Unfinished Business: A Systematic Review of Stump Appendicitis

Abstract

Background Stump appendicitis is defined as interval inflammation of any residual appendicular tissue, after an appendicectomy. We present a systematic review of case series and case reports on stump appendicitis, emphasising on risk factors, diagnosis and surgical management. Methods The English literature (1945–2018) was reviewed, using PubMed, Embase and GoogleScholar, combining the terms “appendix”, “appendicitis”, “stump”, “residual”, “recurrent” and “retained”. In total, 127 studies were included, describing 164 patients (males 59%, mean age 36 ± 17 years). Results Index surgery was open in 59% and laparoscopic in 38%. It was described as “difficult” or “complicated” in 31%. 20% of patients reported episodes of recurrent abdominal pain during the time interval between index and stump appendicitis (range 2 weeks to 60 years, median 2 years). Right lower quadrant pain was the most frequent complain (88%), leukocytosis was found in 56%, whereas 92% of patients underwent imaging testing, which was diagnostic or highly suspicious in 67.5%. Mean delay between beginning of symptoms and surgery was 2.4 ± 2.3 days. The operative approach was open in 61% and laparoscopic in 35% of cases. The operation was characterised as “difficult” or “complicated” in 45%. In the majority (88%), a completion stump appendicectomy was performed, with 11% requiring more extensive procedures. Mean length of resected stump was 3.1 ± 1.6 cm (range 0.5–10 cm). Conclusions Stump appendicitis may occur following both open and laparoscopic approach, when the residual stump is > 0.5 cm. Its clinical significance lies in the delayed diagnosis, leading to higher incidence of complications and the need for more extensive surgery.

A retroperitoneal cyst arising from an appendix fragment

“…One review found that most cases of remnant appendix cancer required further extensive surgery but this was largely attributed to a delayed diagnosis resulting in complications requiring more extensive surgery. 10 In summary, this represents an unusual presentation of a mucinous adenocarcinoma arising from the remnant appendix as a retroperitoneal cyst. It is important to not leave behind any appendix during appendicectomy and caution should be exercised when excising unidentified retroperitoneal lesions due to the risk of rupture and local spread.…”

“…The literature on appendiceal stump adenocarcinoma is limited and it is unclear whether a more aggressive surgical approach should be taken to management. One review found that most cases of remnant appendix cancer required further extensive surgery but this was largely attributed to a delayed diagnosis resulting in complications requiring more extensive surgery 10 …”

Stump appendicitis, a rare but serious complication of appendectomy : a case report

“…Surgical resection seems to be the treatment of choice in the reported cases. The choice of either laparotomy or laparoscopy depends on various factors like the patient's clinical condition and the local expertise and resources [5,12]. A more extensive operation should generally not be required as long as the appendiceal stump can be readily identified and the cecum itself does not show evidence of a significant amount of inflammation.…”

Stump appendicitis, a rare but serious complication of appendectomy: A case report

“…The choice of laparotomy or laparoscopy depends on various factors such as the clinical condition of the patient and whether or not the diagnosis was made preoperatively. 5 , 12 If the appendix stump can be easily identified and the cecum is not significantly inflamed, more extensive surgery should not be indicated. Some authors describe a critical view of the appendix similar to the critical view of safety of cholecystectomy to decrease the rate of this complication.…”