Healthcare - West Virginia State Medical Association

Scientific Article |Appendicitis after Appendectomy? Case Report andLiterature ReviewEhab Akkary, MDDirector of Bariatric and AdvancedLaparoscopic Surgery, Preston MemorialHospital, Kingwood, WVTonya Cramer, MSChicago Medical School, RosalindFranklin University of Medicine andScience, North Chicago, ILMostafa Sadek, MAResearch Fellow, Arthur Smith Institutefor Urology, North Shore Long IslandJewish Health System, Long Island, NYThanh Phan, MDStaff Surgeon, Department of Surgery,North Oakland Medical Centers and St.Joseph Mercy Hospital, Pontiac, MIIntroductionStump appendicitis isinflammation of the residual part ofthe appendix after appendectomy. 1The incidence is not well known withfew cases reported in the literature. 2The clinical picture is the sameas acute appendicitis but the pastsurgical history might mislead thephysician. 3 Moreover, diagnostictesting including blood work andCT scan might be normal and testssuch as CRP and ESR are nonspecific.Herein, we present a case of a 42-year-old male who presented withright lower quadrant pain one monthafter laparoscopic appendectomyin another institution. He wastaken to the operating room wherelaparoscopic stump appendectomywas performed. We also presentour literature review of this rare,probably underreported, clinicalentity explaining the diagnosticwork-up and management.Case ReportA 42-year-old male patientpresented to the emergencydepartment with one day historyof right lower quadrant pain,throbbing and non-radiating. Thepain was associated with anorexia,nausea and vomiting. The patient,who was otherwise healthy, stateda significant past surgical historyof laparoscopic appendectomyat another institution one monthprior to the current presentation.On physical examination, he wasafebrile with stable vital signs;abdominal examination revealedtenderness with rebound in theright lower quadrant and a positiveRovsing’s sign. Blood work revealeda normal WBC count. The patienthad a CT scan of the abdomen andpelvis that was unremarkable. Hewas taken to the operating roomfor diagnostic laparoscopy withthe presumptive diagnosis of acutestump appendicitis. Exploration ofthe cecum revealed mild yellowishdiscoloration of the staple line withtissue firmness on palpation. Thececum was mobilized and bluntdissection was done around thestaple line. The appendiceal stumpwas identified and dissected off thececum, the stump was dissectedall the way down to the junctionbetween the appendix and thececum (Figure 1). The remnantof the mesoappendix was alsoidentified and the appendicularartery was isolated (Figure 2). Stumpappendectomy was completed usingan EndoGIA stapler with a 3.5 mmcartridge after which the artery wasdivided using the same stapler on a2.5 mm vascular cartridge (Figure 3).The specimen was retrieved andthe stump was examined at theside table. The appendiceal stumpwas found to be about 6mm inlength with intraluminal abscess.The histopathological examinationof the specimen showed acuteinflammatory changes with necroticfoci and lymphocytic infiltration.The postoperative course proceededuneventfully and the patient wasdischarged on the first postoperativeday in good condition. At onemonthfollow-up he was doingwell with no complaints andno recurrence of symptoms.DiscussionAppendectomy is one of the mostcommon operations performed bythe general surgeon. The laparoscopicapproach has been gainingpopularity and gradually replacingthe conventional open techniquesince it was described in the surgicalliterature by Semm in 1983. 4 The firstreport of stump appendicitis was in1945 by Rose. 5 Stump appendicitismay occur anytime after incompleteappendectomy and cases have beenreported between a few monthsto 20 years after appendectomy. 2,6Hirano et al reported a case of stumpappendicitis that occurred 40 yearsafter an appendectomy. 7 The criticalrisk factor in this condition is leavingan appendiceal stump of 5mm ormore in length. 1 Imaging studiessuch as ultrasound or CT scan mayhelp in the diagnosis if the stumpis long enough to be detected or incase of abscess formation. CT scanis more helpful than ultrasound inshowing mesenteric stranding and fatinflammation in the pericecal area. 6,8Clinical features: the diagnosis ofstump appendicitis is challengingbecause it is not routinely suspectedwith a history of appendectomy.Additionally, lab tests such asWBC count, CRP, and ESR maypresent in normal ranges and theyare nonspecific. The elevated WBCcount with a left shift, as typicallyexpected with appendicitis, was28 West Virginia Medical Journal