Appendiceal cancer masked as inflammatory appendicitis in the elderly, not an uncommon presentation (Surveillance Epidemiology and End Results (SEER)-Medicare Analysis)

Beyond acute appendicitis: a single-institution experience of unexpected pathology findings after 989 consecutive emergency appendectomy

INTRODUCTION

Appendiceal neoplasms (ANs) are rare, with an estimated incidence of around 1%: neuroendocrine tumours (NETs) and low-grade appendiceal mucinous neoplasms (LAMNs) comprise most cases. Most tumours are cured by appendectomy alone, although some require right hemicolectomy and intra-operative chemotherapy. The aim of the present study is to evaluate our institution's experience in terms of the prevalence of AN, their histological types, treatment and outcomes in adult patients undergoing emergency appendectomy.

MATERIAL AND METHODS

Single-centre retrospective cohort analysis of patients treated for acute appendicitis at a large academic medical centre. Patients with a diagnosis of acute appendicitis (AA) where further compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendiceal neoplasm (AN).

RESULTS

A diagnosis of acute appendicitis was made in 1200 patients. Of these, 989 patients underwent emergency appendectomy. The overall incidence of appendiceal neoplasm was 9.3% (92 patients). AN rate increased with increasing age. Patients under the age of 30 had a 3.8% (14/367 patients) rate of occult neoplasm, whereas patients between 40 and 89 years and older had a 13.0% rate of neoplasm. No difference was found in clinical presentations and type of approach while we found a lower complicated appendicitis rate in the AN group.

CONCLUSION

ANs are less rare with respect to the literature; however, clinically, there are no specific signs of suspicious and simple appendicectomy appears to be curative in most cases. However, age plays an important role; older patients are at higher risk for AN. ANs still challenge the non-operative management concept introduced into the surgical literature.

Incidence trends and survival analysis of appendiceal tumors in the United States: Primarily changes in appendiceal neuroendocrine tumors

BACKGROUND

Appendiceal tumors are considered to be a relatively rare tumor of the gastrointestinal tract and the prognosis is unclear. This study comprehensively investigated trends in the epidemiology and survival of appendiceal tumors in the United States over the past approximately 20 years.

METHODS

Patients with pathologically confirmed appendiceal tumors from 2000 to 2017 were selected from the Surveillance, Epidemiology and End Results (SEER) database. Age-adjusted incidence rates were calculated by SEER*Stat 8.4.0. The Kaplan-Meier method was used to analyze survival and prognostic factors were investigated by a multivariate Cox proportional risk model.

RESULTS

Ultimately, 13,546 patients with appendiceal tumors between 2000 and 2017 were included. The annual incidence of colonic adenocarcinoma and mucinous adenocarcinoma remained relatively stable. Interestingly, the annual incidence of appendiceal neuroendocrine tumors (aNETs) increased significantly, from 0.03 to 0.90 per 100,000 person-years, with the most dramatic increase in the number of patients with localized disease. Patients with aNETs showed a significant improvement in survival between 2009-2017, compared to the period 2000-2008. Moreover, this improvement in survival over time was seen at all stages (localized, regional, distant) of aNETs. However, this improved survival over time was not seen in colonic and mucinous adenocarcinoma.

CONCLUSIONS

The incidence of appendiceal neoplasms has increased significantly over the past nearly two decades, which is mainly due to the increased incidence and significant migration to earlier stages in aNETs. We must note that despite the increased incidence of aNETs, survival rates have improved at different disease stages.

Temporal Trends in the Investigation, Management and Outcomes of Acute Appendicitis over 15 Years in the North of England: A Retrospective Cohort Study

BACKGROUND

Acute appendicitis is a common surgical emergency with an estimated lifetime prevalence of 8.6% for males and 6.7% for females. Despite the frequency of presentation, considerable variation in clinical practice exists. Our study aimed to explore temporal trends in the investigation, treatment and outcomes for patients with appendicitis between 2002 and 2016.

METHODS

Data collected included all patients aged ≥16 years across the NHS trusts in Northern England between 01/01/2002 and 31/12/2016 diagnosed with appendicitis. Patient demographics, co-morbidity and management strategies were included. Outcomes of interest were length of stay and inpatient mortality.

RESULTS

Over a 15 years period, 22,137 patients were admitted with acute appendicitis. A consistent male preponderance (n = 11,952, 54%) was observed, and median age increased over time (2002-2006: 36.4 vs. 2012-2016: 39.5, p < 0.001). Comorbidity of patients also increased (p < 0.001) in recent years. Computed tomography (CT) use increased from 0.8 to 21.9% (p < 0.001) over the study period. Following CT scanning, there was a longer time to theatre (1.22 vs. 0.70 days, p < 0.001), and patients were more frequently managed non-operatively (23.8% vs. 5.7%, p < 0.001). The utilisation of laparoscopic approaches significantly increased from 4.1 to 70.4% (p < 0.001). Laparoscopic patients had a shorter median length of stay (2.97 days) when compared with open surgery (4.44 days) or non-operative (6.19 days) patients. The 30-day mortality rate was 0.33% overall and decreased with time (p = 0.004).

CONCLUSIONS

CT and laparoscopic surgery are increasingly utilised in the management of appendicitis. Along with other advances in clinical practice, they have led to reduced lengths of stay and mortality.

Acute Appendicitis in the Elderly: A Literature Review on an Increasingly Frequent Surgical Problem

With increased life expectancy and the growing total population of elderly patients, there has been rise in the number of cases of acute appendicitis in elderly people. Although acute appendicitis is not the most typical pathological condition in the elderly, it is not uncommon. Most of these patients require surgical treatment, and as with any acute surgical pathology in advanced age, treatment possibilities are affected by comorbidities, overall health status, and an increased risk of complications. In this literature review we discuss differences in acute appendicitis in the elderly population, with a focus on clinical signs, diagnostics, pathogenesis, treatment, and results.