Episode 6 - Appendix and All or None

The Morrissey Movement

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Ladies and gentlemen, welcome to the Morrissey Movement, the purpose of this podcast to discuss and share one aspect of fitness and one aspect of medicine. Being a general surgeon and a garage gym athlete, I have a strong passion for both of these aspects of life. So sit back and enjoy the show. This podcast is for entertainment purposes only. I am in no way forming a patient doctor relationship. All the aspects discussed in this podcast are medically accurate. You should always discuss with your doctor any questions that you may have about the content, you should always discuss with your doctor before starting any new exercise or dietary changes. Hey, what's going on everybody? It's Dr. Chris Morrissey back with another episode of The Morrissey movement. Hope everybody had a great and safe New Year, today's January 1 As of recording this. So the New Year 2022 has launched and so hopefully it'll be a better year than it was last year. So today, I felt this is kind of appropriate time to discuss this. Today's episode six, it's called appendix and all or nothing. So I'm going to discuss the history of an appendix and also what happens when you get your appendix removed, and then proceed into the all or none mentality when it comes to diet and exercise. Because this is the time of year when people join gyms with high hopes. And then things can get derailed very quickly. So I'm hoping that we can shed some light and kind of maybe change your mindset a little bit about what it's like to do training, as well as diet. And hopefully you can get and obtain your goals this coming year. So I'm going to start off with the medical portion today. So I'm gonna start off with the appendix. So the appendix is located down on the right side of your colon, which is kind of close to your right hip bone. The appendix averages about three, three and a half inches long in length, but it can be anywhere from two to 12 inches, it just kind of depends on the person, the diameter or the health how big across it is, is approximately about a quarter of an inch or so. And so anything over about half a half an inch is kind of considered thickened or inflamed. When we look at taking the appendix out. The longest longest appendix has ever been removed was approximately 10 inches long. This is per the internet, so nothing is ever falls on the internet as we all know. So again, it's usually located in the right lower quadrant of the abdomen, which again is near kind of the right hip bone area. The base of the appendix is located about two centimeters, or almost an inch beneath what's called the ileocecal valve. So that you'll have Ileocecal valve is what dumps where the small intestine connects to the large intestine or the small bowel connects to the colon. So its position within the abdomen can be kind of variable that can be located kind of pointing down into the pelvis, it can be pointing over towards the left side, it can actually be behind the colon, which is called retrocecal. So sometimes it makes it difficult to find the appendix especially in the old fashioned way that we used to take appendix is out. Nowadays, when we have CT scans in the laparoscope, we can usually find it. Sometimes it does take a while however. So the appendix is actually connected to the, what's called the mesentery in the lower region of the of the ilium. So your small intestine is broken down into three parts. So the first part is what's called the duodenal or duodenum, which comes right off the stomach. And then there's the jejunum, and ileum. So it's roughly 30, some feet of small intestine and then connects to your colon. There's a little blood vessel called the appendiceal artery that is located inside this little kind of fatty layer where all the blood supply a lot is located for the small bowel in the colon. So what is this thing? It's kind of been identified as a few different things. There is some literature that supports that it being part of your mucosal immune function, particularly what's called B cell mediated immune responses. So you have kind of two main types of cellular immune responses, there's T cell and B cell and that's way above the scope of this discussion. So so it helps in the proper movement and removal of waste matter in the digestive system. It contains lymphatic vessels that can regulate pathogens or microbes. And lastly, it might even produce some early defenses to prevent more serious diseases. Additionally, it is thought that this may provide more immune defenses from invading pathogens and getting into the lymphatic system to fight viruses and bacteria.

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But it's still kind of up in the air whether this is all really happens or not. Some research also shows a positive correlation between the existence of appendix and concentration of SQL lymphoid tissue which supports that, not only does the appendix evolve as a complex with the cecum, but also has major immune benefits. So the appendix does have a few functions. And some people believe it's called a vestigial organ, which means that it's kind of has no function today, but it's evolved over millions of years of evolution. But, you know, some people don't really believe in that either. So, looking at history, back in 1735, Dr. Claudius Amyand performed the world's first successful appendectomy at St. George's Hospital in London. Per history, the patient was an 11 year old boy whose appendix had become perforated by a pin that he had swallowed. The first successful operation to treat acute appendicitis was performed soon after a 19. I'm sorry, in 1759 in Bordeaux. So, general anesthesia wasn't available until the mid 1840s. And so some of these operations basically, kind of was what they call hold still anesthesia where people will hold the patient down and will perform the procedure in an open fashion which is, you know, undoubtedly super painful. Surgical treatment for appendicitis began during the 1880s. Although doctors struggled to decide who should undergo the knife some patients who would recover on their own without surgery, surgical technique and anesthesia has significantly improved outcomes to such an extent that the surgery would rapidly became the gold standard approach. By the end of the 20th century, laparoscopic surgery replaced open surgery in most cases, and I'll get into that here in a little bit. And laparoscopic appendectomy is now considered one of the safest lowest complication surgical procedures that we perform today. According to one source. Despite the excellent track record, many questions about the appendix still persist. The cause of appendicitis is not 100% Understood. And we do not understand why the appendix will rupture in some people and recover and others. In 2007, researchers finally offer a compelling case for the function of the appendix, the tiny organ appears to play a role in both, again, digestive and immune function by acting as a storehouse for viable bacteria, which are enlisted when the GI tract loses its benefit. Sorry, beneficial gut flora. So that's a little bit of the history. Now as far as typical presentation of people that come into the emergency room most most commonly once in a great while, they'll show up in a primary care office with right lower quadrant pain or just generalized abdominal pain. So typically, if you read the textbooks, you'll begin having an adult kind of vague ache around the belly button region, and then it will eventually migrate down to the right lower quadrant. This is due to how you develop in utero where organs actually they start to you start off as a little ball of cells and then things actually stretch out and then different pieces of tissue turn into different organs and they're kind of take their place in the abdomen, and your at your intestines actually herniated come out through your bellybutton and spin on its axis and then actually track back down inside the belly button and then into the abdomen and take you know their place in your anatomic location. So, so yeah, typically, you know, vague abdominal pain around the belly button that goes down the right lower quadrant. Sometimes you'll have a fever, sometimes not. Sometimes you'll have nausea and vomiting, sometimes not. Sometimes they'll be diarrhea, sometimes there isn't. When they arrive in the emergency room, depending on the age of the patient, if it's a child, we typically try not to use CAT scan, since it does submit the patient to a lot of radiation, so we try to use an ultrasound first to find the appendix. If the appendix can be found with ultrasound, it is very specific for appendicitis. However, just because you can't find an appendix with an ultrasound doesn't mean that it's not there and then you're not having an issue with appendicitis. Most commonly, you'll get a CAT scan of the abdomen and the pelvis looking for inflammation around the colon as well as a thickened or sometimes perforated appendix. Typically award or lab work, sometimes you'll get what's called a C reactive protein or CRP which can be elevated in patients that have appendicitis, and usually have an elevated white blood cell count as well.

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Kind of how things happen most often either a small little piece of food will get stuck inside the appendix opening or a kind of a solid piece of stool. The appendix is actually a blind in pouch and it empties into the main main lumen have a colon so if some of them blocks this what happens is it secretes mucus and has a few immune functions like we talked about earlier. Well, if this is blocked, then there's no way for the whatever's inside the appendix, the bacteria and the mucus to get out. So what happens is it keeps doing its job like it's supposed to, and then you start getting bacterial replication. And so pretty soon now the appendix begins to swell. And then after a certain period of time, then the veins become congested, because the veins, you know, the veins take blood away from the appendix. And so once the outflow is obstructed, then it starts putting pressure on the artery. So then once the artery loses, you know, the inflow to the appendix, that's when you get what's called ischemia, where you lose blood flow to the Oregon and then ultimately suffer what's called a perforation or the the appendix bursts, so to speak. So you know, the textbooks will say, between presentation of pain and perforation or rupture is typically within 48 to 72 hours. However, in real life, I've seen it when people said they started hurting three to four hours ago, and they come in with a ruptured appendix. And other people stayed, they've been having abdominal pain for five days, and they still have early appendicitis with no signs of rupture. So it's kind of hard to delineate who is going to show up in this fashion so so once you know we get everything figured out with the diagnosis of appendicitis, typically we end up going to the operating room, and I almost routinely 100% Before my appendectomies laparoscopically. So what what does that mean? So you'll have an IV in your arm will start giving you fluids and IV antibiotics, and then we'll administer anesthesia, you'll get a tube placed in your throat and put on a ventilator. And then your abdomen will be paralyzed, so I can do my job. So then I'll make a small cut above your belly button. And then put an instrument called a trocar, in which is like a little sheath, and then connect it to a tubing and pump co2 into the abdomen or carbon dioxide to then expand the space, I'll have more room to work, then once this is inflated, then I'll place your bed in what's called Trendelenburg position, which is actually kind of put the head down and the feet up that way it kind of uses gravity to move the intestines out of the pelvis. And then what next I typically do is make another cut above the region where your bladder would be kind of above your pubic bone and put another trocar or a sleeve inside. And then another one in the left lower quadrant kind of about partway between the hip bone and the belly button. And this one's typically a little bit larger of a trocar that way that'll accommodate the stapler, so I can staple off the appendix. So what happens next is will roll you to your left side a little bit, and then find the appendix sometimes just sitting there ready to be grasped at the time it takes some digging and dissecting to find it. Once I find it I'll kind of lift it up towards the front of your body. And then there's a little thin membrane at the bottom of the appendix where it attaches to the colon. And then I'll make a little window with an instrument called a Maryland a sector which kind of looks like a compare needlenose pliers. And then we use a staple gun, put a staple gun right along the base of the appendix snug up against the colon and fire that so there's a little stapler that fires and a little knife that cuts and then take down the artery and then put it in a little bag and pull it out through the hole on the left side. And then kind of go back inside and look around maybe irrigate if there's been any spillage control, any bleeding if there is bleeding, and then release all of the gas that was pumped into your abdomen and then remove the three little ports. And then all the stitches are under the skin that usually that'll dissolve on their own in a few months and then you'll just wake up as a medical superglue. So if it all goes nicely like that, then it can be almost an outpatient procedure depending

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on the time of day this is done. I usually tell people you're off work a week, sometimes it's three days, sometimes it's 14 days, it just kind of depends. But now if we get in there and it's so nasty that it's stuck and we can't visualize the structures we need to see sometimes we'll do it in an open fashion. But typically, once we've started laparoscopically, we'll typically do a moat a low midline laparotomy incision. So basically taken knife from underneath the bellybutton straight down to the above the pubic bone. And we have to put our hands in there and kind of do it the old fashioned way. Traditionally, old school open appendectomy is kind of a blind procedure. So they typically make a cut in the right lower quadrant, kind of at an angle, and then go through each layer of the abdomen. So you go through skin and go through fat, then you get to a few layers of muscle, and you kind of split the muscles with an instrument and you go in and kind of find the appendix with a little grasper or a clamp and pull it up and then you either tie it off or use a staple gun or whatever you're have at your disposal to remove the appendix. So that was the old fashioned way to do it. Now, there is some literature out there currently, that does suggest that you can manage this without surgery with just IV antibiotics. There has been some studies done in the pediatric population. You know, it's kind of deemed as one of the safer procedures that we can do so typically, you know, yes, I'm a surgeon but I would just advocate to take it out because on average, you're out of the hospital faster and recovery is quicker. And you know, you Never say always, never say never and medicine but you should never get appendicitis again and if it is removed properly and correctly the first time, once in a great while the entire appendix isn't removed which is called a subtotal, appendectomy, and you can get what's called stump appendicitis if the little remnant of the appendix is left behind, but that's super rare. So, really, that is kind of the the jest of everything now, there is a great once in a while, where if the appendix has already perforated or ruptured, and actually as an abscess cavity formed, we'll do what's called a CT guided drainage so usually send you to interventional radiology. And they'll numb up your skin and and place a really skinny drain tube into the abscess cavity, and then drain that out. And then there's, you know, discussion of whether you do what's called an interval appendectomy later on, which means that you come in as an outpatient, and they get this removed electively, some people do this some people don't it depends on medical comorbidities, it depends on the age of the person. And there's a lot of variables that goes into this as well. Now there is a small subset of people that can get what's called chronic appendicitis, which is basically just it kind of gets irritated here and there and just kind of has a smoldering kind of intermittent right lower quadrant pain and everything else that's been done, all the other workups endoscopy and other procedures can't ever really find the source. So sometimes we'll go in and take someone's appendix out electively to try to alleviate the right lower quadrant pain. And typically, in my practice, more often than not, it does take care of that. But that's kind of as a last resort. And only if we can't figure anything else out, sometimes we'll offer that as a procedure as well. So so that's really kind of the spiel on the appendix part. And now, I'm going to kind of shift gears and go into the all or none mentality and spend a little bit of time talking about this, especially this time of year. You know, in January is kind of the most common time for people to either buy a new gym membership, or they're going to get in shape, or they're going to diet, or you buy some sort of whatever the new sexy workout equipment is on Facebook or on Instagram or on TV or on the internet that you see that you'll use for a few months, and it becomes a expensive coat hanger in your room or in your garage or in your home office wherever you decide to put it. Now since COVID hit I feel there's probably more people doing more workouts at home, instead of going back to the gym. Now some people I know did kind of build a home gym for a while, but then they went back to the gym, as soon as everything was open back again with it, pandemic, but there's still probably a good majority of people that decided they like working out at home better, me included, I'll probably never go back to a gym again, because I love working out of my garage. But anyway, that's neither here nor there. So So again, when it comes to working out and with diet and exercise, there's so many people that I see the get into the what's called the all or none mentality. So basically, kind of what happens is, you know, people will set a goal for themselves, that, you know, you have to work out at least an hour, or you have to burn this many calories and an exercise session or you have to do, you know, spend a certain amount of time doing each exercise for the week. And then what will happen is, is if you have to cut it short for life, or your job or something like that, or you have to skip for whatever reason, then all of a sudden now you think, Well, you know, it's only Monday, but my week is wrecked. You know, I'm just going to scrap everything I'm not going to work out i'll just restart again next Monday.

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So, you know, sometimes we'll just do that just by missing one session. Sometimes, you know, if your didn't get a lot of sleep, if you had to stay up all night, kind of depending on whatever is going on in your life, that you just kind of scrap it it's like I'm you know what, why should I even try, which is the complete opposite of what you should be doing. So if you kind of think about it, this is a silly example but it's kind of like if you lost $1 out of your wallet, then you just throw the whole thing away in the trash regardless of how much money and credit cards are left in there. Or if you get a flat tire you're like well screw it I'm just gonna slash the other three tires because one is wrecked I might as well wreck the whole thing which is completely ridiculous...