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Laparoscopic appendectomy
When the unexpected unveils…
Dr. Grace KY HungKwong Wah Hospital
Case scenario
• 60/M• Right lower quadrant pain and fever• Physical examination
– Stable vitals with temperature 38.5C
– Tenderness over right lower quadrant
Laparoscopic appendectomy offered…
Background
• Acute appendicitis– Lifetime risk ~ 7%1
– One of the most commonly encountered emergency surgical condition
– Peak incidence towards 30 years old
Background
• Pathology– Bacterial infection secondary to
blockage of the lumen– Could be due to faecolith, caecal
tumor, appendiceal tumor, enlargement of lymphoid aggregate, parasites
Background
• Clinical presentation– Typical presentation: fever, right
lower quadrant pain, leukocytosis
Scenarios
• Negative appendectomy• Appendiceal neoplasm (Intra-
operative/histopathological)
Negative appendectomy
• Negative appendectomy rate: – 15% - 25%2,3,4
• Female patient of reproductive age are at higher risk
Negative appendectomy• pic
Differential diagnosis• Gynecological problem• Colonic diverticulitis• Colitis, ileitis• Meckels diverticulitis• Inflammatory bowel disease• Neoplasm (colonic, appendiceal)• Perforated peptic ulcer• Acute cholecystitis• Mesenteric adenitis• Others
Can pre-operative imaging help to decrease negative appendectomy
rate?
Pre-operative CT scan
• Sensitivity 83-99%5
• Specificity 86-100%5
• Krajewski et al (Meta analysis)6
• NAR (CT): 8.7% NAR (no CT): 16.7%• Use of CT was associated with a delay in
time to surgery, yet the appendiceal perforation rates were unchanged
• Depends on– Availability– Expertise in interpretation
CT criteria for infalmmed appendix7
• Diameter greater than 6mm• Appendiceal wall thickness greater
than 1mm• Appendiceal gas• Periappendiceal fat stranding• Caecal arrow-head sign• Caecal bar sign
CT scan of patient with acute appendicitis
• Even with pre-operative CT scan the NAR is 8.7%
• Does pre-operative CT scan has a role?– Yes– Provides additional information for
planning subsequent management
Differential diagnosis• Gynecological problem• Colonic diverticulitis• Colitis, ileitis• Meckels diverticulitis• Inflammatory bowel disease• Neoplasm (colonic, appendiceal)• Perforated peptic ulcer• Acute cholecystitis• Mesenteric adenitis• Others
Differential diagnosis• Gynecological problem• Colonic diverticulitis• Colitis, ileitis• Meckels diverticulitis• Inflammatory bowel disease• Neoplasm (colonic, appendiceal)• Perforated peptic ulcer• Acute cholecystitis• Mesenteric adenitis• Others
• Periappendiceal abscess maybe drained percutaneously
Pre-operative USG
• Rander A et al8
• Mean sensitivity of USG: 78%• Diagnostic accuracy inferior to CT• Still plays a role in patients in whom
radiation exposure is a concern (e.g. pregnant patients)
Sonographic findings in USG
• Compressed diameter greater than 6mm
• Brightly echogenic periappendiceal fat• Periappendiceal fluid collection• Hypervascularity on color Doppler
Scenarios
• Negative appendectomy• Appendiceal neoplasm (Intra-
operative/histopathological)
Tumor recognized at
time of surgery
Tumor recognized at
time of surgery
Tumor <2cmTumor <2cm
Base and mesoappendix:
clear
Base and mesoappendix:
clear
Evidence of perforationEvidence of perforation
Evidence of mucinous ascites
Evidence of mucinous ascites
Right hemicolectomy
Right hemicolectomy
Appendectomy Appendectomy
Appendectomy or, if not possible, tissue biopsy,
cytology on mucusPeritoneal lavage
Analysis of tumor markers (CEA, CA-125, CA 19.9) and
CT abd + pelvisColonoscopy
Appendectomy or, if not possible, tissue biopsy,
cytology on mucusPeritoneal lavage
Analysis of tumor markers (CEA, CA-125, CA 19.9) and
CT abd + pelvisColonoscopy
YES
YES
YES
YES
YES
No
No
No
No
Appendiceal neoplasm
• Accounts for 1% of all GI malignancies9
• Usually present as acute appendicitis• Incidental finding at operation/ on
histopathological examination• Carcinoid tumors are most common10
Classification of appendiceal neoplasms9
Primary Secondary
EpithelialBenign
•Hyperplastic polyp and diffuse mucosal hyperplasia•Serrated adenoma•Colonic type adenoma
Malignant•Low-grade mucinous neoplasms•Adenocarcinoma/ High-grade mucinous neoplasms
Non-epithelialCarcinoid tumors
•Classical carcinoid•Globet cell carcinoids/adenocarcinoids
Mesenchymal tumors•Gastrointestinal stromal tumors•Neuroma•Leiomyoma/sarcoma•Kaposi’s sarcoma•Lymphoma
OvarianColonicMelanoma
Carcinoid tumors• Arise from neuroendocrine cells• Usually located at the tip or distal third of the
appendix• Adverse prognostic feature: size >2cm,
mesoappendiceal extension11
• Simple appendectomy for tumor less than 2cm and does not involve the resection margin or mesoappendix12
• Right hemicolectomy for tumor more than 2cm or when there is involvement of the base of the appendix or mesoappendix12
Malignant epithelial lesions• Range from low grade mucinous neoplasms to
adenocarcinomas• Prognosis depends on whether they have perforated
and whether mucin and epithelial cells are present outside the appendix13
• May spread to peritoneal cavity, giving rise to pseudomyxoma peritonei
• Treatment:– Not perforated tumor not involving the
mesoappendix/base: Appendectomy– Perforated tumor: complete cytoreduction with
intraperitoneal chemotherapy
Synchronous appendiceal and colonic neoplasm
• Associates with a significant incidence of both synchronous and metachronous colorectal neoplasms.14
• 10% of appendiceal carcinoid • 50% of appendiceal malignant
epithelial tumors • Screening and surveillance
colonoscopy should be advocated
Conclusion
• Laparoscopic appendectomy is one of the most commonly performed surgical procedure which carries a negative appendectomy rate of around 15%-25%
• Pre-operative CT scan could decrease the negative appendectomy rate and provide more information for better planning if available.
Conclusion
• Rarely, appendiceal neoplasms are found incidentally during operation/on histopathological examinations
• Tumor less than 2cm without involvement of the resection margin and mesoappendix can be treated by simple appendectomy
• Screening and surveillance colonoscopy should be performed for all patients with appendiceal neoplasm
Reference1. Korner, H., J. A. Soreide, E. J. Pedersen, T. Bru, K. Sondenaa, and L. Vatten. "Stability in
Incidence of Acute Appendicitis. A Population-Based Longitudinal Study." Dig Surg 18, no. 1 (2001): 61-6.
2. Flum, D. R., and T. Koepsell. "The Clinical and Economic Correlates of Misdiagnosed Appendicitis: Nationwide Analysis." Arch Surg 137, no. 7 (2002): 799-804; discussion 804.
3. Humes, D. J., and J. Simpson. "Acute Appendicitis." BMJ 333, no. 7567 (2006): 530-4.4. Humes, D. J., and J. Simpson. "Acute Appendicitis." BMJ 333, no. 7567 (2006): 530-4.5. Musunuru, S., H. Chen, L. F. Rikkers, and S. M. Weber. "Computed Tomography in the
Diagnosis of Acute Appendicitis: Definitive or Detrimental?" J Gastrointest Surg 11, no. 11 (2007): 1417-21
6. Susan Krajewski, Jacqueline Brown, P. Terry Phang, Manoj Raval, Carl J. Brown. "Impact of Computed Tomography of the Abdomen on Clinical Outcomes in Patients with Acute Right Lower Quadrant Pain: A Meta-Analysis." Can J Surg 54, no. 1 (2011): 43-53.
7. Joshua D. Hawkins, Richard C. Thirlby. "The Accuracy and Role of Cross Sectional Imaging in the Diagnosis of Acute Appendicitis." Advances in Surgery 43, (2009): 13-22.
8. van Randen A, Bipat S, Zwinderman A. "Acute Appendicitis: Meta-Analysis Od Diagnostic Performance of Ct and Graded Compression Us Related to Prevalence of Disease." Radiology 249, no. 1 (2008): 97-106.
9. Murphy, E. M., S. M. Farquharson, and B. J. Moran. "Management of an Unexpected Appendiceal Neoplasm." Br J Surg 93, no. 7 (2006): 783-92.
10.Connor, S. J., G. B. Hanna, and F. A. Frizelle. "Appendiceal Tumors: Retrospective Clinicopathologic Analysis of Appendiceal Tumors from 7,970 Appendectomies." Dis Colon Rectum 41, no. 1 (1998): 75-80.
Reference11. Connor, S. J., G. B. Hanna, and F. A. Frizelle. "Appendiceal Tumors: Retrospective
Clinicopathologic Analysis of Appendiceal Tumors from 7,970 Appendectomies." Dis Colon Rectum 41, no. 1 (1998): 75-80.
12.Goede, A. C., M. E. Caplin, and M. C. Winslet. "Carcinoid Tumor of the Appendix." Br J Surg 90, no. 11 (2003): 1317-22.
13.Misdraji, J., R. K. Yantiss, F. M. Graeme-Cook, U. J. Balis, and R. H. Young. "Appendiceal Mucinous Neoplasms: A Clinicopathologic Analysis of 107 Cases." Am J Surg Pathol 27, no. 8 (2003): 1089-103.
14.Fujiwara, T., A. Hizuta, H. Iwagaki, T. Matsuno, M. Hamada, N. Tanaka, and K. Orita. "Appendiceal Mucocele with Concomitant Colonic Cancer. Report of Two Cases." Dis Colon Rectum 39, no. 2 (1996): 232-6.
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