Stump appendicitis: A rare clinical entity.

Stump appendicitis is one of the rare delayed complications after appendectomy with reported incidence of 1 in 50,000 cases. Stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity. We report an 18-year-old patient with Stump appendicitis, who underwent completion appendectomy laparoscopically.

INTRODUCTION

Stump appendicitis is the inflammation of the residual appendiceal tissue after an appendectomy. It is a rare complication with a frequency that is under reported as well as underestimated. Therefore, physicians as well as surgeons need to be aware of this clinical entity and not assume that previous appendectomy precludes recurrent/stump appendicitis. Failure to recognize this possibility may lead to delay in treatment and may result in complications such as perforation, abscess formation, and sepsis. We report a case of stump appendicitis in an 18-year-old boy, 2 years following laparoscopic appendectomy.

CASE REPORT

An 18-year-old boy was admitted by a physician with a 1 day history of severe periumbilical pain radiating to the right iliac fossa with loss of appetite. There was no history of vomiting, fever, altered bowel habits or urinary symptoms. Patient had undergone laparoscopic appendectomy 2 years back and had an uneventful recovery, but the details of the operative findings and histopathology were unavailable. Positive clinical findings included a right lower quadrant tenderness and leukocytosis i.e. 15,000 cells/mm3 (reference normal range 4-11,000 cells/mm3). A computed tomogram of abdomen showed only small collection in right iliac fossa [Figure 1] and initial conservative management was planned by the treating physician.

Figure 1

CT scan of abdomen showing localized fluid collection suggestive of abscess in right iliac fossa

Surgical consultation was sought after two days as the clinical condition of the patient deteriorated. The patient developed fever, tachycardia and guarding in the right iliac fossa. The patient was subsequently posted for a Diagnostic Laparoscopy after informed consent.

Intra operative findings included dense adhesions around the ileocecal region. There was a 3cm long inflamed perforated appendicular stump with abscess formation (~ 30-40 ml pus) [Figures 2 and 3]. The appendicular stump was defined and divided at the base with an Endo Stapler [Figure 4]. The specimen was sent for histopathology and showed suppurative appendicitis with perforation. Patient had port site wound infection in post operative period and was discharged on 4th post operative day.

Figure 2

Intra operative view of abscess in right iliac fossa

Figure 3

Intra operative view of residual perforated appendicular stump

Figure 4

Intra operative view of completion appendicectomy with endoscopic linear stapler

DISCUSSION

Appendectomy is one of the most commonly performed surgical emergencies. Claudius Amyand in 1735, performed the first appendectomy and Reginald Fitz in 1886, described the clinical features and pathological abnormalities of appendicitis. In 1945, Rose was the first to describe stump appendicitis in two patients who had undergone appendectomy for acute appendicitis in past.[1]

The appendix arises from the postero-medial wall of cecum about 3 cm below the ileocecal valve. Its variable position and subserous length, combined with acute inflammation, may result in misidentification of the appendicio-cecal junction. Dissecting the recurrent branch of the appendiceal artery and following the teniae coli on the cecum helps in identifying the true appendicular base. Generally, an appendix stump shorter than 5 mm reduces the risk of stump appendicitis.[23]

Stump appendicitis is one of the rare delayed complications after appendectomy with the reported incidence of 1 in 50,000 cases.[4] Prompt recognition is important to lead to an early treatment, thus avoiding serious complications like wound infection, intra abdominal abscess, and intestinal perforation with peritonitis, bleeding, and adhesions with sub acute intestinal obstructions.[3]

Stump appendicitis can represent a diagnostic dilemma if the treating physician is unfamiliar with this uncommon clinical entity. Clinically, patients present with sign and symptoms mimicking appendicitis or acute abdomen along with a previous history of appendectomy as seen in our case. The presence of an appendectomy scar does not rule out the possibility of stump appendicitis.[5] The time interval for onset of symptoms could range from 2 weeks to years after appendectomy.

The incidence and prevalence of stump appendicitis has been increasing in the recent years. It has been reported following both open and laparoscopic appendectomy.[67] Whether the laparoscopic technique plays any role in the increased incidence of stump appendicitis is yet to be ascertained. The potential limitation of laparoscopy such as lack of 3D vision and absence of tactile feedback has been suggested by some authors to increase the chance of leaving behind a longer stump.[8] However, stump appendicitis has been reported more following open appendectomy.[7] Further advancement in the techniques of laparoscopy and especially the use of angled scopes and high definition cameras provide good visualization of the surgical field.[3] Accurate visualization of the base of the appendix either in open or laparoscopic appendectomy is a must to minimize the incidence of stump appendicitis. Leaving a longer stump may result in chronic inflammation or serve as a reservoir for fecoliths, become ischemic and eventually perforate and / or suppurate. It has been suggested that no appendicular stump longer than 3mm should be left behind.[9]

The common conditions leading to stump appendicitis have been broadly classified under the anatomical and surgically related factors. One common denominator is the inappropriate indentification of the appendicular base i.e appendicular-cecal junction. The anatomically related factors may be a retrocecal or subserous appendix or a duplicated appendix, a rare developmental abnormality seen in about 0.004% in appendectomy patients.[10] The surgical factors predisposing for stump appendicitis may be inadequate indentification of the appendicular base because of severe local inflammation, leaving long stump due to fear of cecal injury or difficult dissection and local ulcerations due to fecoliths.[311] The stump appendicitis has been reported following open appendectomy with stump ligation, open appendectomy with stump inversion, and laparoscopic appendectomy where appendiceal stump is either closed with an endoloop or by stapling. Both the surgical techniques i.e. inversion of stump or simple ligation of stump cannot prevent the possibility of stump appendicitis.[8]

Radiological evaluation by ultrasound and computed tomography (CT Scan) aids in the preoperative diagnosis of stump appendicitis.[1213] CT scan of the abdomen is more specific than ultrasound for the accurate pre operative diagnosis of stump appendicitis because it excludes other etiologies of acute abdomen. CT findings may be similar to those seen in acute appendicitis. They include pericecal inflammatory changes, abscess formation, fluid in the right paracolic gutter, cecal wall thickening, and an ileocecal mass. In the era of laparoscopy a diagnostic laparoscopy may prove to be the next diagnostic and therapeutic option in case of ambiguity.[2]

Completion appendectomy either by open or by laparoscopic intervention is the treatment of choice for stump appendicitis.[14] Very rarely, extensive surgery such as ileocolic resection may be necessary if there is significant inflammation around the ileocecal region. It is imperative to adequately visualize the appendicular base and the ileocecal region to ensure that a stump not more than 5 mm remains after appendix removed.[310]

CONCLUSION

Stump appendicitis is a rare but serious complication of appendectomy. The prevalence and incidence of stump appendicitis has been increasing in the recent years. Clinical presentation of stump appendicitis mimics symptoms and signs of acute appendicitis or acute abdomen and with a previous appendectomy. Henceforth, it merits consideration in the differential diagnosis of acute abdomen. The diagnosis is often missed or delayed if the clinician is unaware of this rare clinical entity. Clinical awareness and a high level of suspicion would prevent unnecessary delay in initiating treatment thus avoiding serious complications. Intra-operatively meticulous dissection, proper indentification of the appendicular base i.e. appendicio-cecal junction and leaving the appendix stump shorter than 5 mm minimizes the incidence of stump appendicitis.