Can Appendix Be Infected Again After Being Removed

JSLS. 2011 Jul-Sep; 15(3): 373–378.

Stump Appendicitis: A Surgeon's Dilemma

Kurt E. Roberts

Department of Surgery, Yale New Oasis Infirmary, Yale School of Medicine, New Haven, Connecticut United states of america.

Lee F. Starker

Section of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut USA.

Andrew J. Duffy

Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut Us.

Robert Fifty. Bell

Section of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut USA.

Jamal Bokhari

Department of Diagnostic Radiology, Yale New Haven Infirmary, Yale Schoolhouse of Medicine New Haven, Connecticut, USA.

Abstract

Background:

Stump appendicitis is divers by the recurrent inflammation of the residuum appendix afterwards the appendix has been only partially removed during an appendectomy for appendicitis. Xl-eight cases of stump appendicitis were identified in the English literature.

Database:

The institutional CPT codes were evaluated for multiple hits of the appendectomy code, yielding a total of 3 patients. Afterwards appropriate blessing from an internal review board, a retrospective chart review was completed and all bachelor data extracted. All 3 patients were diagnosed with stump appendicitis, ranging from 2 months to twenty years subsequently the initial procedure. 2 patients underwent a laparoscopic and the one an open completion appendectomy. All patients did well and were discharged habitation in good condition.

Determination:

Surgeons need a heightened awareness of the possibility of stump appendicitis. Correct identification and removal of the appendiceal base without leaving an appendiceal stump minimizes the risk of stump appendicitis. If a CT scan has been obtained, it enables exquisite delineation of the surrounding beefcake, including the length of the appendiceal remnant. Thus, we suggest that unless there are other mitigating circumstances, the completion appendectomy in cases of stump appendicitis should as well be performed laparoscopically guided by the CT findings.

Keywords: Appendicitis, Stump appendicitis, Laparoscopic appendectomy

INTRODUCTION

Appendectomy is i of the near common surgical procedures performed in the United states with more than than 250,000 cases per yr.¹ Obstruction of the appendiceal orifice by fecalith, lymphoid hyperplasia, or neoplasm remains the most likely causative gene. Progressive appendiceal luminal distention compromises lymphatic and vascular period, resulting in appendiceal wall ischemia followed by consequent bacterial invasion, inflammation, and frank perforation if surgical treatment is delayed. Perforation at presentation ranges from sixteen% to 30%, and it is significantly increased past a filibuster in diagnosis ordinarily seen at extremes of historic period or atypical presentation.ⁱⁱ Treatment is appendectomy, and postoperative complications include wound infection, bleeding, intraabdominal abscess, minor-bowel obstruction, and, rarely, stump appendicitis. Residue appendiceal tissue left at the fourth dimension of appendectomy may predispose to the rare development of stump appendicitis. Stump appendicitis is divers every bit the interval repeated inflammation of remaining residual appendiceal tissue later on an appendectomy.³ Partially removing an appendix leaves a stump behind, which allows for recurrent appendicitis (Figure i). Today, most clinicians are non enlightened of the possibility of recurrent appendicitis or, more precisely, stump appendicitis every bit a differential diagnosis for patients with correct lower quadrant (RLQ) pain after previous appendectomy.^4,v Therefore, this phenomenon can cause a real diagnostic dilemma, which tin lead to delays in treatment and subsequently to an increase in morbidity.^six Currently, but 40 reported cases of stump appendicitis are found in the English language medical literature. We evaluated a total of 3 cases of stump appendicitis seen at our institution. Our PubMed search on stump appendicitis in January 2009 revealed iv additional cases including ours, to a prior existing review of the literature reporting 36 cases. Altogether, there are a total of forty cases of stump appendicitis reported in the English literature (Table 1).⁷

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CT scan of recurrent stump appendicitis. Appendix is dilated and fluid filled with evidence of surrounding inflammation (arrow).

Table 1.

Review of the English Medical Literature for Reported Stump Appendicitis

Author	Historic period	Sex	Primary Surgery^a	Interval	Pain^a	Dx Manner^a	Echo Surgery	Stump Length^a	Perforated^a
Harris⁴	26	Chiliad	Open up	10yr	RLQ	CT	Open	NA	Y
Devereaux⁵	49	M	Lap	2 mo	RLQ	NA	Open up	2cm	Y
Walsh⁶	72	F	Lap	5mo	ABD	Xray	Open	2.5cm	Y
Liang^seven	32	F	Lap	5 mo	RLQ	CT	Lap	four cm	Y
Rose⁸	23	One thousand	Open	1yr	NA	NA	Open	v.1cm	NA
	forty	One thousand	Open	2yr	NA	NA	Open	5.1cm	NA
Greenberg¹¹	31	M	Lap	4mo'	RLQ	CT	Open	3.5cm	N
Milne¹⁵	25	G	Lap	18mo	ABD	NA	Open	iii.2cm	N
Rao²¹	39	F	Open	34yr	ABD	CT	Open up	NA	Y
Aschkenasy²²	27	Yard	Open up	25yr	RLQ	CT	Open	NA	N
Roche-Nagle²³	35	M	NA	NA	RLQ	CT	Open	3-4cm	Y
Shin²⁴	41	M	Lap	NA	RLQ	CT	Lap	6.5cm	Northward
Watkins²⁵	63	F	Lap	9mo	RLQ	CT	Lap	five.5cm	Y
Nahon²⁶	33	M	Open	18yr	RLQ	Colonoscopy	Open	NA	Y
Mangi²⁷	43	F	Open	40yr	Ni	CT	Open	0.5cm	Y
	64	F	Open	NA	Ni	Be	Open	0.6cm	Y
Baldisserotto²⁸	13	F	Open up	2mo	RLQ	Us	Lap	2cm	North
Gupta²⁹	11	One thousand	Open up	1yr	RLQ	CT	Open	4.5cm	Y
Erzurum³⁰	11	F	Open	8mo	RLQ	CT	Open	iii.5cm	Y
Thomas³¹	53	F	Open up	21yr	RLQ	CT	Open	NA	NA
Wright³²	35	M	Lap	2mo	RLQ	Be	Open	iv.5cm	NA
	48	M	Lap	8mo	RLQ	CT	Open	4.0cm	NA
Feigin³³	26	M	Open up	1yr	ABD	NA	Open	NA	Y
Greene³⁴	27	F	Open up	12yr	RLQ	BE	Open up	NA	North
	42	F	Open	16yr	ABD	NA	Open	NA	Y
	53	F	Open	20yr	RLQ	BE	Open	NA	Y
Siegel³⁵	51	F	Open up	23yr	RLQ	NA	Open	1.5cm	Y
Baumgardner³⁶	55	M	Open	3mo	RLQ	NA	Open up	NA	Y
Uludag³⁷	47	M	Open	20yr	RLQ	CT	Open	2cm	Y
De³⁸	26	F'	Open	1yr	RLQ	NA	Open	NA	NA
Durgun³⁹	68	F	Open	8mo	ABD	NA	Open	3cm	Y
Tang^forty	14	Thousand	Open	5yr	ABD	CT	Open	3cm	Northward
	11	Chiliad	Open	2mo	NA	CT	Open	NA	Y
	13	F	Open	10mo	ABD	CT	Open	4cm	Due north
Leff⁴¹	33	F	Lap	2weeks	RLQ	CT	NA	NA	N
	24	1000	Lap	7mo	ABD	CT	Lap	NA	Y
Chikamori⁴²	24	Yard	Lap	4days	ABD	US	Lap	7mm	Y
Burt⁴³	27	Thou	Open up	NA	RLQ	CT	Open	NA	Y
Waseem⁴⁴	15	M	Lap	2yr	ABD	CT	Open up	6mm	North
O'Leary⁴⁵	43	M	Open	10yr	RLQ	US	Open	2.5cm	N

Mean historic period for all 40 patients described in the literature was 37 years (range, 8 to 72). Sixty-2 pct of the patients were males (23/40 males and 17/40 females). Lx- eight pct (27 cases) of the initial appendectomies were performed open, while 32% (thirteen cases) were performed laparoscopically. The boilerplate interval from the first appendectomy to developing stump appendicitis followed by subsequent appendectomy was 8 years (range, 2 months to 40 years).

Hateful white blood cell count on presentation of all reported twoscore cases was thirteen,700 cells/mm^three (range, eight to 27,000). The most commonly performed radiographic exam used to diagnose stump appendicitis is the abdominal CT scan. It was used in 52% (25 cases). Ultrasound was used in 10% (5 cases). The remaining patients either had Barium enema studies or were taken to the operating room based on the clinical diagnosis of local peritonitis. In 83% (33 cases), an open approach for the definite treatment of the stump appendicitis was chosen. The remaining 17% (7 cases) were performed laparoscopically. Of the initially performed laparoscopic cases (33%, 13 cases), a full of 46% (half-dozen cases) were for laparoscopic reoperation and removal of the stump. The average stump length for all cases was three.4cm (range, 0.v to 6.5). Perforation was found in 60% (24/twoscore cases). Complications included wound infections, bleeding, abscess formation, and postoperative ileus. Mean hospital stay was 8 days (range, ane to 28).

DATABASE CASES

Case I

Patient ane was a 33-year-old female who presented with a 1-day history of astute unrelenting abdominal hurting in April 2006. She had undergone an open appendectomy in Africa in 1986. Her workup in the emergency department at our institution revealed a white claret cell count of ten,000 cells/mmⁱⁱⁱ (reference Normal <11,000 cells/mm³). A CT browse of her abdomen/pelvis revealed an appendiceal remnant that was dilated, fluid filled, and measuring 8mm in bore. There was pericecal/periappendiceal stranding suggestive of astute appendicitis. An uncomplicated laparoscopic appendectomy was performed. The pathology revealed acute appendicitis and periappendicitis with abscess formation. The appendix measured 5cm in length. Our patient had no postoperative complications and was discharged dwelling on postoperative day (POD) 5.

Case Two

Patient two was a 48-year-old male who originally presented to our emergency section with acute right lower quadrant (RLQ) abdominal pain in Dec 2006. At that time, a CT scan of the abdomen/pelvis was consistent with acute appendicitis. Therefore, he underwent an uncomplicated laparoscopic appendectomy. The pathology revealed astute appendicitis and an appendix measuring four.2cm in length. No complications were observed, and the patient was discharged home on POD 2.

Iii and 1/two months later, the patient re-presented to our emergency department with complaints of abdominal cramps and pain, localized in the RLQ for ane solar day. He denied febrile episodes at home and had a white blood cell count of 8,000 cells/mmⁱⁱⁱ. Nevertheless, he underwent a CT scan of the abdomen/pelvis, which revealed a 3-cm tubular construction adjacent to the cecum with significant inflammatory changes suggestive of stump appendicitis. Based on the CT and subsequent laparoscopic evaluation, the removal of the remaining inflamed appendiceal stump was performed without difficulties. Pathology revealed patchy acute and chronic mural inflammation and serositis of the appendix. The appendix measured 2cm in length. No intra- or postoperative complications were encountered. The patient was discharged habitation on POD 3.

Example Three

The third patient was a 52-year-old male who presented to our institution originally in July of 2008 with acute RLQ hurting and was found to have astute appendicitis. The CT browse of the abdomen showed acute appendicitis with microperforation. Afterwards, he underwent an unproblematic laparoscopic appendectomy. The pathology revealed acute appendicitis with focally suppurative and organizing periappendicitis. The appendix measured 3cm in length. The patient was discharged home on POD 3.

Ii months later, he re-presented with persistent intestinal discomfort in the RLQ, which was unrelenting despite removal of an inflamed appendix. He was found to have a depression-form temperature and a white claret cell count of xiv,000 cells/mm³. A repeat CT scan of his abdomen/pelvis demonstrated further progression of his previously documented appendicitis compared to his previous CT scan. He was taken to the OR for an open uncomplicated appendectomy. The pathology revealed purulent appendicitis with periappendicitis. The appendix measured half-dozen.1cm in length. The patient had no postoperative complications and was discharged home on POD four.

Give-and-take

Claudius Amyand is credited with performing the start appendectomy in 1735, and Reginald Fitz was the first to describe the clinical features and pathologic abnormalities of appendicitis in 1886. In 1945, Rose was the get-go to describe stump appendicitis in patients who had previously undergone an appendectomy for appendicitis.⁸ Today, one of the dilemmas of diagnosing stump appendicitis is that surgeons or physicians in the emergency room demand to exist more aware that stump appendicitis exists and needs to exist kept in the differential diagnosis for patients with right lower quadrant pain after prior appendectomy. The presenting symptoms of stump appendicitis are basically indistinguishable from those of master appendicitis. They include pain that starts periumbilically and wanders to the right lower quadrant and is associated with anorexia, nausea, and vomiting.

The laparoscopic appendectomy has been well studied and has been found to be equivalent to the more traditional open technique in overall ability to adequately remove the inflamed appendix.^9,10 There is the notion that stump appendicitis is a new phenomenon that mainly occurs in laparoscopically performed appendectomies.^11,12 At least theoretically, there is the potential for an increased incidence of stump appendicitis in laparoscopic surgery due to the lack of a 3-dimensional perspective, and the absenteeism of tactile feedback. Subsequently, a longer stump might be left behind. However, in sharp contrast to this theoretical assumption stands the fact that 66% of the reported cases occurred afterward open appendectomies.⁷ Withal, laparoscopic appendectomies are a relatively new procedure compared to the more than proven and historic open technique and therefore, at that place may be some merit to the in a higher place assertion.

Several factors influence the occurrence of stump appendicitis. I very common problem is the correct identification of the base of the appendix, ie, the cecal appendiceal junction. Misidentification of the cecal appendiceal junction seems to occur more often with extensive inflammation of the appendix, which can, but does not necessarily, extend to the cecum. Additionally, a consummate or partial retrocecal lying appendix, ie, the base of operations is retrocecal or a role of the appendiceal shaft lies retrocecal and the tip turns back and is hands visualized intraperitoneally and therefore the office of the appendix that disappears in the retrocecal expanse is misidentified equally the base of operations and falsely transected leaving a stump behind.

Moreover, careful consideration should be given to the length of the resected appendix. In 7 of the 48 cases reported to a higher place, the pathology revealed that the mean length of the removed appendices was iv.4cm (7/48 cases, range, 3 to 6.5).⁷ Therefore, while the normal length of the appendix is variable, we recommend inspecting and verifying that, whenever the resected appendix is ≤6.5cm in length, there is no appendiceal stump longer than 3mm left behind.

Besides the possibility of stump appendicitis, there is another possible explanation for appendicitis after previous appendectomy: a duplicated appendix. This is a very rare developmental abnormality, which can be seen in about 0.004% in appendectomy patients. Three types have been described by Cave and Wallbridge.^thirteen,14 Type A has incomplete duplication with both appendices having a mutual base; type B has complete duplication with the first appendix arising from its usual location at the confluence of the tenia coli, and the 2nd appendix is located at various sites forth the colon; and type C has complete duplication of the cecum, with each part having its own appendix.

Full general recommendations for the resection of the acutely inflamed appendix in either open or laparoscopic surgery include the proper identification and visualization of the base of operations of the appendix or cecal appendiceal junction.^15,sixteen This tin be achieved past post-obit the convergence of the tenia coli to the appendix. It is likewise of import to resect the appendix completely or, if leaving a stump, it should be <3mm in length. Guidance in determining the length of the appendix may besides exist obtained from the CT browse if one has been obtained. Also, the respond to the question of what to do with an incidental finding of an appendiceal stump seen on CT seems to exist observation rather than surgical removal.

Yet, completion appendectomy is the treatment of stump appendicitis.¹⁷ An boosted ileocecostomy was necessary in 18% of the cases (9/48). This more extensive operation should by and large not exist required as long as the appendiceal stump can be readily identified and the cecum itself does not show evidence of a significant corporeality of inflammation. The completion appendectomy has been done as an open procedure for the majority of the cases reported in the literature. A neat debate has been waged over the inversion of the remaining stump versus simple ligation.^18–20 Not only is the diagnosis of stump appendicitis beingness increasingly made by CT scan,²¹ but CT scan also enables exquisite depiction of the beefcake including the length of the remnant. Thus, we propose that unless there are other mitigating reasons, the completion appendectomy should also be performed laparoscopically guided by the CT findings as in our case 2.

CONCLUSION

Stump appendicitis is a real and probable underreported disease process in gastrointestinal surgery. Although a rare complication afterwards appendectomy, information technology can and does occur after both laparoscopic and open appendectomies. It is yet to be definitely determined whether the incidence of this is indeed increasing with laparoscopic appendectomies as claimed past some. Stump appendicitis can certainly correspond a diagnostic dilemma if the treating physician is unaware of this uncommon phenomenon. During surgery, a severely inflamed completely or partially lying retrocecal appendix might be one of the contributing factors leading to the misidentification of the cecal appendiceal junction. Likewise a stump longer than 3mm left behind during the initial surgery can lead to appendicitis afterward appendectomy. Surgeons therefore must autumn back on their training of anatomy, particularly in difficult cases where severe inflammation is present. A thorough exploration and meticulous dissection with the critical view of the appendiceal- cecal junction is imperative to prevent this potentially devastating complication. This may be facilitated through superlative of the appendix, toward the abdominal wall, providing balmy tension, which volition aid in the dissection of the significantly inflamed tissue planes. In one case a diagnosis of stump appendicitis has been made, the rules of appendectomy remain consistent between the traditional and laparoscopic techniques in that removal of the entire affected structure must exist completed with appropriate visualization of the anatomical landmarks.

Therefore, surgeons need to accept a heightened awareness of the possibility of stump appendicitis, identify the appendiceal base correctly and remove the appendix without leaving a stump to minimize the run a risk of stump appendicitis. If a CT scan has been obtained, it enables exquisite delineation of the anatomy including the length of the remnant. Thus, we propose that unless there are other mitigating reasons, the completion appendectomy should also exist performed laparoscopically guided by the CT findings rather than by the open route in cases of stump appendicitis.

Contributor Information

Kurt E. Roberts, Department of Surgery, Yale New Haven Infirmary, Yale School of Medicine, New Haven, Connecticut United states of america.

Lee F. Starker, Section of Surgery, Yale New Haven Infirmary, Yale Schoolhouse of Medicine, New Haven, Connecticut USA.

Andrew J. Duffy, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Oasis, Connecticut U.s..

Robert L. Bong, Department of Surgery, Yale New Haven Infirmary, Yale School of Medicine, New Haven, Connecticut USA.

Jamal Bokhari, Department of Diagnostic Radiology, Yale New Haven Hospital, Yale Schoolhouse of Medicine New Haven, Connecticut, The states.

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