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A Rare Cause of Acute Appendicitis after Appendectomy: Tip Appendicitis/Apendektomiden Sonra Akut Apandisitin Nadir Bir Nedeni: Uc Apandisit.

Introduction

Acute appendicitis is one of the most common surgical causes of acute abdomenand the mainstay treatment of acute appendicitis is appendectomy. However, appendectomy has been shown to cause a number of complications including wound site infection, abscess, appendix stump leakage, peritonitis, and ileus. In addition, though rarely, appendectomy may also lead to acute appendicitisdue toleaving a long stump behind during the initial surgery, which has been shown to have an incidence of 1/50.000. (1,2) In this report, we present a patient with acute appendicitis caused by the appendiceal tip left behind after the initial appendectomy.

Case Report

A 55-year-old male patient presented to our clinic with the complaint of abdominal pain. Patient history revealed that the patient had undergone appendectomy and subsequently undergone open abdominal surgery due to wound site infection and wound dehiscenceat another center one year earlier. The patient stated that the abdominal pain commenced after the abdominal surgery and occurred intermittently but gradually became highly severe before presenting to our clinic. The patient had no remarkable clinical history. Physical examination showed a median incision scar above and below the abdomen and a 10x15 cm fascial defect in the abdominal wall. Moreover, the patient also had rebound tenderness and defense in the right lower quadrant. Laboratory and biochemical parameters were normal except for the leukocyte count, which was 16.000/uL. On ultrasonographic examination, no abnormality was detected except for incisional hernia.

The patient was operated on with the diagnosis of acute abdomen. Surgical exploration showed the residues of the suture material of the stump in the appendectomy site and a normal stump. Moreover, the exploration also showed the tip of the free, inflamed appendix below the ileocecal joint, measuring 1.5 cm in length, with its mesentery ligated with one side of the appendix (Figure 1). Total appendectomy was performed and the patient was uneventfully discharged at postoperative day 3. pathological examination confirmed the diagnosis of acute appendicitis. Informed consent form was obtained.

Discussion

Acute appendicitis after appendectomy results from incomplete appendectomy, mainly due to a long stump left behind after the initial surgery. Moreover, acute appendicitis typically occurs in the appendiceal stump and can occur at any age and even long years after the initial appendectomy. (3,4) Literature reviews indicate that there has been a few cases reported with acute appendicitis caused by the appendiceal tip left behind with its mesentery. In that one patient, the appendiceal tip was left behind at the retrocecal joint away from the staple line, probably after the laparoscopic right hemilectomy performed due to a malignant polyp. Moreover, the appendiceal tissue maintained its vitality since its feeding vascular structures were left intact. (5) In our patient, the appendiceal tip was also left behind with its mesenteric arteries, similar to the case presented in the literature. However, the main differences between the two cases were the diagnoses of the patients and the surgical procedures performed in the initial surgeries. In our patient, the appendiceal tip left behind was located in the retrocecal area. The surgical records of the patient regarding the initial appendectomy revealed that the appendix was perforatedin the middle portion and the visibility of the appendix was obscured by the adhesions in the right lower quadrant and the accumulation of inflammatory material and debris. Depending on these records, we considered that a complete exploration of the retrocecal area was not performed due to the poor visibility of the appendix and since the tip of the appendix was localized in the retrocecal area. In addition, we also considered that the distal tip of the appendix was ligated since it was probably mistaken for the mesentery of the appendix and that the appendiceal tissue maintained its vitality since the mesenteric arteries of the appendix were left intact.

After appendectomy due to acute appendicitis, several cases of tip appendicitis have been reported in the literature. We had similar features in this cases that we have presented in these cases. (6,7)

Stump appendicitis that occurs after the appendectomy performed due to acute appendicitis is a frequent occurrence; however, to our knowledge, acute appendicitis caused by the tip of the appendix has been reported in several cases. In patients undergoing a second surgery due to acute abdomen following initial appendectomy, the retrocecal area should be explored completely, particularly if the stump has a normal appearance.

Ethics

Informed consent: Consent form was filled out by the patient.

Peer-rewiev: External and internal peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: M.U., A.D., E.R.A., Concept: M.U., O.U.O., H.C., Design: H.C., O.U.O., A.D., E.R.A., Data Collection or Processing: O.U.O., H.C., Analysis or Interpretation: M.U., A.D., O.U.O., Literature Search: H.C., E.R.A., H.C., Writing: M.U., O.U.O.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

References

(1.) Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000;66:739-741.

(2.) Martinez Chamorro E, Merina Castilla A, Munoz Fraile B, Koren Fernandez L, Borruel Nacenta S. Stump appendicitis: preoperative imaging findings in four cases. Abdom Imaging 2013;38:1214-1219.

(3.) Geraci G, Di Carlo G, Cudia B, Modica G. Stump appendicitis.A case report. Int J Surg Case Rep 2016;20:21-23.

(4.) Rios RE, Villanueva KM, Stirparo JJ, Kane KE. Recurrent (stump) appendicitis: a case series. Am J Emerg Med 2015;33:480.e1-2.

(5.) Tan V, Stevignon T, Chaddad M, Dugue L. Appendicitis after right colectomy? How can this be possiple? J Visc Surg. 2014;151:477-478.

(6.) Parthsarathi R, Jankar SV, Chittawadgi B, Sabnis SC, Kumar SS, Rajapandian S, Raj PP, Palanivelu C. Laparoscopik management of symptomatic residual appendicular tip: A rare case report. J Minim Access Surg 2017;13:154-156.

(7.) O'Leary DP, Myers E, Coyle J, Wilson I. Case report of recurrent acute appendicitis in a residual tip. Cases J 2010;3:14.

Mustafa Ugur, Ozan Utku Ozturk, Huseyin Cigin, Akin Dedemoglu, Ersin Rasim Arslan

Mustafa Kemal University Faculty of Medicine, Department of General Surgery, Hatay, Turkey

Address for Correspondence/Yazisma Adresi: Mustafa Ugur MD, Mustafa Kemal University Faculty of Medicine, Department of General Surgery, Hatay, Turkey

Phone: +90 505 346 32 09 E-mail: drmustafaugur@gmail.com ORCID ID: orcid.org/0000-0002-5922-2367

Received/Gelis Tarihi: 13.03.2018 Accepted/Kabul Tarihi: 24.04.2018

DOI: 10.4274/tjcd.56833
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Title Annotation:CASE REPORT
Author:Ugur, Mustafa; Ozturk, Ozan Utku; Cigin, Huseyin; Dedemoglu, Akin; Arslan, Ersin Rasim
Publication:Turkish Journal of Colorectal Disease
Article Type:Case study
Date:Dec 1, 2018
Words:1079
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