30 chapter The Appendix

Mike K. Liang, Roland E. Andersson,

Bernard M. Jaffe, and David H. Berger

Historical Background 1241 Operative Interventions Acute Appendicitis during

Embryology, Anatomy, for the Appendix 1251 Pregnancy / 1256
and Physiology 1241 Open Appendectomy / 1251 Postoperative Care
Embryology / 1241 Laparoscopic Appendectomy / 1252 and Complications 1257
Anatomy / 1242 Laparoscopic versus Open Surgical Site Infection / 1257
Physiology / 1242 Appendectomy / 1253 Stump Appendicitis / 1257
Laparoscopic Single-Incision Incidental Appendectomy 1257
Acute Appendicitis 1243
Appendectomy / 1254
Epidemiology / 1243 Neoplasms of the Appendix 1257
Natural Orifice Transluminal
Etiology and Pathogenesis / 1243 Endoscopic Surgery / 1254 Prevalence of Neoplasms / 1257
Microbiology / 1243 Carcinoid / 1258
Special Circumstances 1256
Natural History / 1243 Adenocarcinoma / 1258
Acute Appendicitis
Clinical Presentation / 1243 in the Young / 1256 Mucocele / 1258
Differential Diagnosis / 1246 Acute Appendicitis Pseudomyxoma Peritonei / 1258
Initial Management / 1248 in the Elderly / 1256 Lymphoma 1259

HISTORICAL BACKGROUND treated with appendectomy. In 1886, Reginald H. Fitz presented

his findings regarding appendicitis and recommended consid-
Appendiceal disease is a frequent reason for emergency hospital eration for operative treatment. In 1889, Charles McBurney
admission, and appendectomy is one of the most common emer- published his landmark paper in the New York State Medical
gency procedures performed in contemporary medicine. Despite Journal describing the indications for early laparotomy for the
the prevalent role this organ plays in healthcare today, the treatment of appendicitis.5 During the following decade, the
human appendix was not noted until 1492. Leonardo da Vinci role of surgical treatment was discussed intensely between pro-
depicted the appendix in his anatomic drawings, but these were ponents of early appendectomy and of a more expectant man-
not published until the eighteenth century.1 In 1521, Berengario agement. It was recognized that most instances of appendicitis
Da Capri and, in 1543, Andreas Vesalius published drawings could resolve without surgical treatment; but, the problem was
recognizing the appendix.2 how to identify early the patients who had the progressive, often
Credit is given to Jean Fernel for first describing appen- lethal form of the disease.6 Eventually, early appendectomy
diceal disease in a paper published in 1544. He reported on a became the accepted standard of care, with broad indications in
7-year-old girl whose diarrhea he treated with doses of quince, order to prevent perforation. This change in practice resulted in
an apple-like fruit used in folk remedies. She developed abdom- an enormous increase in the number of appendectomies during
inal pain and died. At autopsy, the quince was found to have the first decades of the twentieth century. However, this had
obstructed the lumen of the appendix, causing necrosis and per- almost no impact on the incidence of perforated appendicitis
foration.3 Lorenz Heister provided the first description of classic or on the mortality of appendicitis.7 In the 1970s, the negative
appendicitis in 1711.1 effects of the large number of appendectomies of uninflamed
The first known appendectomy was performed in 1736 by appendices were noted, and the focus gradually shifted toward
Claudius Amyand in London. He operated on an 11-year-old a more conservative approach to exploration.8
boy with a scrotal hernia and a fecal fistula. Within the hernia
sac, Amyand found a perforated appendix surrounded by omen-
tum. The appendix and omentum were amputated. The patient EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY
was discharged a month later in good condition.4
It would be over a century later before appendicitis was Embryology
widely recognized as a common cause of right lower quadrant In the sixth week of human embryonic development, the appen-
pain and early appendectomy advocated as treatment. Through- dix and cecum appear as outpouchings from the caudal limb
out this period, there was extensive discussion of typhlitis and of the midgut. The appendiceal outpouching, initially noted in
perityphlitis as the common etiologies of right lower quadrant the eighth week, begins to elongate at about the fifth month
pain. Only sporadic cases of right lower quadrant pain were to achieve a vermiform appearance.9,10 The appendix maintains
 Key Points
1 Appendicitis is one of the most common surgical emergen- 7 Complicated appendicitis without signs of sepsis or gen-
cies in contemporary medicine, with a yearly incidence rate eralized peritonitis may benefit from nonoperative man-
of about 100 per 100,000 inhabitants. Lifetime risk for agement. The role of interval appendectomy in these
appendicitis is 8.6% for males and 6.7% for females, with cases remains controversial.
the highest incidence in the second decade of life. 8 Single-incision appendectomy provides no obvious
2 The natural history of appendicitis is unclear, but it appears advantage over standard laparoscopic appendectomy.
that progression to perforation is not predictable and that Natural orifice transluminal endoscopic surgery remains
spontaneous resolution is common, suggesting that nonper- an investigational procedure.
forated and perforated appendicitis may, in fact, be different 9 The incidence of fetal loss following normal appendec-
diseases. tomy in pregnant patients is 4%, and the risk of prema-
3 Right lower quadrant pain, gastrointestinal symptoms start- ture delivery is 10%. The greatest opportunity to
ing after the onset of pain, and a systemic inflammatory improve fetal outcomes may be through improving
response with leukocytosis and neutrophilia, increased diagnostic accuracy and reducing the rate of negative
C-reactive protein concentration, and fever are considered appendectomy.
diagnostic of appendicitis. The Appendicitis Inflammatory 10  Antibiotic prophylaxis is effective in the prevention of
Response Score or Alvarado score can help improve diag- postoperative surgical site infection. Postoperative anti-
nostic accuracy. biotics are unnecessary following uncomplicated appen-
4 Computed tomography scan has improved diagnostic accu- dicitis. For complicated appendicitis, a treatment
racy in individual studies. However, in population-wide duration of 4 to 7 days is recommended.
studies, the rate of misdiagnosis of appendicitis remains con- 11  The role of incidental appendectomy is limited to patients
stant. Rates of misdiagnosis are highest in female patients of at high risk for misdiagnosis of appendicitis (malrotation,
child-bearing age and patients on the extremes of age (i.e., patients unable to respond or react normally), patients at
very young and very old). high risk for complications with appendicitis (children
5 The role of nonoperative treatment for uncomplicated appen- ready to undergo chemotherapy), and patients with lim-
dicitis remains controversial. Currently, appendectomy ited access to modern healthcare.
remains the standard of care. Laparoscopic appendectomy 12  The prevalence of appendiceal malignancy remains at or
has a slight benefit over open appendectomy. below 1% of appendectomies. Carcinoid and mucinous
6 Perforated or complicated appendicitis is more common in adenocarcinoma remain the most frequent histologic
the very young (age <5 years) and very old (age >65 years). diagnosis.

its position at the tip of the cecum throughout development. terior to the terminal ileum, entering the mesoappendix close
The subsequent unequal growth of the lateral wall of the cecum to the base of the appendix.12 The lymphatic drainage of the
causes the appendix to find its adult position on the posterior appendix flows into lymph nodes that lie along the ileocolic
medial wall, just below the ileocecal valve. The base of the artery. Innervation of the appendix is derived from sympa-
appendix can be located by following the longitudinally ori- thetic elements contributed by the superior mesenteric plexus
ented taeniae coli to their confluence on the cecum. The tip of (T10-L1) and afferents from the parasympathetic elements via
the appendix can be located anywhere in the right lower quad- the vagus nerves.12
rant of the abdomen, pelvis, or retroperitoneum. The histologic features of the appendix are contained
In patients with midgut malrotation and situs inversus, the within the three following layers: the outer serosa, which is an
cecum (and thus the appendix) will not reside in the usual right extension of the peritoneum; the muscularis layer, which is not
lower quadrant location. With midgut malrotation, the midgut well defined and may be absent in certain locations; and finally,
(small bowel and proximal colon) incompletely rotates or fails the submucosa and mucosa. Lymphoid aggregates occur in the
to rotate around the axis of the superior mesenteric artery during submucosal layer and may extend into the muscularis mucosa.
fetal development. In this situation, the appendix will remain Lymphatic channels are prominent in regions underlying these
in the left upper quadrant of the abdomen. Situs inversus is a lymphoid aggregates. The mucosa is like that of the large intes-
rare autosomal recessive congenital defect characterized by the tine, except for the density of the lymphoid follicles. The crypts
transposition of abdominal and/or thoracic organs. In this situ- are irregularly sized and shaped, in contrast to the more uniform
ation, the appendix is found in the left lower quadrant of the appearance of the crypts in the colon. Neuroendocrine com-
abdomen.11 plexes composed of ganglion cells, Schwann cells, neural fibers,
and neurosecretory cells are positioned just below the crypts.13,14
Anatomy
In the adult, the average length of the appendix is 6 to 9 cm; Physiology
however, it can vary in length from <1 to >30 cm. The outer For many years, the appendix was erroneously believed to be a
diameter varies between 3 and 8 mm, whereas the luminal diam- vestigial organ with no known function. It is now well recog-
eter varies between 1 and 3 mm.9 nized that the appendix is an immunologic organ that actively
The appendix receives its arterial supply from the appen- participates in the secretion of immunoglobulins, particularly
1242 dicular branch of the ileocolic artery. This artery originates pos- immunoglobulin A.
 Although there is no clear role for the appendix in the process soon involves the serosa of the appendix and in turn 1243
development of human disease, an inverse association between the parietal peritoneum. This produces the characteristic shift in
appendectomy and the development of ulcerative colitis has pain to the right lower quadrant.
been reported, suggesting a protecting effect of the appendec- The mucosa of the appendix is susceptible to impair-
tomy. However, this association is only seen in patients treated ment of blood supply; thus, its integrity is compromised early
with appendectomy for appendicitis before age 20.15-17 in the process, which allows bacterial invasion. The area with
The association between Crohn’s disease and appendec- the poorest blood supply suffers the most: ellipsoidal infarcts
tomy is less clear. Although earlier studies suggested that appen- develop in the antimesenteric border. As distension, bacterial
dectomy increases the risk of developing Crohn’s disease, more invasion, compromise of the vascular supply, and infarction
recent studies that carefully assessed the timing of appendectomy progress, perforation occurs, usually on the antimesenteric bor-
in relationship to the onset of Crohn’s disease demonstrated no der just beyond the point of obstruction. This sequence is not

CHAPTER 30 The Appendix

correlation.17 A recent meta-analysis demonstrated a significant inevitable, however, and some episodes of acute appendicitis
risk of Crohn’s disease early following appendicitis.18 This risk may resolve spontaneously.
diminishes later, which suggests that a diagnostic (misidentifying
Crohn’s disease as appendicitis) rather than a physiologic rela- Microbiology
tionship exists between appendectomy and Crohn’s disease. Appendicitis may occur in clusters, suggesting an infectious
The appendix may function as a reservoir to recolonize genesis. However, an association with various contagious bac-
the colon with healthy bacteria. One retrospective study dem- teria and viruses has only been found in a small proportion of
onstrated that prior appendectomy may have an inverse relation- appendicitis patients.25 The flora of the inflamed appendix dif-
ship to recurrent Clostridium difficile infections.19 However, in fers from that of the normal appendix. About 60% of aspirates
another retrospective study, prior appendectomy did not affect of inflamed appendices have anaerobes compared to 25% of
the rate of C. difficile infections.20 The role of the appendix in aspirates from normal appendices.26 Tissue specimens from
recolonizing the colon remains to be elucidated. the inflamed appendix wall (not luminal aspirates) virtually all
grow Escherichia coli and Bacteroides species on culture.27,28
Fusobacterium nucleatum/necrophorum, which is not present in
ACUTE APPENDICITIS the normal cecal flora, has been identified in 62% of inflamed
appendices.29 In addition to the other usual species (Peptostrep-
Epidemiology tococcus, Pseudomonas, Bacteroides splanchnicus, Bacteroides
The lifetime risk of developing appendicitis is 8.6% for males intermedius, Lactobacillus), previously unreported fastidious
1 and 6.7% for females, with the highest incidence in the
second and third decades.21 The rate of appendectomy for
gram-negative anaerobic bacilli have been encountered. Patients
with gangrene or perforated appendicitis appear to have more
appendicitis has been decreasing since the 1950s in most coun- tissue invasion by Bacteroides.
tries. In the United States, it reached its lowest incidence rate
of about 15 per 10,000 inhabitants in the 1990s.22 Since then, Natural History
there has been an increase in the incidence rate of nonperforated Because of the current predilection for surgical treatment, the
appendicitis. The reason for this is not clear, but it has been pro- natural history of appendicitis has not been well described. An
posed that the increased use of diagnostic imaging has led to a increasing amount of circumstantial evidence suggests that not
higher detection rate of mild appendicitis that would otherwise all patients with appendicitis will progress to perforation and
resolve undetected. that resolution may be a common event.30 Among the
2 strongest evidence are two randomized trials comparing
Etiology and Pathogenesis early laparoscopy with conservative management of patients
The etiology and pathogenesis of appendicitis are not completely with acute abdominal pain. These studies found three to five
understood. Obstruction of the lumen due to fecaliths or hyper- times more patients with appendicitis in the group of patients
trophy of lymphoid tissue is proposed as the main etiologic factor who were randomized to laparoscopy.31,32 Based on epidemio-
in acute appendicitis. The frequency of obstruction rises with the logic differences, it has been proposed that nonperforated and
severity of the inflammatory process. Fecaliths and calculi are perforated appendicitis may, in fact, be different diseases.22
found in 40% of cases of simple acute appendicitis,23 in 65% of
cases of gangrenous appendicitis without rupture, and in nearly
90% of cases of gangrenous appendicitis with rupture.24 Clinical Presentation
Traditionally, the belief has been that there is a predict- The inflammatory process in the appendix presents as pain, which
able sequence of events leading to eventual appendiceal rupture. initially is of a diffuse visceral type and later becomes more local-
The proximal obstruction of the appendiceal lumen produces ized as the peritoneal lining gets irritated (Table 30-1).33
a closed-loop obstruction, and continuing normal secretion by Symptoms.  Appendicitis usually starts with periumbilical and
the appendiceal mucosa rapidly produces distension. Disten- diffuse pain that eventually localizes to the right lower quad-
sion of the appendix stimulates the nerve endings of visceral rant (sensitivity, 81%; specificity, 53%).34 Although right lower
afferent stretch fibers, producing vague, dull, diffuse pain in the quadrant pain is one of the most sensitive signs of appendici-
mid-abdomen or lower epigastrium. Distension increases from tis, pain in an atypical location or minimal pain will often be
continued mucosal secretion and from rapid multiplication of the initial presentation. Variations in the anatomic location of
the resident bacteria of the appendix. This causes reflex nausea the appendix may account for the differing presentations of the
and vomiting, and the visceral pain increases. As pressure in somatic phase of pain.
the organ increases, venous pressure is exceeded. Capillaries Appendicitis is also associated with gastrointestinal symp-
and venules are occluded but arterial inflow continues, result- toms like nausea (sensitivity, 58%; specificity, 36%), vomiting
ing in engorgement and vascular congestion. The inflammatory (sensitivity, 51%; specificity, 45%), and anorexia (sensitivity,
1244 Table 30-1
Signs and symptoms of appendicitis (data from Andersson33)

True Positive 95% Confidence True Negative 95% Confidence

Likelihood Ratio Interval Likelihood Ratio Interval
Duration of symptoms (hours)
>9 1.01 0.97–1.05 0.94 0.62–1.42
>12 0.96 0.90–1.04 1.19 0.87–1.63
>24 0.65 0.47–0.90 1.47 1.14–1.90
>48 0.49 0.36–0.67 1.20 1.08–1.34
PART II
UNIT II

Fever 1.64 0.89–3.01 0.61 0.49–0.77

Gastrointestinal dysfunction
Anorexia 1.27 1.14–1.41 0.59 0.45–0.77
Nausea 1.15 1.04–1.36 0.72 0.57–0.91
Vomiting 1.63 1.45–1.84 0.75 0.69–0.80
SPECIFIC CONSIDERATIONS

Pain
Pain migration 2.06 1.63–2.60 0.52 0.40–0.69
Pain progression 1.39 1.29–1.50 0.46 0.27–0.77
Direct tenderness 1.29 1.06–1.57 0.25 0.12–0.53
Indirect tenderness 2.47 1.38–4.43 0.71 0.65–0.77
Psoas sign 2.31 1.36–3.91 0.85 0.76–0.95
Rebound 1.99 1.61–2.45 0.39 0.32–0.48
Percussion tenderness 2.86 1.95–4.21 0.49 0.37–0.63
Guarding 2.48 1.60–3.84 0.57 0.48–0.68
Rigidity 2.96 2.43–3.59 0.86 0.72–1.02
Temperature (degrees centigrade)
>37.7 1.57 0.90–2.76 0.65 0.31–1.36
>38.5 1.87 0.66–5.32 0.89 0.71–1.12
White blood cells (10 /L)
9

≥10 4.20 2.11–8.35 0.20 0.10–0.41

≥15 7.20 4.31–12.00 0.66 0.56–0.78
C-reactive protein (mg/L)
>10 1.97 1.58–2.45 0.32 0.20–0.51
>20 2.39 1.67–3.41 0.47 0.28–0.81
Conclusions: Individually, disease history, clinical findings, and laboratory tests are weak. But, when combined, they yield high discriminatory power.

68%; specificity, 36%). Gastrointestinal symptoms that develop a ­sudden pain, the so-called rebound tenderness. Indirect ten-
before the onset of pain suggest a different etiology such as derness (Rovsing’s sign) and indirect rebound tenderness (i.e.,
gastroenteritis.34 Many patients complain of a sensation of pain in the right lower quadrant when the left lower quadrant is
3 obstipation prior to the onset of pain and feel that defeca- palpated) are strong indicators of peritoneal irritation. Rebound
tion will relieve their abdominal pain. Diarrhea may occur in tenderness can be very sharp and uncomfortable for the patient.
association with perforation, especially in children. It is therefore recommended to start with testing for indirect
Signs.  Early in presentation, vital signs may be minimally rebound tenderness and direct percussion tenderness.
altered. The body temperature and pulse rate may be normal Anatomic variations in the position of the inflamed appen-
or slightly elevated. Changes of greater magnitude may indi- dix lead to deviations in the usual physical findings. With a ret-
cate that a complication has occurred or that another diagnosis rocecal appendix, the abdominal findings are less striking, and
should be considered.35 tenderness may be most marked in the flank. When the appen-
Physical findings are determined by the presence of peri- dix hangs into the pelvis, abdominal findings may be entirely
toneal irritation and are influenced by whether the organ has absent, and the diagnosis may be missed. Right-sided rectal ten-
already ruptured when the patient is first examined. Patients derness is said to help in this situation, but the diagnostic value
with appendicitis usually move slowly and prefer to lie supine is low. Pain with extension of the right leg (psoas sign) indicates
due to the peritoneal irritation. On abdominal palpation, there a focus of irritation in the proximity of the right psoas muscle.
is tenderness with a maximum at or near McBurney’s point Similarly, stretching of the obturator internus through internal
(Fig. 30-1).5 On deep palpation, one can often feel a muscu- rotation of a flexed thigh (obturator sign) suggests inflammation
lar resistance (guarding) in the right iliac fossa, which may be near the muscle.
more evident when compared to the left side. When the pres- Laboratory Findings. Appendicitis is associated with an
sure of the examining hand is quickly relieved, the patient feels inflammatory response that is strongly related to the severity of
 all normal. The inflammatory response in acute appendicitis 1245
is a dynamic process. Early in the process, the inflammatory
response can be weak. CRP elevation, in particular, can have up
to a 12-hour delay. A decreasing inflammatory response may
indicate spontaneous resolution.
Urinalysis can be useful to rule out the urinary tract as the
source of infection; however, several white or red blood cells
can be present from irritation of the ureter or bladder. Bacteri-
uria is generally not seen.
Clinical Scoring Systems.  The clinical diagnosis of appendi-

CHAPTER 30 The Appendix

citis is a subjective estimate of the probability of appendicitis
based on multiple variables that individually are weak discrimi-
nators; however, used in conjunction, they possess a high pre-
dictive value. This process can be made more objective by the
use of clinical scoring systems, which are based on variables
with proven discriminating power and assigned a proper weight.
Figure 30-1.  McBurney’s point (1 = anterior superior iliac spine; The Alvarado score is the most widespread scoring system. It
2 = umbilicus; x = McBurney’s point). is especially useful for ruling out appendicitis and selecting
patients for further diagnostic workup.37 The Appendici-
the disease. Laboratory examinations are therefore an impor- 3 tis Inflammatory Response Score resembles the Alvarado
tant part of the diagnosis. Mild leukocytosis is often present in score but uses more graded variables and includes CRP
patients with acute, uncomplicated appendicitis and is usually (Table 30-2).38,39 Studies have shown it to perform better than
accompanied by a polymorphonuclear prominence. It is unusual the Alvarado score in accurately predicting appendicitis.38,39
for the white blood cell count to be >18,000 cells/mm3 in uncom- However, clinical scoring systems have not gained widespread
plicated appendicitis. Counts above this level raise the possibility acceptance in making the diagnosis of appendicitis.
of a perforated appendix with or without an abscess. An increased Imaging Studies.  Plain films of the abdomen can show the
C-reactive protein (CRP) concentration is a strong indicator of presence of a fecalith and fecal loading in the cecum associ-
appendicitis, especially for complicated appendicitis.36 ated with appendicitis but are rarely helpful in diagnosing acute
White blood cell counts can be low due to lymphopenia appendicitis40; however, they may be of benefit in ruling out other
or septic reaction, but in this situation, the proportion of neutro- pathology. A chest radiograph is helpful to rule out referred pain
phils is usually very high. Therefore, all inflammatory variables from a right lower lobe pneumonic process. If the appendix fills
should be viewed together. Appendicitis is very unlikely if the on barium enema, appendicitis is unlikely41; however, this test
white blood cell count, proportion of neutrophils, and CRP are is not indicated in the acute setting. Technetium-99m–labeled

Table 30-2
Scoring systems

Alvarado Score37 Appendicitis Inflammatory Response Score38,39

Findings Points Findings Points
Migratory right iliac fossa pain 1 Vomiting 1
Anorexia 1 Pain in the right inferior fossa 1
Nausea or vomiting 1 Rebound tenderness or muscular defense
Tenderness: right iliac fossa 2 Light 1
Rebound tenderness right iliac fossa 1 Medium 2
Fever ≥36.3°C 1 Strong 3
Leukocytosis ≥10 × 109 cells/L 2 Body temperature ≥38.5°C 1
Shift to the left of neutrophils 1 Polymorphonuclear leukocytes
70%–84% 1
≥85% 2
White blood cell count
10.0–14.9 × 109 cells/L 1
≥15.0 × 109 cells/L 2
C-reactive protein concentration
10–49 g/L 1
≥50 g/L 2
Score: <3: Low likelihood of appendicitis Score: 0–4: Low probability. Outpatient follow-up.
4–6: Consider further imaging 5–8: Indeterminate group. Active observation or diagnostic laparoscopy.
≥7: High likelihood of appendicitis 9–12: High probability. Surgical exploration.
1246 leukocyte scan has been reported for use in diagnosing appendi- Alternatively, selective CT scanning based on the likelihood of
citis with good results but has not gained widespread use due to appendicitis takes advantage of the clinical skills of the surgeon
its relative unavailability and impracticality in daily use.42 and, when indicated, adds the expertise of the radiologist.
Ultrasonography and computed tomography (CT) scan are Despite the increased use of ultrasonography and CT,
the most commonly used imaging tests in patients with abdomi- the rate of misdiagnosis of appendicitis has remained constant
nal pain, particularly in evaluation of possible appendicitis. (15%). The percentage of misdiagnosed cases of appendici-
Multiple meta-analyses have been performed comparing the two tis is significantly higher among women than men (22% vs.
imaging modalities (Table 30-3).43-47 Overall, CT scan is more 9.3%).50,51 The negative appendectomy rate is highest in women
sensitive and specific than ultrasonography in diagnosing of reproductive age.
4 appendicitis.
Graded compression ultrasonography is inexpensive, can Differential Diagnosis
be performed rapidly, does not require a contrast medium, and The differential diagnosis of acute appendicitis is essentially the
PART II
UNIT II

can be used in pregnant patients. Sonographically, the appen- diagnosis of acute abdomen. An identical clinical picture can
dix is identified as a blind-ending, nonperistaltic bowel loop result from a wide variety of acute processes within the peri-
originating from the cecum. With maximal compression, the toneal cavity that produce the same physiologic alterations as
diameter of the appendix is measured in the anterior-posterior acute appendicitis.
direction. Thickening of the appendiceal wall and the presence The accuracy of preoperative diagnosis should be higher
SPECIFIC CONSIDERATIONS

of periappendiceal fluid are highly suggestive of appendicitis. than 85%. If it is consistently less, it is likely that unnecessary
Demonstration of an easily compressible appendix measur- operations are being performed and a more rigorous preopera-
ing <5 mm in diameter excludes the diagnosis of appendicitis. tive differential diagnosis is needed.
The sonographic diagnosis of acute appendicitis has a reported The most common findings in the case of an erroneous
sensitivity of 55% to 96% and a specificity of 85% to 98%. preoperative diagnosis of appendicitis—together accounting
Ultrasonography is similarly effective in children and pregnant for more than 75% of cases—are, in descending order of fre-
women, although its application is limited in late pregnancy. quency, acute mesenteric adenitis, no organic pathologic condi-
Ultrasonography has its limitations, particularly the operator- tion, acute pelvic inflammatory disease, twisted ovarian cyst or
dependent nature of results. In the adult population, ultrasonog- ruptured graafian follicle, and acute gastroenteritis.
raphy remains limited in its use. The differential diagnosis of acute appendicitis depends on
With high-resolution helical CT, the inflamed appendix four major factors: the anatomic location of the inflamed appen-
appears dilated (>5 mm), and the wall is thickened. There is dix; the stage of the process (uncomplicated or complicated);
often evidence of inflammation, which can include periappen- the patient’s age; and the patient’s gender.52-56
diceal fat stranding, thickened mesoappendix, periappendiceal Pediatric Patient.  Acute mesenteric adenitis is the disease
phlegmon, and free fluid. Fecaliths can be often visualized; most often confused with acute appendicitis in children. Almost
however, their presence is not pathognomonic of appendicitis. invariably, an upper respiratory tract infection is present or has
CT scanning is also an excellent technique for identifying other recently subsided. The pain usually is diffuse, and tenderness
inflammatory processes masquerading as appendicitis. Several is not as sharply localized as in appendicitis. Voluntary guard-
CT techniques have been used, including focused and nonfo- ing is sometimes present, but true rigidity is rare. Generalized
cused CT scans and contrast and noncontrast scans. Surpris- lymphadenopathy may be noted. Laboratory procedures are of
ingly, all of these techniques have yielded essentially identical little help in arriving at the correct diagnosis, although a rela-
rates of diagnostic accuracy: 92% to 97% sensitivity, 85% to tive lymphocytosis, when present, suggests mesenteric adenitis.
94% specificity, 90% to 98% accuracy, 75% to 95% positive Observation for several hours is appropriate if the diagnosis of
predictive value, and 95% to 99% negative predictive value. mesenteric adenitis is suspected, as it is a self-limited disease.
The additional use of rectal contrast does not improve the results
of CT scanning. Elderly Patient.  Diverticulitis or perforating carcinoma of
A number of studies have documented improvement in the cecum or of a portion of the sigmoid that overlies the right
diagnostic accuracy with the liberal use of CT scanning in the lower abdomen may be impossible to distinguish from appendi-
workup of suspected appendicitis. CT lowered the rate of nega- citis. These entities should be considered, particularly in older
tive appendectomies from 19% to 12% in one study48 and the patients. CT scanning is often helpful in making a diagnosis in
incidence of negative appendectomies in women from 24% to older patients with right lower quadrant pain and atypical clini-
5% in another study.49 Use of CT altered the care of 24% of cal presentations. In patients successfully managed conserva-
patients studied and provided an alternative diagnosis in half of tively, interval surveillance of the colon (colonoscopy or barium
the patients with normal appendices on CT scan. enema) may be warranted.
Despite the potential usefulness of CT, there are signifi- Female Patient.  Diseases of the female internal reproductive
cant disadvantages. CT scanning is expensive, exposes the organs that may erroneously be diagnosed as appendicitis are,
patient to significant radiation, and has limited use during preg- in approximate descending order of frequency, pelvic inflam-
nancy. Allergy to iodine or contrast limits the administration of matory disease, ruptured graafian follicle, twisted ovarian cyst
contrast agents in some patients, and others cannot tolerate the or tumor, endometriosis, and ruptured ectopic pregnancy. As a
oral ingestion of luminal dye. result, the rate of misdiagnosis remains higher among female
The role of CT scanning in patients who present with right patients.
lower quadrant pain is unclear. One rationale is universal CT In pelvic inflammatory disease, the infection is usually
scanning. There is, however, an argument that indiscriminate bilateral but, if confined to the right tube, may mimic acute
diagnostic imaging can increase the detection of clinically non- appendicitis. Nausea and vomiting are present in patients with
significant appendicitis that would resolve without treatment. appendicitis but in only approximately 50% of those with pelvic
Table 30-3
Meta-analyses comparing CT scan and US outcomes

Author Summary

Terasawa Weston Doria Al-Khayal Van Randen

Year 2004 2005 2006 2007 2008
No. of studies 22 21 57 25 6
No. of patients CT 1172 NR NR NR NR
US 1516 NR NR NR NR
Total 2688 5039 13697 13046 671
Sensitivity CT 94% (CI: 91%–95%) 97% (CI: 95%–98%) 94% (CI: 92%–97%) 93% (CI: 92%–95%) 91% (CI: CT more sensitive than US in five of
US 86% (CI: 83%–88%) 87% (CI: 85%–89%) 88% (CI: 86%–90%) 84% (CI: 82%–85%) 84%–95%) five meta-analyses
78% (CI:
67%–86%)
Specificity CT 95% (CI: 93%–96%) 95% (CI: 93%–96%) 94% (CI: 94%–96%) 93 (CI: 92%–94%) 90% (CI: CT more specific than US in four of
US 81% (CI: 78%–84%) 93% (CI: 92%–94%) 93% (CI: 90%–96%) 96 (CI: 95%–96%) 85%–94%) five meta-analyses
83% (CI:
76%–88%)
Positive CT NR 94% (CI: 92%–95%) NR 90% (CI: 89%–92%) NR CT has superior positive predictive
predictive US NR 89% (CI: 87%–90%) NR 90% (CI: 89%–91%) NR value in one of two meta-analyses
value
Negative CT NR 97% (CI: 96%–98%) NR 96% (CI: 95%–97%) NR CT has superior negative predictive
predictive US NR 92% (CI:91%–93%) NR 93% (CI: 92%–94%) NR value in both ­
value meta-analyses
Accuracy CT NR NR NR 94% (CI: 93%–94%) NR CT is more accurate in the one study
US NR NR NR 92% (CI: 92%–96%) NR reporting results
CI = confidence interval; CT = computed tomography; NR = not reported; US = ultrasonography.

CHAPTER 30 The Appendix

1247
1248 inflammatory disease. Pain and tenderness are usually lower, patients were found to have perforated appendicitis at laparot-
and motion of the cervix is exquisitely painful. Intracellular dip- omy.58 The increased risk of appendiceal rupture may be related
lococci may be demonstrable on smear of the purulent vaginal to the delay in presentation seen in this patient population.57,58 A
discharge. The ratio of cases of appendicitis to cases of pelvic low CD4 count is also associated with an increased incidence of
inflammatory disease is low in females in the early phase of the appendiceal rupture.57
menstrual cycle and high during the luteal phase. The careful The differential diagnosis of right lower quadrant pain is
clinical use of these features has reduced the incidence of nega- expanded in HIV-infected patients compared with the general
tive findings on laparoscopy in young women to 15%. population. In addition to the conditions discussed elsewhere
Ovulation commonly results in the spillage of sufficient in this chapter, opportunistic infections should be considered as
amounts of blood and follicular fluid to produce brief, mild a possible cause of right lower quadrant pain.57,58 Neutropenic
lower abdominal pain. If the amount of fluid is unusually copi- enterocolitis (typhlitis) should also be considered in the differential
ous and is from the right ovary, appendicitis may be simulated. diagnosis of right lower quadrant pain in HIV-infected patients.57,58
PART II
UNIT II

Pain and tenderness may be rather diffuse, and leukocytosis and

fever minimal or absent. Because this pain occurs at the mid- Initial Management
point of the menstrual cycle, it is often called mittelschmerz. Uncomplicated Appendicitis
Serous cysts of the ovary are common and generally remain Operative versus Nonoperative Management of Uncompli-
asymptomatic. When right-sided cysts rupture or undergo tor- cated Appendicitis  In patients with uncomplicated appendici-
SPECIFIC CONSIDERATIONS

sion, the manifestations are similar to those of appendicitis. tis, surgical treatment has been the standard of treatment since
Patients develop right lower quadrant pain, tenderness, rebound, McBurney reported his experiences. The concept of nonopera-
fever, and leukocytosis. Both transvaginal ultrasonography and tive treatment for uncomplicated appendicitis developed from
CT scanning can be diagnostic. two lines of observations. First, for patients in an environment
Torsion requires emergent operative treatment. If the tor- where surgical treatment is not available (e.g., submarines,
sion is complete or longstanding, the pedicle undergoes throm- expeditions in remote areas), treatment with antibiotics alone
bosis, and the ovary and tube become gangrenous and require was noted to be effective. Second, many patients with signs
resection. However, simple detorsion, fenestration of the cyst, and symptoms consistent with appendicitis who did not pursue
and fixation of the ovary as a primary intervention, followed by medical treatment would occasionally have spontaneous resolu-
a laparoscopy a few days later, can be recommended because tion of their illness.
it is often difficult to preoperatively determine the viability of A handful of observational studies and controlled trials
the ovary. have reported the outcomes of nonoperative versus opera-
Blastocysts may implant in the fallopian tube (usually the tive treatment of presumed uncomplicated appendicitis
ampullary portion) and in the ovary. Rupture of right tubal or (Table 30-4).59-64 Overall, there is a reported 9% short-term
ovarian pregnancies can mimic appendicitis. Patients may give (<30 days) failure rate with nonoperative management of
a history of abnormal menses, either missing one or two periods appendicitis (13% if evaluated per protocol). In patients in
or noting only slight vaginal bleeding. Unfortunately, patients whom nonoperative treatment fails, nearly half of patients have
do not always realize they are pregnant. The development of complicated (perforated or gangrenous) appendicitis. After 1
right lower quadrant or pelvic pain may be the first symptom. month, about 1% of patients in the trials underwent an interval
The diagnosis of ruptured ectopic pregnancy should be rela- appendectomy, and 13% of patients who initially were success-
tively easy. The presence of a pelvic mass and elevated levels fully treated with nonoperative measures developed recurrent
of human chorionic gonadotropin are characteristic. Although appendicitis, with an 18% rate of complicated appendicitis.
the leukocyte count rises slightly, the hematocrit level falls as Follow-up was not longer than 1 year in any study. In addition,
a consequence of the intra-abdominal hemorrhage. Vaginal one-third of patients declined or dropped out from nonoperative
examination reveals cervical motion and adnexal tenderness, management of appendicitis.
and a more definitive diagnosis can be established by culdocen- In comparison, operative appendectomy demonstrated a
tesis. The presence of blood and particularly decidual tissue is relatively low dropout rate (2%), lower proportion of compli-
pathognomonic. The treatment of ruptured ectopic pregnancy is cated appendicitis (25%), small proportion of a normal appendix
emergency surgery. (5%), and low rates of superficial surgical site infection (3.7%)
Immunosuppressed Patient.  The incidence of acute appen- and intra-abdominal abscess (1.3%).
dicitis in patients infected with human immunodeficiency The results in these studies must viewed with caution due
virus (HIV) is reported to be 0.5%. This is higher than the to unclear selection of patients, incomplete diagnostic workup
0.1% to 0.2% incidence reported for the general population.57
The presentation of acute appendicitis in HIV-infected patients
5 inoperated
the nonoperated patients, unclear gold standard for the
patients, and high rates of crossover between the
is similar to that in noninfected patients. The majority of HIV- treatment arms. The consequences in terms of use of hospital
infected patients with appendicitis have fever, periumbilical beds, length of hospital stay, morbidity of delayed surgical treat-
pain radiating to the right lower quadrant (91%), right lower ment after failed nonsurgical treatment, delayed diagnosis for
quadrant tenderness (91%), and rebound tenderness (74%). patients with an underlying cancer in the appendix or cecum,
HIV-infected patients do not manifest an absolute leukocyto- and risk of increased antibiotic resistance need to be further
sis; however, if a baseline leukocyte count is available, nearly investigated. Thus, operative treatment of presumed uncom-
all HIV-infected patients with appendicitis demonstrate a rela- plicated appendicitis still remains the standard of care. Certain
tive leukocytosis.57 subgroups with uncomplicated appendicitis may do well with
The risk of appendiceal rupture appears to be increased in nonoperative therapy. Patients pursuing nonoperative manage-
HIV-infected patients. In one large series of HIV-infected patients ment should be carefully counseled regarding the risks of treat-
who underwent appendectomy for presumed appendicitis, 43% of ment failure and recurrent appendicitis.
Table 30-4
Outcomes associated with nonoperative and operative management of acute appendicitis

Nonoperative Outcomes

Dropout Failed Follow-Up Dura-

after Ran- Therapy in Complicated Interval Failed Therapy Complicated tion in Months
Author Study Type No. Male Age domization 0–30 Days Appendicitis Appendectomy in >30 Days Appendicitis (range)
Vons PRCT 120a 75 21±9b 3 14 9 NR 30 3 12
Hansson PRCT 202 103 38±1c 96 9 6/11 d
NR 11 4/12 d
12
Turhan PCT 107 65 21c
5 14 0 NR 8 0 NR
Liu RT 19 8 34±1 e NA 0 0 5 6 1 NR
Styrud PT 128 128 18–50 79/104 f
15 7 NR 16 5 4 (1–10)
Eriksson PRCT 20 14 28 (18–53) 5g 1 1 NR 7 1 7 (3–12)

Overall 596 393 (66%) 23 188 (33%) 53 (8.9%) 23 (42%) 5 (0.8%) 78 (13%) 14 (17.7%) <1 year

Operative Outcomes

Dropout after Complicated Intra-abdominal

Author Study Type No. Male Age Randomization Appendicitis Normal Appendix SSI, Superficial Abscess
Vons PRCT 120 70 34±12b 1 21 NR 1 NR
Hansson PRCT 167 92 38±1 c 13 92/250 f
30/250 f
7 5
Turhan PCT 183 125 26±1 NR 34 NR 6 2
Liu RT 151 104 34±1 e NR 47 5 9 0
Styrud PT 124 124 18-50 NR 7 4 NR NR
Eriksson PRCT 20 13 35 (19–85) NR 9 3 1 0

Overall 765 528 (69%) 33 14 (1.8%) 210 (24.8%) 42 (5.0%) 24 (3.7%) 7 (1.3%)
a
Although 123 patients were randomized to nonoperative management and 3 patients dropped out, only 120 patients were included in the intent-to-treat analysis.
b
Standard deviation.
c
Standard error of the mean.
d
Study only reported pathology results based on the per-protocol group and not the intent-to-treat group.
e
Study did not report the meaning of these values.
f
Study did not report the intent-to-treat values; instead, at one institution, 79 of 104 patients declined to be included in the trial.
g
These patients declined to be included in the study and opted for surgical management.
NA = not applicable; NR = not reported; PCT = prospective controlled trial; PRCT = prospective randomized controlled trial; RT = retrospective trial; SSI = surgical site infection.

CHAPTER 30 The Appendix

1249
1250 Urgent versus Emergent Appendectomy for Uncomplicated consider performing appendectomy in an urgent fashion as
Appendicitis  Traditionally, appendicitis has been considered a opposed to emergently.
surgical emergency. Once diagnosed, a patient was emergently Complicated Appendicitis.  Complicated appendicitis typi-
taken to the operating room for surgical treatment. However, cally refers to perforated appendicitis commonly associated
delays in diagnosis, lack of access to available operating suites, with an abscess or phlegmon. The yearly incidence rate of
and nonoperative management of appendicitis have challenged perforated appendicitis is about 2 per 10,000 persons and has
the notion that uncomplicated appendicitis is a surgical emer- remarkable little variance over time, geographic region, and
gency. age.51,68,69 The proportion of perforated appendicitis, commonly
Three retrospective studies have evaluated the role of around 25%, is often used as an indicator of quality of care.
emergent or urgent surgery for uncomplicated appendicitis; Differences in this proportion are almost entirely related to dif-
the emergent group had a time from presentation to the operat- ferences in the incidence of nonperforated appendicitis. A low
ing room of <12 hours, whereas the urgent group had a time
PART II
UNIT II

proportion of perforations may therefore be the consequence

from presentation to the operating room of 12 to 24 hours of a higher rate of detection and treatment of early or resolving
(Table 30-5).65-67 There was no statistically significant increase appendicitis.
in the number of complicated appendicitis cases in the urgent Children less than 5 years of age and patients more than
group when compared to the emergent group. Similarly, rates 65 years of age have the highest rates of perforation (45% and
of surgical site infection, intra-abdominal abscesses, conversion
SPECIFIC CONSIDERATIONS

51%, respectively). The proportion of perforation increases

to an open procedure, or operative time showed no difference 6 with increasing duration of symptoms. There is, however,
between the two groups. While length of stay was longer for no association of in-hospital delay with perforation. This suggests
the urgent group, it was not statistically or clinically different that most perforations occur early, before the patient arrives to
from the emergent group. Important caveats in consideration hospital. It has also been proposed that the increasing propor-
of urgent as opposed to emergent surgical care include the tion of perforations with time is explained by selection due to
patient’s clinical examination, time of presentation from onset spontaneous resolution of noncomplicated appendicitis.
of symptoms, and duration of “delay” in surgery. Patients with Perforated appendicitis has been suggested to increase the
clinical signs of perforation, patients with delayed presentation risk of female infertility due to impaired tubal function, but this
of greater than 48 hours from onset of symptoms, and patients has not been shown in epidemiologic studies.70
whose definitive therapy may be delayed for more than 12 hours Rupture should be suspected in the presence of generalized
were beyond the scope of these studies. peritonitis and a strong inflammatory response. In many cases,
Emergent versus urgent operation for uncomplicated rupture is contained and patients display localized peritonitis.
appendicitis is dependent on each institution and surgeon. Insti- In 2% to 6% of cases, a palpable mass is detected on physical
tutions without readily available operating rooms and staff may examination. This could represent a phlegmon, which consists

Table 30-5
Emergent versus urgent surgery

Author

Abou-Nukta Stahlfeld Ingraham Summary

Year 2006 2007 2010
No. of patients Emergent 233 53 24,647
Urgent 76 18 4934
Time from presentation to Emergent 6.7±2.7 3.2±2.4 1.5
OR (hours) Urgent 16.7±3.6 15.8±5.5 8.5
% Complicated Emergent 32% NR NR No difference in complicated appendicitis
Urgent 37%
Conversion to open, % Emergent NR 15% NR No difference in conversion rates
Urgent 7%
Operative duration Emergent 81±31 54 51 No difference in operative duration
(minutes) Urgent 82±31 56 50
SSI, % Emergent 1% 7.5% NR One study demonstrates increased infections
Urgent 1% 0% with emergent operation
Intra-abdominal abcess, % Emergent 2% NR NR No difference in intra-abdominal abscess
Urgent 1% rates
Length of stay (days) Emergent 2.5±2.3 2.7 1.8 No significant difference in length of stay
Urgent 2.9±1.8 2.1 1.8
NR = not reported; OR = operating room; SSI = surgical site infection.
of matted loops of bowel adherent to the adjacent inflamed colleagues noted that 9% of the group treated conservatively 1251
appendix or a periappendiceal abscess. Patients who present developed recurrent appendicitis. The authors concluded that
with a mass have experienced symptoms for a longer dura- immediate surgical treatment was superior to conservative treat-
tion, usually 5 to 7 days. Distinguishing acute, uncomplicated ment with interval appendectomy.
appendicitis from acute appendicitis with perforation based on Interval Appendectomy Following Nonoperative Manage-
clinical findings is often difficult, but it is important to make ment of Complicated Appendicitis  Interval appendectomy is
the distinction because the treatments may differ. CT scan may defined as performing an appendectomy following initial suc-
be beneficial in establishing a diagnosis and guiding therapy. cessful nonoperative management in patients with no further
Operative versus Nonoperative Management of Complicated symptoms. The major argument against interval appendectomy
Appendicitis  Patients who present with signs of sepsis and gen- is that many patients treated conservatively never develop mani-

CHAPTER 30 The Appendix

eralized peritonitis should be taken to the operating room imme- festations of appendicitis, and those who do generally can be
diately with concurrent resuscitation. The surgical approach is treated without additional morbidity. The major argument for
based on the surgeon’s level of comfort; however, open appen- interval appendectomy is to prevent future attacks of appendici-
dectomy through a lower midline incision may be necessary to tis or to identify other disease, such as appendiceal malignancy.
treat these complicated cases. There has only been one small prospective randomized
In patients with complicated appendicits and a contained controlled trial (n = 40) investigating this subject. The litera-
abscess or phlegmon but limited peritonitis (focal right lower ture is largely populated with small case series and retrospective
quadrant pain), the treatment options become more complicated. cohort studies; there is no meta-analysis evaluating the subject
Often, these patients will require a challenging procedure with (Table 30-6).74-81 Of the 1434 patients who had presumed com-
a high risk for development of a postoperative intra-abdominal plicated appendicitis and were successfully treated conserva-
abscess. Options include operative management versus conser- tively, 8.8% developed recurrent appendicitis with a median
vative management (antibiotics, bowel rest, fluids, and possible follow-up of 35 months. The incidence of complicated appen-
percutaneous drainage). dicitis following recurrence was low (2.4%). Malignancy was
There have been no prospective randomized controlled noted in 1.3% of cases where pathology was reported. Many
studies comparing operative versus conservative management of of the patients were excluded from these studies due to persis-
complicated appendicitis in adults; all studies have been retro- tent symptoms, persistent infections, or note of malignancy on
spective cohort studies. Two meta-analyses have been performed. screening colonoscopy.
In Andersson and Petzold’s 2007 analysis of 61 studies evaluating Alternatively, of the 344 patients who had presumed com-
this issue, they noted that initial nonoperative management had plicated appendicitis, were successfully treated conservatively,
superior outcomes.70 Nonoperative management included intra- and subsequently underwent interval appendectomy, surgical
venous fluids, minimizing gastrointestinal stimulation, parenteral complications occurred in 9.4% of the patients. Most patients
antibiotics, and percutaneous drainage where deemed appropri- underwent interval appendectomy 2 to 4 months after their acute
ate. The morbidity of immediate operative treatment was 36.5%, presentation. Although operative and pathologic details were
whereas the morbidity of conservative management was 11%. Of not uniformly reported in these patients, many continued to
patients undergoing conservative treatment, 7.6% failed conser- have evidence of appendicitis or abscess at the time of interval
vative treatment and underwent operative management. This sub- appendectomy; 3.6% of patients had malignancy in cases where
group had an overall complication rate of 13.5%. The recurrence pathology was reported.
rate was 7.4%, which does not necessitate interval appendectomy. The role of interval appendectomy following successful
The authors concluded that conservative treatment was favored management of conservative treatment of complicated appen-
over early operation in complicated appendicitis.30 dicitis is unclear. Close clinical follow-up, a complete history
Simillis and colleagues performed a meta-analysis of 17 searching for persistent symptoms, and screening colonoscopy
studies.71 They noted that conservative treatment was associ- (when age appropriate) should all be used to help guide the dis-
ated with fewer overall complications (odds ratio, 0.24; cussion with the patient on the role of interval appendectomy fol-
7 95% confidence interval [CI], 0.13 to 0.44), intra-abdom- lowing conservative management of complicated appendicitis.
inal abscesses (odds ratio, 0.19; 95% CI, 0.07 to 0.58), bowel
obstructions (odds ratio, 0.35; 95% CI, 0.17 to 0.71), and reop- OPERATIVE INTERVENTIONS FOR THE APPENDIX
erations (odds ratio, 0.17; 95% CI, 0.04 to 0.75).71 The authors
concluded that conservative treatment was favored over early Open Appendectomy
operation in complicated appendicitis. Typically performed with a patient under general anesthesia, the
In the pediatric literature, there have been two prospec- patient is placed in supine position. The entire abdomen should
tive randomized controlled trials72,73 demonstrating that early be prepped and draped in case a larger incision is needed. For
operative intervention had equivalent or superior outcomes to early nonperforated appendicitis, a right lower quadrant inci-
conservative management, but these studies included interval sion at McBurney’s point (one-third of the distance from the
appendectomy for all patients in their calculations. St. Peter anterior superior iliac spine to the umbilicus) is commonly used.
and colleagues72 demonstrated that 20% of patients failed con- A McBurney (oblique) or Rocky-Davis (transverse) right lower
servative treatment. Early surgical intervention had equivalent quadrant muscle splitting incision is made. If perforated appen-
results to interval appendectomy. Alternatively, Blakely and dicitis is suspected or the diagnosis is in doubt, a lower midline
colleagues73 noted that interval appendectomy, versus early laparotomy can be considered. Although it has been reported
appendectomy, had a higher incidence of adverse events (50% that the position of the base of the appendix can change with
vs. 30%, P = .003), intra-abdominal abscesses (37% vs. 19%, pregnancy, prospective studies have demonstrated that preg-
P = .02), small bowel obstruction (10.4% vs. 0%, P = .01), and nancy does not change the proportion of patients with the appen-
readmissions (31% vs. 8%, P = .06). In addition, Blakely and diceal base within 2 cm of McBurney’s point.82
1252 Table 30-6
Interval appendectomy following nonoperative management of complicated appendicitis
No Interval Appendectomy

Follow-Up
Study Recurrent Duration
Author Year Type No. Appendicitis Appendectomy Complicated Complications Malignancy (months)
Youssef 2010 PCT 51 9 7 1 1 NR 24
Tekin 2008 CS 89 15 NR NR NR NR NR
PART II
UNIT II

Lai 2006 RT 94 24 20 NR NR 2 33
Kaminski 2005 CS 1012 39 39 NR NR NR 48
Kumar 2004 PRCT 20 2 2 NR NR 1 34
Eryilmaz 2004 CS 25 3 3 NR NR NR 35
SPECIFIC CONSIDERATIONS

Dixon 2003 RT 116 32 22 0 NR 0 NR

Adalla 1996 CS 27 2 2 NR NR NR NR
Overall 1434 126 (8.8%) 95 (7.1%) 1 (2.4%) 1 (11%) 3 (1.3%) 35
Interval Appendectomy

Author Year Study Type No. Complications Malignancy Time of Surgery (months)
Lugo 2010 PT 46 3 2 2
Youssef 2010 PCT 10 1 NR 3
Lai 2006 RT 70 NR 2 2
Kumar 2004 PRCT 20 0 1 3
Dixon 2004 RCT 114 NR NR 2
Friedell 2000 CS 5 0 1 2
Yamini 1998 CS 41 6 1 2
Eriksson 1998 CS 38 5 1 4
Overall 344 15 (9.4%) 8 (3.6%) 3
CS = case series; NR = not reported; PCT = prospective controlled trial; PRCT = prospective randomized controlled trial; RT = retrospective trial.

Following entry into the abdomen, the patient should be The skin can also be closed primarily in patients with perforated
placed in slight Trendelenburg position with rotation of the bed appendicitis.
to the patient’s left. If the appendix is not easily identified, the If appendicitis is not found, a methodical search must be
cecum should be located. Tracing the taenia libera (anterior tae- made for an alternative diagnosis. The cecum and mesentery
nia), the most visible of the three taeniae coli, distally, the base should be inspected. The small bowel should be evaluated in a
of the appendix can be identified. retrograde fashion beginning at the ileocecal valve. Concerns
The appendix will often have attachments to the lateral for Crohn’s disease or Meckel’s diverticulum should be of
wall or pelvis that can be dissected free. Dividing the mesen- priority. In female patients, the reproductive organs should be
tery of the appendix first will often allow improved exposure of closely inspected. If purulent or bilious fluid is encountered, it
the base of the appendix. The appendiceal stump can be man- is imperative that the source be identified. For example, Val-
aged by simple ligation or by ligation and inversion. As long entino’s appendicitis, or a perforated duodenal ulcer presenting
as the stump is clearly visible and the base of the cecum is not as appendicitis, should be excluded in such cases. A medial
involved with the inflammatory process, the stump can be safely extension of the incision (Fowler-Weir) or superior extension
ligated. Obliteration of the mucosa with electrocautery with the of the lateral incision is appropriate if further evaluation of the
intention to obviate the development of a mucocele is recom- lower abdomen or right colon is warranted. Selective laparos-
mended by some surgeons; however, no data have evaluated the copy through a right lower quadrant incision has also been
risk or benefit of this surgical maneuver. Inversion of the stump described.89 If upper abdominal pathology is encountered, a
with plication of the cecum has also been described. Placement midline incision should be made.
of surgical drains for both uncomplicated83 and complicated
appendicitis,84-87 practiced by many surgeons, has not been sup- Laparoscopic Appendectomy
ported in clinical trials. Pus in the abdomen should be aspirated, The first reported laparoscopic appendectomy was performed
but irrigation in complicated appendicitis is not recommended.88 in 1983 by Semm; however, the laparoscopic approach did
not come into widespread use until much later, following the position, and the retracted appendix at the 10 o’clock posi- 1253
success of laparoscopic cholecystectomy. This may be due to tion to allow proper identification of the base of the appendix
the small incision already commonly used with open appen- (Fig. 30-3).90 Through the infraumbilical port, the mesentery
dectomy. should be gently dissected from the base of the appendix and a
Laparoscopic appendectomy is performed under general window created. Typically the base of the appendix is stapled,
anesthesia. An oro- or nasogastric tube and urinary catheter are followed by stapling of the mesentery. Alternatively, the mesen-
placed. The patient should be placed supine with his or her left tery may be divided by an energy device or clipped and the base
arm tucked and securely strapped to the operating table. Both of the appendix secured with an Endoloop. The stump should
surgeon and assistant should be standing on the patient’s left be carefully examined to ensure hemostasis, complete transec-
facing the appendix. The laparoscopic screens should be posi- tion, and ensure that no stump is left behind. The appendix is
tioned on the patient’s right or at the foot of the bed. Standard removed through the infraumbilical trocar in a retrieval bag.

CHAPTER 30 The Appendix

laparoscopic appendectomy typically uses three ports. Typi-
cally, a 10- or 12-mm port is placed at the umbilicus, whereas Laparoscopic versus Open Appendectomy
two 5-mm ports are placed suprapubic and in the left lower There have been multiple prospective, randomized controlled
quadrant. The patient should be placed in Trendelenburg and trials comparing laparoscopic and open appendectomy out-
tilted to the left (Fig. 30-2). comes. A number of meta-analyses have been performed evalu-
The appendix should be identified similarly as in open sur- ating the cumulative outcomes (Table 30-7).91-99
gery by tracking the taenia libera/coli to the appendiceal base. Laparoscopic appendectomy is associated with fewer inci-
Through the suprapubic port, the appendix should be grasped sional surgical site infections compared to open appendectomy.
securely and elevated to the 10 o’clock position. An “appendi- However, laparoscopic appendectomy may be associated with
ceal critical view” should be obtained where the taenia libera increased risk of intra-abdominal abscess compared to open
is at the 3 o’clock position, the terminal ileum at the 6 o’clock appendectomy. There is less pain, shorter length of stay, and

Anesthesiologist

Assistant

Surgeon

Figure 30-2.  Operating room setup.

1254
PART II
UNIT II
SPECIFIC CONSIDERATIONS

Figure 30-3.  A and B. Appendiceal critical view.

quicker return to normal activity with laparoscopic appendec- laparoscopic appendectomy. The appendix may be placed in a
tomy when compared to open appendectomy. Laparoscopic retrieval bag or removed through the single incision.
appendectomy is associated with increased operative duration There have been multiple small trials evaluating the effi-
and increased operating rooms costs; however, overall costs are cacy of laparoscopic single-incision appendectomy compared
likely similar when compared to open appendectomy. Patients to standard appendectomy; however, there has only been one
tend to have improved satisfaction scores with laparoscopic prospective randomized study (in the pediatric population) and
appendectomy. Many of the differences, while statistically sig- one meta-analysis. Gill and colleagues, in 2012, reviewed nine
nificant, have nominal clinical difference, such as length of stay studies for a total of 275 laparoscopic single-incision appen-
where differences are measured in hours.91-99 dectomies and 348 standard laparoscopic appendectomy proce-
In addition, laparoscopic appendectomy may provide a dures. In this meta-analysis, there was no difference in operative
benefit when the diagnosis is in question, such as in female time (57 ± 10 vs. 55 ± 13 minutes), complications (11% vs.
patients of reproductive age, older patients in whom malignancy 8.3%), incisional surgical site infections (5.6% vs. 4.9%), intra-
is suspected, and morbidly obese patients for whom larger open abdominal abscesses (1.8% vs. 1.4%), or length of stay (3 ± 2
appendectomy incisions may be required. vs. 4 ± 1 days). Cases were converted to open or additional ports
were placed in 4% of laparoscopic single-incision appendecto-
Laparoscopic Single-Incision Appendectomy mies and 0.9% of standard laparoscopic procedures. There was
There has been growing interest in laparoscopic single-incision no difference in return to bowel function, postoperative pain,
appendectomy. Instead of two or three incisions, a single inci- or return to normal activity. There was no difference in overall
sion is made, typically periumbilical. The first published lapa- cost. The incidence of hernia formation following the laparo-
roscopic-assisted, single-incision appendectomy was reported scopic single-incision appendectomy procedure compared to
by Inoue in 1994, where the appendix was identified laparo- standard laparoscopy has not been reported.100
scopically and grasped and pulled through the laparoscopic Although further study is needed, it appears that in lapa-
incision and the appendectomy completed in an open manner. roscopic appendectomy, laparoscopic single-incision appendec-
The first reports of a pure laparoscopic single-incision appen- tomy conveys no discernible advantage or disadvantage with
dectomy were described in 2009 by multiple surgical groups. short-term outcomes. Late outcomes and patient quality-
By this time, industry had designed multiple options for true 8 of-life outcomes remain to be investigated.
single-port access as opposed to makeshift single-incision
access. Natural Orifice Transluminal Endoscopic
With laparoscopic single-incision appendectomy, the Surgery
patient is prepared similarly to laparoscopic appendectomy. Natural orifice transluminal endoscopic surgery (NOTES) is a
Under general anesthesia, the patient is secured in a supine posi- new surgical procedure using flexible endoscopes in the abdom-
tion with the left arm tucked. The surgeon and assistant stand on inal cavity. In this procedure, access is gained by way of organs
the left side facing the appendix and the screen. When perform- that are reached through a natural, already-existing external
ing laparoscopic single-incision appendectomy, the surgeon’s orifice. The hoped-for advantages associated with this method
hands perform the opposite function that they would normally include the reduction of postoperative wound pain, shorter con-
in standard laparoscopic surgery. The surgeon’s right hand will valescence, avoidance of wound infection and abdominal wall
grasp the appendix and retract it to the right lower quadrant at hernias, and the absence of scars.
the 10 o’clock position.90 The surgeon’s left hand will dissect One hundred thirteen NOTES appendectomies in human
the mesenteric window and, upon identifying the appendiceal patients have been reported in the medical literature. Eighty-
critical view, staple across the base of the appendix and mesen- seven were performed transvaginally, and 26 were performed
tery. If the base of the appendix cannot be definitively identified transgastrically.101 The vast majority of these cases are hybrid
or the appendiceal critical view cannot be obtained, additional procedures (NOTES plus laparoscopic assist port) with only
ports can be placed to perform a “plus one” or even standard 14 cases of pure NOTES appendectomies (three transvaginal
Table 30-7
Meta-analysis comparing laparoscopic versus open appendectomy outcomes

Author Summary
Wei Lui Li Markides Bennet Temple Garbutt Sauerland Golub
Year 2011 2010 2010 2010 2007 1999 1999 1998 1998
No. of studies 25 16 44 12 34 8 11 28 16
No. of patients LA 2220 1587 2609 NR 2064 730 2877 887
OA 2474 1674 2683 NR 2350 653 795
Total 4694 3261 5292 4414 1383 1375 1682
SSI LA (%) 3.8 2.8 9/9 favor LA
OA (%) 8.4 7.0 3/9 not SS
Odds Ratio∗ 0.51 0.45 0.43 0.52 0.40 –5.6 to –0.8 06.1 to –2.3
95% CI 0.36–0.73 0.34–0.59 0.34–0.55 0.39–0.70 0.24–0.59 –3.2 –4.2 0.19–0.47
Pooled effect 0.30–0.56
IAA LA (%) NR 2.0 3/8 LA = OA
OA (%) 0.94 7/8 not SS
Odds Ratio∗ 1.56 1.24 2.29 1.94
95% CI 0.93–2.14 1.01–2.43 0.84–1.84 1.48–3.53 0.98–5.58 –0.8 to 2.4 –0.4 to 2.3 0.88–6.64
Pooled effect 0.8 0.52
Pain Difference∗ –0.52 NR –0.7 NR –0.8 NR –1.19 –.05 NR 6/6 favor LA
1 not SS
LOS LA (days) 1.2 1.9 1.4 3.2 9/9 favor LA
OA (days) 1.8 3.0 2.0 3.8 3/9 not SS
Differencea –0.68 –0.82 –0.60 –1.10 –0.62 –0.16 –0.58 –15.0
Return activity LA (days) 8.0 NR 7.8 11.9 8/8 favor LA
OA (days) 12.5 10.0 19.0 1/8 not SS
Differencea –3.1 –6.9 –4.5 –2.2 –5.7 –5.5 –6.5 –7.1
Operative time LA (min) 24.0 30.0 25.0 69.8 9/9 favor OA
OA (min) 11.7 17.2 10.4 52.9
Differencea 10.7 7.6 12.35 12.8 14.6 18.1 16.8 15.7 16.2
Cost Difference a
11% NR NR NR NR NR NR NR –3% 1/3 favors LA
1/3 favors OA
1/3 LA = OA
2/3 not SS
Conversion rate NR NR NR NR NR 11% 11% 8% NR
a
Index is open.
IAA = intra-abdominal abscess (specifically organ/space surgical site infection); LA = laparoscopic appendectomy; LOS = length of stay; NR = not reported; OA = open appendectomy; SS = statistically significant;
SSI = surgical site infection (specifically superficial and deep).

CHAPTER 30 The Appendix

1255
1256 and 11 transgastric). Although reported complication rates Elderly patients usually present with lower abdominal
appear low, conversion rates (to hybrid procedures) remain pain, but on clinical examination, localized right lower quadrant
high. tenderness is not as common as in younger patients. A ­history
The main concern with NOTES has been complications of periumbilical pain migrating to the right lower quadrant
with closure of the enterotomy. To date, there is no reliable is reported infrequently. Although currently there are no criteria
method of closure of the gastrotomy site, and there has been that definitively identify elderly patients with acute a­ ppendicitis
significant morbidity reported with this approach. who are at risk of rupture, prioritization should be given to
Although the transvaginal approach appears to be more patients with a temperature of greater than 38°C (100.4°F) and a
promising, in women surveyed on their perception of NOTES, shift to the left in leukocyte count of more than 76%, especially
three-quarters were either neutral or unhappy about the pros- if they are male, are anorexic, or have had pain of long duration
pects of NOTES.102 before admission.65
Much work remains to demonstrate whether NOTES is As a result of increased comorbidities and an increased
PART II
UNIT II

able to provide the theoretical benefits purported. Great care rate of perforation, postoperative morbidity, mortality, and hos-
must be taken to prevent significant morbidity or mortality en pital length of stay are increased in the elderly compared with
route to studying these procedures. younger populations with appendicitis. Although no random-
ized trials have been conducted, it appears that elderly patients
benefit from a laparoscopic approach to treatment of appen-
SPECIFIC CONSIDERATIONS

SPECIAL CIRCUMSTANCES dicitis. The use of laparoscopy in the elderly has significantly
increased in recent years. In general, laparoscopic appendec-
Acute Appendicitis in the Young
tomy offers elderly patients with appendicitis a shorter length
The establishment of a diagnosis of acute appendicitis is more
of hospital stay, a reduction in complication and mortality rates,
difficult in young children than in the adult. The inability of
and a greater chance of discharge to home (independent of fur-
young children to give an accurate history, diagnostic delays
ther nursing care or rehabilitation).109
by both parents and physicians, and the frequency of gastro-
intestinal distress in children are all contributing factors to the
misdiagnosis and delay in diagnosis.103 In children, the physical Acute Appendicitis during Pregnancy
examination findings of maximal tenderness in the right lower Appendectomy for presumed appendicitis is the most common
quadrant, the inability to walk or walking with a limp, and pain surgical emergency during pregnancy. The incidence is approxi-
with percussion, coughing, and hopping were found to have the mately 1 in 766 births. Acute appendicitis can occur at any time
highest sensitivity for appendicitis.104 during pregnancy but is rare in the third trimester.110 The overall
The more rapid progression to rupture and the inability of negative appendectomy rate during pregnancy is approximately
the underdeveloped greater omentum to contain a rupture lead 25% and appears to be higher than the rate seen in nonpregnant
to significant morbidity rates in children. Children <5 years of women.110,111 A higher rate of negative appendectomy is seen
age have a negative appendectomy rate of 25% and an appendi- in the second trimester, whereas the lowest rate is in the third
ceal perforation rate of 45%. These rates may be compared with trimester. The diversity of clinical presentations and the diffi-
a negative appendectomy rate of <10% and a perforated appen- culty in making the diagnosis of acute appendicitis in pregnant
dix rate of 20% in children 5 to 12 years of age.50,51 The inci- women are well established. This is particularly true in the late
dence of major complications after appendectomy in children second trimester and the third trimester, when many abdominal
is correlated with appendiceal rupture. The wound infection symptoms may be considered pregnancy related. In addition,
rate after the treatment of nonperforated appendicitis in chil- during pregnancy, there are anatomic changes in the appendix
dren is 2.8%, compared with a rate of 11% after the treatment and increased abdominal laxity that may further complicate clini-
of perforated appendicitis. The incidence of intra-abdominal cal evaluation.
abscess also is higher after the treatment of perforated appen- Appendicitis in pregnancy should be suspected when a
dicitis than after nonperforated appendicitis (6% vs. 3%).105 pregnant woman complains of abdominal pain of new onset.
The treatment regimen for perforated appendicitis generally The most consistent sign encountered in acute appendicitis dur-
includes immediate appendectomy. Antibiotic coverage is lim- ing pregnancy is pain in the right side of the abdomen. Sev-
ited to 24 to 48 hours in cases of nonperforated appendicitis. enty-four percent of patients report pain located in the right
For perforated appendicitis, intravenous antibiotics usually are lower abdominal quadrant, with no difference between early
given until the white blood cell count is normal and the patient and late pregnancy. Only 57% of patients present with the clas-
is afebrile for 24 hours. Laparoscopic appendectomy has been sic history of diffuse periumbilical pain migrating to the right
shown to be safe and effective for the treatment of appendicitis lower quadrant. Laboratory evaluation is not helpful in estab-
in children.106 lishing the diagnosis of acute appendicitis during pregnancy.
The physiologic leukocytosis of pregnancy has been defined as
Acute Appendicitis in the Elderly high as 16,000 cells/mm3. In one series, only 38% of patients
Compared with younger adults, elderly patients with appendi- with appendicitis had a white blood cell count of more than
citis often pose a more difficult diagnostic problem because of 16,000 cells/mm3.110 Recent data suggest that the incidence of
the atypical presentation, expanded differential diagnosis, and perforated or complex appendicitis is not increased in pregnant
communication difficulty. These factors may be responsible for patients.111
the disproportionately high perforation rate seen in the elderly. When the diagnosis is in doubt, abdominal ultrasound
In the general population, perforation rates range from 20% to may be beneficial. Another option is magnetic resonance
30%, compared with 50% to 70% in the elderly.107 In addition, imaging, which has no known deleterious effects on the fetus.
the perforation rate appears to increase with age greater than The American College of Radiology recommends the use
80 years.108 of nonionizing radiation techniques for front-line imaging in
pregnant women.70 Laparoscopy has been advocated in equiv- initial surgery. Patients ­presenting with stump appendicitis are 1257
ocal cases, especially early in pregnancy; however, laparo- more likely to have complicated appendicitis, have an open pro-
scopic appendectomy may be associated with an increase in cedure, and undergo colectomy.
pregnancy-related complications. In an analysis of outcomes The key to avoiding stump appendicitis is prevention.
in California using administrative databases, laparoscopy was Use of the “appendiceal critical view” (appendix placed at
found to be associated with a 2.31 times increased risk of fetal 10 o’clock, taenia coli/libera at 3 o’clock, and terminal ileum at
loss compared with open surgery.111 6 o’clock) and identification of where the taeniae coli merge and
The overall incidence of fetal loss after appendectomy disappear is paramount to identifying and ligating the base of
is 4%, and the risk of early delivery is 7%. Rates of fetal loss the appendix during the initial operation. The remaining stump
are considerably higher in women with complicated appendici- should be no longer than 0.5 cm, as stump appendicitis has only
tis than in those with a negative appendectomy or with simple been noted in stumps ≥0.5 cm in the literature.

CHAPTER 30 The Appendix

appendicitis. It is important to note that a negative appendectomy In patients who have had prior appendectomy, a low index
is not a benign procedure. Removing a normal appendix is associ- of suspicion is important to prevent delay in diagnosis and com-
ated with a 4% risk of fetal loss and 10% risk of early delivery. plications. Prior appendectomy should not be an absolute crite-
9 Maternal mortality after appendectomy is extremely rare rion in ruling out acute appendicitis.
(0.03%). Because the incidence of complicated appendix is simi-
lar in pregnant and nonpregnant women and because maternal
mortality is so low, it appears that the greatest opportunity to
INCIDENTAL APPENDECTOMY
improve fetal outcomes is by improving diagnostic accuracy and Decisions regarding the efficacy of incidental appendectomy
reducing the rate of negative appendectomy.110-113 should be based on the epidemiology of appendicitis. The best data
were published by the Centers for Disease Control and Prevention
based on the period from 1979 to 1984.120 During this period, an
POSTOPERATIVE CARE AND COMPLICATIONS average of 250,000 cases of appendicitis and 310,000 incidental
Following uncomplicated appendectomy, complication rates are appendectomies occurred annually in the United States. It was esti-
low,114 and most patients can quickly be started on a diet and mated that 36 incidental appendectomies had to be performed to
discharged home the same day or the following day.115 Postop- prevent one patient from developing appendicitis.121 In view of the
erative antibiotic therapy is unnecessary.116 added costs and risk of morbidity for each extension of a surgical
Alternatively, with complicated appendectomy, compli- intervention, this does not seem to justify incidental appendectomy.
cation rates are increased compared to uncomplicated appen- The financial aspects of the decision to perform inciden-
dicitis.114 Patients should be continued on broad-spectrum tal appendectomy were assessed.122 For open appendectomy,
antibiotics for 4 to 7 days.117,118 Postoperative ileus may there was a financial disincentive to perform incidental appen-
10 occur, so diet should be started based on daily clinical dectomy. On an annual basis, $20,000,000 had to be spent to
evaluation. These patients are at increased risk for surgical site save the $6,000,000 cost of appendicitis. With the laparoscopic
infections. approach, it was cost-effective to perform incidental appen-
dectomy only in patients less than 25 years of age and only
Surgical Site Infection if the reimbursement for surgeons was 10% of the usual and
In patients with incisional (superficial or deep) surgical site
customary charges. At a higher rate of reimbursement, inci-
infection, treatment should be opening of the incision and
dental appendectomy was not cost-effective in any age group.
obtaining a culture. Following laparoscopic appendectomy,
Although incidental appendectomy is generally neither clini-
the extraction port site is the most common site of surgical site
cally nor economically appropriate, there are some special patient
infection. Patients with cellulitis can be started on antibiotics.
groups in whom it should be performed during laparotomy or
The cultured organisms are typically bowel flora, as opposed to
laparoscopy for other indications. These include children about to
skin flora.119
undergo chemotherapy, the disabled who cannot describe symp-
Patients with postoperative intra-abdominal abscesses can
toms or react normally to abdominal pain, patients with Crohn’s
present in a variety of ways. Although fever, leukocytosis, and
disease in whom the cecum is free of macroscopic disease, and
abdominal pain are common presentations, patients with ileus,
individuals who are about to travel to remote places where
bowel obstruction, diarrhea, and tenesmus may also harbor intra- 11 there is no access to medical or surgical care.123
abdominal abscesses. Small abscesses can be simply treated with
Appendectomy is routinely carried out during the perfor-
antibiotics; however, larger abscesses require drainage. Most
mance of Ladd’s procedure for malrotation because displace-
commonly, percutaneous drainage with CT or ultrasound guid-
ment of the cecum into the left upper quadrant would complicate
ance is effective. For abscesses not amenable to percutaneous
the diagnosis of subsequent appendicitis.
drainage, laparoscopic abscess drainage is a viable option.

Stump Appendicitis NEOPLASMS OF THE APPENDIX

Incomplete appendectomy represents a failure of removing the
entire appendix on the initial procedure. A review of literature Prevalence of Neoplasms
has revealed only 60 reports of this phenomenon. Likely, incom- Multiple studies have evaluated the prevalence of mass lesions
plete appendectomy is underreported, and the true prevalence is present in appendectomy specimens (Table 30-8).124-132 The
much higher. Reported as “stump appendicitis,” patients typi- prevalence of identifying a mass within the appendix is less than
cally present with recurrent symptoms of appendicitis approxi- 1%. Appendiceal carcinoid and appendiceal adenomas are the
mately 9 years after their initial surgery. There was no difference most common lesions identified. There is no clear age
in initial surgery between laparoscopic and open procedures. 12 relationship associated with the identification of these
However, there were more complicated appendectomies on masses.
1258 Table 30-8
Prevalence of malignancy associated with appendix specimens

Author No. Male Gender Age (mean) Age (range) Adenoma Carcinoid Other Overall
Ozer 2376 22 (81.5%) 26.7 NR NR 27 (1.13%) NR 27 (1.13%)
Lee 3744 NR NR NR 14 (0.35%) 9 (0.24%) 5 (0.12%) 28 (0.7%)
Sieren 141 6 (60%) 47 NR NR NR NR 10 (7.1%)
Debnath 1941 11 (69%) 41.8 NR NR 16 (0.82%) NR 16 (0.82%)
In’t Hof 1485 4 (57%) 32.7 20–59 NR 7 (0.47%) NR 7 (0.47%)
PART II
UNIT II

Smeenk 167,744 608 (41%) 61 7–93 NR NR NR 1482 (0.9%)

O’Donnel 2154 8 (36%) 30 14–83 NR 11 (0.5%) 11 (0.5%) 22 (1.02%)
Marudanayagam 2660 NR NR NR 16 (0.6%) 14 (0.52%) 10 (0.39%) 40 (1.50%)
Overall 184,118 30 (0.47%) 57 (0.54%) 26 (0.30%) 1558 (0.89%)
SPECIFIC CONSIDERATIONS

Laia 1873 11 (69%) 69 42–89 NR NR 16 (0.85%) 16 (0.85%)

Lai reported only the incidence of colon cancer presenting as appendicitis.
a

NR = not reported.

In older patients, the prevalence of identifying colon can- appendiceal adenocarcinoma are at significant risk for both syn-
cer appearing as appendicitis has been reported in a single study chronous and metachronous neoplasms, approximately half of
with a prevalence of less than 1%. The mean age in this case which will originate from the gastrointestinal tract.135
series was 69 years (range, 42 to 89 years).
Mucocele
Carcinoid A mucocele of the appendix is an obstructive dilatation by
The finding of a firm, yellow, bulbar mass in the appendix intraluminal accumulation of mucoid material. Mucoceles may
should raise the suspicion of an appendiceal carcinoid. The be caused by one of four processes: retention cysts, mucosal
appendix is the most common site of gastrointestinal carcinoid, hyperplasia, cystadenomas, and cystadenocarcinomas. The
followed by the small bowel and rectum. Carcinoid syndrome is clinical presentation of a mucocele is nonspecific, and often it
rarely associated with appendiceal carcinoid unless widespread is an incidental finding at operation for acute appendicitis. An
metastases are present, which occur in 2.9% of cases. Symp- intact mucocele presents no future risk for the patient; however,
toms attributable directly to the carcinoid are rare, although the the opposite is true if the mucocele has ruptured and epithelial
tumor can occasionally obstruct the appendiceal lumen much cells have escaped into the peritoneal cavity. As a result, when
like a fecalith and result in acute ­appendicitis.131,133,134 a mucocele is visualized at the time of laparoscopic examina-
The majority of carcinoids are located in the tip of the tion, conversion to open laparotomy is recommended. Conver-
appendix. Malignant potential is related to size, with tumors sion from a laparoscopic approach to a laparotomy ensures that a
<1 cm rarely resulting in extension outside of the appendix benign process will not be converted to a malignant one through
or adjacent to the mass. The mean tumor size for carcinoids is mucocele rupture. In addition, laparotomy allows for thorough
2.5 cm.133 Carcinoid tumors usually present with localized dis- abdominal exploration to rule out the presence of mucoid fluid
ease (64%). Treatment for tumors ≤1 cm is appendectomy. For accumulations.135
tumors larger than 1 to 2 cm located at the base, involving the The presence of a mucocele of the appendix does not
mesentery, or with lymph node metastases, right hemicolectomy mandate performance of a right hemicolectomy. The princi-
is indicated. Despite these recommendations, surveillance, epi- ples of surgery include resection of the appendix, wide resec-
demiology, and end results data indicate that proper surgery for tion of the mesoappendix to include all the appendiceal lymph
carcinoids is not performed at least 28% of the time.133 nodes, collection and cytologic examination of all intraperito-
neal mucus, and careful inspection of the base of the appendix.
Adenocarcinoma Right hemicolectomy or, preferably, ileocecectomy is reserved
Primary adenocarcinoma of the appendix is a rare neoplasm with for patients with a positive margin at the base of the appen-
three major histologic subtypes: mucinous adenocarcinoma, dix or positive periappendiceal lymph nodes. Recently, a more
colonic adenocarcinoma, and adenocarcinoid.135 The most com- aggressive approach to ruptured appendiceal neoplasms has
mon mode of presentation for appendiceal carcinoma is that of been advocated. This approach includes a thorough but mini-
acute appendicitis. Patients also may present with ascites or a mally aggressive approach at initial laparotomy, as described
palpable mass, or the neoplasm may be discovered during an earlier, with subsequent referral to a specialized center for con-
operative procedure for an unrelated cause. The recommended sideration of reexploration and hyperthermic intraperitoneal
treatment for all patients with adenocarcinoma of the appendix chemotherapy.134
is a formal right hemicolectomy. Appendiceal adenocarcinomas
have a propensity for early perforation, although they are not Pseudomyxoma Peritonei
clearly associated with a worsened prognosis.134 Overall 5-year Pseudomyxoma peritonei is a rare condition in which diffuse
survival is 55% and varies with stage and grade. Patients with collections of gelatinous fluid are associated with mucinous
implants on peritoneal surfaces and omentum. Pseudomyxoma i­ nitiating adjuvant therapy. Adjuvant therapy is not indicated for 1259
is two to three times more common in females than in males. lymphoma confined to the appendix.142,143
Recent immunocytologic and molecular studies suggest that the
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CHAPTER 30 The Appendix

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