#usually due to infection and around the 8th or so day after surgery

[egginfroggin]

Got to use the word "dehscence" in a fic, and that fact just fills my heart with rainbows :>

[mycelier]

My name is Simone and I would like to tell you a tale!

I will not have access to my laptop for some days more and because writing on my phone is kind of painful (physically, because I am working on hand mobility now), this may end up in drafts and taking a while to post. I am going to share what has been happening the last 2 months because I feel like everything went from 0 to 100 in the span of a few weeks and its been really, really wild.

So!!! LETTUCE begin!

For roughly 5 years I've been struggling to get a diagnosis on an extremely painful area of my arm. There was literally nothing visible; no lump, discoloration or any other physical abnormality to indicate anything was wrong. I spent thousands on pretty much every kind of imaging you can do, and was told time and time again that there was nothing wrong and, perhaps, it was psychosomatic and I needed therapy or, more often than not, I was given a shrug and a vague "i dunno" response.

This year, something changed. I deal with chronic pain (my spine is congenitally fused in my neck and lower spine and I have baby bone spurs all over), and in the process of trying to work on that I brought up my arm again to a dr I no longer see. He'd told me my arm was SEVERAL things over the years I had been seeing him but this time said it was a fibromyalgia knot, something I had been told by a team of doctors some time before that. I said okay cool and was sent to a physical therapy rehab center where the dr worked with myofascial release and stretches to help with injuries. This amazing man fixed my plantar fasciitis and helped get my chronic headaches under control but NOTHING we did helped my arm pain. Within a month he was worried bc we had started to notice that there was a hardness to the spot that never changed with any exercise or massage.

Worried that there was a nerve being trapped or crushed (another diagnosis I'd gotten over the years), this amazing man sent me to a neurosurgeon who immediately frowned and said he didn't think my neck pain and my arm pain were connected. He ordered an MRI of my arm and despite it not being visible on an MRI 2 years before, he found something PHYSICALLY THERE where I said I had pain. He considered doing the surgery to remove it (despite being a neurosurgeon he was fascinated with this weird horribly painful spot) but eventually sent me a surgeon for an oncology center, assuring me it was because this new surgeon was one of the best in Texas for removing soft tissue tumors, not because there was any thought of cancer.

I met with the surgeon who gave me one more diagnosis of an AVM (arteriovenous malformation), snd said they were benign and not necessary to remove as well as the possibility that if removed it would likely return. Truly, at this point after 5 years of constant nauseating horric pain when someone brushed against me or if I gently brushed against ANYRHING, a pain so bad that it had basically made me stop using my right arm as much as possible (of course I'm right handed lol), I said GET THAT FUCKER OUT OF THERE MAN and my first surgery was scheduled.

Surgery one occurred Nov 5th and was an out patient event. I went home and passed out. At some point my mom said that while I'd been in recovery the dr said the thing in my arm hadn't looked like what he expected so he had sent it to pathology. I went back to work and was hanging out until the Tuesday before Thanksgiving when I went in for a super immediate meeting with a different doctor who told me that what had been in my arm was a synovial sarcoma, aka, cancer! He, this incredibly kind man I did not know, gently discussed chemo and told me I needed to have a CT scan immediately. Based on the CT, i was either in stage one or stage four if it has spread to lungs. The day before Thanksgiving I received the news that it was stage one, it had not spread, and i was so fucking happy.

Then it was time talk about next steps. My surgeon marked out a circle on my arm to indicate how much he was gonna remove in order to guarantee clear margins..but it was not enough of a meeting for me to grasp the surgery I was about to receive.

The day of my second surgery, dec 8th, came quickly and i met with the plastic surgeon, the kindest, most patient man. He moved my arm around and explained how he was going to hijack a vein from my forearm in order to keep the blood flow health to the flap he was gonna take from the donor site: My inner thigh.

It has been 11 days and I am living in an inpatient rehab facility, working on dealing with the nerve damage/pain, the EXTREME pain of my donor site, and the lost mobility that I am working on getting back, both in my leg and my hand. The majorities of my arm is numb...except where the nerve pain burns my wrist and forearm and makes it painful to wear my arm sling (I can't fully extend my arm, nor can I lift, push, pull or use my arm in any way that would stress out my new arm flap). Also may have a brand new urinary tract infection but as I write this I'm chugging water for a urine sample to hopefully get that treated. Below are some pictures I have taken/had taken of my arm! Im not ready to look at my leg outside of the bandages (which, since having the wound vac removed today, hell yeah, will need daily dressing changes).

EDIT: I tried posting pictures of my arm last night and my post disappeared immediately so I will try to make a new post with these photos in case the whole post was erased because of them. I will tag them as post surgery photos. I do not consider them gory or excessive but hey that's just me.

I intend to post more things as I keep healing and as I gain more mobility. I was given "independence" in my room yesterday which means I can officially get up without any assistance needed (using my badass new cane to help me lift my foot in and out of bed)!!!! Which also means I can get up whenever I want without the bed alarm going off. I have a badass cane that has been the best tool in helping me get around (and has inspired my mom and others to suggest and look into getting me a cane sword which makes me laugh REAL hard). See below me using the cane to move my foot in and out of bed!

Part of why I'm posting this is because I really needed to talk about it and while later posts may not be this long or expository but I wanted to have a base post to explain other ones related to this one!!!

I will update with some newer pics tomorrow night when my mom comes by to help me take newer pics. The arm flap looks super healthy (according to the drs), and when they changed my leg dressing they said its looking really good and healthy!

I......also really wanted to post my Amazon wishlist. Due to this stupid wild bad lottery ticket, I've been struggling to pay my bills and rent but!!! I have good insurance, thankfully (since I live in the US and my hospital stay and this rehab stay would have more than bankrupted me), and im hoping my disability checks will get here in time for rent!!! I'm putting up my wishlist bc I can't afford some of the "essentials" on there and, also, because I havent been able to have any kind of comfort during any of this. I never ask for anything for holidays because usually i...dont want to burden people with spending money on me since I know how hard money is, especially right now. And if I don't have enough for rent later I might have to create a go fund me...but right now everything looks good for rent and bills just...not for anything fun.

Thank you so much for your time!!! And happy holidays you wild bastards!!!

https://www.amazon.com/hz/wishlist/ls/36PG6BAYD18U7?ref_=wl_share

[surgicalcases]

Fecal peritonitis due to ruptured appendix: a rare case

Fecal Peritonitis: presentation of a rare case

Geroukalis F. Andreas, Panousopoulos S.G., Alevra Xanthi Department Of Surgery, “Ippokratis” General Clinic Pireus

Abstract In this case report we present a patient who came to the hospital with fecal peritonitis, after she had previously visited their general practitioner 3 times, and the answer she was receiving for her condition was that she was suffering from a “cold in the belly”. The patient was admitted and a CT was performed only to reveal free air in the peritoneal cavity and fluid in several peritoneal compartments. In this case report the aim is to note that despite a wrong diagnosis, despite the delay in the management of the patient, following the elementary “rules” of managing such an acute patient, a positive outcome is possible.

Introduction A 62 years old woman came in the emergency department of the hospital complaining about acute abdominal pain, and that she could not take it anymore.After a though history taking, the patient said that she had visited her general practitioner three times, complaining about the pain in her abdomen, but initially he said that she had a “cold” in her belly, the second time he told her that the cold was getting worse, and the third time he advised her to take hot water baths to manage the pain. After these three days, the patient was admitted with signs of acute abdomen in our clinic, where IV fluids were instituted, laboratory examinations were made, and of course image studies were performed.  

Presenting Symptoms& Clinical Findings Patient presented with generalized acute and severe pain all over the abdomen. There was rebound tenderness, distended belly, and a silent abdomen. There also was shortness of breath, tachypnea, and tachycardia, while the patient was irritated but not disoriented. There was no fever, but there was nausea and actually the patient had two episodes of vomiting. The patient had no appetite and she mentioned that in the last days she did not want to receive any solid food. No gases were passed, and there was moderate urine output according to her recall. Her pulse was strong but very rapid. Examination and auscultation of the chest revealed no finding from the pulmonary fields, apart from the tachycardia.

Diagnostic Focus & Assessment WBC count was elevated reaching levels of 24 x 103/μL, with more than 92% neutrophils, the PLT count was normal, and although the Hemoglobin levels were normal for the patient’s age, hematocrit was elevated (46,5%) probably as a result of dehydration and hemoconcentration. CRP was greatly elevated (> 55), as were urea and creatinine respectively due to the dehydration. No other electrolytic imbalances were noted. On the chest x-ray no significant pathology was revealed, and the CTR was normal. On the abdominal x-ray the findings were striking: 1. there was free air in the peritoneal cavity, 2. the small intestine appeared distended at a degree that it was pressing against the large bowel, and 3. the typical “ladder” sign of ileus was present, but no sign of obstruction could be detected. CT scanning set the diagnosis, since it validated the findings of the abdominal x-ray, but it also revealed a mass around the anatomic position of the appendix, although the appendix itself could not be identified, gas distention of the large bowel was prominent, while the presence of fluid was evident around most of the enteric loops all over the peritoneal cavity. Despite the patient’s history of removal of her right fallopian tube, it was identified on the CT and presented with edema. The patient was prepared for emergency surgery and after less than 45 minutes the patient was taken to the OR.

Management & Therapeutic Approach During the operation the main findings were, generalized peritonitis with pus all over the peritoneal cavity (Ffig. 1), after the pus was drained and the peritoneal cavity was thoroughly washed with warm saline solution (about 3 liters), the finding included a small lesion of rupture on the ileus (about 20cm from the ileocecal valve) with diameter of less than 2cm (Fig. 2), a rupture site on the caecum (Fig. 2), a gangrenous appendix (Fig. 3), and an inflamed right fallopian tube, with ischemic changes on its surface.

fig.1 pus in the peritoneal cavity

fig.2 small bowel perforation & pseudomembrane

fig.3 gangrenous appendix

Postoperatively we followed an aggressive rehydration strategy, that included not only enriched normal solution and Ringer’s solutions, but also 2 units of fresh frozen plasma (FFP) in order to manage the generalized oozing of blood resulting from the massive mobilization of the whole  small bowel, the removal of symphyses, and the removal of pseudomembranes. Broad spectrum antibiotic therapy was installed, and included metronidazole 500mg every 8hs, second generation cephalosporin 750mg every 8hs. We need to make notice that a single dose of aminoglyside was given intraioperatively. Due to the severity of the case, and the complications that can arise from fecal peritonitis the patient was moved after the operation in the ICU for monitoring and postoperative treatment. On the 3rd postoperative day the patient was returned to her bed on the floor, and on the 8th day she was discharged from the hospital, in a very good condition. The patient is followed by our team, and she is expected to return in the end on January 2017 to repair/close the loop eileostomy.

Discussion What makes this case relatively rare is the fact that the patient visited her GP not once but 3 times before she was brought in to the clinic by her family. It is important to understand that usually time is of the essence in such cases since the septic effects resulting from fecal peritonitis are detrimental and usually lead to poor outcomes when delays arise in their management. In this case the delay was so severe, it could cost the life of the patient. Fortunately enough, the patient had no other comorbidities, she is not a smokler, she rarely has a drink (not even typical social consumption of alcohol) and she tries to follow a healthy diet and a healthy way of living (although she is not athletic, she walks almost 5-6 km per day). All these fact contribute greatly to the end result,  which in this case was amazing, considering the severity of the case. From the surgical point of view a few points must be noted: 1. During the opening of the patient, we decided a middle section to be done, since it allows for better approach to the lesions, allows more movement around demanding anatomic positions and also allows for a thorough inspection of the lest peritoneal cavity. 2. The patient was informed that she had her right fallopian tube removed in a previous operation, yet not only she had her tube, but also it is possible that inflammation of the tube led to this condition. 3. The major problem in this case is the lack of suspicion from the GP. We believe that some rules must be instituted for such cases, especially rules that follow the classic saying in surgery “better safe than sorry”. All physicians, when in doubt should ask for a consult, or if no consult is available should refer the patient to a hospital or to a surgeon, so as therapy and management start on time, and not placing the patient’s life into any danger. 4. Through our experience in fecal peritonitis, all cases with peritonitis that have been left untreated for more than 48 hours, should be treated with hemicolectomy of the appropriate site of the colon, and completed with a loop eileostomy that will be closed after 60 to 90 days. Our main and primary target is to save and preserve life, so we need to take steps that will add to it., even if eileostomy is something no one (patients, family of the patient, spouses like to see and take care of, even if it is only temporary ) wants. Finally I want to underline the importance of the use of drainage in such cases, since the tube is essentially our eye in the patients abdominal cavity, plus it allows us for manipulation even is it is limited.  

Bibliography Jedeikin RJ, Engelberg M, Shapira AL, Kaplan R, Hoffman S. Fecal peritonitis. An approach to its management. Isr J Med Sci. 1983 Feb;19(2):119–123. [PubMed] Tolhurst Cleaver CL, Hopkins AD, KeeKwong KC, Raftery AT. The effect of postoperative peritoneal lavage on survival, peritoneal wound healing and adhesion formation following fecal peritonitis: an experimental study in the rat. Br J Surg. 1974 Aug;61(8):601–604. [PubMed] Edmiston CE, Jr, Goheen MP, Kornhall S, Jones FE, Condon RE. Fecal peritonitis: microbial adherence to serosal mesothelium and resistance to peritoneal lavage. World J Surg. 1990 Mar-Apr;14(2):176–183. [PubMed] Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005. 65(12):1611-20. [Medline]. Schein M. Surgical management of intra-abdominal infection: is there any evidence? Langenbeck’s Arch Surg 2002; 387: 1-7 Lamme B et al. Meta-analysis of relaparotomy for secondary peritonitis. Br. J. Surg. 2002; 89: 1516-1524 Mulier et al Factors affecting mortality in generalised postoperative peritonitis: multivariate analysis in 96 patients. World J. Surg. 2003; 27: 379-384