrence of infection.
For those who already have abdominal infection signs should first use effective or combined application of antibiotics with traditional Chinese medicine and physical therapy. If an abscess has been formed, different parts of the incision should be used for drainage according to the location of the abscess, and pelvic abscess can be drained through the rectum.
Portal phlebitis and liver abscess are due to the spread of purulent infection in the appendiceal vein through the superior mesenteric vein system, forming portal phlebitis, which in turn can form liver abscess. Children present with high fever, chills, jaundice, hepatomegaly, and in some cases, infectious shock. Treatment is mainly with powerful and effective antibiotics, which can mostly be controlled. In recent years, such complications are rare.
Postoperative intestinal fistula and sinus tract
Postoperative intestinal fistula can be discovered due to intestinal injury caused by careless operation or incomplete anesthesia; or due to severe edema and necrosis of the appendix root or cecum, improper treatment of the appendix stump and poor healing. After surgery, limited peritonitis and fever appear first, followed by signs of right lower abdominal abscess, and some of them are punctured by the incision after 3-5 days, and pus and feces flow out. At this time, in addition to systemic antibiotics, the incision should be enlarged to allow unobstructed drainage. Since most of them are indirect tubular fistulas, most of them can heal spontaneously after the drainage is cleared. If the fistula does not heal, a fistula repair should be performed.
Postoperative sinus tracts are due to incisional infections that leave fistulas that do not heal for a long time or recur, and the effluent is pus and blood without fecal material.
The sinus tract often reoccurs because of the remaining thread knots. In recurrent cases, sinus tract pantoplanar angiography should be performed to observe the depth and course of the sinus tract and the presence or absence of intestinal passages to exclude intestinal fistulas. For pure rustic tracts, scraping can be performed to remove necrotic tissues to obtain healing. If the sinus tract is not healed after treatment, sinus resection is feasible.
IV. Postoperative intestinal obstruction
Postoperative intestinal obstruction mainly occurs when the appendiceal lesion seriously pollutes the abdominal cavity, the abdominal pus is not completely removed, or the surgical injury is serious. Therefore, avoiding the above factors is an important means to prevent postoperative intestinal adhesions.
Those with severe intra-abdominal inflammation mostly have slow recovery of intestinal peristalsis and intestinal paralysis in the early postoperative period, which is the basis for the occurrence of early intestinal adhesions. This kind of adhesions are mostly extensive non-complete obstruction, and the child’s performance is mainly abdominal distension, and abdominal pain is not obvious. They can be cured by active bed activity or combined Chinese and Western medicine treatment.
Late intestinal obstruction mostly occurs several months after surgery, mostly due to intestinal adhesions after the unabsorbed remains of fibrous bands and cords caused by intestinal obstruction, some can occur intestinal torsion, intestinal strangulation, intestinal necrosis. The onset of the disease is rapid and the symptoms are severe, so early diagnosis and timely surgical treatment are required. Due to appendiceal lesions and surgical treatment, some of them cause large omental adhesions in the right lower abdomen to form a special type of intestinal adhesions, namely large omental adhesion syndrome.
After surgery, patients often have post-prandial bloating, nausea and even vomiting, and some are often constipated. Severe symptoms can be relieved by laparoscopic or surgical exploration of the large omental adhesions.
V. Appendiceal stump infection
This complication is less common. This complication is mainly due to the long appendiceal stump, which usually does not exceed 1 cm. The long appendiceal stump may be due to poor anatomy of local adhesions in appendicitis, incomplete separation of the appendix from the intestinal wall, or unskilled technique.
To prevent the appendiceal stump from being left too long, the junction between the appendiceal root and the cecum, i.e., the intersection of the colonic band, should be accurately seen when dissecting the appendix, and then the appendix should be removed as required. The clinical manifestations of appendiceal stump infection are the same as those of appendicitis, and the possibility of appendiceal stump infection should be considered after appendectomy with signs and symptoms of appendicitis. In addition to clinical signs, a low-pressure barium enema may reveal appendiceal stump images. If the diagnosis is confirmed, appendiceal stump resection should be performed again.
VI. Other complications
In addition to the complications directly related to the operation, other systemic complications such as pulmonary infection, urinary tract infection, and complications related to anesthesia can also occur due to anesthesia, surgical stimulation, and postoperative reactions. Signs of possible complications should be closely observed after surgery for early detection and treatment.