Stump appendicitis: a rare and unusual
complication after appendectomy.
Ann. Ital. Chir.
Published online (EP) 7 April 2014
pii: S2239253X14022270
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Case report and review of the literature
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Simona Papi, Francesca Pecchini, Roberta Gelmini
University of Modena and Reggio Emilia, Department of Surgery. Policlinico of Modena, Modena, Italy
Stump appendicitis: a rare and unusual complication after appendectomy. Case report and review of the literature
INTRODUCTION: Stump appendicitis is a rare but important complication that can occour after an open or laparoscopic appendectomy. Although it represents a recognized serious condition that should not be overlooked, it is not often considered by surgeons within the differential diagnoses faced with a patient presenting right iliac fossa abdominal pain,
particularly those who present a previous history of appendectomy.
MATERIAL OF STUDY: A comprehensive review of English literature was performed and 87 cases of stump appendicitis
were identified. Each case was charted based on 10 variables and data were analyzed. One original case of stump appendicitis after open appendectomy treated at our institution is also described and taken as a model.
DISCUSSION: Several factors may contribute to the etiology of stump appendicitis, mainly related to the length of the
residual tissue after appendectomy. A delay in diagnosis, possibly misled by a previous history of appendectomy, represents
a risk of complications and possible stump perforation. The imaging studies, especially CT scan, seem to be helpful tools
in getting the earliest possible diagnosis.
CONCLUSION: Surgeons should be aware of the occurrence of this rare but dangerous entity, in order to avoid a delay
in diagnosis and in the appropriate therapeutic choice. We want to emphasize also the technical recommendations to be
respected in course of appendectomy.
KEY
WORDS:
Appendectomy, Appendicular residue, Diagnosis, Stump appendicitis
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Introduction
Stump appendicitis may be considered as one of the
rarest complications after appendectomy. It is underreported in literature and the incidence is probably underestimated.
The clinical presentation is often similar to acute appendicitis and is not often considered as a possible differ-
Pervenuto in Redazione Ottobre 2013. Accettato per la pubblicazione
Dicembre 2013.
Correspondence to Roberta Gelmini, MD, Department of Surgery,
Policlinico of Modena, University of Modena and Reggio Emilia, Via
del Pozzo, 71 41124 Modena, Italy (e.mail: roberta.gelmini@unimore.it)
ential diagnosis when evaluating a right iliac fossa pain.
Surgeons, faced against a patient presenting a localized
right lower quadrant abdominal pain with a prior history of appendectomy, often exclude appendicitis as diagnosis1; therefore the failure of identification of that condition and the delay of treatment result to increase the
incidence of comorbidities and complications that can
occur, first of all the perforation of the residual appendix2,3.
A systematic review of the literature referred to stump
appendicitis cases was performed, in order to highlight
the clinical, diagnostic and therapeutic aspects of this
disease.
We describe also a case which focuses on the necessity
of an early preoperative diagnosis of stump appendicitis
in front of a patient presenting acute appendicitis sympPublished online (EP) 7 April 2014 - Ann. Ital. Chir
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S. Papi, et al.
Case Report
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A 45-year-old man presented to our attention with a 1day history of right lower quadrant pain. He also complained of fever and nausea. Three months before he
had undergone an open appendectomy at another institution; histology revealed a gangrenous appendix and the
post-operative was complicated by purulent discharge
from the abdominal drainage, solved with conservative
treatment.
On clinical examination the patient reported right iliac
fossa pain, tenderness and fever; laboratory investigation
showed leucocytosis with neutrophilia.
Abdominal X–ray imaging was negative, while an abdominal ultrasound revealed distended bowel and increased
size mesenteric nodes. CT scan reported the presence in
the ileo-cecal region of a 4 cm tubular structure with
thickening of wall, referred to appendiceal stump inflammation, fat tissue imbibition and enlarged mesenteric
nodes (Fig. 1a, 1b); coronal and sagittal reconstructions
were useful to clarify the CT scan diagnoses (Fig. 2a, 2b).
A laparotomy was then performed by using the previ-
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toms who had previously undergone an appendectomy.
It’s our aim to draw attention to pre-operative imaging
modalities and to surgical procedures to be observed in
an appendectomy execution in order to avoid the risk
of complications such as inflammation of stump appendix.
A
B
Fig. 1a, 1b: Abdominal CT scan reveals an approximately 4 cm appendiceal stump in the ileo-cecal area, fat tissue imbibition and enlarged nodes.
B
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A
Fig. 2a, 2b: Coronal and sagittal CT scan reconstructions
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Ann. Ital. Chir - Published online (EP) 7 April 2014
Stump appendicitis: A rare and unusual complication after appendectomy. Case report and review of the literature
Systematic Review
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METHODS
appendicitis, in 1 case it was suspected. X-Ray was performed only in 8 patients and it was never specific.
Further diagnostic examinations were colonoscopy (2 cases), fistulogram (2 cases) and barium enema (6 cases).
After pre-operative studies, all patients underwent a second appendectomy: an open procedure was performed
in 77% and a laparoscopic approach in 17%. Only in
one case, a conservative treatment by antibiotic therapy,
was chosen.
60 histopathological diagnoses were reported in the
reviewed cases and all of them confirmed stump appendicitis; in 17 cases there was only an appendiceal inflammation, the presence of abscess and/or suppurative
appendix was in 10 patients, necrosis and gangrenous
tissue were described in 8 cases, and the most common
complication was the appendix perforation (40%).
The mean appendicular stump length was about 1,5 cm
(± 1,5), with a range of 0,5-6,5 cm.
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ous incision. An abscess was discovered in the ileo cecal
region and the tubular structure proved to be stump
appendicitis with suppurative inflammation.
Complete appendectomy was performed and the stump
was inverted into the caecum.
Final pathology confirmed the diagnosis of perforated
appendicitis. The post-operative was uneventful.
A systematic literature search was performed on PubMed
MEDLINE using the key-words ‘stump appendicitis’,
‘residual appendix’ and ‘recurrent appendicitis’.
199 articles were identified, and 23 more papers were
revealed by further bibliographic search.
We considered only English papers, both case-reports and
reviews, directly referred to stump appendicitis; a total
of 71 publications resulted, providing 87 cases of stump
appendicitis.
For each case we reported 10 variables and all the data
were then analyzed.
Results
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The first two cases of stump appendicitis were described
by Rose in 19454, since then other 85 cases were reported in literature (Table I).
55 (63%) were male, 32 (37%) were female; the mean
patient’s age was 34,6 (± 16) years, with a range between
1-80 years.
The initial appendectomy was open in 52 cases (60%)
and laparoscopic in 30 patients (35%), in 5 cases it was
not reported.
The histology, described only in 17 cases, showed 7 perforated appendixes, 3 gangrenous, 5 phlegmonous or
with abscess and 2 normal ones; the mean appendiceal
length was 4,4 cm (range 3,5-6 cm).
A mean of 98,1 months (± 149) represents the time interval from the first appendectomy to stump appendicitis representation, with a range from 24 hours5 to 50 years6.
The total of patients presented with abdominal pain,
most referred to the right iliac fossa; other commons
symptoms were nausea and vomiting (27%) and fever
(21%). Peritonitis was found in 6 patients, 4 cases had
diarrhea and 3 cases presented with wound infection.
The WBCC on presentation of stump appendicitis were
reported in 51 cases, of which 43 showed values ≥
10.000 cells/mm3, up to 26.400 cells/mm3.
Abdominal CT scan was the most imaging examination
performed (64,3%), and in 66% it revealed the appendiceal stump inflammation; 36 patients underwent only
CT scan and it was diagnostic by itself in the 80%.
24% of patients had pre-operative Ultrasound examination and only in 33% of cases it was diagnostic of stump
Discussion
Appendectomy is considered as one of the most frequently surgical performed procedures, although it is not
free of risks. Short-term complications associated with
appendectomy include post-operative bleeding, wound
infection and intra-abdominal abscesses; long-term complications are poorly reported and they include adhesions, hernias, nerve injury and appendix stump inflammation 2,5.
Focusing on stump appendicitis, it is a rare occurrence
on which no particular attention is paid.
Stump appendicitis can occur from a few days to several decades after appendectomy 2,7, and symptoms
appear to be similar to acute appendicitis.
Several elements have been proposed as the cause of
stump appendicitis. The main one is represented by the
length of the appendicular residue; according to several
Authors an appendiceal stump longer than 0,5 cm represents a possible reservoir for coprolith and resulting
inflammation2,8. No cases of appendicular inflamed
stump shorter than 0,5 cm were described in our review,
by suggesting that a stump not exceeding 0,5 cm is unlikely to result in re-inflammation. Other Authors consider
0.3 cm as the safe length of appendicular stump 9.
Other causes of stump appendicitis are the incomplete
removal of the appendix tissue, complicated appendicitis, such as edema or abscesses, and retro-cecal appendix localization: they all contribute to the difficult visualization of surgical anatomy 2,5.
Therefore, under appendectomy, the proper identification of the appendicular base with the appendiceal-cecal
junction and the careful dissection of appendix from its
tip toward the base, prove to be key elements. Some
Authors believe that the failure of identification of the
appendiceal base, under laparoscopic procedure, is an
indication to convert to open appendectomy 2,9.
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Stump appendicitis: A rare and unusual complication after appendectomy. Case report and review of the literature
Published online (EP) 7 April 2014 - Ann. Ital. Chir
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Surgeons are required to observe some technical anatomical landmarks.
In particular:
– the appendiceal-cecal junction must be identified as
an essential starting point for a correct section of the
appendix mesentery and its vascular arcade. For that reason the cecal anterior taenia is a sure landmark 3,8;
– it is necessary to ensure the complete removal of the
appendix especially in case of concomitant peri-cecal
abscess or retroperitoneal location of the same;
– an excessive traction or rough handling of the appendix, especially in case of acute inflammation, can cause
its rupture, with a long stump disappearing in the depth
of an abscess cavity 10.
Instead, there are not demonstrations concerning the fact
that the stump inversion, in addition to simple ligation,
can minimize the risk of subsequent inflammation 2,11.
The absence of a 3-dimensional perspective view and the
lack of a tactile feedback in course of laparoscopic procedure are considered by several Authors as causes of incomplete removal of appendicular tissue and consequent risk
of re-inflammation, but in more than half (59%) of reported cases in this review laparotomy was first performed.
According to Galatioto et al. 12, laparoscopic appendectomy is safe and effective and there are no statistically
differences in the management of appendix stump with
endoloops or stapler.
Imaging modalities seem to be very useful in the stump
appendicitis diagnosis. This review shows that CT scan
is more specific than US methodic: US diagnosis can’t
always reveal accurate informations5, while an abdominal CT scan is able to provide more details 1,2,13 in terms
of inflammatory thickening of the cecal wall, presence
of fluid or abscess formation and, as in our case, a
prompt identification of the inflamed appendix stump.
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Ann. Ital. Chir - Published online (EP) 7 April 2014
Only Yang et al.14 got a stump appendicitis diagnosis by
using a colonoscopy. Yigit et al 15 and Tang et al. 16
described two cases of wound infection trough which a
fistulography was performed with success.
If the instrumental investigations do not lead to a definitive diagnosis, an exploratory laparoscopy may be diagnostic as well as therapeutic 5,17.
It’s our aim to emphasize the importance of an early
diagnosis in case of stump appendicitis, as a delay in
diagnosis and therapeutic approach can increase the rate
of associated complications, primarily represented by perforation 2,14, as confirmed by our review.
The treatment of choice for stump appendicitis is represented by a second appendectomy: according to our
review the open procedure appears to be the most performed one (77%), supposing that it could be more adequate in case of perforation or peritonitis, and in case
of necessity of more extensive resective interventions 2
even if we consider that the choice of surgical approach
(laparoscopic or open) depends on multiple factors.
Patient’s clinical conditions, local resources and surgeon’s
expertise influence the operative technique 70.
Conclusion
Inflammation of the appendix stump is a rare occurrence
of which surgeons must have awareness in relation to a
patient presenting clinical findings similar to acute
appendicitis with a previous history of appendectomy.
The inclusion of stump appendicitis in differential diagnosis and the execution of appropriate imaging procedures are important in avoiding delay of diagnosis and
treatment, thus reducing the potential associated complications.
Two general recommendations must be addressed, particularly to young surgeons: diagnosis of acute appen-
Stump appendicitis: A rare and unusual complication after appendectomy. Case report and review of the literature
dicitis can be not always easy, especially in the rare case
of stump or recurrent appendicitis; here computed
tomography offers an effective aid appendectomy, usually considered a simple procedure, can offer difficulties,
especially in identifying surgical anatomy, sometimes subverted by a suppurative inflammatory process.
7. Leff DR, Sait Mr, Hanief M, Salakianathan S, et al.:
Inflammation of the residual appendix stump: A systematic review.
Colorectal Dis, 2012; 14(3):282-93.
8. Ismail I, Iusco D, Jannacci M, Navarra GG, et al.: Prompt
recognition of stump appendicitis is important to avoid serious complications: A case report. Cases J, 2009; 2: 7415.
Riassunto
10. Poole GV: Management of the difficult appendiceal stump: How
I do it. Am Surg; 1993.
11. Awe JA, Soliman AM, Gourdie RW: Stump appendicitis: An
uncompleted surgery, a rare but important entity with potential problems. Case Rep Surg, 2013; 2013:972596.
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L’appendicite del moncone rappresenta una rara ma
importante complicanza che può fare seguito a un intervento di appendicectomia, sia laparoscopica che laparotomica, e rappresenta un’eventualità nosologica da tenere presente, e da includere nella diagnosi differenziale
dell’addome acuto di un paziente già appendicectomizzato. I casi riportati in letteratura non sono numerosi,
probabilmente però come risultato di una sottostima.
Il caso clinico riportato riguarda un uomo di 43 anni
operato tre mesi prima di appendicectomia laparoscopica e ricoverato con un tipico caso di addome acuto.
L’ecografia si è dimostrata non efficace per la diagnosi,
mentre la TC ha definito con sufficiente chiarezza la
situazione, ponendo l’indicazione ad una laparotomia
esplorativa, nel corso della quale si è proceduto
all’asportazione del residuo appendicolare. L’esame istologico ha poi in seguito confermato la diagnosi di appendicite acuta perforata del moncone.
A conclusione si è proceduto ad un’analisi di 87 casi
analoghi presenti nella letteratura di lingua Inglese per
evidenziare le caratteristiche anatomo-chirurgiche ed anatomo-patologiche dei diversi casi, e l’esperienza diagnostica nella definizione del singolo caso.
Si conclude con i suggerimenti tecnici per prevenire
l’evenienza di tali “appendiciti” ricorrenti sia con la tecnica laparoscopica che laparotomica, e stimolando la consapevolezza di tale eventualità.
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9. Mangi AA, Berger DL: Stump appendicitis. Am Surg, 2000;
66(8): 739-41.
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