Inverted appendiceal orifice masquerading as a cecal polyp on virtual colonoscopy

Apéndice cecal invertida: hallazgos en colonoscopía

Introducción. El apéndice cecal invertido, inversión apendicular o intususcepción apendicular, corresponde a una condición anatómica descrita en 1859. La primera operación de invaginación apendicular se realizó en 1890, y desde entonces se han descrito diferentes técnicas quirúrgicas y endoscópicas para el tratamiento de esta alteración. Casos clínicos. Se presentan dos casos de pacientes a quienes se les indicó colonoscopia como parte de estudio de dolor abdominal y diarrea y se identificó una intususcepción apendicular completa y apendicitis y una inversión del muñón apendicular. Resultados. Mediante la colonoscopia se hizo el diagnóstico de apendicitis aguda en una de las pacientes, quien presentaba inversión apendicular completa tipo 5, que fue tratada con manejo farmacológico y seguimiento clínico. En la otra paciente hubo un hallazgo incidental de inversión del muñón apendicular tipo 3. Conclusiones. Durante la realización de estudios colonoscópicos, se debe tener en cuenta el diagnóstico de intususcepción apendicular o apéndice invertido, para evitar intervenciones erróneas, como polipectomías, que generen riesgo potencial en los pacientes.

CT Colonography: Improving Interpretive Skill by Avoiding Pitfalls

An earlier incorrect version of this article appeared online. This article was corrected on December 20, 2019.

The iatrogenic caecal polyp: can it be avoided?

A 60-year-old farmer was admitted with symptoms and signs suggestive of appendicitis. The diagnosis was confirmed at open appendicectomy where the appendix base was ligated and inverted into the caecum with a purse-string suture. Following an uneventful recovery and discharge, a barium enema identified a 2 cm filling defect in the caecal pole. A subsequent colonoscopy revealed only a tiny sessile polyp in the caecum with histology demonstrating normal colonic mucosa. This case report discusses the rare occurrence of an inverted appendix stump mimicking caecal pathology and the rationale of post-appendicectomy colonic investigation in the elderly patient.

Back to basics: A meta-analysis of stump management during open appendicectomy for uncomplicated acute appendicitis

AIM: To compare simple ligation vs stump invagination during open appendicectomy for uncomplicated acute appendicitis on the risk of postoperative complications.

METHODS: A meta-analysis was conducted on randomised controlled trials comparing the two stump closure methods in open appendicectomy. Databases searched were PubMed, EMBASE and Cochrane Library databases. Included were those studies focusing on inflamed and suppurative appendicitis while perforated and gangrenous appendix was excluded. We also excluded retrospective case-control studies, commentaries, historical technical articles, or trials involving laparoscopic appendicectomies. The outcome of the meta-analysis was to find eventual differences in the incidence of postoperative ileus and wound infections between the two techniques of stump invagination.

RESULTS: Seven studies were included corresponding to 1468 patients. Postoperative complications consisted in wound infections (7%), ileus (4%), pyrexia (2%), vomiting (1%), obstructions from adhesions (0.1%). No cases of peritonitis, fecal fistulas (stump leaks), abdominal abscesses or wound dehiscences were reported. Postoperative ileus within the first 72 h was four times more frequent with stump invagination compared to simple ligation (OR: 4.06; 95%CI: 2.14-7.70; P < 0.0001). No significant differences were noted for wound infections (OR: 1.24; 95%CI: 0.83-1.87; P = 0.30) while for the remaining complications the incidence was extremely low in both groups. There was a high homogeneity on results (Q value for heterogeneity of postoperative ileus P = 0.17; Q value for heterogeneity of wound infections P = 0.98).

CONCLUSION: Stump invagination does not seem to prevent infective complications but is associated with an increased risk of postoperative ileus in uncomplicated cases. Appropriate studies on complicated appendicitis should now evaluate the influence of the two techniques in this higher-risk subgroup.

CT colonography: visualization methods, interpretation, and pitfalls

Virtual colonoscopy interpretation is improving rapidly with the development of efficient software using two-dimensional, three-dimensional (3D) endoluminal, and 3D novel views such as those that seem to cut the colon open and lay it flat for interpretation. Comparison of these various views, comparisons of supine and prone positioning, and comparisons of lung and soft tissue windows aid in the recognition of various pitfalls of interpretation.