Appendix tumors in the era of laparoscopic appendectomy

Treatment for appendicitis in cancer patients on chemotherapy: a retrospective cohort study

Purpose

Whether to perform surgery or conservatively manage appendicitis in immunosuppressed patients is a concern for clinicians. This study aimed to compare the outcomes of these 2 treatment options for appendicitis in patients with cancer undergoing chemotherapy.

Methods

This retrospective study included 206 patients with cancer who were diagnosed with acute appendicitis between August 2001 and December 2021. Among them, patients who received chemotherapy within 1 month were divided into surgical and conservative groups. We evaluated the outcomes, including treatment success within 1 year, 1-year recurrence, and the number of days from the diagnosis of appendicitis to chemotherapy restart, between the 2 groups.

Results

Among the 206 patients with cancer who were diagnosed with acute appendicitis, 78 received chemotherapy within 1 month. The patients were divided into surgery (n = 63) and conservative (n = 15) groups. In the surgery group, the duration of antibiotic therapy (7.0 days vs. 16.0 days, P < 0.001) and length of hospital stay (8.0 days vs. 27.5 days, P = 0.002) were significantly shorter than conservative groups. The duration from the diagnosis of appendicitis to the restart of chemotherapy was shorter in the surgery group (20.8 ± 15.1 days vs. 35.2 ± 28.2 days, P = 0.028). The treatment success rate within 1 year was higher in the surgery group (100% vs. 33.3%, P < 0.001).

Conclusion

Surgical treatment showed a significantly higher success rate than conservative treatment for appendicitis in patients less than 1 month after chemotherapy. Further prospective studies will be needed to clinically determine treatment options.

Appendiceal cancer showing a submucosal tumor-like morphology in the ascending colon on colonoscopy: a case report

Few reports have described a submucosal tumor (SMT)-like colon tumor together with appendiceal cancer. Moreover, some appendiceal tumors may exhibit a cecal protuberance. Here, we report an uncommon case of appendiceal cancer with an SMT-like tumor, which was a protuberant lesion in the ascending colon. To our knowledge, this is the first report in Japan. Our case was a 50-year-old man with an ascending colon tumor presented at our hospital for further evaluation of this lesion. This was discovered as a cystic lesion near the ascending colon on colonoscopy. Our initial diagnosis was an ascending colon SMT-like tumor, and our treatment strategy was laparoscopic resection. The differential diagnosis was appendiceal cancer or mucocele. Postoperative pathological findings led to a diagnosis of adenocarcinoma of the appendix. The postoperative course was uneventful, and the patient was followed up with computed tomography and blood sampling on an outpatient basis.

Appendiceal stump closure in laparoscopic appendectomy: one endoloop vs. two endoloops vs. two endoclips-does it matter?

PURPOSE

Appendiceal stump leak rate after laparoscopic appendectomy is extremely low. Various methods are used to close the appendiceal stump. This study aimed to compare the outcome of three appendiceal stump closure methods.

METHODS

A retrospective study comparing stump closure methods and postoperative outcomes was conducted from January 2018 to June 2020. Patient data included demographics, pre-operative data, surgical technique, findings, and postoperative complications.

RESULTS

Out of 1021 appendectomy patients, 733 underwent laparoscopic appendectomy for acute appendicitis utilizing one of the three compared appendiceal stump closure methods. Consequently, 360 appendixes were ligated with one endoloop (1EL group), 300 appendixes had two endoloops (2EL group), and 73 appendixes were ligated with two endoclips (2EC group). All groups used a LigaSure for resection. The rate of postoperative intra-abdominal abscess was 1% (4 patients) in 1EL group vs. 1% (3 patients) in 2EL group vs. none in 2EC group (p = 0.43). There were no reported appendiceal stump leaks. Overall complication rates were 4% (14 patients), 3% (9 patients), and 0 (p = 0.15), and the mean operative length was 43 ± 21, 54 ± 22, and 43 ± 20 mins for the 1EL, 2EL, and 2EC, respectively (p < 0.01). Average cost of one endoloop is 110$, and one endoclip cartridge is 180$.

CONCLUSIONS

None of the methods were found clinically superior over the others. Considering the low and mild complication rate, it appears reasonable to prefer one method simply by cost. The use of a single endoloop may result in substantial cost reduction. Medical centers may advise surgeons to use a single-endoloop technique.

Appendiceal schwannoma presenting as acute appendicitis

Schwannomas are nerve sheath tumors that rarely occur in the gastrointestinal tract. In the gastrointestinal tract, schwannomas are mostly found in the stomach and small bowel. Herein, we describe a case of appendiceal schwannoma that caused appendix obstruction and developed acute appendicitis. An 83-year-old woman was admitted to the emergency department with 3 days' history of abdominal pain. She had tenderness and rebound tenderness in the lower right quadrant. Computed tomography revealed a 1.3 cm mass in the appendix orifice, with associated distal appendiceal dilatation and wall thickening. The patient underwent emergency surgery (laparoscopic partial cecectomy). Histopathological examination confirmed that the mass was a schwannoma and was associated with acute suppurative appendicitis. Our case is significant in that it adds to another rarely reported case of appendiceal schwannoma. Moreover, it is important to recognize the presence of an appendiceal tumor associated with acute appendicitis.

Comparison of the risk of appendiceal tumors in uncomplicated and complicated appendicitis

BACKGROUND

Interval appendectomy or non-operative management is commonly performed for complicated appendicitis in adult patients. However, these treatments are still controversial because the incidence rate of appendiceal tumors recognized after interval appendectomy is reportedly higher than that after emergency appendectomy. Thus, this study aimed to compare the appendiceal tumor rates between uncomplicated and complicated appendicitis.

METHODS

This study was a retrospective review of patients with appendicitis who underwent surgical removal at a single institution over 7.5 years. The primary objective was the comparison of the incidence rate of appendiceal tumors using propensity score matching, and the secondary objective was the same comparison among older patients, defined as patients aged ≥ 60 years.

RESULTS

A total of 1277 patients were included. Of these patients, 297 (23.3%) were preoperatively diagnosed with complicated appendicitis. Moreover, 22 (1.7%) patients, including 14 cases of complicated appendicitis and 8 cases of uncomplicated appendicitis, were diagnosed with appendiceal tumors based on pathological examination. No significant difference was found in the incidence rate of appendiceal tumors between the two groups after matching for patients' background, including age, sex, and history of appendicitis by propensity score matching (P = 0.073). However, among patients aged ≥ 60 years, the incidence of appendiceal tumors was significantly higher in complicated than in uncomplicated appendicitis (P = 0.006).

CONCLUSIONS

Although the overall risk of appendiceal tumors did not differ between complicated and uncomplicated appendicitis when analyzed by the propensity score matching, in older patients aged ≥ 60 years, the risk increased among those with complicated appendicitis. Therefore, although the incidence is low, complicated appendicitis, particularly, among older patients, should be examined carefully and be performed IA when unusual findings exist.

The association between appendicitis severity and patient age with appendiceal neoplasm histology-a population-based study

PURPOSE

Recent studies have reported alarming appendiceal tumor rates associated with complicated acute appendicitis, especially in patients presenting with a periappendicular abscess. However, the data on histology of appendiceal tumors among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. We have previously reported the association of increased appendiceal tumor prevalence with complicated acute appendicitis in this population-based study. The objective of this secondary analysis was to evaluate the association of both appendicitis severity and patient age with appendiceal tumor histology.

METHODS

This nationwide population-based registry study (The Finnish Cancer Registry) was conducted from 2007 to 2013. All appendiceal tumors (n = 840) and available medical reports (n = 504) of these patients at eight study hospitals were previously evaluated, identifying altogether 250 patients with both acute appendicitis and appendiceal tumor.

RESULTS

The severity of acute appendicitis was significantly associated with more malignant tumor histology. The risk of adenocarcinoma or pseudomyxoma was significantly higher among patients with periappendicular abscess (OR 15.05, CI 95% 6.98-32.49, p < 0.001) and patients presenting with perforated acute appendicitis (OR 4.09, CI 95% 1.69-9.90, p = 0.0018) compared to patients with uncomplicated acute appendicitis. Similarly, patient age over 40 years was significantly associated with the risk of adenocarcinoma and pseudomyxoma (OR 26.46, Cl 95% 7.95-88.09, p < 0.001). Patient sex was not associated with a more malignant appendiceal tumor histology (p = 0.67).

CONCLUSION

More malignant appendiceal tumor histology of adenocarcinoma or pseudomyxoma was significantly associated with patient age over 40 years and complicated acute appendicitis, especially periappendicular abscess.

Immunohistochemistry features and molecular pathology of appendiceal neoplasms

Primary appendiceal neoplasms (ANs) comprise a heterogeneous group of tumors. The pathology and classification of ANs have been controversial, and thus, a new classification of these neoplasms was published in the World Health Organization (WHO) classification of tumors (5th edition, 2019). However, immunohistochemistry (IHC) features of epithelial ANs are not explained in this edition and the limited data on the molecular pathology of these tumors shows inconsistent findings in various studies. It would be useful to identify biomarkers appropriate for each subtype to better aid in treatment selection. Therefore, we reviewed the literature to investigate what is known of the molecular pathology and IHC features of the most frequently diagnosed pathological subtypes of epithelial ANs based on the recent classification. The inconsistencies in research findings regarding the IHC features and molecular pathology of ANs could be due to differences in the number of samples and their collection and preparation as well as to the lack of a universally accepted classification system for these neoplasms. However, the literature shows that epithelial ANs typically stain positive for MUC2, CK20, and CDX2 and that the expression of SATB2 protein could be used as a biomarker for appendix tumor origin. Low-grade appendiceal mucinous neoplasms tend to have mutations in KRAS and GNAS but are usually wild-type for BRAF, APC, and P53. Conversely, appendiceal adenocarcinomas are frequently found with mutations in KRAS, GNAS, P53, PIK3CA, and APC, and have significant nuclear expression of β-catenin, loss of nuclear or nuclear and cytoplasmic expression of SMAD4, and loss of cytoplasmic membranous expression of E-cadherin. Goblet cell carcinomas (GCCs) typically stain positive for keratin and mucin markers and are frequently mutated in P53 and chromatin-modifier genes, but they tend to be wild-type for KRAS, GNAS, APC, and PIK3CA. The expression of CK7 and SATB2 proteins is usually negative in appendiceal neuroendocrine neoplasms and they lack the mutations in common cancer-associated genes including APC, BRAF, SMAD4, and PIK3C. The available data suggest that GCCs have distinct molecular and immunohistochemical features and that they have characteristics more in common with adenocarcinoma than classical neuroendocrine tumors. In addition, MSI does not seem to have a role in the pathogenesis of epithelial ANs because they are rarely detected in these tumors. Finally, hereditary predisposition may have a role in the development of ANs because heterozygous CTNNβ1, NOTCH1, and NOTCH4 germline mutations have recently been identified in low and high grades ANs.

Risk Factors for Appendiceal Cancer After Appendectomy

BACKGROUND

Appendiceal cancer (AC) is a rare malignancy usually diagnosed incidentally after appendectomy. Risk factors for AC are poorly understood. We sought to provide a descriptive analysis for patients with AC discovered after appendectomy for acute appendicitis (AA).

METHODS

The 2016-2017 American College of Surgeons-National Surgical Quality Improvement Program Procedure-Targeted Appendectomy database was queried for adult patients who underwent appendectomy for image-suspected AA. Patients with pathology consistent with AA were compared to patients found to have AC. A multivariable logistic regression model was used for analysis.

RESULTS

From 21 058 patients, 203 (1.0%) were found to have AC on pathology. Compared to patients with AA, patients with AC were older (median, 48 vs. 40 years old, P < .001). The AA group had a similar rate of perforated appendix compared to the AC group (16.3% vs. 13.4% P = .32). After adjusting for covariates, associated risk factors for AC were: age ≥65 years old (odds ratio (OR) 2.25, 1.5-3.38, P < .001), absence of leukocytosis (OR 1.58, 1.16-2.17, P = .004), and operative time ≥1 hour (OR 1.57, 1.14-2.16, P = .006). Gender, race, and history of smoking were not independent associated risk factors for AC.

CONCLUSION

The incidence of AC after appendectomy for suspected AA is approximately 1% in a large national analysis. These factors may be used to help identify patients at higher risk for AC after appendectomy.

Synchronous primary adenocarcinoma of the appendix and colon: Case report and literature review

•

Primary adenocarcinoma of appendix is rare pathology that is discovered usually on histopathologic examination of resected appendix.

•

It is important to report all pathologic reports to the primary physician in order to confirm primary diagnosis and discuss it with their patients.

•

If a diagnosis of PAA is reported, a surveillance lifelong colonoscopy screening is mandatory to rule out synchronous or metachronous occurrence of colonic malignances.

Introduction

Primary adenocarcinoma of the appendix (PAA) is rare with fewer than 300 cases reported from 1882 Up to 2004. Synchronous occurrence of PAA with a second primary colonic carcinoma is even more unusual. Literature review shows a total of 40 reported synchronous cases in the English literature from the first case reported in1947 up to 2017. Hereby, an additional case is presented, which is the first case reported in Jordan.

Presentation of case

A 39-year-old woman presented in October 2016 with persistent right lower quadrant abdominal pain diagnosed clinically as acute appendicitis. Abdominal computed tomography showed an oval shaped 3 × 3.4 cm mass at the sub-hepatic region, associated with increased attenuation of surrounding mesenteric fat and multiple enlarged lymph nodes. Three days later, a right hemicolectomy was carried out. A diagnosis of invasive primary adenocarcinoma of the ascending colon with an incidental, microscopic primary adenocarcinoma of the distal part of the appendix was reported.

Discussion

Primary appendiceal adenocarcinoma is rare pathology with an incidence ranges from 0.01% to 0.3% that is characterized by presence of adenocarcinomatous cells originating in the appendix that are in direct continuity with the normal appendiceal mucosa. Even it is less common, synchronous primary adenocarcinoma of the appendix and the colon has been reported in literature, with less than 37 cases being reported in literature so far. PAA are seldom suspected in preoperative phase or even intraoperatively, and it is diagnosed based on histopathologic examination of the resected appendix. Once PAA is diagnosed, a lifelong surveillance with colonoscopy is mandatory to detect synchronous or metachronous colonic malignancies.

Conclusions

Once a diagnosis of primary appendiceal adenocarcinoma is proved histologically, it is it is warranted to perform surveillance for synchronous or metachronous tumors because of the increased risk of a second primary malignancy in the gastrointestinal tract.

National trends in the presentation of surgically resected appendiceal adenocarcinoma over a decade

BACKGROUND

Rates of nonoperative management of acute appendicitis and appendiceal adenocarcinoma have increased over a decade, but the presentation and outcomes of appendiceal adenocarcinoma over this period is not well-characterized.

METHODS

Patients with surgically resected Stage I-III appendiceal adenocarcinoma were identified from the 2006 to 2015 National Cancer Data Base and classified into two cohorts, 2006-2010 and 2011-2015, based on year of diagnosis. Three-year overall survival (OS) was analyzed using Cox proportional hazards regression and Kaplan-Meier survival estimates.

RESULTS

Of 4233 patients, 1369 (32.3%) and 2864 (67.7%) were diagnosed in 2006-2010 and 2011-2015, respectively. Following multivariable analysis, patients in 2011-2015 were more likely to be <40 years of age (6.4% vs. 4.7%, odds ratio [OR] 1.53, p .015), present with pT4 tumors (40.2% vs. 34.4%, OR 1.46, p .004), and undergo hyperthermic intraperitoneal chemotherapy (4.4% vs. 2.4%, OR 1.97, p .001). Comparing patients diagnosed in 2011-2015 to 2006-2010, adjusted 3-year OS was no different among all patients (81.1% vs. 79%, p .778).

CONCLUSIONS

There has been an increase in the proportion of patients with pT4 appendix tumors over time, primarily among older (≥60 years) patients. Even so, these shifts in presentation have not resulted in differences in survival outcomes.

Open versus laparoscopic surgery for primary appendiceal tumors: a large multicenter retrospective propensity score-matched cohort study in Japan

BACKGROUND

The feasibility of laparoscopic surgery for primary appendiceal tumors compared to that of open surgery has not been demonstrated to date because primary appendiceal tumors are rare. This study aimed to compare the long-term outcomes between laparoscopic and open surgeries for primary appendiceal tumors.

METHODS

In this multicenter retrospective cohort study, the data of patients who had been histologically diagnosed with primary appendiceal tumors at 43 tertiary hospitals in Japan between 2000 and 2017 were analyzed. In total, 922 patients were assessed, and 679 cases were eligible for analysis. Using propensity scores, the baseline characteristics were matched for 114 open surgery cases and 114 laparoscopic surgery cases. The primary endpoints were recurrence-free survival (excluding patients with stage IV disease with distant metastasis) and overall survival.

RESULTS

The rate of conversion from laparoscopic to open surgery was 1.5%. The 5-year recurrence-free survival rates were 80.4% (95% confidence interval: 71.0-89.7) and 78.2% (95% confidence interval: 69.0-87.3) in the laparoscopic and open surgery groups, respectively, with no significant difference (p = 0.57). No significant difference was observed in the 5-year overall survival rates between the laparoscopic [83.5% (95% confidence interval: 74.4-92.7)] and open surgery [72.7% (95% confidence interval: 62.3-83.0); p = 0.09] groups. In multivariate analysis, laparoscopic surgery was not identified as an independent prognostic factor for overall survival [hazard ratio: 0.49 (95% confidence interval: 0.23-1.06), p = 0.0707].

CONCLUSIONS

Laparoscopic surgery is comparable to open surgery and can be considered a treatment option for primary appendiceal tumors.

Carcinoid tumours of the appendix: an analysis of emergency appendicectomies over a 24-year period and outcomes of laparoscopic versus open resection

BACKGROUND

Carcinoid tumours of the appendix are the most common primary malignant lesion of the appendix. However, the overall incidence remains low; found in as few as 0.3-0.9% appendicectomy specimens. Almost all appendiceal carcinoids are found incidentally during surgery for suspected appendicitis.

METHODS

A retrospective review of all appendiceal carcinoids was performed in six hospitals from January 1990 until December 2013. Demographic data, operative technique, histopathological characteristics, clinic reviews and need for further treatment were recorded and compared with literature.

RESULTS

Appendiceal carcinoids were identified in 175 specimens. The mean age is 32 years (range 8-87 years), with 69 (39.4%) males and 106 (60.6%) females (P < 0.0001). Of these, 106 underwent open surgery with standard McBurney incision, nine underwent full laparotomy and 60 underwent laparoscopic surgery. Six of the laparoscopic surgeries were converted to open procedures. We recorded 159 (90.75%) classical carcinoids and 16 (9.25%) goblet cell carcinoids. Overall, 131 (75.7%) had concurrent appendicitis; classical carcinoid 72.6% versus goblet cell carcinoid 93.8%. The median size of the goblet cell carcinoids was significantly larger than classical carcinoids. Classical carcinoids were mostly distal to the base, while goblet cell carcinoids had equal distribution. It appears that the involvement of resection margins was not influenced by the surgical technique. Thirty patients required further right hemicolectomy as treatment for high-risk features; open 19 (15.9%) versus laparoscopic 11 (20.4%).

CONCLUSIONS

Laparoscopic appendicectomy did not seem to adversely influence the margin clearance in appendiceal carcinoid, though we recommend that all appendicectomies should include the mesoappendix.

Pathology findings following interval appendectomy: Should it stay or go?

PURPOSE

Interval appendectomy following nonoperative management of complicated appendicitis remains controversial. The aim of this study was to evaluate surgical pathology and clinical outcomes after pediatric interval appendectomy.

METHODS

Pathology results from children with complicated appendicitis who underwent interval appendectomy at a single children's hospital from 2010 to 2017 were reviewed. The primary outcome was pathology results. Secondary outcomes included complications and readmission following initial treatment and after interval appendectomy.

RESULTS

Among 149 patients (median age 11 years; range, 1-18), all had evidence of persistent inflammation on surgical pathology, 25 (17%) had an appendicolith, and no neoplasms were identified. Median duration of the initial admission was 8 days (range, 2-28) and 70% received a percutaneous drain prior to appendectomy. Interval appendectomy was performed at a median of 7.5 weeks (range, 2.9-29.1). Thirty-six (24%) returned to the hospital prior to their scheduled appendectomy and 6 (4%) required appendectomy earlier than planned. Nine patients (6%) experienced a complication following interval appendectomy, of which superficial surgical site infection was the most common (n = 4).

CONCLUSION

All children had evidence of ongoing inflammation on surgical pathology. While the clinical implications of persistent inflammation remain uncertain, these findings suggest that interval appendectomy is an appropriate treatment following medical management of complicated appendicitis in children.

LEVEL OF EVIDENCE SECTION

IV, Case series with no comparison groups.

Appendicular neoplasms and consequences in patients undergoing surgery for suspected acute appendicitis

INTRODUCTION

In patients treated with an appendectomy for acute appendicitis, the specimen is generally sent for histological evaluation. In an era of increasing non-operative treatment for acute appendicitis, it is important to know the incidence, the diagnostic accuracy, and treatment consequences of appendicular neoplasms that are found in acute appendicitis. We hypothesize that pre- and intra-operative parameters might predict an appendicular neoplasm.

METHODS

Data was used from our previous prospective observational cohort study. All patients undergoing surgery for suspected acute appendicitis were included. The primary outcome was the incidence of appendicular neoplasms in patients operated for acute appendicitis. Secondary outcomes were pre-operative diagnostics and imaging outcomes, intra-operative surgical judgment, and postoperative management and outcome. Possible predictors of an appendicular neoplasm were identified and used in multivariable logistic regression. Patients with an appendicular neoplasm were followed for 3 years after initial appendectomy.

RESULTS

A total of 1975 patients underwent surgery for suspected acute appendicitis and in 98.3% (1941/1975) the appendix was removed. In 1.5% (30/1941) of these patients, an appendicular neoplasm was found. Among the malignant neoplasms, the majority were grade 1 neuroendocrine tumors (NET) in 65% (13/20). On pre-operative imaging, there was no suspicion of malignancy. In three cases, there was an intra-operative suspicion of malignancy. Multivariable analysis showed only age as an independent predictor for appendicular neoplasms. No recurrent or new malignancy was found during follow-up.

DISCUSSION

The incidence of appendicular neoplasm in patients undergoing an acute appendectomy is very low and clinical risk factors could not be identified.

Communication and management of incidental pathology in 1,214 consecutive appendicectomies; a cohort study

BACKGROUND

Important incidental pathology requiring further action is commonly found during appendicectomy, macro- and microscopically. We aimed to determine whether the acute surgical unit (ASU) model improved the management and disclosure of these findings.

METHODS

An ASU model was introduced at our institution on 01/08/2012. In this retrospective cohort study, all patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. The primary outcomes were rates of appropriate management of the incidental findings, and communication of the findings to the patient and to their general practitioner (GP).

RESULTS

1,214 patients underwent emergency appendicectomy; 465 in the Traditional group and 749 in the ASU group. 80 (6.6%) patients (25 and 55 in each respective period) had important incidental findings. There were 24 patients with benign polyps, 15 with neuro-endocrine tumour, 11 with endometriosis, 8 with pelvic inflammatory disease, 8 Enterobius vermicularis infection, 7 with low grade mucinous cystadenoma, 3 with inflammatory bowel disease, 2 with diverticulitis, 2 with tubo-ovarian mass, 1 with secondary appendiceal malignancy and none with primary appendiceal adenocarcinoma. One patient had dual pathologies. There was no difference between the Traditional and ASU group with regards to communication of the findings to the patient (p = 0.44) and their GP (p = 0.27), and there was no difference in the rates of appropriate management (p = 0.21).

CONCLUSION

The introduction of an ASU model did not change rates of surgeon-to-patient and surgeon-to-GP communication nor affect rates of appropriate management of important incidental pathology during appendectomy.

[Incidental finding of mucinous neoplasia of the appendix : Treatment strategies]

Tumors of the appendix are not a uniform group but differ significantly in terms of their origin/histology and metastatic behavior. Furthermore, tumors of the appendix are often diagnosed as incidental findings after appendectomy for acute appendicitis. A subgroup of these neoplasms are low-grade appendiceal mucinous neoplasms (LAMN). These are mucus-forming tumors of the appendiceal lumen, which can lead to rupture of the appendix and seeding into the abdominal cavity. Therefore LAMN are considered precursors of pseudomyxoma peritonei (PMP). It is essential to clearly differentiate the subgroups of LAMN as well as the resection status. According to this it is determined whether (radical) appendectomy is a sufficient therapy or further treatment, such as ileocecal resection with hyperthermic intraperitoneal chemotherapy (HIPEC) or cytoreductive surgery (CRS) is necessary. There is no standardized concept regarding the follow-up after resection of LAMN. Generally, it is recommended to perform a computed tomography (CT) scan of the abdomen and determination of tumor markers 6 months postoperatively and then once a year. A recommendation regarding the duration of follow-up is difficult as there are case reports in which PMP has occurred more than 15 years after removal of LAMN.

Laparoscopic ileocecal resection can be applied for appendiceal cancer with an ileal fistula: A case report

INTRODUCTION

Primary appendiceal cancer with fistula formation is extremely rare. We report a case of a patient with appendiceal cancer invading the ileum who underwent successful laparoscopic ileocecal resection.

PRESENTATION OF CASE

A 76-year-old man who presented with fever and abdominal pain was diagnosed with acute appendicitis and received antibiotics at a local hospital. After a few days, he was referred to our hospital because of an abnormality found in the colonoscopy, which was an oozing ulcer in the terminal ileum. Laparoscopic ileocecal resection was performed with a preoperative diagnosis of ileal cancer. The tumor adhered to the right internal inguinal ring. We dissected the right spermatic cord involved in the tumor. The resected specimen revealed a fistula between the appendiceal orifice and ileac ulcer. Histopathological examination revealed a well differentiated tubular adenocarcinoma. We made the diagnosis of appendiceal cancer with an ileal fistula because the ileal ulcer was derived from the appendiceal site.

DISCUSSION

Most cases of appendiceal cancer with a fistula undergo laparotomy, but in selected cases, laparoscopic resection should be considered a feasible, safe, and curative procedure. Our patient underwent laparoscopic ileocecal resection, whereby the tumor and other organs with invasion were resected successfully with a negative surgical margin.

CONCLUSION

This is the first case report of appendiceal cancer with an ileal fistula successfully treated with laparoscopic resection. Laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration.

Laparoscopic Resection of Appendiceal Schwannoma

Background

Schwannoma arises from Schwann's cell of the neural sheath. Schwannoma of the large intestine, particularly of the appendix, is rare. We report a case of appendiceal schwannoma resected using laparoscopic surgery.

Case Presentation

A 75-year-old man was referred to our hospital for abdominal fullness and nausea since 2 months. Abdominal CT revealed a well-demarcated oval mass of 25 mm at the tip of the appendix. Contrast-enhanced CT revealed a lesion with gradually enhanced contrast from the arterial phase to the equilibrium phase. Abdominal US revealed a well-demarcated hypoechoic tumor. Preoperative diagnosis indicated appendiceal mesenchymal or neuroendocrine tumor. Ileocecal resection with D3 lymph node dissection was performed. Pathological and immunohistochemical findings confirmed the diagnosis of appendiceal schwannoma.

Conclusions

For determining the surgical procedure of nonepithelial tumor of the appendix, preoperative diagnosis of mesenchymal or neuroendocrine tumors is required. However, appendiceal schwannoma is extremely rare, and its characteristic findings have not yet been established. Accumulating cases of appendiceal schwannomas is necessary for improving imaging diagnosis and surgical treatment.

Analysis of Appendiceal Neoplasms on 3544 Appendectomy Specimens for Acute Appendicitis: Retrospective Cohort Study of a Single Institution

Background

Appendiceal neoplasms are rare and generally determined in appendectomy specimens for acute appendicitis. Depending on a tumor’s histopathology and size, appendectomy or right hemicolectomy are the surgical treatment options. Adenocarcinomas, mucinous neoplasms, goblet cell carcinoids and neuroendocrine tumors are the types of the primary appendiceal neoplasm histopathology. In this study, we aimed to determine the incidence of appendiceal neoplasms in an acute appendicitis cohort. Also, histopathological distributions, demographic data, preoperative radiological diagnosis, and intraoperative findings were revealed for analysis, retrospectively.

Material/Methods

Between October 2011 and September 2017, 3554 appendectomies were performed for acute appendicitis in Bezmialem University Hospital, Istanbul Turkey. The medical records of these consecutive 3554 patients were evaluated retrospectively. After the histopathological analysis of the appendectomy specimens, a total of 28 patients were detected as having appendiceal neoplasm including appendiceal adenocarcinoma, low grade mucinous neoplasia, and appendiceal neuroendocrine tumors.

Results

Appendiceal neoplasms were determined in 28 out of 3554 acute appendicitis patients with an incidence of 0.78%. According to the histopathological types, 3 of the cases (10.7%) were appendiceal adenocarcinoma, 8 of the cases (28.5%) were low grade mucinous neoplasia, and 17 of the cases (60.8%) were neuroendocrine tumors. The overall incidence of the appendiceal neuroendocrine tumors was 0.48%.

Conclusions

The information obtained from our study suggests that pathological examination of the specimen may not be necessary if there is no doubt according to preoperative radiological diagnosis and/or intraoperative findings of the surgeon.

Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

BACKGROUND

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.

METHODS

This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.

RESULTS

A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.

CONCLUSIONS

The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

Occult Appendiceal Neoplasms in Acute and Chronic Appendicitis: A Single-Institution Experience of 1793 Appendectomies

The incidence of appendiceal neoplasms may have been underreported in the past. Patients undergoing incidental appendectomies or appendectomies for chronic appendicitis may be at higher risk for an incidental appendiceal neoplasm. To determine the incidence of occult appendiceal neoplasms and identify risk factors associated with this pathology, a retrospective review of a pathology specimen database was conducted from November 2007 to December 2011, in a single tertiary care hospital center. All patients with appendectomies were included for analysis (n = 1793). Pathology specimens were grouped based on the indication for appendectomy, and the incidence of appendiceal neoplasms, and patient variables among the groups were compared using χ2 test and Student's t test. A total of 1793 appendectomy specimens met criteria for evaluation. The total number of appendiceal neoplasms was 31 (1.7%). There were 14 neoplasms in 1337 (1.0%) cases of acute appendicitis with 2 in 41 (4.9%) cases of chronic and 15 in 415 (3.6%) cases, where an incidental appendectomy was performed (P < 0.001). Patients with carcinoid tumors were significantly younger than patients with noncarcinoid tumors (P = 0.0001). Indication for operation was the only significant factor for predicting an appendiceal tumor on final pathology. Patients who undergo interval or incidental appendectomies may be at higher risk of appendiceal neoplasm compared with those performed for other indications. Younger patients may be at a higher risk of occult appendiceal carcinoid neoplasms than other age groups. Pathologic diagnosis in specific high-risk patient groups may be the only way to effectively capture these tumors for optimal treatment.

Is there any role for minimally invasive surgery in NET?

Neuroendocrine tumors (NET) represent the variability of almost benign lesions either secreting hormones occurring as a single lesion up to malignant lesions with metastatic potential. Treatment of NET is usually performed by surgical resection. Due to the rarity of NET, surgical treatment is mainly based on the experience and recommendations of experts and less on the basis of prospective randomized studies. In addition, the development and establishment of new surgical procedures is made more difficult by their rarity. The development of laparoscopic-assisted surgery has significantly improved the treatment of many diseases. Due to the well-known advantages of laparoscopic surgery, this method has also been increasingly used to treat NET. However, due to limited comparative data, the assumed superiority of laparoscopic surgery in the area NET remains often unclear or not yet proven. This review focuses on the present usage of laparoscopic techniques in the area of NET. Relating to the current literature, this review presents the evidence of various laparoscopic procedures for treatment of adrenal, pancreatic and intestine NET as well as extraadrenal pheochromocytoma and neuroendocrine liver metastases. Further, this review focuses on recent new developments of minimally invasive surgery in the area of NET. Here, robotic-assisted surgery and single-port surgery are promising approaches.

Peritoneal Involvement Is More Common Than Nodal Involvement in Patients With High-Grade Appendix Tumors Who Are Undergoing Prophylactic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Right hemicolectomy is routinely recommended in patients with histologic findings of high-grade appendix tumors after appendicectomy. Undetected peritoneal disease may be encountered at surgery. In high-grade appendix tumors with disease detected radiologically, complete cytoreduction may not be possible and outcomes poor. For these reasons, we adopted a policy of prophylactic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

OBJECTIVE

The purpose of this study was to quantify the rates of peritoneal and nodal metastatic disease in patients with high-grade appendix tumors without obvious metastatic disease and to report the long-term outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in these patients.

DESIGN

Data regarding peritoneal and nodal metastatic disease were extracted from surgical and histologic records.

SETTINGS

The study was conducted at a high-volume tertiary referral center for peritoneal malignancy.

PATIENTS

Patients referred with histologically high-grade appendix tumors at appendicectomy, without detectable metastatic spread, between January 1994 and September 2016 were included MAIN OUTCOME MEASURES:: A total of 62 patients with high-grade pathology at appendicectomy, without clinical or radiological peritoneal disease, underwent complete cytoreduction with hyperthermic intraperitoneal chemotherapy.

RESULTS

Thirty-five (57%) of 62 patients had peritoneal disease (median peritoneal cancer index 5 (range, 1-28)). Eleven (31%) of 35 had microscopic peritoneal disease. Overall, 23 (37%) of 62 had peritoneal disease beyond the confines of a standard right hemicolectomy. Nine (15%) of 62 had nodal involvement. Mean overall and disease-free survival were 110.9 (95% CI, 94.8-127.0 mo) and 102.1 months (95% CI, 84.3-119.9 mo), with 5-year overall and disease-free survival of 83.2% and 76.0%.

LIMITATIONS

The retrospective nature limits the interpretation of these results.

CONCLUSIONS

Complete cytoreduction was achieved in all of the patients, with excellent long-term survival. The incidence of peritoneal spread (57%) compared with nodal involvement (15%) supports cytoreductive surgery and hyperthermic intraperitoneal chemotherapy as definitive treatment rather than prophylaxis in patients with high-grade appendix tumors, even without radiologically detectable disease. High-grade appendix tumors benefit from early aggressive operative management to deal with potential peritoneal and nodal spread and should be considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. See Video Abstract at http://links.lww.com/DCR/A360.

Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy

Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient’s factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon’s skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.

Incidental appendectomy? Microscopy tells another story: A retrospective cohort study in patients presenting acute right lower quadrant abdominal pain

BACKGROUND

Optimal management of macroscopically normal appendix encountered during laparoscopy for acute abdominal pain is still unclear.

METHODS

164 acute abdominal pain cases in which laparoscopy showed a normal appendix were reviewed. No other intra-peritoneal acute disease was present in 50 patients (Group 1) whereas a miscellanea of intra-peritoneal conditions was identified in the other 114 (Group 2). All the patients underwent appendectomy with specimen examination.

RESULTS

Following incidental appendectomy significant microscopical changes were seen in 125 specimens (76%). Among these, inflammation was found in 122 and neuroendocrine tumors in 3. Appendices harbored pathological changes in n = 45 patients (90%) of Group 1 and in n = 34 patients (70%) of Group 2 patients (p < 0.05). Morbidity for incidental appendectomy was 2%.

CONCLUSION

This study supports an appendectomy in patients who are undergoing laparoscopy for acute right lower quadrant abdominal pain even when the appendix appears normal on visual inspection.

Two rare cases of appendiceal collision tumours involving an appendiceal mucinous neoplasm and carcinoid

We report two rare cases of appendiceal collision tumours, each involving an appendiceal mucinous neoplasm with a concomitant appendiceal carcinoid. The first case presented with acute appendicitis while the second presented with an incidental radiological finding of an enlarged appendix as part of evaluation for raised serum carcinoembryonic antigen. Diagnosis in both cases was made postoperatively on histological assessment following appendicectomy. Clinical and histological features of both tumour types in each case did not necessitate further surgical resection or adjuvant treatment. Both patients did well postoperatively and had no evidence of disease recurrence on follow-up.

Appendiceal neuroendocrine neoplasms: diagnosis and management

Gastrointestinal neuroendocrine neoplasms (GI-NENs) are increasingly being recognised, while appendiceal NENs (aNENs) currently constitute the third most common GI-NEN. Appendiceal NENs are generally considered to follow an indolent course with the majority being localised at diagnosis. Thus, the initial surgical approach is not that of a planned oncological resection. Due to the localised nature of the disease in the majority of cases, subsequent biochemical and radiological assessment are not routinely recommended. Histopathological criteria (size, mesoappendiceal invasion, Ki-67 proliferation index, neuro- and angio-invasion) are mainly used to identify those patients who are also candidates for a right hemicolectomy. Goblet cell carcinoids are a distinct entity and should be treated as adenocarcinomas. Despite the absence of any substantial prospective data regarding optimal management and follow-up, recent consensus statements and guidelines have been published. The purpose of this review is to overview the published studies on the diagnosis and management of appendiceal NENs and to suggest a possible management protocol.

Mucocele of the Appendix: Dilemmas in Differential Diagnosis and Therapeutic Management

Mucocele of the appendix (AM) is a descriptive term for mucinous distension of the appendiceal lumen. It refers to the progressive retrograde dilatation of the vermiform appendix. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. We present three isolated cases of AM complicated by the development of acute inflammation of the appendix. Currently, the assessment of appendiceal lesions relies heavily on Ultra Sonography (US) as the primary diagnostic tool. This however may not always identify the origin of such a tumour. Therefore, additional investigative modalities are implemented. Despite recent research on the therapeutic strategies against appendiceal neoplastic disorders, surgical resection appears the only potentially curative approach. Accepted management includes appendectomy, right hemicolectomy, partial colectomy with debulking or palliative resection combined with additional chemotherapy. Even if laparoscopy has been successfully used to perform appendectomy, some concerns exist regarding its use in dealing with mucinous secreting lesions because of possible spillage of mucin intra-operatively. The aim of this investigation was to analyze all cases of AM complicated by the development of acute inflammation of the appendix presented in our institution. The relevant literature is briefly reviewed. Clinical features, diagnostic approach and management algorithm for appendiceal lesions are also discussed.

Unexpected Histopathological Findings in Appendectomy Specimens: a Retrospective Study of 1627 Cases

Pathologic evaluation of the appendix after appendectomy is routine and can occasionally identify unexpected findings. The aim of the present study was to determine the incidence and type of pathologic diagnoses found in appendectomy specimens at our institution. The clinicopathological data of 1627 patients who underwent appendectomies for presumed acute appendicitis from January 2008 to October 2014 were reviewed retrospectively. There were 986 men and 641 women (sex ratio M/F = 1.5) aged between 16 months and 90 years (mean = 30 years). All patients underwent appendectomy (either open or laparoscopic). Histological examination of the surgical specimen showed acute inflammation of the appendix in 1455 cases (89.42 %), fibrosed appendix in 37 cases (2.27 %), and Enterobius vermicularis (n = 23). In 101 cases (6.2 %), the appendix was histologically normal. Incidental unexpected pathological diagnoses were noted in 57 appendectomy specimens. They included pinworm (n = 23), mucinous neoplasms (n = 12), neuroendocrine tumors (NET) (n = 8), adenocarcinoma (n = 2), granulomatous inflammation (n = 5), tuberculosis (n = 2), hyperplastic polyp (n = 1), tubular adenoma (n = 1), diverticulitis (n = 1), endometriosis (n = 1), and actinomycosis (n = 1). The routine histopathological examination of the appendix is of value for identifying unsuspected conditions requiring further postoperative management. Gross examination alone does not appear to be a good indicator of an unexpected finding on microscopic exam. It is recommended that in order to avoid misdiagnoses, all appendices should be histopathologically examined.

Solitary Peutz-Jeghers-type appendiceal hamartomatous polyp growing into the terminal ileum

Solitary Peutz-Jeghers type hamartomatous polyp is rare. It is considered to be related to a variant Peutz-Jeghers syndrome (PJS) and may be a separate disease entity. A 50-year-old man was referred to our hospital with a diagnosis of intussusception in the terminal ileum and underwent segmental ileal resection with appendectomy. We identified a 3.5-cm diameter polyp arising from the appendix with ingrowth into the terminal ileum. The polyp was confirmed to be a hamartomatous polyp of Peutz-Jeghers-type, histologically. However, the patient had no characteristic manifestations of PJS such as mucocutaneous pigmentation and family history. There are few reports of appendiceal hamartomatous polyp in PJS patients and solitary appendiceal hamartomatous polyp is even rarer. Also, rather than telescoping, ours is the first reported intussuscepted lesion, to the best of our knowledge.

Unusual findings in appendectomy specimens of adults: retrospective analyses of 1466 patients and a review of literature

BACKGROUND

Diseases and tumors of the appendix vermiformis are very rare, except acute appendicitis.

OBJECTIVES

This retrospective study was conducted to document the unusual findings in appendectomy specimens.

PATIENTS AND METHODS

Data of 1466 adult patients were gathered retrospectively. Appendectomy was performed in 1169 and in 297 patients following a diagnosis of acute appendicitis and during other abdominal operations, respectively. The data of 57 (3.88 %) patients who were pathologically reported to have unusual appendix findings were retrospectively collected. The records were analyzed according to patients' age, gender, clinical presentations, operative reports, pathological reports and follow up.

RESULTS

Unusual pathologic examination findings were detected in the appendectomy specimens of 57 patients with a mean age of 48.34 ± 19. Twenty-nine patients (50.8 %) were male and 28 (49.2 %) were female. Normal appendix tissues were observed in specimens of 26 (45.6 %) patients and inflamed appendix in 31 (54.3 %). The most common unusual finding was parasitic diseases of the intestine. Pathological diagnosis of malignancy and benign features were reported in specimens of 14 and 43 patients, respectively. Macroscopic evaluation of appendectomy specimens during surgery might result in negligence of the presence of unusual pathology.

CONCLUSIONS

Even if the macroscopic appearance of the specimen is normal or acute appendicitis, we suggest routine histopathological examination.

The incidence of mucinous appendiceal malignancies: a population-based study

PURPOSE

Mucinous appendiceal tumours were described already 180 years ago, but reliable data on the incidence of these tumours are sparse. The clinical importance of these tumours is increasing since they are now identified as the most common site of origin for pseudomyxoma peritonei (PMP), which is currently recognised as a treatable condition.

METHODS

Data on the incidence of mucinous appendiceal tumours were retrieved from the Eindhoven Cancer Registry, which collects data on all patients with newly diagnosed cancer in a large part of the southern Netherlands that comprises about 2.3 million inhabitants. From 1980 to 2010, all cases of primary adenocarcinomas of the appendix were included.

RESULTS

From 1980 to 2010, a mucinous adenocarcinoma was diagnosed in 78 patients being 48 % of all cases of appendiceal adenocarcinoma diagnosed during this period (n = 164). The incidence increased during the study period from 0.6 to 1.9 per 1,000,000 person-years for women and from 0.4 to 1.0 per 1,000,000 person-years for men.

CONCLUSION

The reported incidence of mucinous adenocarcinomas of the appendix shows an increasing trend. This is probably mainly explained by the increased awareness of this tumour and its relation with PMP, and better registration of this specific diagnosis.

Appendiceal intussusception to the cecum caused by mucocele of the appendix: Laparoscopic approach

INTRODUCTION

Appendiceal intussusception is a very rare disease that is found in only 0.01% of patients who have undergone an appendectomy. Clinical symptoms vary and some patients are asymptomatic. Laparoscopic surgery for appendiceal tumors is still controversial. We present a case of intussusception of the appendix with a mucinous cystadenoma treated by laparoscopic surgery.

PRESENTATION OF CASE

We report a case of 47 year-old-women patient who presented with a six month history of intermittent right lower abdominal pain. Abdominal computer tomography CT showed appendiceal mass with intussusception. A laparoscopic right hemicolectomy was performed because the tumor involved the entire appendix. Histopathological examination revealed mucocele due to mucinous cystadenoma of appendix.

DISCUSSION

Appendiceal intussusception to the cecum caused by mucocele of the appendix is extremely rare. It is very difficult to diagnose the presence of an intussuscepted appendix pre-operatively and investigations will usually include colonoscopy and CT scan. An appendicular intussusception should not be reduced by colonoscopy. Laparoscopic surgery for appendiceal tumors is still controversial; the main concerns to be addressed are the adequacy of resection and intraperitoneal rupture of the tumor. Our patient successfully underwent laparoscopic surgery without any complications.

CONCLUSION

Appendiceal intussusception to the cecum caused by mucocele of the appendix is a rare cause of abdominal pain and difficult to diagnose. The laparoscopic surgery for appendiceal tumors is safe, feasible, and even may be beneficial.

Pedunculated hamartomatous polyp of the appendix: report of a case

We experienced a rare case of a pedunculated polyp of the appendix, which had been incidentally found by preventive appendectomy performed when providing surgical treatment for rectal carcinoma. A pathological investigation of this polypoid lesion demonstrated branches of fibro-muscular stalks connecting with the lamina muscularis covered by a hyperplastic mucosa, which proved to be consistent with the features of hamartoma. The patient had no external characteristics of Peutz-Jeghers syndrome, including mucocutaneous pigmentation and gastrointestinal polyposis, observed by endoscopy. This case is considered to be a Peutz-Jeghers type polyp of the appendix with a pedunculated form, which is very rare.

Increased Risk of Neoplasm in Appendicitis Treated with Interval Appendectomy: Single-Institution Experience and Literature Review

Appendicitis is a common diagnosis encountered by the acute care surgeon. Management of complicated appendicitis is controversial and often involves initial nonoperative therapy with interval appendectomy. This study reviews single-institutional experience with management of complicated appendicitis with interval appendectomy and addresses an unusually high occurrence of incidental appendiceal malignancies observed with a review of relevant literature. A retrospective review of all diagnoses of appendicitis was performed over 5 years at a tertiary care center. Patient demographics, time to surgery, operative technique, pathologic diagnosis, and clinical outcomes were examined. Three hundred fifteen patients were diagnosed with acute appendicitis. Of these, 24 (7.6%) were deemed complicated and did not undergo immediate appendectomy, and 18 ultimately underwent appendectomy at our institution and were included in analysis. There were no statistical demographic or symptomatic differences between the immediate and interval appendectomy patients. Ninety-nine per cent of the immediate appendectomy patients were treated laparoscopically; 78 per cent of the interval group underwent attempted laparoscopic treatment with 56 per cent completed without conversion to open ( P < 0.01). Neoplasms were discovered in 1 per cent of the acute appendectomy group and 28 per cent of the interval appendectomy group ( P < 0.0001). Two of the three neoplasms in the acute group were carcinoid, whereas three of the five neoplasms in the interval group were adenocarcinoma. Surgeons should consider appendiceal or colonic neoplasms in cases of complicated appendicitis when nonoperative management is considered. This is most important in patients older than 40 years, in those who forego interval appendectomy, or in those who could be lost to follow-up.

[Surgical strategies for accidental detection of appendix carcinoids]

Carcinoids (neuroendocrine tumors NET) of the appendix are rare tumors and even today mostly detected only postoperatively by histopathology following operations for acute appendicitis or other abdominal procedures. Most NETs of the appendix are located at the tip of the appendix, less than 2 cm in size and non-metastasizing. Secondary right hemicolectomy with lymph node dissection bears a considerable risk of complications compared to simple appendectomy. To decide upon secondary surgery histopathological risk factors, such as grading, invasion of the mesoappendix, and tumor type in addition to tumor localization and size should be taken into consideration. Up to 20% of NETs of the appendix are associated with various neoplasms of the gastrointestinal tract. Follow-up examination should therefore also consider both appendix carcinoids and synchronous or metachronous neoplasms of the gastrointestinal tract.

Unusual histopathological findings in appendectomy specimens: A retrospective analysis and literature review

AIM: To document unusual findings in appendectomy specimens.

METHODS: The clinicopathological data of 5262 patients who underwent appendectomies for presumed acute appendicitis from January 2006 to October 2010 were reviewed retrospectively. Appendectomies performed as incidental procedures during some other operation were excluded. We focused on 54 patients who had unusual findings in their appendectomy specimens. We conducted a literature review via the PubMed and Google Scholar databases of English language studies published between 2000 and 2010 on unusual findings in appendectomy specimens.

RESULTS: Unusual findings were determined in 54 (1%) cases by histopathology. Thirty were male and 24 were female with ages ranging from 15 to 84 years (median, 32.2 ± 15.1 years). Final pathology revealed 37 cases of enterobiasis, five cases of carcinoids, four mucinous cystadenomas, two eosinophilic infiltrations, two mucoceles, two tuberculosis, one goblet-cell carcinoid, and one neurogenic hyperplasia. While 52 patients underwent a standard appendectomy, two patients who were diagnosed with tuberculous appendicitis underwent a right hemicolectomy. All tumors were located at the distal part of the appendix with a mean diameter of 6.8 mm (range, 4-10 mm). All patients with tumors were alive and disease-free during a mean follow-up of 17.8 mo. A review of 1366 cases reported in the English literature is also discussed.

CONCLUSION: Although unusual pathological findings are seldom seen during an appendectomy, all appendectomy specimens should be sent for routine histopathological examination.

Laparoscopic approach to a case of appendicular schwannoma

Appendicular schwannoma is a rare tumor originating from Schwann's cells in the Auerbach plexus. The preoperative diagnosis is difficult because the clinical features are nonspecific, and it is mostly found accidentally via a radiologic image as a tumor, mimicking malignancy. We report a case of an appendicular schwannoma coexisting with an adenocarcinoma in the lung. A laparoscopic appendectomy was done with a clear resection margin, and the immunohistochemical staining showed positive S-100 protein, which confirmed the schwannoma. The patient also underwent a left upper lobectomy of the lung. The patient has been free of recurrence for the 6 months since the operation. The laparoscopic approach could be available for treatment of an appendicular schwannoma, thus avoiding an unnecessary laparotomy.

Primary appendiceal carcinoma--epidemiology, surgery and survival: results of a German multi-center study

BACKGROUND

While carcinoma of the colon is a common malignancy, primary carcinoma of the appendix is rare. Many retrospective reviews outlined experience from different centers on appendiceal neoplasms. However, the study population is often small because it is so rare. The aim of this study was to analyze the type of surgery and survival of patients with appendiceal malignancies using data from a German multi-center observational study (31 341 patients).

METHODS

During a five-year period, 196 consecutive patients with malignant appendiceal tumors were distributed into four groups: appendiceal carcinoids, adenocarcinoma, mucinous adenocarcinoma and adenosquamous carcinoma. The following parameters were analyzed: demographics, clinical presentation, comorbidities, type and appropriateness of surgery, final pathology and survival.

RESULTS

Adenocarcinoma had the highest incidence (50.5%). The most common presentation was that of acute appendicitis. Mean age at presentation was youngest for carcinoid tumors. Carcinoid tumors had lowest tumor size and localized disease was present in 72.9%. Metastatic spread at presentation was highest for adenosquamous and mucinous adenocarcinoma and each had a distinct pattern. Right hemicolectomy was performed in 71.4%, limited resection in 11.7%. Overall 5-year survival was 83.1% for carcinoid vs. 49.2% for non-carcinoid tumors. Histological subtype and tumor stage significantly affected survival.

CONCLUSIONS

Long-term outcome of carcinoid tumors is superior to non-carcinoid neoplasms. Among all appendiceal neoplasms, adenosquamous carcinoma is the rarest histological subtype which is most commonly associated with advanced tumor stage and worst prognosis. Appropriate oncologic resection is being performed in a significant percentage of cases in Germany. However, the high rate of right hemicolectomy in patients with small carcinoid tumors needs to be critically discussed.

Laparoscopic right hemicolectomy for goblet-cell carcinoid of the appendix: report of a rare case and literature survey

Tumors of the appendix are rare entities, and the majority of them are discovered accidentally during an investigation for other conditions. Laparoscopic surgery for appendiceal goblet-cell carcinoid (GCC) has only been reported once before. Our patient was incidentally discovered to have an appendiceal tumor and was referred to us for laparoscopy. The tumor involved the body of the appendix and was adherent to the cecum. A laparoscopic hemicolectomy was successfully performed for the patient. Postoperative recovery was uneventful. Histopathology confirmed an appendiceal goblet-cell carcinoid. Immunohistochemistry was negative for the neuroendocrine markers, CK20 and CK7. GCC is a rare tumor of the appendix. Hemicolectomy is indicated in specific situations, such as local involvement or tumor size >2 cm. In our patient, the tumor was adherent to the cecum and tumor size was 5 cm. Therefore, a laparoscopic right hemicolectomy was performed primarily. There are several reports in the literature supporting both the laparoscopic and open approaches. Laparoscopic surgery for appendiceal tumors is safe, feasible, and even may be beneficial.

Diverticular disease of the vermiform appendix: a diagnostic clue to underlying appendiceal neoplasm

Acquired diverticula of the vermiform appendix are rare and arise as a result of different pathogenetic mechanisms. One of the etiologies includes proximally located, often unsuspected small neoplasms. Although the association of appendiceal diverticulosis and neoplasia is known, it remains underemphasized in the teaching and practice of surgical pathology. To investigate the frequency of appendiceal neoplasms with acquired diverticulosis, we conducted a retrospective analysis of all appendectomy specimens received in our institution for a 55-month period (January 2002-July 2006). A total of 1361 appendectomy specimens were identified. Diverticulosis was diagnosed in 23 (1.7%) of all cases. Eleven (48%) appendectomy specimens with diverticulosis also harbored an appendiceal neoplasm. The association of appendiceal neoplasms with diverticulosis was statistically significant (P < .0001, 2-sided Fisher exact test). Neoplastic processes included 5 well-differentiated neuroendocrine tumors (carcinoids), 3 mucinous adenomas, 1 tubular adenoma, and 2 adenocarcinomas. In one case, routine representative sections sampled only a small focus of carcinoma, which originally went undiagnosed. We stress the need for meticulous gross assessment with histologic examination of the entire appendectomy specimen in cases of appendiceal diverticulosis. Thorough examination is required to rule out an underlying neoplasm as a cause of diverticulosis. As acquired diverticula represent a rare finding, examination of the entire appendix in this setting does not create a significant impact on the workload within the pathologic laboratory.