The American Journal of Surgery Volume 203, Issue 4 , April 2012, Pages 503–507

2. A 60-year literature review of stump appendicitis: the need for a critical view The American Journal of SurgeryVolume 203, Issue 4, April 2012, Pages 503–507 S . Fallahzadeh

3. Appendectomy remains one of the most commonly performed procedures by the general surgeon. More than 250,000 appendectomies are performed each year in America for acute appendicitis, and the lifetime risk of developing appendicitis is 8.6% for men and 6.7% for women.1 Short-term complications associated with surgery for acute appendicitis include wound infection, deep infection, stump disruption, bleeding, and normal appendectomy. The long-term complications are often vague and poorly defined but include hernias, small bowel obstructions, and stump appendicitis. • Stump appendicitis is an underreported and poorly defined condition. It is the interval development of obstruction and inflammation of any remaining appendix after an appendectomy. It has been proposed that this problem is unique to laparoscopic surgery; however, this has never been substantiated.

4. Methods • A PubMed MEDLINE (National Library of Medicine) search was performed using the terms “stump appendicitis” and “retained appendix” to obtain reported cases of stump appendicitis. The search was not limited by language or year of publication. One hundred ninety-eight articles were identified; case reports and review articles of stump appendicitis were reviewed. A total of 47 publications provided 57 cases of stump appendicitis. Also, 4 cases were submitted to us for our personal review. • By using Microsoft Excel spreadsheet software (Microsoft, Redmond, WA), each case was charted based on 14 variables covering the comprehensive aspects of the disease process including age, sex, procedure type and findings at initial appendectomy, time interval to stump appendicitis, signs and symptoms, laboratory values, diagnostic studies, intraoperative findings, operative procedure, stump length, and length of hospital stay. Data were then analyzed.

5. Clinical presentation • The mean age at presentation of stump appendicitis was 37 ± 2 years, and 62.3% were men. • Patients presented a mean of 108 ± 20 months after their initial appendectomy with symptoms of abdominal pain (93%). Forty-seven patients (77%) presented specifically with right lower quadrant pain. One patient (1.6%) presented with a fistula in the right lower quadrant from the appendiceal stump. Another (1.6%) had pain in the right upper quadrant secondary to a retained appendiceal tip located by the gallbladder. Fifty-seven percent of the patients presented with gastrointestinal symptoms, including nausea and vomiting.

6. Initial appendectomy • Of the 58 cases that reported the type of initial appendectomy performed, 34.5% (n = 20) were performed laparoscopically and 65.5% (n = 38) were open • Twenty-three (37.7%) cases reported on findings at the initial surgery: 17 (73.9%) appendices were inflamed or gangrenous (13 laparoscopic, 3 open), 5 (21.7%) were perforated (2 laparoscopic, 3 open), and 1 (4.3%) had an associated phlegmon (open). Two (3.3%) of the initial appendices were incidentally removed as part of another procedure. • The length of the initial appendix was only provided in 9 (14.8%) cases, and the mean length was 5 ± .1 cm.

7. Laboratory and diagnostic imaging • Overall, the mean WBC on admission for stump appendicitis was 15 ± .6 cells/L. • Forty-six of the 61 patients (75.4%) underwent further diagnostic procedures: 34 (73.9%) patients underwent computed tomography (CT) scan, 10 (21.7%) underwent abdominal ultrasound (US), 5 (10.9%) underwent barium enema, 3 (6.5%) underwent colonoscopy, and one (2.2%) underwent plain abdominal x-rays.

8. Operative treatment • Only 9 (14.8%) of the cases of stump appendicitis were treated laparoscopically. The remaining 52 patients (85.2%) underwent open procedures: 34 (65.4%) underwent open appendectomy, 10 (19.2%) underwent ileocecectomy, 5 (9.6%) required right hemicolectomy, and 2 (3.8%) underwent partial cecectomy. One (1.9%) underwent an open resection; however, the extent was not described. Another (1.9%) underwent an exploratory laparotomy and the removal of a retained appendiceal tip. Intraoperative findings included perforation in 30 patients (49.2%). The cecum was perforated in 6 patients (9.8%). • Of the patients with perforated stump appendicitis (n = 30), only 3 (10%) were able to be treated with a laparoscopic procedure. The remaining required open procedures including 18 (60.0%) open appendectomy, 5 (16.7%) ileocecectomy, 3 (10%) right hemicolectomy, and 1 (3.3%) partial cecectomy. The mean stump length was 3.3 ± .2 cm (.5–6.5 cm).

9. Morbidity • One female patient who was pregnant went into preterm labor after surgery for stump appendicitis. The 26-week premature baby survived. Overall, the median length of hospital stay was 6 days (1–28 days). No patients died.

10. Comments • The first appendectomy is credited to Claudius Amyand in 1735. However, in 1886, Reginald Fitz described the clinical and pathological abnormalities of acute appendicitis and determined that appendectomy was the appropriate treatment.6 • Acute appendicitis is one of the most common indications for emergency abdominal surgery and accounts for about 1% of all surgical operations. A known but underreported complication after appendectomy is stump appendicitis. • In our review, we found 60 cases of stump appendicitis and 1 case of a retained appendiceal tip. It is unclear as to what factors contribute to stump appendicitis. Laparoscopic technique, complicated appendicitis, length of stump left, and/or inadequate visualization of the base of the appendix have all been proposed to contribute to stump appendicitis.

11. Laparoscopic technique • Some speculate that the incidence of stump appendicitis may be higher with laparoscopic appendectomy secondary to the narrow field of vision, the lack of 3-dimensional perspective, and the absence of tactile feedback. • However, the majority of cases have occurred after open appendectomy, as noted in our review in which almost 66% of the initial appendectomies were performed • This suggests that stump appendicitis is not unique to the laparoscopic technique.

12. Complicated appendicitis • Complicated appendicitis at initial appendectomy may be a contributing factor resulting in stump appendicitis because of the increased difficulty with dissection of the appendix and visualization of the base. • Our review observed a 26% incidence of complicated initial appendicitis (perforated, abscess, or phlegmon). • Although complicated appendicitis may contribute to incomplete appendiceal resection, the vast majority of resultant cases of stump appendicitis do not fall in this category.

13. The length of appendiceal stump • The length of appendiceal stump left has been proposed as an etiology as well. • Authors recommend leaving appendiceal stumps <.5 cm to minimize the incidence of stump appendicitis.AndA stump >.5 cm is large enough to become a reservoir for a fecolith • In our review, the mean stump length was 3.3 cm with a range from .5 cm to 6.5 cm. There were no cases of stump length <.5 cm. • This suggests that appendiceal stumps <.5 cm are unlikely to result in future stump appendicitis.

14. Improper identification of the surgical anatomy • Improper identification of the surgical anatomy has been proposed as the main contributing factor to resultant stump appendicitis. • Dissection should be carefully performed from the tip of the appendix to its base, especially for retrocecal appendices. The identification of the appendiceal-cecal junction is essential. To identify this critical junction, the tenia coli of the cecum must be followed to the base of the appendix

15. “critical view” • To prevent stump appendicitis, we propose a “critical view” be achieved, similar to that in a laparoscopic cholecystectomy. This would ensure proper identification of the entire appendix and its base. After the tip of the appendix is dissected free from surrounding inflammation, the appendix should be retracted toward the left upper aspect of the screen (10 o'clock position) during laparoscopic appendectomy. The taenia libera, the most visible of the tenia coli, has no attachments, is most clearly identifiable on the surface of the colon, and can be visualized converging at the base of the appendix traveling from right to left on the monitor (in the 3 o'clock position) The terminal ileum is then positioned at the inferior aspect of the screen (in the 6 o'clock position)

16. The mesoappendix can then be dissected and ligated with either sutures or staples. A space must then be created to confirm the base of the appendix

17. The base can then be unquestionably ligated and divided with either sutures or staples to allow a <.5 cm stump .A similar approach should be taken during an open appendectomy with identification of the appendiceal base, taenia libera, and terminal ileum.

18. morbidity • The significance of stump appendicitis lies in its associated increased morbidity because of the high incidence of perforation, the delay in diagnosis, and the need for more extensive surgery. • Current reports document that 17% of cases of initial acute appendicitis are perforated. • Our review noted a 59% incidence of perforated stump appendicitis or cecal perforation, which is higher than that described in initial appendicitis. This greater incidence of perforation can likely be attributed to the associated delay in diagnosis. • The diagnosis of stump appendicitis is often not in the differential diagnosis because there is a prior history of appendectomy, which can lead to a delay in diagnosis and surgical treatment.

19. ultrasound imaging • Imaging modalities have been used to facilitate the diagnosis of stump appendicitis. The use of ultrasound for the diagnosis of acute appendicitis was introduced by Puylaert in 1986, and many authors recommend it as the first-line imaging modality for the diagnosis of stump appendicitis. • With a high index of suspicion and a familiarity with the sonographic findings, early diagnosis with ultrasound imaging alone is possible. • The sonographic images can reveal a thickened appendiceal stump, inflammatory changes in and around the appendiceal stump, the presence of a fecolith, fluid in the right iliac fossa and surrounding the appendiceal stump, and edema of the cecum.

20. abdominal computed tomography • An abdominal computed tomography scan is commonly performed in and may secure the diagnosis of stump appendicitis. • Computed tomography scan findings most likely will not be specific for stump appendicitis and include pericecal inflammatory changes, cecal wall thickening, and abscess formation and fluid in the right paracolic gutter. • However, there are classic computed tomography scan findings that may be present.

21. treatment • The treatment of choice for stump appendicitis is completion appendectomy, either via an open or laparoscopic approach. However, extended resection may be required in the presence of extensive inflammation, peritonitis, and/or perforation. • A delay in diagnosis may also affect the extent of resection by allowing more time for progression to perforation. Our review documented over half of the cases of stump appendicitis required open appendectomy, and nearly one third of the cases resulted in major bowel resection. • The finding of perforated stump appendicitis is more common than in initial acute appendicitis, and a resection more than a completion appendectomy is often required in these cases. In our review of the 30 perforated appendiceal stumps, 27 (90%) required either an open appendectomy or colon resection.

22. In conclusion • stump appendicitis is a rare, but noteworthy, diagnosis that warrants early detection. • Patients can present with vague symptoms of abdominal pain, nausea, and vomiting. • A prior history of an appendectomy can delay the diagnosis of stump appendicitis. • Diagnosis can be made with abdominal ultrasound or computed tomography scan. If treated early, laparoscopic or open completion appendectomy can be performed. However, if diagnosis is delayed and perforation is found, extensive resection is often required. A “critical view,” as described in this article, is key for the prevention of stump appendicitis.

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