Thread by @DrThawabeh

How Can Acute Appendicitis Lead to Blindness Followed By Death?
Read this before you choose general surgery as your career!

What you learn from complications, is 1000x more than success stories.

Sharing this is painful , but the benefit is superior .

Discussion is open 👇

1- this is a 17 year old male patient,taken by family to a peripheral hospital with lower abdominal pain , diagnosed as a case of acute appendicitis.The junior staff started the operation as happens in all hospitals around the world. They had difficulty, patient started to bleed.

2- They called their senior doctor and the bleeding didn’t stop, they had to start transfusion due to hemodynamic instability, they had to make a wrong incision because they panicked, you don’t make a bridge between Mcburny incision and the midline incision .

3- They were looking for the source of bleeding, but if you don’t know the principles, you will increase the damage , the patient is thin as you can see in the picture, you can reach the diaphragm without effort. Yet , packing and blood weren’t enough !

4- according to the father, they asked him to bring blood inside the OR , the operation took 4 hours , and he was almost inside the OR with them! , they called the attending eventually , and bleeding stopped.

5- the patient , as expected, didn’t improve post operatively , and over the next 5 days, he started to be septic , feverish , hypotensive, family raged and asked for transfer for the hospital I work at.

6- I received a patient who is critically ill post appendicitis in the surgical ICU , what do I expect? Maybe bowel injury , maybe early collection , worst case scenario? Missed diagnosis ! Okay, resuscitated him , and did CT abdomen with contrast.

7- surprise , the radiologist called “ are you sure this patient is your patient ? “ , “ yes sir he’s mine ! “ .. “ does he has any known anomalies ? “ ,, “ nothing that i’m aware of ! “ ... “ okay young resident, your patient has a ligated superior mesenteric artery ! “ enjoy!

8- before informing anyone , I tried to review everything, the images , before I look dumb in front of my seniors , yes , it was ligated , as you can see in the second picture, SMA comes at L1 , just below the pancreas , and it was patent only for 2 cm, then it was ligated !

9-I tried to imagine what happened, you have a heavy bleeding intraoperatively , you don’t know what to do , think patient , you start clamping everything, you hit a big vessel that you think is the source of the bleeding, you are right, it’s the one supplying all the Small bowel

10- we tried to contact the surgeons in that hospital , and nobody gave us a clear picture of what happened , then , there’s one way to discover things, take your patient to OR .

11- we explored him as soon as his condition allowed for the mildest anasthesia ( remember, 17 yr old with acute appendicitis ! ) and there was the 3rd picture, completely gangrenous bowel from 15 cm distal to duodenum , to few cm proximal to iliocecal valve. Almost 2.5m , black!

12- we had to resect everything , duodonostomy , close the distal stump of resection , and here you go , short bowel syndrome on day 7 or 8 post op . Post open appendectomy.

13- patient started on TPN , kept to be febrile and septic despite all AB on earth , explored again and everything was a miss. No chance for anything.

14- a week after , started to have a fistula , high output , not only the duodonostomy! But also the jujenal stump opened through the skin . Check the 4th picture.

15- the patient kept deteriorating , he was supposed to get his appendix out and go on for his exams . But he never had the chance. We kept him on TPN. And we started noticing every single complication mentioned in books about TPN.

16- can we do anything at this stage? No , not fit for anything you can think of , even if you have a small bowel transplant team ready , he’s not fit.

17 - eventually , few days before his death , in the morning round, he told me suddenly , doctor , I can’t see anything , why ? We did everything to rule out any ischemic or embolic brain insult , but guess what ,it wasn’t anything of that , it was the rarest complication of TPN.

He lost his vision , then his life . After giving a hard lesson for everyone. family went to the 1st hospital and broke everything. Then came to our ICU and did the same, police took over and closed the place. I was unlucky to receive him , and to write his death certificate.

18. Why did this happened? Because young surgeons take things lightly, they think they are qualified to do any surgery after few months of training, they want to feel the adrenaline rush of controlling an OR full of nurses with 10+ times their experience. It’s not their mistake!

19. You need to know that the simplest surgery can go wrong if you don’t know what to do;a lipoma excision can bleed to death , a wrong local anasthesia dose can cause toe amputation in the simple ingrown toe nail procedure you give to your junior. It’s not a game , never a game.

The lesson:we aren’t here to blame anyone, you need to feel lucky that you are reading this but not living it.Try to take the lesson in a less difficult way.The only way for that is to know your limits,appreciate everything related to the patient. And above all, expect the worse.

Lesson: always have plan B, think what are you going to do if you are in trouble inside the OR,how much stress can you handle? How many decision can you take when you are about to collapse? And keep in mind, what happens inside those small rooms doesn’t always bring happiness.

the greatest lesson:if you want to be qualified inside the operation room, there’s no way for that other than being qualified outside it!You can’t be a hero holding a scalpel without reading and writing notes,without presenting cases and asking questions. Respect your patient!

Note: this case happened in 2011 , a big lawsuit case followed the young boys death and it was resolved with justice to the family. It wasn’t allowed to be published either in journals or media, and lots of scientific meetings were held immediately after, to study the

Possible causes of what happened , anatomists were there to give all they know about SMA anomalies. And everyone concluded that it shouldn’t happen regardless of what the anomaly or the situation was. It was a great lesson for everyone, and the boys name is still in our minds .

@MGHSurgery @SurgeryTraining @AmBdSurg @ColorectalDis @AmCollSurgeons @RCSnews @AmerMedicalAssn @JAMA_current @JAMASurgery @NEJM @nejmcatalyst @JWatch @BJSurgery

For doctors interested in reading the causes of blindness in patients receiving TPN:

ncbi.nlm.nih.gov/m/pubmed/26290…

For SMA normal anatomy and anomalies in details :

pdfs.semanticscholar.org/33ec/a089a6dbd…

SMA should be your friend and enemy , along with all the major retroperitoneal vessels , these are killers when you don’t know what do if they get angry during whatsoever surgery you are performing.

Now to make the most benefit out of this tragedy:
For Vascular surgeons; if you were called in this case 3 hours after the SMA was ligated , what’s your strategy of intervention? Interposition SV graft or synthetic graft? @VascularMD @stanfordvasc @ColemanDM_vasc @RKTvascular

@DrMahmoudRefaat @cfbechara @KyleCooperMD @IsamOsman1

Personal reaction to adverse events varies, and some surgeons will have a long term psychological impact , which can be controlled if we understand the phases of reacting to complications.

The paragraph below from:

Surg Clin N Am 92 (2012) 153–161
doi:10.1016/j.suc.2011.12.002