Is the laparoscopic approach appropriate for pediatric subhepatic appendicitis?

Subhepatic Appendicitis Presenting With Recurrent Abdominal Pain

Gut malrotation may result in failure of descent of the cecum to the right iliac fossa, resulting in the anomaly where the cecum and appendix are situated in the subhepatic/gallbladder region. Although the true incidence of subhepatic cecum or appendix is not known, there is a handful of case reports in the literature describing the diagnosis and management of subhepatic appendicitis and associated challenges. Some case reports describe subhepatic appendicitis, where the cecum is in a normal position, but the subhepatic tip of the long appendix gets perforated or inflamed, resulting in the process being in the subhepatic region. We report a patient with subhepatic appendicitis, who had multiple episodes of abdominal pain for almost one year, treated with antibiotics, but was never diagnosed properly. The case was diagnosed by abdominal sonography and was managed successfully in our institution.

Rare appendiceal escapades in childhood: the Grande experience!

Acute appendicitis in children is known to present in two broad forms: (1) uncomplicated and (2) complicated. Apart from this, a variety of atypical presentations can occur that may pose difficulty in diagnosis or treatment approach. We hereby present a series of such rare experiences namely appendiceal oxyuriasis, sub-hepatic appendicitis and appendiceal mucocele that were encountered and managed accordingly.

Interval laparoscopic appendectomy after antibiotic therapy for appendiceal abscess in elderly patients

INTRODUCTION

The aim of this study was to evaluate the safety and efficacy of interval laparoscopic appendectomy after antibiotic therapy in elderly patients with appendiceal abscess.

METHODS

We retrospectively analyzed data for 50 patients with appendiceal abscess aged ≥18 years who had initially planned to undergo interval laparoscopic appendectomy after antibiotic therapy and 50 patients with appendicitis aged ≥70 years who had undergone early laparoscopic appendectomy. All patients were treated at the National Hospital Organization Kumamoto Medical Center between 2012 and 2018. We compared perioperative outcomes after interval appendectomy between patients aged <70 years and ≥70 years.

RESULTS

Clinical progression of appendicitis during antibiotic therapy developed in one patient (2.0%), and recurrent appendicitis after antibiotic therapy for appendiceal abscess occurred in two patients (4.0%). Pathological findings confirmed appendiceal neoplasms in four patients (8.0%). Postoperative infectious complications occurred in 1 of 47 patients (2.1%) who had undergone successful interval laparoscopic appendectomy, and the median length of postoperative hospital stay was 4 days (interquartile range, 3-5 days). There were no significant differences in outcomes after interval appendectomy between patients aged <70 years and ≥70 years. In the secondary analysis, the median length of postoperative hospital stay after interval laparoscopic appendectomy for appendiceal abscess (4 days) was significantly shorter than that after early laparoscopic appendectomy for uncomplicated appendicitis (7 days; P < .001).

CONCLUSIONS

Interval laparoscopic appendectomy for appendiceal abscess may be safe and effective in elderly patients without severe comorbidities. Interval appendectomy may be necessary for determining the underlying cause of appendiceal abscess in adults.

Subhepatic Appendicitis in an 11-year-old Boy: A Case Report

Appendicitis is a common surgical emergency. When present in an abnormal subhepatic location, it can pose a challenge in its diagnosis and management. Subhepatic appendicitis is a rare phenomenon, especially in the pediatric age group. Herein, we present a rare case of subhepatic appendicitis in an 11-year-old boy with delayed presentation but managed successfully.

Variations and morphometric features of the vermiform appendix: A systematic review and meta-analysis of 114,080 subjects with clinical implications

Determining the true and indisputable data regarding the vermiform appendix (VA) morphology is of a great clinical interest. The aim of this study was to provide the best evidence-based anatomical overview of the variations in location and size of VA using a systematic and meta-analytical approach. A systematic review with meta-analysis was performed of studies reporting variants of the location and morphometric data regarding the VA. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science databases were thoroughly searched throughout June 2018. The reported locations of the body of the VA were re-classified into a new, standardized classification system divided into nine categories. The AQUA tool was used to assess the quality of included studies. The research was conducted following PRISMA guidelines and registered at PROPSERO database. Our meta-analysis included 242 studies (n = 114,080). Overall, the VA was most commonly found in the retrocecal location (32.1%, 95%CI: 29.2-35.1), followed by the pelvic (28.5%, 95%CI: 26.7-30.4) and ileal (14.5%, 95%CI: 11.8-17.7) locations. Subjects without known appendiceal pathologies had significantly smaller VA outer diameters (5.84 mm, 95%CI: 5.68-5.99) than patients diagnosed with acute appendicitis (10.64 mm, 95%CI: 10.14-11.15). The overall pooled mean length of the VA was 80.29 mm (95%CI: 76.68-83.89). Significant differences were found in size of the VA between imaging modalities. The results obtained from this evidence-based anatomy study will improve the clinical understanding of the VA anatomy, which in turn will have major implications for clinical practice. Clin. Anat. 32:85-98, 2019. © 2019 Wiley Periodicals, Inc.

Pediatric subhepatic appendicitis with elevated lipase

Appendicitis is the most common surgical emergency in children, of which most are located in the retrocecal space or pelvis. Appendicitis occurring in the subhepatic space is uncommon and may present with atypical features such as right upper quadrant pain, leading to delayed diagnosis and complications. We present a rare case of subhepatic appendicitis in an 11-year-old female, who presented with a three-day history of both right upper quadrant (RUQ) and right lower quadrant (RLQ) abdominal pain and serum lipase elevated four times the upper normal limit. The abdominal ultrasound was normal, except for prominent RLQ abdominal lymph nodes. Hours later, a computed tomography scan revealed a non-ruptured subhepatic appendicitis and normal pancreas. Our patient encounter demonstrates the need to be aware of the atypical presentations of pediatric appendicitis in general and subhepatic appendicitis in particular. Moreover, to our knowledge, this is the first reported case of elevated lipase (with a radiographically normal pancreas) in association with subhepatic appendicitis. Providers should be aware elevated serum lipase levels may be due to conditions other than pancreatitis and further evaluation should be considered if the elements of the clinical picture are incongruent.