What is the appendix?

If the appendix becomes infected (appendicitis), the infected appendix must be surgically removed (emergency appendectomy) before a hole develops in the appendix (perforation) and spreads the infection to the entire abdominal space (peritonitis).

The appendix is a narrow, small, finger-shaped portion of the large intestine that generally hangs down from the lower right side of the abdomen.

What is appendicitis and what causes it?

Appendicitis is a sudden inflammation of the appendix. Although the appendix does not seem to serve any purpose, it can become diseased and, if untreated, can burst, causing infection and even death.

The cause of appendicitis is usually unknown. Appendicitis may occur after a viral infection in the digestive tract or when the tube connecting the large intestine and appendix is blocked or trapped by stool. It is thought that blockage of the opening of the appendix into the bowel by a hard, small stool fragment causes inflammation and infection of the appendix (appendicitis). The inflammation can cause infection, a blood clot, or rupture of the appendix.

The infected appendix then must be surgically removed (emergency appendectomy) before a hole develops in the appendix and spreads the infection to the entire abdominal space.

What are the symptoms of appendicitis?

• Abdominal pain – pain may begin in the upper-middle abdomen then develop to sharp localized pain
• Abdominal pain may be worse when walking or coughing
• Fever usually occurs within several hours
• Loss of appetite
• Nausea
• Vomiting
• Constipation
• Rectal tenderness
• Chills and shaking

If you have these symptoms, see a doctor immediately! Because of the risk of rupture, which may happen as soon as 48 to 72 hours after symptoms begin, appendicitis is considered an emergency.

How is appendicitis treated?

The best treatment of appendicitis is its surgical removal. Mild appendicitis may sometimes be cured with antibiotics. More serious cases are treated with surgery to remove the appendix, called an appendectomy. Doctors either use an “open” technique or a minimally invasive approach to remove the appendix.

Appendicitis is considered an emergency and anyone with symptoms needs to see a doctor immediately!

What is a laparoscopic appendectomy?

The laparoscopic (minimally invasive) surgical technique involves making several tiny cuts in the abdomen and inserting a miniature camera and surgical instruments. As many as three or four incisions are made. The surgeon then removes the appendix with the instruments, so there is usually no need to make a large incision in the abdomen. The camera projects a magnified image of the area onto a television monitor which helps guide the surgeons as they remove the appendix.
What is the benefit of laparoscopic appendectomy?

Most cases of acute appendicitis can be treated laparoscopically. The main advantages are : -

• Less post-operative pain
• Faster recovery and return to normal activity
• Shorter hospital stay
• Less post-operative complications
• Minimally sized incisions/scars

In most cases, patients can be discharged within 24 to 36 hours. By contrast, the hospital stay is typically two to five days for an open procedure.

Can every patient have a laparoscopic appendectomy?

No. Patients with cardiac diseases and COPD would not be good candidates for laparoscopic appendectomy. In addition, laparoscopic appendectomy is not recommended for those with pre-existing disease conditions.

Laparoscopic appendectomy may also be more difficult in patients who have had previous lower abdominal surgery and for obese patients. The elderly may also be at increased risk for complications with general anesthesia. We evaluate every patient to determine the appropriate type of surgery to perform.

Treatment Options:

The appendix is then removed using a camera through the belly button as well as two other small incisions. Depending on how advanced the infection is, the patient is kept on antibiotics. If the infection is very advanced, the operation may be delayed while the patient receives antibiotics for several weeks. After the infection has improved, a laparoscopic appendectomy is performed.

Laparoscopic appendectomy is a safe and effective treatment for appendicitis. However, in the presence of infection, adhesions, or variations in anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications. Other complications, although rare, include bleeding and infection. It is extremely uncommon to require a blood transfusion for this operation.

This operation is generally performed with general anesthesia. An IV line will be placed in your arm for fluids and you will be brought into the operation room. The anesthesiologist and nurses will use monitors to check your heart rate and breathing during the procedure. These may include EKG leads, a blood pressure cuff, an oxygen mask and sleeves on your legs to prevent clots from forming.

Once you are asleep, the operating room team will work together to perform your operation. When your operation is complete, you will be awakened from anesthesia in the operating room but you may not remember this. After a few hours in the recovery room, the nurses will help you out of bed and give you something to drink. It is common to feel groggy and nauseated soon after surgery and medication is available to help with these discomforts. This information is not intended to replace a visit with your physician.

Picturised Procedure of Laparoscopic Appendectomy:

Laparoscopic Appendectomy

This is a normal appendix in a female patient found to have an infection of the reproductive organs. Since the appendix serves no useful function, it will be removed to save her from ever getting appendicitis in the future

The first step is to free up the appendix down to where it is attached to the large bowel. This requires dividing the mesentery which contains the blood vessels that supply the appendix. Bipolar forceps apply an electric current which seals the blood vessels and prevents bleeding.

Next, scissors are used to divide the mesentery. Alternating application of the bipolar forceps and scissors allow complete mobilization of the appendix down to its base.

 

Now the base of the appendix is tied off using a pretied suture which is now being positioned.

The suture has now been tightened and appears secure. The knot is a fisherman’s knot, which can be tightened, but will not loosen on its own.

As shown in this picture, the suture is now cut with the scissors.

Finally, the appendix is cut free and is ready to be removed.

The operation is complete, and the area is inspected a final time to make sure there is no bleeding.

 

Symptoms:

Because people do not think about newborns and children having strokes, they are not often recognized or treated properly. Another challenge with newborns is that they cannot communicate symptoms that are not readily visible.

The common stroke warning signs used to identify stroke in adults can also be used to identify strokes in children.  But, there are some specific symptoms that you should look for in children depending on their age.

In newborns and infants

• Seizures.
• Extreme sleepiness.
• Tendency to use only one side of their body.

In children and teens

• Severe headaches
• Vomiting
• Sleepiness
• Dizziness
• Loss of balance or coordination

CAUSES:

While high blood pressure, an irregular heartbeat and a hardening of the arteries are common causes of adult strokes, they are rare in children. Common risk factors for stroke in children include:

• Congenital heart defects
• Sickle-cell disease
• Immune disorders
• Diseases of the arteries
• Abnormal blood clotting
• Head or neck trauma
• Maternal history of infertility
• Maternal infection in the fluid surrounding an unborn baby
• Premature rupture of membrane during pregnancy
• Pregnancy related high blood pressure in the mother

TREATMENTS:

Children usually recover better from strokes than adults do because their brains are still growing. However, children can experience permanent complications from stroke, such as seizures, weakness, and vision problems.

Treatment for pediatric stroke depends on the specific cause. Some common treatments used with adults are not appropriate for young children and infants. One of the best treatments for ischemic strokes for adults is tPA, or tissue plasminogen activator, a drug that dissolves blood clots.

With children under 18, use of tPA is controversial and currently limited to clinical trials. Further studies on safety and benefits of this treatment are necessary. Rehabilitation methods with pediatric stroke survivors are also not clear and require further clinical trials.

Current treatments for pediatric stroke include:

• Supportive care to maintain normal body temperature, proper hydration, and normal blood sugar levels.
• Controlling high blood pressure.
• Detecting and treating seizures with EEG monitoring and anticonvulsant medication.
• Managing intracranial pressure.
• Blood transfusions for children with sickle-cell disease.
• Antithrombotic therapy, which refers to medications used to prevent blood clots from forming or growing, is used in children but generally not infants.
• Surgery related to hemorrhagic stroke (and less commonly, ischemic stroke) is sometimes performed to relieve pressure on the brain.

 

Vasculitis is a general term for a group of uncommon diseases that feature inflammation of the blood vessels. The blood vessels of the body are referred to as the vascular system. The blood vessels are comprised of arteries that pass oxygen-rich blood to the tissues of the body and veins that return oxygen-depleted blood from the tissues to the lungs for oxygen. Vasculitis is characterized by inflammation in and damage to the walls of various blood vessels.

Each of the vasculitis diseases is defined by certain patterns of distribution of blood vessel involvement, particular organ involvement, and laboratory test abnormalities. As a group, these diseases are referred to as vasculitides.

The word vasculitis is derived from the Latin “vasculum”, vessel + “- itis”, inflammation. Another term for vasculitis is angiitis. When arteries are the inflamed blood vessels, the condition is also referred to as arteritis. When the veins are inflamed, it is referred to as venulitis.

The actual cause of these vasculitis diseases is usually not known. However, immune system abnormality and inflammation of blood vessels are common features. Each form of vasculitis has its own characteristic pattern of symptoms, much of which depends on what particular organs are affected.

Examples of vasculitis include:

• Kawasaki disease,
• Behçet’s disease,
• polyarteritis nodosa,
• Wegener’s granulomatosis,
• Cryoglobulinemia,
• Takayasu’s arteritis,
• Churg-Strauss syndrome,
• Giant cell arteritis (temporal arteritis), and
• Henoch-Schönlein purpura.

 

The actual cause of these vasculitis diseases is usually not known. However, immune system abnormality and inflammation of blood vessels are common features. Each form of vasculitis has its own characteristic pattern of symptoms, much of which depends on what particular organs are affected.

Examples of vasculitis include:

• Kawasaki disease,
• Behçet’s disease,
• polyarteritis nodosa,
• Wegener’s granulomatosis,
• Cryoglobulinemia,
• Takayasu’s arteritis,
• Churg-Strauss syndrome,
• Giant cell arteritis (temporal arteritis), and
• Henoch-Schönlein purpura.

Vasculitis can also accompany:

• Infections (such as hepatitis B),
• Exposure to chemicals (such as amphetamines and cocaine),
• Medications,
• Cancers (such as lymphomas and multiple myeloma), and
• Rheumatic diseases (such as rheumatoid arthritis and systemic lupus erythematosus

Treatments:

The treatment of the various forms of vasculitis is based on the severity of the illness and the organs involved. Treatments are generally directed toward stopping the inflammation and suppressing the immune system. Typically, cortisone-related medications, such as prednisone , are used. Additionally, other immune suppression drugs, such as cyclophosphamide (Cytoxan) and others, are considered. Additionally, affected organs (such as the heart or lungs) may require specific medical treatment when the disease is active.

The management of vasculitis is an evolving field in medicine. The ideal programs for monitoring and treatment will continue to improve as disease patterns and causes are defined by medical research.

Craniosynostosis (kray-nee-o-sin-os-TOE-sis) is a birth defect in which one or more of the joints between the bones of your baby’s skull close prematurely, before your baby’s brain is fully formed. When your baby has craniosynostosis, his or her brain can’t grow in its natural shape and the head is misshapen.

Craniosynostosis can affect one or more of the joints in your baby’s skull. In some cases, craniosynostosis is associated with an underlying brain abnormality that prevents the brain from growing properly.

Treating craniosynostosis usually involves surgery to separate the fused bones. If there’s no underlying brain abnormality, the surgery allows your baby’s brain adequate space to grow and develop.

What is an aneurysm?

An aneurysm is an arterial condition in which the wall of an artery weakens, creating a bulge, or distension of the artery.

An aneurysm can occur in important arteries such as those supplying blood to the brain, and the aorta; the large artery that originates at the left ventricle of the heart and passes down through the chest and abdominal cavities.

The normal diameter of the aorta is around 0.8 inches. This width can bulge to beyond 2 inches with an aneurysm, a width that would typically necessitate surgical treatment.

An aneurysm can also occur in peripheral arteries – usually behind the knee (popliteal aneurysms) – although rupture of these is relatively uncommon.

The two most important common locations for aneurysms are:

• In the artery directly leaving the heart – an aortic aneurysm (including thoracic and, further down, abdominal aortic aneurysms)
• In an artery in the brain – a cerebral aneurysm.

Thoracic aortic aneurysm is often abbreviated to TAA, and abdominal aortic aneurysm to AAA. Brain aneurysms are often termed intracranial aneurysms, as well as “berry aneurysms” on account of their size and shape.

Two other examples of aneurysm are mesenteric artery aneurysm (affecting the artery supplying the intestines of the gut) and splenic artery aneurysm (occurring in the spleen, an abdominal organ).

Symptoms of aneurysm:

Most aneurysms do not themselves cause any symptoms.

Even if an aneurysm does not rupture, however, a large aneurysm may obstruct circulation to other tissues. An aneurysm can also contribute to the formation of blood clots that then obstruct smaller blood vessels, potentially causing ischemic stroke or other serious problems; this is known as thromboembolism.

Abdominal aneurysms are sometimes associated with symptoms if they grow rapidly. Some people report abdominal or lower back pain, or a pulsating sensation in the abdomen.

Similarly, thoracic aneurysms can cause symptoms by affecting nearby tissues, including nerves and other blood vessels.

If an aneurysm compresses the laryngeal or vagus nerve, it can cause chest or back pain and symptoms such as coughing, wheezing and difficulty swallowing. Compression of the coronary artery can also cause chest pain.

Otherwise, aneurysms tend to produce symptoms only when there are complications such as rupture.

Symptoms can also be related to the cause of the aneurysm rather than the aneurysm itself. In the case of infection or vasculitis (blood vessel inflammation), for example, there may be fever, malaise or weight loss.

Complications of aneurysm

If an aneurysm has remained undetected, the first sign of it could be when there is a complication – in particular, a rupture – with symptoms resulting from this rather than the aneurysm itself.

The majority of people living with an aneurysm do not suffer any of the complications in the following list. Managing the risk factors is important, however, because all of these possibilities are serious.

Complications of aneurysm include:

• Thromboembolism – depending on where the clot has traveled to, thromboembolism can cause pain in the extremities or the abdomen. If a clot travels to the brain, it can cause a stroke
• Dissection of the aorta – see below for more detail
• Severe chest and/or back pain – if a silent or diagnosed aortic aneurysm in the chest ruptures, severe chest or back pain may arise. Such symptoms may help hospital medical staff diagnose an aneurysm.
• Angina – certain types of aneurysm can lead to angina, another type of chest pain; the pain is related to narrowed arteries supplying the heart itself (causing myocardial ischemia and possibly heart attack).
• Sudden extreme headache – if a brain aneurysm leads to subarachnoid hemorrhage (a kind of stroke), the main symptom is sudden extreme headache; often so severe that it is unlike any previous experience of head pain.
• Other symptoms – with any aneurysm rupture there may be pain, low blood pressure, a rapid heart rate, and light-headedness.

Again, most people with an aneurysm will not suffer any of these complications, and the risk can be reduced by taking preventive steps.

Treatments for aneurysm

Not all cases of unruptured aneurysm need active treatment, but when an aneurysm ruptures, emergency surgery is needed.

More details follow for the treatment options against the two main types of aneurysm.

Aortic aneurysm treatment options

An aortic aneurysm, whether abdominal or thoracic, may not need any active treatment and instead may just be monitored regularly. Medications and preventive measures may form part of conservative management or they may accompany active surgical treatment – through open or endovascular surgery.

Aneurysms that rupture require emergency surgery. Without immediate repair, a ruptured aneurysm is always fatal in the thoracic aorta, and almost always fatal in the abdominal aorta.

The decision to operate on an unruptured aneurysm in the aorta depends on a number of factors related to the individual patient, as well as to features of the aneurysm itself:

• Individual factors – age, general health, coexisting conditions and personal choice
• The aneurysm’s characteristics – size relative to location in the thorax or abdomen and the rate of growth
• Other factors – chronic abdominal pain or risk of thromboembolism may make surgery a good option.

An aortic aneurysm that has a larger diameter (about 2 inches or 5 cm) is more likely to prompt a recommendation of surgery, as is an aneurysm which is growing more quickly (a little less than 1/4 inch over the last 6-12 months).

For both elective unruptured and emergency ruptured cases, surgery can take one of two forms:

• Open surgery to fit a synthetic or stent graft
• Endovascular stent-graft surgery.

Endovascular surgery involves accessing the blood vessels through a small incision near the hip. In stent-graft surgery, an endovascular graft is inserted through this incision using a catheter and is positioned in the aorta to seal off the aneurysm.

In the emergency of a ruptured abdominal aortic aneurysm, the decision over which procedure to perform will be urgent. For elective operations to repair unruptured aneurysms, a review published in 2014 sought to determine the relative risks and benefits of open vs. endovascular surgery.

The review found that while there was a lack of robust studies comparing the two options directly, similar rates of complication were reported for both types of surgery.

The evidence suggested that endovascular aneurysm repair (EVAR) was “less invasive,” but the procedure did “not always significantly alter the postoperative course or length of hospital stay for patients.”

The authors concluded that open surgery still had a role for those patients who were not suitable for endovascular surgery.

Endovascular surgery has become the generally preferred method of aortic aneurysm surgery because of:

• Shorter operative times
• Often shorter hospital stays
• Better levels of surgical experience
• A perceived lower risk of disease or death surrounding surgery compared with laparoscopic surgery (although the review found this could be more perception than reality).

Endovascular surgery for the repair of aortic aneurysms does carry the following risks however, in addition to the usual risks of surgery:

• Bleeding around the graft (which requires additional surgery)
• Bleeding before or after the procedure
• Blockage of the stent
• Nerve damage, resulting in weakness, pain or numbness in the leg
• Kidney failure
• Reduced blood supply to the legs, kidneys or other organs
• Erectile dysfunction
• Unsuccessful surgery that then requires open surgery
• Slippage of the stent.

Cerebral aneurysm treatment options

Surgical treatment of an aneurysm in the brain is reserved for cases that present a high risk of rupture.

Aneurysms that are less likely to burst are not treated surgically because of the potential risk of brain-damage resulting from possible surgical complications.

In lieu of surgery, patients are given guidance on how to monitor and modify, where possible, the risk factors for rupture of a brain aneurysm. This will likely involve monitoring blood pressure – see prevention below.

Where a ruptured brain aneurysm has led to a subarachnoid hemorrhage (a medical emergency), a patient may be admitted to hospital and undergo brain surgery.

Such a procedure would aim to close off the artery that ruptured due to the aneurysm, in the hope of preventing another bleed.

Prevention of aneurysm

The single most important way a person can reduce their risk of developing an aneurysm is to not smoke or to quit if already smoking. Smoking is not only the strongest risk factor for the development of an aortic aneurysm, it is also one of the greatest risk factors for an aneurysm growing and rupturing.

Smoking is a greater risk factor for aneurysm than it is for atherosclerosis, the cardiovascular disease where fatty deposits accumulate on the arterial wall and which can weaken artery walls.

The fact that smoking is also a big risk factor for atherosclerosis is directly relevant, however, because most aneurysms are caused by weakening of the artery wall brought on by atherosclerosis:

Studies have shown that continued smoking induces a significantly faster expansion of aortic aneurysms – by about 0.4 millimeters a year).

Brain aneurysms are not always possible to avoid to the same extent as aortic aneurysms because ruptured brain aneurysms causing subarachnoid hemorrhage stroke can be congenital – present at birth.

Brain aneurysm has both genetic and environmental risk factors, and a history of brain aneurysms in the family is an established risk factor, as is increasing age. However, known risk factors also include, alongside hypertension (high blood pressure), smoking.

Cigarette smoke is also a major source of free radicals which cause oxidative stress. Oxidative stress and resulting tissue damage can occur due to higher production or reduced removal of free radicals. Oxidative stress can also increase inflammation, which contributes to the formation and rupture of cerebral aneurysms.