Peritonitis Management through Appendicular Perforation in the Department of Surgery Bougouni Hospital (Mali)

Introduction: Appendicular peritonitis is a complication of acute appendicitis characterized by the spread of the infectious process in the peritoneal cavity thus achieving wide spread or localized purulent peritonitis; it’s a medico-surgical emergency. Our objectives are to determine the frequency, describe the clinical, therapeutic and prognostic aspects of peritonitis by appendicular perforations. Patients-Method: This was a 24-month retro, prospective, descriptive study from January 1, 2018 to December 31, 2019; conducted in the Bougouni Reference Health Center Surgery Unit. All patients of appendicular peritonitis at the Bougouni Reference Health Centre were included. Results: During the study period, 68 cases of generalized acute peritonitis including 30 appendicular peritonitis cases were collected. Appendicular peritonitis accounted for 44.1% of surgical procedures. Males accounted for 71.0% with a sex ratio of 1.2 at risk of men, the average age was 26.07 years. Abdominal pain and vomiting were the reasons for consultation in 86.7% and 76.7% of cases. Physical examination was used in most cases to make the diagnosis. X-ray of the


Introduction
Appendicular peritonitis is complications of acute appendicitis which is characterized by the spread of the infectious process into the peritoneal cavity, thus producing generalized or localized purulent peritonitis. It can appear immediately or follow the stage of appendicular abscess. Perforation is the rupture of the wall of the appendix putting its septic contents in communication with the peritoneal cavity. Peritonitis is a medical-surgical emergency and the prognosis can be serious.
Despite effective health coverage in the West, the incidence of appendicular peritonitis is not decreasing (20/100,000/year) [1]. Many studies carried out on peritonitis caused by digestive perforations have shown the predominance of appendicular perforations [2] [3] [4] [5] [6]. Flum. DR et al. [7] in the USA in a retrospective study of 63,707 appendectomies, found 25.85% of peritonitis by appendicular perforation. In Europe, Kraemer M. [8] in 2003 in a prospective multicenter study in 11 surgical departments in Germany and Austria on 519 cases of appendicitis, found 17.7% of peritonitis by appendicular perforation. In Africa, Chavda SK [9] in Kenya in 2005 in a retrospective and descriptive study on 289 patients operated on for appendicitis found 29.7% of cases of appendicular perforations with a morbidity of 19.4% and a mortality of zero. In Mali, numerous studies have shown the predominance of appendicular perforations in digestive perforations. SOGOBA G. [4] in a prospective study on non-traumatic digestive perforations obtained a frequency of 60% of appendicular perforations.
DARRA MO [5] in a prospective and descriptive study, found 59 cases of acute generalized peritonitis, 84.3% of which were appendicular perforations.
In Bougouni, no study has so far been performed on appendicular peritonitis despite its high frequency. The lack of data on this pathology motivated us to do this work.

Patients and Method
Type and study period: This was a 24-month retro prospective and descriptive retro study from Janu- Inclusion criteria: All patients operated on for peritonitis whose origin was appendicular per operative.
Non-inclusion criteria: Not included in the study were non-appendicular peritonitis, out-of-service surgery patients, and unusable records.
Data extraction: was done from texts and possibly tables and figures.
Parameters studied: The following parameters were analyzed: patient demographic characteristics (age, gender), clinical presentation, diagnostic confirmation, methods and therapeutic results.
Statistical method: The data collected was put together in a database in the form of an Excel ® table. Variables are expressed as mean or median with extremes. Data analysis was performed using Epi Info 7TM software.

Results
During the study period we performed 400 surgical procedures, 68 cases of acute

Discussion
We conducted a 24-month retrospective and descriptive study from January 1,  [17]. The rapidity of installation of general signs is correlated with the severity of peritoneal contamination [2]. Fever is usually high from the onset of the disease. Appendicular peritonitis produces an acute peritonitis picture that is essentially clinically diagnosed. Abdominal contracture is the major physical sign [18] [19]. If the examination is early it can be localized or limited to a simple generalized defense which is the semiological significance [15]. The stillness of the abdomen reflects the peritoneal attack, it is a symptom frequently encountered [2] [5] [20], it was found in 73.3% of our patients. Pain in Douglas' cul-de-sac is of diagnostic interest in peritoneal syndrome and testifies to peritoneal irritation [2] [5]. Abdominal ultrasound has become a routine examination as long as the clinical diagnosis is not typical or to eliminate certain differential diagnoses [20]. Positive signs are a tubular structure more than 6 mm in diameter with sometimes an intra-luminal appendicolith not visible on the abdomen radiography without preparation. It is also possible to see an effusion in the peritoneal cavity perioperative (abscess) or diffuse (peritonitis) knowing that the absence of effusion does not eliminate peritonitis [20]. Undated abdomen x-ray was requested in 30% of our patients because the diagnosis was already done with ultrasound. It allowed for the objective of a diffuse fuzzy greyness in 4 patients (13.3%) and this greyness was associated with hydro-aeric levels in 2 patients or 6.7%. Pneumoperitoneum was not found in our study, its absence in [21]. We did not perform an abdominal scan because of its unavailability. The goal of the treatment of appendicular peritonitis is to eradicate the infectious focus, fight infection and ensure hydro-electrolytic balance. Resuscitation is the first essential time, it combines: the hydro-electrolytic rebalancing by the infusion of solutes through a central venous pathway that allows the repeated measurement of the central venous pressure; the nasogastric tube needed to suck up gastric stasis fluids and quantify water losses; urinary tube for monitoring hourly diuresis and kidney function. All of our patients received resuscitation, this resuscitation was brief in the preoperative period and continued in post-operative.
Antibiotic therapy is intended to prevent the spread of the infectious process by combating bacteremia [2]. The products used must be active on aerobic and anaerobicgerms, most commonly encountered and have good intra-peritoneal penetration. The combination of aminosides, imidazoles and betalactamines corresponds to this pattern [2]. We used the combination of ciprofloxacin, gentamicin and metronidazole. This association was used by several authors [22] [23] and was in accordance with the recommendations of the French Society of Anesthesia and Resuscitation [24]. Surgical management of appendicular peritonitis accounts for the bulk of therapy. It should be as early as possible. In the face of an appendicular lesion, appendectomy is the rule. The first preferred route was median laparotomy [12] [13]. In France in the series of MARIAGE M.
[13] 96.6% of patients were operated on laparoscopy. Appendectomy associated with an abundant peritoneal toilet with physiological salt serum, suction and systematic drainage of the parieto-colic gutters and Douglas cul de sac were performed in all of our patients.

Conclusion
Appendicular peritonitis is one of the most common etiological features. They are characterized by a delay in consultation. Diagnosis is mostly clinical and management is medical-surgical. Although they have a good prognosis; mortality and morbidity are not negligible in developing countries. Improved technical plateau, adequate health coverage and health education could reduce mortality and morbidity.

Consent
Informed patient consent, from a file pre-established in this context has been obtained. All patients have been informed and have given their consent.
The informed consent: The informed consent form was submitted and explained to all patients. They accepted and signed the form.