Randomized clinical trial evaluating elective laparoscopic appendicectomy for chronic right lower-quadrant pain

Systematic Review of the Efficacy of Treatment for Median Arcuate Ligament Syndrome

OBJECTIVE

Since the first description of the median arcuate ligament syndrome (MALS), the existence for the syndrome and the efficacy of treatment for it have been questioned.

METHODS

A systematic review conforming to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted, with a broader view on treatment for MALS including any kind of coeliac artery release, coeliac plexus resection, and coeliac plexus blockage, irrespective of age. Online databases were used to identify papers published between 1963 and July 2021. The inclusion criteria were abdominal symptoms, proof of MALS on imaging, and articles reporting at least three patients. Primary outcomes were symptom relief and quality of life (QoL).

RESULTS

Thirty-eight studies describing 880 adult patients and six studies describing 195 paediatric patients were included. The majority of the adult studies reported symptom relief of more than 70% from three to 228 months after treatment. Two adult studies showed an improved QoL after treatment. Half of the paediatric studies reported symptom relief of more than 70% from six to 62 months after laparoscopic coeliac artery release, and four studies reported an improved QoL. Thirty-five (92%) adult studies and five (83%) paediatric studies scored a high or unclear risk of bias for the majority of the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) items. The meaning of coeliac plexus resection or blockage could not be substantiated.

CONCLUSION

This systematic review suggests a sustainable symptom relief of more than 70% after treatment for MALS in the majority of adult and paediatric studies; however, owing to the heterogeneity of the inclusion criteria and outcome parameters, the risk of bias was high and a formal meta-analysis could not be performed. To improve care for patients with MALS the next steps would be to deal with reporting standards, outcome definitions, and consensus descriptions of the intervention(s), after which an appropriate randomised controlled trial should be performed.

Clinical, Morphological, and Immunohistochemical Justification of Surgery for Chronic Appendicitis in Children

Objective: Chronic appendicitis (CA) is a diagnosis characterized by long-standing right lower quadrant pain. We analyzed clinical, morphological, and immunohistochemical studies of the appendix to confirm the adequacy of surgery for CA in children with chronic right lower quadrant pain. Patients and Methods: We carried out comparative studies of clinical presentations and results of morphological and immunohistochemical studies of remote appendicitis in 55 children with chronic recurrent lower quadrant pain (CRLQP). Results: Morphological and immunohistochemical studies revealed three types of changes in the appendix. Type 1 (n = 21)-chronic inflammation. Inflammatory leukocyte infiltration was localized within the mucous membrane of the appendix. An immunohistochemical study revealed a significant (P < .01) increase in the expression of CD106 (vascular cell adhesion molecule 1) and in the number of matrix metalloproteinase 9 (MMP-9) positive cells. Type 2 (n = 20)-lymphoid hyperplasia. Morphological changes were characterized by lymphoid infiltration of the mucosa and submucosa of the appendix. Immunological changes were characterized by an increase (P < .01) in the expression and number of MMP-9, expression of CD106 positive cells, an increase in the expression of collagen IIIα in combination with a decrease in the expression and number of positive vascular endothelial growth factor (VEGF) and vasoactive intestinal peptide cells. Type 3 (n = 12)-catarrhal inflammation. Morphological changes were characterized by impaired blood circulation only in the mucous membrane, without destructive or inflammatory changes. Immunological changes were characterized by an increase (P < .01) in the expression and number of VEGF-positive cells, which may indicate a response to local hypoxia of the appendix and explain neovascularization in a chronic condition. The abdominal syndrome after appendectomy was noted to disappear in 89% of patients. The established changes in remote appendicitis, other than acute inflammation, make it possible to consider reasonable appendectomy a way of treating CRLQP in children. Conclusions: We have identified immunohistochemical and morphological changes pointing to autoimmune and vascular mechanisms of appendix damage in children with CRLQP. Laparoscopic appendectomy helps to eliminate abdominal pain in most CA patients.

Neurogenic appendicopathy: an underestimated disease-systematic review of the literature

PURPOSE

Appendectomy is one of the most frequently performed surgeries worldwide, but neurogenic appendicopathy (NA) remains a poorly understood disease with controversial clinical management. The aim of this review was to obtain a clear definition of the disease and summarize its management.

METHODS

We performed a systematic review of the literature on NA in PubMed, EMBASE, Web of Science, and Cochrane databases from inception to 19/01/2021 according to PRISMA statement standards. Eligibility criteria were original articles examining histopathology, clinical management, and/or follow-up of patients with NA. The literature review is complemented by a clinical case.

RESULTS

In 40 articles, the estimated incidence of NA among appendectomies performed in patients with a suspicion of acute appendicitis (AA) was 10.4% (N = 740, range 1.8-32%). NA more frequently causes recurrent and longer lasting pain compared to AA; however, these diseases are usually not clinically or radiologically distinguishable. Based on our analysis, NA is defined as the presence of three criteria: (1) clinical presentation of AA, (2) absence of acute inflammation on histopathology, and (3) presence of S-100-positive spindle cells or proliferation of Schwann cells. Laparoscopic appendectomy has been shown to be a safe and successful treatment.

CONCLUSIONS

NA is a poorly known disease, which may clinically appear as AA but is often related to recurrent and longer lasting abdominal pain. Patients with NA may suffer for years before diagnosis. In cases of typical symptoms, appendectomy should be performed even in cases of macroscopically and radiologically normal-appearing appendices with normal laboratory results.

Laparoscopic Appendectomy for Chronic Right Iliac Fossa Pain: Correlating Histology with Outcome

BACKGROUND

Chronic right iliac fossa (CRIF) pain in children is associated with repeated hospital attendance, inconclusive investigations, and missed school days. There is increasing evidence for the role of laparoscopic appendectomy for the management of CRIF pain. However, currently there is no substantial evidence to correlate histological changes identified in the appendixes removed with resolution of pain.

METHOD

This study collected prospective data for a single surgeon's series of laparoscopic appendectomy performed for CRIF pain between 2003 and 2014.

RESULTS

Forty patients with a median age of 13 years (range 5-19 years) underwent laparoscopic appendectomy for CRIF pain. Twenty-nine patients (73%) had macroscopically normal appendixes, but histological changes were identified in 28 patients (70%). Other findings at laparoscopy included gynecological pathology (ovarian/para-ovarian cysts), unfixed mobile caecum, and a well-defined peritoneal band extending from the caecum to the anterolateral abdominal wall (caeco-peritoneal band). Patients were followed up for a median of 2 months (range 1-15 months). All patients reported resolution of CRIF pain.

DISCUSSION

Laparoscopic appendectomy appears to be an effective treatment for CRIF pain, while also providing the opportunity to diagnose and treat potential sources of CRIF pain other than the appendix. Consistent with the literature, a small number of patients appear to have resolution of pain, despite no histological change being identified in the appendix removed and no other pathology having been identified. The same histological changes commonly seen have also been demonstrated in appendixes removed incidentally. Caution therefore should be applied when interpreting the significance of histological changes seen.

Endoscopic imaging of the vermiform appendix (with video)

BACKGROUND

Chronic appendicitis may be detected in as many as 10% of patients with right lower quadrant pain. Although the appendiceal orifice is easily identified during colonoscopy, its lumen has not been investigated so far.

OBJECTIVES

To determine the feasibility of endoscopic appendix imaging to identify features of chronic appendicitis in patients with recurrent right lower quadrant pain.

DESIGN

Prospective, proof-of-concept study.

SETTING

University-based tertiary referral hospital.

PATIENTS

Colonoscopy scheduled because of right lower quadrant pain.

INTERVENTIONS

First, the appendix orifice was cannulated with a guidewire and a Jagtome. Next fluoroscopic imaging was performed by injection of contrast agent into the appendix orifice, and then a SpyGlass endoscope was inserted for imaging of the appendiceal mucosa and for biopsy. Patients were monitored 3 hours after investigation, with follow-up at 4 weeks.

MAIN OUTCOME MEASUREMENTS

Cannulation rate.

RESULTS

Thirteen patients were included. Endoscopic imaging of the appendix was successful in 9 of 13 patients (69%). In 10 patients, a guidewire was placed; in 7 patients, biopsy specimens were taken, revealing histological signs of inflammation in 5. In 4 patients, visible fecoliths were removed by flushing. All patients were discharged on the same day. No adverse events occurred. Three patients reported resolution of pain at follow-up. One patient with strictures at appendicoscopy underwent surgical appendectomy. Histology confirmed the findings of chronic appendicitis with fibrosis.

LIMITATIONS

Patient number limits power for analysis.

CONCLUSION

Endoscopic imaging of the appendix is feasible, safe, and clinically useful in patients with suspected chronic appendicitis.

Laparoscopic appendectomy for chronic right lower quadrant abdominal pain

PURPOSE

The appendix can be a rare cause for chronic right lower quadrant abdominal pain (RLQAP), even though no objective disorder can be determined to the appendix. This condition can be described as chronic appendicitis or (neurogenic) appendicopathy. After careful selection, elective appendectomy is performed in our centre for this group of patients.

METHODS

All patients that underwent an elective appendectomy between 2006 and 2013 were prospectively analysed. Inclusion criterion was chronic RLQAP without abnormalities seen on imaging. Exclusion criterion was pain after conservative treatment of (complicated) appendicitis or an abnormal appendix on imaging like a mass, mucocoele or faecolith. Primary outcome was the effect on the pain postoperatively.

RESULTS

In the period of the study, ten patients met the inclusion criteria and underwent an appendectomy for chronic RLQAP. Average preoperative pain score assessed with visual analogue scale (VAS) was 8.6. Preoperative work-up showed no abnormalities. No macroscopic abnormalities were seen during surgery in any of the patients. Histopathological analysis was obtained and showed limited abnormalities in eight of ten patients, mostly suspicion of previous inflammation. Postoperatively, no complications occurred, and at revision after 3 weeks, average VAS was 1.0. Long-term follow-up showed that patients remained free of symptoms; average VAS after a median of 33 months was 1.0.

CONCLUSIONS

A significant reduction of pain was achieved after an appendectomy in all patients suffering from chronic RLQAP in this series. Seven out of ten patients were completely free of pain.

Role of elective laparoscopic appendicectomy for chronic right lower quadrant pain

Chronic right lower quadrant pain is a common clinical entity and continues to remain a diagnostic and therapeutic problem. Laparoscopy is changing the view regarding exploration in patients with chronic right lower quadrant pain. Of recent, chronic or recurrent right lower quadrant pain is an entity that has generated much interest, hence this study has been undertaken. To study the role of elective laparoscopic appendicectomy for chronic or recurrent right lower quadrant pain. To study the relationship between clinical improvement and histopathological findings of removed appendix. Forty three cases of chronic right lower quadrant pain, who met the inclusion criteria, were included in the clinical study. Three cases were excluded during initial diagnostic laparoscopy because of ovarian cyst. Laparoscopic appendicectomy was performed in 40 cases. In our study amongst 40 (100 %) patients, 36(90 %) patients were relieved of pain completely. Only 4(10 %) patients continued to have persistent right lower quadrant pain. Duration of follow up was 6 months. Postoperative pain scores favour appendicectomy (p < 0.005). There was no association between postoperative pain scores and histopathology findings. There was no mortality in our study. Persistent or recurrent right lower quadrant pain can be treated successfully by elective laparoscopic appendicectomy in properly selected cases. Laparoscopic appendectomy is a feasible and safe procedure. Histopathology of the removed appendix does not contribute to the diagnosis.

Appendicopathy--a clinical and diagnostic dilemma

PURPOSE

The term "neurogenic appendicopathy" has been used for patients operated on for acute appendicitis with their appendices lacking signs of acute inflammation. The aim of this retrospective study was to clarify the presence of potential neurogenic appendicopathies, analyzing patients' clinical symptoms and their corresponding appendiceal specimens.

METHODS

One hundred twenty-one patients were identified showing a histological diagnosis of chronic appendicitis. Eventually, 40 patients qualified for the potential diagnosis "neurogenic appendicopathy." Appendix specimens were immunohistochemically examined for the expression of S-100, vasoactive intestinal polypeptide (VIP), and substance P. Controls consisted of 110 patients with acute appendicitis and 120 patients following appendectomies operated on for other reasons.

RESULTS

Eventually, 40 of 120 patients qualified for the potential diagnosis "neurogenic appendicopathy." Compared to patients with acute appendicitis, there was only little difference in clinical symptoms. Histologically, neuromas, thought of being characteristic of neurogenic appendicopathy, were demonstrated significantly more often in the control group (p = 0.01). S-100 was significantly more expressed in the appendicopathy group (p = 0.0024), but nearly 50% of control specimens showed an intense staining, too. S-100(+) neurofibers were significantly (p = 0.00122) more often found in the mucosa of appendicopathy specimens, but this was true for only 25% of specimens. VIP was more strongly expressed in control specimens (p = 0.0211). Substance P was of no diagnostic value.

CONCLUSIONS

Our study could not confirm the neurogenic origin of appendicopathies. Yet, clinical data strongly suggest the existence of the entity "appendicopathy." Therefore, we suggest removing a macroscopically unaffected appendix in patients with appendicitis-like symptoms if, on laparoscopy, no other cause can be found.

Is there an overlap between irritable bowel syndrome and appendicopathy syndrome? A new theory

BACKGROUND AND AIMS

The costs of irritable bowel syndrome are huge - personally, socially and financially. Yet despite numerous articles on the subject, an effective treatment seems far away. The hypothesis to be offered in this paper is: that a (laparoscopic) appendicectomy could also be useful in treating at least some of the patients with IBS. Using data I have collected from my own surgery practice over a number of years, I will demonstrate the link between the effective treatment of appendicitis by laparoscopic appendectomy and propose that this could also be a useful treatment for some cases of IBS. The study of symptoms of IBS showed that it shared several of the symptoms found in appendicopathy. The aim of this study is: (1) to confirm the cure rate of the laparoscopic appendectomy in cases of appendicopathy, (2) to determine the overlap of symptoms and (3) examine a new theory - that some cases of IBS originate in the appendix.

SUPPORTING DATA

Two succeeding series of patients sent to me for possible appendicopathy were treated with laparoscopic appendectomy if their list of symptoms suggested this was appropriate. The first series comprised 114 patients. The results prompted a second series of 126 patients. This second group was primarily set up to confirm the results obtained from the first group. In our material we found statistical evidence that both groups were comparable indeed. Both groups suffered from not only pain, but also other side effects: indigestion, problems with exercise, feelings of stress, defecation disorders, disuria and loss of energy. The favourable results of the second series were roughly the same as those of the first one. Not only were about 80% of the patients pain free after 6 months or less, but the co-morbidity was gone in about 80% of the patients as well. In the literature, there are several reports describing a favourable outcome of appendicectomy for appendicopathy. Especially positive was one of only a few randomised, double-blinded, placebo controlled, parallel group trials in the history of surgery (Roumen, cs), which proved that "persistent or recurrent lower abdominal pain can be treated by elective appendicectomy with significant pain reduction in properly selected cases". An important part of the symptoms of both syndromes do overlap: (1) pain in the abdomen, varying in strength and more pain after a large meal, (2) changing bowel habits between constipation and diarrhoea, (3) indigestion and (4) stress.

CONCLUSION

Taking into account the overlap in several symptoms between IBS and Appendicopathy there is a possibility that both syndromes originate (partly) in the appendix and therefore laparoscopy and appendicectomy may play a part in the treatment of IBS as well. Pilot studies in this direction seem to be indicated.

Laparoscopy as a diagnostic and therapeutic option in evaluating chronic unexplained right iliac fossa pain

BACKGROUND

Management of chronic right iliac fossa (CRIF) pain is poorly documented in literature. No guidelines are available on the best therapeutic approach.

METHOD

Patients presenting from October 2007 to August 2009 with pain persisting or recurring in right lower abdomen over a period of 6 weeks or more were assessed. Severity of CRIF pain was documented using a ten-point visual analogue scale. Initial history and examination were followed by urine analysis, blood counts, X-ray and ultrasound scan of the abdomen. Full colonoscopy was performed in all negative cases. Diagnostic or therapeutic laparoscopy was offered to patients with normal initial investigations. The normal-looking appendix was removed in the absence of other positive laparoscopic findings. Patient's immediate complications, pain score at 8 weeks and histology of appendix were assessed.

RESULTS

Nineteen patients with median age of 43 years (range 32-52 years) underwent laparoscopy. All were female. Median pain score was 5 (range 4-6). During surgery, 12 (64%) had positive findings. Of these, 6 (30%) had adhesions, which were separated. Three patients with congested appendices were removed. One caecal perforation, tubal mass and ovarian cyst were treated laparoscopically. Seven (36%) patients who had macroscopically normal appendices underwent appendicectomy. There were no immediate postoperative complications. Significant improvement was seen in overall pain score after surgery (median 5, range 4-6 versus median 0, range 0-6; p = 0.001). However, only 57% of patients with normal appendix had improved pain scores (median 5, range 4-6 versus median 1, range 0-6; p = 0.12). All patients with positive laparoscopic findings improved after surgery.

CONCLUSION

Laparoscopy seems effective in evaluation and treatment of CRIF pain. The role of appendicectomy with normal-looking appendix needs further evaluation.

Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coproliths?

AIM: To examine the role of coprostasis and coproliths in recurrent appendicitis.

METHODS: We evaluated four hundred and twenty seven consecutive pathology reports of all appende-ctomy specimens from January 2003 to December 2004. Findings were categorised as showing acute appen-dicitis, acute recurrent appendicitis, subacute recurrent appendicitis, chronic appendicitis, or appendices without inflammation. All patients had presented with acute right lower quadrant pain. In 94 instances, there was a history of recurrent similar episodes in the past.

RESULTS: Of the 427 histology reports, 294 were inter-preted as showing acute appendicitis, 56 acute recurrent appendicitis, 34 subacute recurrent appendicitis, 28 chronic appendicitis, and 15 non-inflamed appendices. Coprostasis was observed in 58 patients (13.58%) and the presence of coprolith in 6 (1.4%). Coprostasis, and age, were among the predictors in the final model.

CONCLUSION: Coprostasis but not coproliths seems to be a contributing factor to acute exacerbations of chronic inflammatory appendicitis.