Incidence and predictors of appendiceal tumors in elderly males presenting with signs and symptoms of acute appendicitis

A Rare Presentation of Appendiceal Carcinoma

Appendiceal cancer is a rare malignancy. Our patient presented initially to her primary care physician due to symptoms of lightheadedness and dizziness and was found to have severe anemia requiring hospital admission. She underwent a colonoscopy and was found to have mucosal ulceration in the appendiceal orifice. She underwent a biopsy of the ulceration, which was remarkable for moderately differentiated adenocarcinoma. The patient then underwent a right hemicolectomy. The usual presentation for appendiceal carcinoma is acute appendicitis; however, our patient presented with the microcytic anemia.

Appendiceal adenocarcinoma found by surgery for acute appendicitis is associated with older age

BACKGROUND

Appendectomy for acute appendicitis is the most common procedure performed emergently by general surgeons in the United States. The current management of acute appendicitis is increasingly controversial as non-operative management gains favor. Although rare, appendiceal neoplasms are often found as an incidental finding in the setting of appendectomy. Criteria and screening for appendiceal neoplasms are not standardized among surgical societies.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent appendectomy over a 9-year period (2010-2018). Over the same time period, patients who underwent appendectomy in two municipal hospitals in The Bronx, New York City, USA were reviewed.

RESULTS

We found a 1.7% incidence of appendiceal neoplasms locally and a 0.53% incidence of appendiceal tumors in a national population sample. Both groups demonstrated an increased incidence of appendiceal carcinoma by age. This finding was most pronounced after the age of 40 in both local and national populations. In our study, the incidence of appendiceal tumors increased with each decade interval up to the age of 80 and peaked at 2.1% in patients between 70 and 79 years.

CONCLUSIONS

Appendiceal adenocarcinomas were identified in patients with acute appendicitis that seem to be associated with increasing age. The presence of an appendiceal malignancy should be considered in the management of older patients with acute appendicitis before a decision to embark on non-operative therapy.

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.

Vesico-appendiceal fistula secondary to adenocarcinoma of the appendix: a case report and literature review

A 50-year-old woman presented with a 5-month history of recurrent urinary tract infections. She had no complaints of any intestinal symptoms. She had been treated previously with oral antibiotics. The episodes became more frequent and she started with pain in the lower abdomen and fetid urine. Complete study lead to diagnosis of adenocarcinoma of the appendix with bladder fistula. The lesion was removed by laparoscopic right hemicolectomy and en bloc partial cystectomy. Pathological examination revealed a mucinous adenocarcinoma that had originated in the appendix and extended into the bladder wall. Six years after the operation, the patient remains asymptomatic with no evidence of recurrent or metastatic disease. Appendiceal carcinoma extending to the bladder is extremely rare and approximately 40 cases have been described. Management of recurrent urinary tract infections should not limit to empiric antibiotic therapy before the exclusion of possible organic causes. Appendiceal carcinoma may invade the bladder without intestinal symptoms but with urinary symptoms only, because of its anatomical position. The recommended treatment for non-carcinoid appendiceal tumours is right hemicolectomy and for T4 tumours en bloc resection of the involved structures. Further study is needed to determine adjuvant therapy. A literature review was made.

Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study

BACKGROUND

The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal malignancy.

METHODS

Using the Eastern Association for the Surgery of Trauma Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, we included all patients from 28 centers undergoing immediate, delayed, or interval appendectomy between 2017 and 2018. Univariate then multivariable analyses were performed to compare patients with and without malignancy and to identify independent demographic, clinical, laboratory, and/or radiological predictors of malignancy. Akaike information criteria for regression models were used to evaluate goodness of fit.

RESULTS

A total of 3,293 patients were included. The median age was 38 (27-53) years, and 46.5% were female patients. On pathology, 48 (1.5%) had an underlying malignancy (adenocarcinoma [60.4%], neuroendocrine [37.5%], and lymphoma [2.1%]). Patients with malignancy were older (56 [34.5-67] vs 37 [27-52] years, P < .001), had longer duration of symptoms before presentation (36-41 vs 18-23 hours, P = .03), and were more likely to have a phlegmon on imaging (6.3% vs 1.3%, P = .03). Multivariable analyses showed that an enlarged appendiceal diameter was independently associated with malignancy (odds ratio = 1.06, 95% confidence interval = 1.01-1.12; P = .01). The incidence of malignancy in patients >40 years with an appendiceal diameter >10 mm on computed tomography was 2.95% compared with 0.97% in patients ≤40 years old with appendiceal diameter ≤10 mm. The corresponding risk ratio for that population was 3.03 (95% confidence interval: 1.24-7.42; P = .02).

CONCLUSION

The combination of age >40 and an appendiceal diameter >10 mm is associated with a greater than 3-fold increased risk of malignancy in patients presenting with appendicitis.

The Understated Malignancy Potential of Nonoperative Acute Appendicitis

Cancer of the appendix is rare and is most commonly found incidentally on pathology after an appendectomy for uncomplicated appendicitis (UA). The medical management alternative with antibiotics and observation remains an ongoing debate. The purpose of our study was to develop modern epidemiological data for adult patients completing an appendectomy for UA secondary to an appendiceal neoplasm (AN). ACS-NSQIP database was queried (2005–2016) to identify patients completing an appendectomy. Cohorts of patients who were diagnosed with UA and an AN were included in the study. Relevant perioperative clinical and outcomes data were collected. Type of AN, surgical procedure, and mortality were analyzed. A total of 239,615 UA patients were identified, of whom 2,773 (1.2%) met the inclusion criteria of AN. Patients with AN were predominantly white (79.5%), with a mean age of 54.5 ± 15.9 years, and 54.6 per cent were females. AN pathology findings included malignant neoplasm (64.5%), malignant carcinoid (17.3%), benign carcinoid (9.3%), and benign neoplasm (8.8%). The overall reported incidence was 1.2 per cent and the mortality rate was 0.7 per cent. Our study emphasizes surgical intervention in adult UA maintains a 1 per cent incidence of AN, and treatment with antibiotics alone will presumably lead to a delay in surgical treatment and progression of disease.

Geriatric patients undergoing appendectomy have increased risk of intraoperative perforation and/or abscess

BACKGROUND

The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission.

METHODS

The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis.

RESULTS

From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01-2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12-1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79-8.25, P = .116), compared with the younger cohort.

CONCLUSION

Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy.

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Risk factors for appendiceal neoplasm and malignancy among patients with acute appendicitis

PURPOSE

Non-operative management of acute uncomplicated appendicitis has shown promising results but might carry the risk of delayed diagnosis of premalignant or malignant appendiceal tumors found by chance in 0.7-2.5% of appendiceal specimen after appendectomy. Purpose of this study was to analyze whether appendiceal tumors are associated with a complicated appendicitis and to determine risk factors for appendiceal neoplasm and malignancy in patients with acute appendicitis.

METHODS

We performed a retrospective analysis of 1033 adult patients, who underwent appendectomy for acute appendicitis from 2010 to 2016 at the University hospital Erlangen. Data included patients' demographics; comorbidities; pre-, intra- and postoperative findings; and histopathological results. Complicated appendicitis was defined in the presence of perforation or abscess.

RESULTS

Appendiceal neoplasm respectively malignancy rate was 2.8% respectively 1.5%. Using univariate analysis, we identified seven risk factors at least for appendiceal neoplasm or malignancy: age, ASA, C-reactive protein, appendiceal diameter, perforation, intraoperative perithyphilitic abscess, and complicated appendicitis. Risk for appendiceal neoplasm or malignancy was 4.4% respectively 2.7% in complicated acute appendicitis compared to 2.0% respectively 1.0% in uncomplicated appendicitis (p = 0.043 respectively p = 0.060). In multivariate analysis, age ≥ 50 years and a diameter of the appendix in the sonography ≥ 13 mm were independent risk factors predicting the presence of appendiceal neoplasm and malignancy.

CONCLUSION

Among patients with appendicitis, there are relevant risk factors predicting appendiceal tumors, especially age and appendiceal diameter in sonography. But the identified risk factors have a low sensitivity and specificity, so obtaining a confident preoperative diagnosis is challenging.

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

BACKGROUND

The misdiagnosis of appendiceal cancer as inflammatory appendicitis is becoming of greater clinical concern because of the rise of nonoperative management especially in the elder population. To quantify this rate of misdiagnosis, we retrospectively reviewed SEER-Medicare data.

METHODS

The SEER-Medicare database was reviewed from 2000 to 2014. We identified patients older than 65 years old who were diagnosed with appendiceal cancer and then cross-referenced them for a diagnosis of inflammatory appendicitis. Demographic data and oncologic stage were collected.

RESULTS

Our results showed that 28.6% of appendiceal cancer patients received an incorrect initial diagnosis of inflammatory appendicitis. Patients older than 75 years of age were more likely to be misdiagnosed than those between ages 65 and 75 (risk ratio [RR]: 0.81; 95% confidence interval: 0.70-0.93; P = .003). We found that 42% of patients within the misdiagnosis group presented with an earlier stage of disease (stage 1 or 2) compared to 26% of those primarily diagnosed with appendiceal cancer (P < .001).

CONCLUSION

A significant proportion of patients older than 65 years old with appendiceal cancer were initially misdiagnosed with acute appendicitis. We suggest caution when considering a nonoperative approach for appendicitis in the elderly and follow-up imaging or an interval appendectomy should be part of the treatment plan.

Tubulo-villous adenoma of the appendix: A case report and review of the literature

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Tubulo-villous adenoma is a rare benign appendiceal neoplasm.

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This neoplasm is often asymptomatic and occasionally discovered at surgery.

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Acute appendicitis is the most common clinical presentation.

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Pre-operative diagnosis, even with the help of radiological imaging, is difficult.

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Appendectomy is considered the correct treatment.

Introduction

Tubulo-villous adenoma is a rare benign appendiceal neoplasm often asymptomatic with the most clinical manifestation that resembles acute appendicitis. Pre-operative diagnosis is difficult by its rarity and the absence of typical symptoms. Adequate treatment is surgical resection.

Presentation of case

A 69-year-old male was admitted to the Emergency Department with a two-day history of abdominal pain associated with constipation. Abdominal examination revealed abdominal pain localized, at deep palpation, in the right iliac fossa and in hypogastrium without obvious muscle guarding or rebound tenderness. Laboratory tests showed a normal white blood cell count with 82.3% neutrophils and high C-reactive protein level. After a negative abdominal ecography, the patient was evaluated by abdominal computed tomography, which revealed acute appendicitis. The patient was submitted to surgery and open appendectomy was performed. The post-operative course was uneventful and the patient was discharged on the 5^th post-operative day.

Discussion

Acute appendicitis may be a clinical manifestation of a benign appendiceal neoplasm. Pre-operative radiological investigations not always are useful for an early diagnosis that is mandatory because of the potential risk of malignant degeneration. Appropriate treatment of acute appendicitis is debated: some surgeons suggest operative treatment, but others advocate for non-operative management. In our case the patient was submitted to surgery avoiding the risk of diagnostic delay of neoplasm.

Conclusion

Appendiceal tubulo-villous adenoma is a rare neoplasm difficult to diagnose and suspect because of lack of pathognomonic symptoms and specific diagnostic signs. Acute appendicitis is the most common clinical presentation. Appendectomy is the appropriate treatment.

Two concurrent appendiceal neoplasms in an elderly patient: A case report

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Acute appendicitis is a rare diagnosis in the elderly; atypical causes like cancer should be considered in these scenarios.

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Risk factors for appendiceal cancer include older age, abnormally long duration of symptoms, and low hematocrit.

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High incidence of synchronous colon cancers with appendiceal tumors entails ruling out such lesions before definitive surgery.

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The role/timing of right hemicolectomy in appendiceal cancers remain controversial - evaluate on a case by case basis.

Introduction

Acute appendicitis, one of the commonest surgical diagnoses, is rare and more complex presentation in the elderly. Physicians must consider atypical causes appendicitis in this population, which could affect the management of the patient.

Presentation of case

An elderly female presented with a two-day history of lower abdominal pain, associated with low-grade fevers and chills. Studies showed leukocytosis and computed tomography (CT) findings consistent with appendicitis. She underwent laparoscopic appendectomy. Intra-operatively, the Appendix had an unusual appearance, so a frozen-section was obtained, suggestive of a mucinous neoplasm with grossly clear margins. Despite the possibility that she may require a more extensive cancer operation pending the final Pathology results, the decision was made to complete the operation at this stage, and return at a later date if needed, after completing the patient's work-up with a colonoscopy to rule out any synchronous colonic lesions that could alter her surgical management. Final Pathology revealed both a low-grade appendiceal mucinous neoplasm, as well as a tip carcinoid tumor, both of which were adequately treated with appendectomy alone.

Discussion

Physicians treating elderly patients with appendicitis should suspect an atypical etiology, such as appendiceal cancer. Early identification and appropriate pre-operative counseling may alter the surgical management.

Conclusion

The role and timing of right hemicolectomy in treating appendiceal cancers remain controversial, and should be evaluated on a case by case basis.

Utility of Appendiceal Calcifications Detected on Computed Tomography as a Predictor for an Underlying Appendiceal Epithelial Neoplasm

BACKGROUND

Mucinous appendiceal neoplasms can contain radiopaque calcifications. Whether appendiceal radiographic calcifications indicate the presence of an appendiceal epithelial neoplasm is unknown. This study aimed to determine whether appendiceal calcifications detected by computed tomography (CT) correlate with the presence of appendiceal epithelial neoplasms.

METHODS

From prospective appendiceal and pathology databases, 332 cases of appendiceal neoplasm and 136 cases of control appendectomy were identified, respectively. Only cases with preoperative CT scans available for review were included in the study. Images were reviewed by two abdominal radiologists. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated, and the kappa statistic was used to determine agreement between the radiologists' interpretations.

RESULTS

Interobserver agreement between the radiologists was substantial, with a kappa of 0.74. Appendiceal mural calcifications were identified on CT scans in 106 appendiceal neoplasm cases (32%) and in 1 control case (1%) (P = 0.0001). In the appendiceal neoplasm subgroup, the presence of radiographic calcifications was associated with mucinous histology (35% vs 17%; P = 0.006; odds ratio [OR], 0.38; 95% confidence interval [CI], 0.18-0.78) and with well-differentiated histologic grade (40% vs 24%; P = 0.002; OR, 0.47; 95% CI, 0.29-0.76). The findings showed a sensitivity of 31.9% (95% CI, 26.9-37.2%), a specificity of 99.3% (95% CI, 96-100%), a PPV of 99.1% (95% CI, 94.9-100%), and an NPV of 37.4% (95% CI, 32.4-42.6%).

CONCLUSION

This case-control study showed that appendiceal mural calcifications detected on CT are associated with underlying appendiceal epithelial neoplasms and that the identification of incidental mural appendiceal calcifications may have an impact on decisions regarding surgical intervention.

Predicting appendiceal tumors among patients with appendicitis

BACKGROUND

As nonoperative management of appendicitis gains popularity, vigilance for appendiceal tumors becomes increasingly important. We hypothesized that, among patients presenting with acute appendicitis, those with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis would be more likely to have underlying appendiceal tumors.

METHODS

We performed a 4-year retrospective cohort analysis of 677 consecutive adult patients who underwent appendectomy for appendicitis at our tertiary care center. Patients with an appendiceal tumor on their final pathology report were compared to patients with no tumor. Conditions present on admission were used to create a multivariate logistic regression model to predict appendiceal tumor. Risk factors were reported as odds ratio (OR) [95% CI]. Model strength was assessed by area under the receiver operating characteristic curve.

RESULTS

Seventeen patients (2.5%) had an appendiceal tumor. Within this group. 14 underwent immediate appendectomy, two initially had nonoperative management but failed to improve on antibiotics and underwent appendectomy during the initial admission, and one had successful nonoperative management and elective appendectomy 19 days after discharge. Four variables contributed to the multivariate model to predict the presence appendiceal tumor: age ≥ 50 (OR 3.6 [1.1-11.4]), outpatient steroid/immunosuppressant use (OR 12.1 [2.0-72.5]), the absence of migratory right lower quadrant pain (OR 4.7 [1.2-18.1]), and the appearance of a phlegmon on CT scan (OR 7.0 [1.6-30.2]); model area under the receiver operating characteristic curve: 0.860 [0.705-0.969].

CONCLUSION

For patients presenting with acute appendicitis, conditions present on admission may predict underlying appendiceal tumor. Patients with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis should be considered for appendectomy during the index admission or at earliest convenience if nonoperative management is necessary.

LEVEL OF EVIDENCE

Prognostic study, level III.

Appendicitis in Cancer Patients is often Observed and Can Represent Appendiceal Malignancy

Appendectomy is standard of care for uncomplicated appendicitis, but cancer patients may not be optimal surgical candidates. Interval appendectomy is controversial, and appendiceal malignancy is rare. Study objectives were to review the role of surgery, observation, and interventional radiology (IR)-guided drainage in patients with appendicitis and advanced malignancy. Retrospective review was performed on cancer patients presenting to a tertiary academic cancer center from January 1, 2001 to December 31, 2014. Patients diagnosed with appendicitis were assigned to observation, surgery, and IR drainage after surgical evaluation. Success rates of initial treatment strategies were calculated. Rates of interval appendectomies and pathology were reviewed. Of 72 consults, 32 patients were included. Median age was 53 years, 50 per cent (16/32) were male, 50 per cent (16/32) had chemotherapy less than six weeks to presentation, and 63 per cent (20/32) had advanced stage malignancy. Of the 62.5 per cent (20/32) observed, 25 per cent (8/32) received immediate surgery, 12.5 per cent (4/32) required IR drainage, and 69 per cent (22/32) of patients were initially managed without surgery. Interval appendectomy rate was 19 per cent (6/32). Pathology confirmed appendiceal malignancies in 9.3 per cent (3/32). Cancer patients with acute appendicitis are frequently observed. High incidence of appendiceal malignancy may be due to the older median age. Interval appendectomy should be considered in this population.

Incidence of right-sided colonic tumors (non-appendiceal) in patient's ≥40 years of age presenting with features of acute appendicitis

INTRODUCTION

Non-appendiceal tumors can mimic and present with clinical features of acute appendicitis in patients of age 40 years or above. The aim of this prospective study is to investigate the incidence of right-sided (non-appendiceal) colonic tumors in patients presenting with clinical features of acute appendicitis.

METHODS

A prospective data analysis of 1662 patients using appendectomy database was performed from 2005 to 2011. Patients above age 40 years or older were included. Patients were compared for demographic data, clinical presentation, radiological findings, operative technique & findings, histo-pathological findings and postoperative complications. The primary outcome was incidence of right-sided colonic (non-appendiceal) tumors presenting with features of acute appendicitis. Secondary outcomes measured were, role of diagnostic radiology, negative appendectomy rate, length of stay and changing trends in operative techniques.

RESULTS

From 1662 patients initially reviewed, only 179 patients (10.77%) age 40 years or above mean (56 ± 11.75), median 54 (40-89), with clinical features of acute appendicitis were included in the final analysis. F:M ratio was (1:1.06). CT scan showed in only 1 patient (1.25%, OR = 0.806, p = 0.695), suspicion of cecal tumor and underwent right hemicolectomy. Histological examination of specimen showed, 2 patients (1.11%, OR = 1.10, p = 0.47) had primary appendiceal tumors, in which one patient was histologically reported as appendiceal mucocele (mucinous cystadenoma with low-grade dysplasia), while the other one had appendeceal carcinoid (Goblet cell carcinoid). In the other tumor group one patient had metastatic involvement of appendix from ovarian tumor. The time to appendectomy in radiological group was delayed by (9.2 ± 3.7 h). 131 (73.1%) had laparoscopic while 48 (26.81%) underwent open appendectomy. The negative appendectomy rate was (1.12%) and 30 days complication rate was (11.73%, p = 0.27). Mean length of stay was 3.54 ± 2.1 days.

CONCLUSION

Right-sided colonic (cecal) tumors rarely present with features of acute appendicitis. Only those patients with atypical presentation and findings should have pre-operative radiological evaluation.

MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome

Elderly adults are at increased risk for complications related to both delayed diagnosis of appendicitis and to unnecessary appendectomy. We assessed the diagnostic performance of computed tomography (CT) in a consecutive elderly cohort with clinically suspected appendicitis. CT findings and clinical outcomes were analyzed for 262 consecutive adult patients age 65 and older (mean 75.6 ± 7.5 years; range 65-94; M/F 111:151) referred for clinically suspected appendicitis at a single medical center between January 2000 and December 2009. The overall prevalence of proven acute appendicitis in this elderly cohort with clinically suspected appendicitis was 16.8% (44/262). CT sensitivity, specificity, PPV, and NPV for acute appendicitis were 100% (44/44), 99.1% (216/218), 95.7% (44/46), and 100.0% (216/216), respectively. The negative appendectomy rate was 2.3% (1/43). The perforation rate was 40.9% (18/44). There were no false-negative and two false-positive CT interpretations. All patients with appendicitis suspected on CT were hospitalized (44/44), with an average stay of 5.7 ± 3.2 days, and 93.5% (43/46) underwent appendectomy. Overall surgical complication rate was 34.9% (15/43). Compared with younger adults over the same period, elderly patients had higher rates of perforation and surgical complications, and longer hospital stays (p < 0.003). CT is highly accurate for the evaluation of clinically suspected appendicitis in elderly patients. Prompt diagnosis is important given the higher rates perforation and surgical complications relative to younger adults.

The laparoscopic approach for perforated appendicitis, including cases complicated by abscess formation

BACKGROUND

Although the laparoscopic approach for perforated appendicitis is commonly performed, there is some controversy over its use because of postoperative complications. These may be associated with various types of disease entities, from gangrenous change to diffuse peritonitis with abscess formation. The aim of the present study was to evaluate the safety and benefits of the laparoscopic approach for perforated appendicitis, including cases complicated by abscess, compared to open.

MATERIALS AND METHODS

A total of 1747 patients underwent treatment for appendicitis over a period of 3 years. The diagnosis of perforated appendicitis was made by radiology, operative finding, and pathology. Of our five attending surgeons, three performed open surgery for perforated appendicitis, while two performed laparoscopy.

RESULTS

There were 474 patients (27%) with perforated appendicitis without abscess (156 underwent laparoscopy, 318 underwent open) and 113 patients (6.4%) with perforated appendicitis and abscess (44 underwent laparoscopy, 69 underwent open). The duration for resumption of diet and hospital stay was shorter in the laparoscopy group than in the open group. There were no significant differences in postoperative complications between patients who had no abscess with laparoscopy and those with open: 5 intra-abdominal abscesses and 10 wound infections versus 11 intra-abdominal abscesses and 25 wound infections (P = 0.88, 0.12), and between patients who had abscesses with laparoscopy and those with open: 4 intra-abdominal abscesses and 3 wound infections versus 6 intra-abdominal abscesses and 6 wound infections (P = 0.94, 0.72).

CONCLUSIONS

The laparoscopic approach may be a safe, effective treatment for perforated appendicitis, even in the presence of an abscess.

Primary appendiceal malignancy: a clinicopathologic study

Primary appendiceal cancer is a rare neoplasm. We analyzed the clinicopathologic characteristics and clinical outcomes of patients with primary appendiceal cancer treated at Buddhist Tzu Chi General Hospital in Eastern Taiwan. We reviewed the medical records of patients who had appendectomy at our hospital over a 10-year period and studied those who had histologically proven malignant appendiceal neoplasms. We treated eight such patients: seven males and one female. Their median age was 66 years (range, 59-78 years). There were three mucinous adenocarcinomas, two colonic type adenocarcinomas, and three adenocarcinoids. No patient was diagnosed correctly before surgery, and five (62.5%) had a preoperative diagnosis of acute appendicitis. Operative procedures included right hemicolectomy or partial colectomy in four, debulking and right hemicolectomy in three, and appendectomy only in one. With a mean follow-up of 64 months (range, 3-132), patients with adenocarcinoid lesions had better prognosis than those with adenocarcinomas. The important prognostic factors of primary appendiceal cancer included histologic subtypes and the extent of dissemination. In our series, palliative resection for disseminated lesions with or without additional chemotherapy resulted in long-term survival.

Appendiceal carcinoma masquerading as recurrent urinary tract infections: Case report and review of literature

We report on a female patient who presented with recurrent urinary tract infections. The investigations revealed an adenocarcinoma of the appendix fistulating into the bladder and causing irritative symptoms. After right hemicolectomy and partial cystectomy, she was well at 3 months without any need for adjuvant therapy. This unusual situation reminds us that the finding of bladder adenocarcinoma is rare, and it would be prudent to examine the lower gastrointestinal tract thoroughly to look for a bowel source, before recommending any ablative surgery.