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Appendicitis after appendectomy? Case report and literature review.

Introduction

Stump appendicitis is inflammation of the residual part of the appendix after appendectomy. (1) The incidence is not well known with few cases reported in the literature. (2) The clinical picture is the same as acute appendicitis but the past surgical history might mislead the physician. (3) Moreover, diagnostic testing including blood work and CT scan might be normal and tests such as CRP and ESR are nonspecific. Herein, we present a case of a 42-year-old male who presented with right lower quadrant pain one month after laparoscopic appendectomy in another institution. He was taken to the operating room where laparoscopic stump appendectomy was performed. We also present our literature review of this rare, probably underreported, clinical entity explaining the diagnostic work-up and management.

Case Report

A 42-year-old male patient presented to the emergency department with one day history of right lower quadrant pain, throbbing and non-radiating. The pain was associated with anorexia, nausea and vomiting. The patient, who was otherwise healthy, stated a significant past surgical history of laparoscopic appendectomy at another institution one month prior to the current presentation. On physical examination, he was afebrile with stable vital signs; abdominal examination revealed tenderness with rebound in the right lower quadrant and a positive Rovsing's sign. Blood work revealed a normal WBC count. The patient had a CT scan of the abdomen and pelvis that was unremarkable. He was taken to the operating room for diagnostic laparoscopy with the presumptive diagnosis of acute stump appendicitis. Exploration of the cecum revealed mild yellowish discoloration of the staple line with tissue firmness on palpation. The cecum was mobilized and blunt dissection was done around the staple line. The appendiceal stump was identified and dissected off the cecum, the stump was dissected all the way down to the junction between the appendix and the cecum (Figure 1). The remnant of the mesoappendix was also identified and the appendicular artery was isolated (Figure 2). Stump appendectomy was completed using an EndoGIA stapler with a 3.5 mm cartridge after which the artery was divided using the same stapler on a 2.5 mm vascular cartridge (Figure 3). The specimen was retrieved and the stump was examined at the side table. The appendiceal stump was found to be about 6mm in length with intraluminal abscess. The histopathological examination of the specimen showed acute inflammatory changes with necrotic foci and lymphocytic infiltration. The postoperative course proceeded uneventfully and the patient was discharged on the first postoperative day in good condition. At one-month follow-up he was doing well with no complaints and no recurrence of symptoms.

Discussion

Appendectomy is one of the most common operations performed by the general surgeon. The laparoscopic approach has been gaining popularity and gradually replacing the conventional open technique since it was described in the surgical literature by Semm in 1983. (4) The first report of stump appendicitis was in 1945 by Rose. (5) Stump appendicitis may occur anytime after incomplete appendectomy and cases have been reported between a few months to 20 years after appendectomy. (2,6) Hirano et al reported a case of stump appendicitis that occurred 40 years after an appendectomy. (7) The critical risk factor in this condition is leaving an appendiceal stump of 5mm or more in length. (1) Imaging studies such as ultrasound or CT scan may help in the diagnosis if the stump is long enough to be detected or in case of abscess formation. CT scan is more helpful than ultrasound in showing mesenteric stranding and fat inflammation in the pericecal area. (6,8)

Clinical features: the diagnosis of stump appendicitis is challenging because it is not routinely suspected with a history of appendectomy. Additionally, lab tests such as WBC count, CRP, and ESR may present in normal ranges and they are nonspecific. The elevated WBC count with a left shift, as typically expected with appendicitis, was not present in our case. As such, the diagnosis requires a high degree of clinical suspicion. Clinical presentation of stump appendicitis is the same as acute appendicitis and may include right lower quadrant pain, nausea, vomiting and anorexia with right lower quadrant tenderness, positive peritoneal signs as Rovsing, Markle, obturator and psoas signs. It should be noted that appendicitis is primarily a disease associated with youth and there is no data suggesting that age is an independent factor for developing stump appendicitis. Younger patients may be more likely to present with stump appendicitis based on the prevalence of the disease in younger populations but incidence in the literature presents too wide a range of time between the initial surgery and the secondary onset to make any conclusions in this respect. As a diagnostic tool, CT scan confirmed the diagnosis in only five patients of the few stump appendicitis cases reported in the surgical literature. (9)

Management: Treatment of stump appendicitis is stump appendectomy via open or laparoscopic approach. In the case we present, the CT scan was negative; however; the patient was taken to the operating room based on our clinical judgment. Overall, treatment of stump appendicitis follows the guidelines for acute appendicitis and as such is subject to the same complications including perforation, abscess, peritonitis and death. Antibiotic use may be indicated in select cases of interval appendectomy (after 6 weeks of the acute episode).

Literature review: While the true incidence of stump appendicitis is unknown, (7) to the best of our knowledge, there are only 37 cases reported in the literature. (10) As CT scan was helpful in identifying only five, or approximately 14% of the cases (5 out of 37), CT scan results cannot be considered definitive in diagnosis. A study by Mangi and Berger from Harvard Medical School reviewed 2,185 appendectomy cases between 1960 and 1998 where three cases of stump appendicitis were identified. An appendiceal stump of 5mm in length or more was found to be a risk factor (11) which is consistent with Durgun's finding. (1) They stated that the incidence of stump appendicitis may be decreased with proper dissection of the base of the appendix at its junction with the cecum and also leaving a stump less than 3mm in length. (11) Greene et al reported three cases of stump appendicitis where they stressed the importance of dissecting the base of the appendix to avoid this complication. (12) In our literature review, the risk factors of stump appendicitis were either insufficient stump inversion or a long appendiceal stump. (13-15) Furthermore, although initially stump inversion was thought to reduce the possibility of stump appendicitis, prospective studies have shown that there is no advantage to inverting the stump. (16) Some reports suggested that a laparoscopic approach represents a risk factor for stump appendicitis. (13,17,18) However, these were older reports and this finding may be attributed to the learning curve as a relatively new approach during that time. The concerns around laparoscopic appendectomy continue to diminish as evidenced by the more recent data. Moreover, an extensive literature review by Watkins et al showed that 76% of the reported cases occurred after open appendectomies (19) which validates the safety of the laparoscopic approach if the proper technique is followed. (11) The main cause of this condition is poor surgical technique where the taenia coli are not traced to their point of convergence at the base of the appendix. This has been adopted as a routine technique in open appendectomies to identify the appendiceal base and should be implemented in the laparoscopic approach as well. (20) As such, the main risk factor of residual or stump appendicitis is leaving an appendiceal stump of 5mm or more in length. (1)

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Conclusion

Stump appendicitis is a rare but serious complication after appendectomy. The past surgical history of appendectomy might mislead the physician, thereby leading to delayed diagnosis with the morbid complications of perforation, peritonitis and intra-abdominal abscess. Imaging studies such as ultrasound and CT scan may help with diagnosis but they were inconclusive in most of the reported cases. A high degree of clinical suspicion, thorough history, and physical exam are the key points in diagnosing stump appendicitis. Diagnostic laparoscopy should be considered if there is inconsistency between the imaging studies and the clinical findings. The critical risk factor for developing stump appendicitis is leaving an appendiceal remnant of 5 mm or more in length. The proper technique should be followed to avoid this complication by dissecting the base of the appendix and leaving a stump shorter than 3 mm.

[FIGURE 3 OMITTED]

References

(1.) Durgun AV, Baca B, Ersoy Y, Kapan M. Stump appendicitis and generalized peritonitis due to incomplete appendectomy. Tech Coloproctol. 2003; 7:102-4.

(2.) Gupta R, Gernshiemer J, Golden J et al. Abdominal pain secondary to stump appendicitis in a child. J Emerg Med. 2000; 18:431-3.

(3.) Aschkenasy MT, Rybcicki. Acute appendicitis of the appendiceal stump. J Emerg Med. 2005; 28:41-3.

(4.) Semm K. Endoscopic Appendectomy. Endoscopy. 1983;15:59-64.

(5.) Rose TF. Recurrent appendiceal abscess. Med J Aust. 1945;32:659-62.

(6.) Fillipi de la Palavesa MM, Vaxmann D, Campos M et al. Appendiceal stump abscess. Abdom Imaging. 1996; 65-6.

(7.) Hirano Y, Shimizu J, Kinoshita S et al. Stump appendicitis with lipohyperplasia of the ileocecal valve: Report of a case. Indian J Surg. 2004; 66:367-9.

(8.) Carcacia I, Vazquez J, Iribarren M et al. Preoperative diagnostic imaging in stump appendicitis. Radiologica 2007;49(2): 133-5.

(9.) Rao PM, Sagarin MJ, McCabe CJ. Stump appendicitis diagnosed preoperatively by computed tomography. Am J Emerg Med. 1998; 16:309-11.

(10.) Sandy Craig. Acute appendicitis. E-medicine. Oct 24, 2006.

(11.) Mangi AA, Berger DL. Stump appendicitis. Am Surg. 2000;66(8):739-41.

(12.) Greene JM, Peckler D, Schumer W et al. Incomplete surgical removal of the appendix: its complications. J Int Coll Surg. 1958;29:141-6.

(13.) Devereaux DA, McDermott JP, Caushaj PF. Recurrent appendicitis following laparoscopic appendectomy. Report of a case. Dis Colon Rectum. 1986;1:107.

(14.) Greenberg JJ, Esposito TJ. Appendicitis after laparoscopic appendicectomy: a warning. J Laparoendosc Surg. 1996;6:185-7.

(15.) Berne TV, Ortega A. Appendicitis and appendiceal abscess. In: Nyhus LM, Baker RJ, Fischer JE editors. Mastery of Surgery. Boston: Little Brown; 1997:1407-11.

(16.) Fitzgibons RJ, Ulualp KM. Laparoscopic appendicectomy. In: Nyhus LM, Baker RJ, Fischer JE editors. Mastery of Surgery. Boston: Little Brown; 1997:1412-9.

(17.) Walsh DC, Roediger WE. Stump appendicitis-A potential problem after laproscopic appendectomy. Surg Laparosc Endosc. 1997;7:357-8.

(18.) Milne AA, Bradbury AW. "Residual" appendicitis following incomplete laparoscopic appendicetomy. Br J Surg. 1996;83:217.

(19.) Watkins BP, Kothari SN, Landercasper J. Stump appendicitis, case report and review. Surg Laparosc Endosc Percutan Tech. 2004;14(3):167-71.

(20.) Liang MK, Lo HG, Marks JL. Stump appendicitis: a comprehensive review of literature. Am Surg. 2006;72:162-6.

Ehab Akkary, MD

Director of Bariatric and Advanced Laparoscopic Surgery, Preston Memorial Hospital, Kingwood, WV

Tonya Cramer, MS

Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL

Mostafa Sadek, MA

Research Fellow, Arthur Smith Institute for Urology, North Shore Long Island Jewish Health System, Long Island, NY

Thanh Phan, MD

Staff Surgeon, Department of Surgery, North Oakland Medical Centers and St. Joseph Mercy Hospital, Pontiac, MI
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Title Annotation:Scientific Article
Author:Akkary, Ehab; Cramer, Tonya; Sadek, Mostafa; Phan, Thanh
Publication:West Virginia Medical Journal
Article Type:Case study
Geographic Code:1USA
Date:Nov 1, 2010
Words:1868
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