Stump appendicitis: a rare and unusual complication after appendectomy. Ann. Ital. Chir. Published online (EP) 7 April 2014 pii: S2239253X14022270 www.annitalchir.com ra Case report and review of the literature pi a ST dig AM ita l e PA d i VI so ET la AT let t A u 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 co 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 1 S. Papi, et al. Case Report pi a ST dig AM ita l e PA d i VI so ET la AT let t A u 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- ra 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 co A Fig. 2a, 2b: Coronal and sagittal CT scan reconstructions 2 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 pi a ST dig AM ita l e PA d i VI so ET la AT let t A u 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. ra 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 co 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. Published online (EP) 7 April 2014 - Ann. Ital. Chir 3 co pi a ST dig AM ita l e PA d i VI so ET la AT let t A u ra S. Papi, et al. 4 Ann. Ital. Chir - Published online (EP) 7 April 2014 co pi a ST dig AM ita l e PA d i VI so ET la AT let t A u ra 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 5 pi a ST dig AM ita l e PA d i VI so ET la AT let t A u ra S. Papi, et al. co 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. 6 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. pi a ST dig AM ita l e PA d i VI so ET la AT let t A u 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. ra 9. Mangi AA, Berger DL: Stump appendicitis. Am Surg, 2000; 66(8): 739-41. References co 1. Lupinacci RM, Bouchet-Doumenq C, Salepcioglu H, Egels S, et al.: Stump appendicitis. A diagnostic trap. Clin Res Hepatol Gastroenterol, 2013. 2. Subramanian A, Liang MK: A 60-year literature review of stump appendicitis: The need for a critical view. Am J Surg, 2012; 203(4): 503-07. 3. Roberts KE, Starker LF, Duffy AJ, Bell RL, et al.: Stump appendicitis: A surgeon’s dilemma. JSLS, 2011; 15(3):373-78. 4. Rose T: Recurrent appendiceal abscess. Am J Surg, 1945; 1954: 630-32. 5. Minguez G, Gonzalo R, Tamargo A, Turenzio E, et al.: An unsuspected clinical condition: Appendicitis of appendicular residual, three cases report. Int J Surg Case Rep, 2013; 4(4):371-74. 6. Robledo-Ogazòn F, Bojalil-Duràn L, Vargas-Rivas A, TorresVieyra L et al.: Appendiceal stump appendicitis. Case report. Cir Cir, 2005; 73(4):311-4. 12. Galatioto C, Guadagni S, Zocco G, Mazzilo M et al.: Mesoappendix and appendix stump treatment in laparoscopic appendectomy: A retrospective study in 1084 patients. Ann Ital Chir, 2013; 84:269-74. 13. Shin LK, Halpern D, Weston SR, Meiner EM: Prospective CT diagnosis of stump appendicitis. AJR Am J Roentgenol, 2005; 184:(3 Suppl):S62-64. 14. Yang Y, Clark TR, Phan HH: Stump appendicitis after childhood incidental appendectomy. J Pediatr Surg, 2012; 47(11): e15-7. 15. Yigit T, Mentes O, Erylmaz M, Balkan M, et al.: Stump resections resulting from incomplete operations. Am Surg, 2007; 73(1):75-78. 16. Tang XB, Qu RB, Bai YZ, Wang WL: Stump appendicitis in children. J Pediatr Surg, 2011; 46(1): 233-36. 17. Salehi H, Anjamrooz SH: Successfully treated stump appendicitis diagnosed by CT and ultrasonography. Indian J Surg, 2008; 70(2): 89-91. 18. Crocco S, Pederiva F, Zanelli E, Scarpa M, et al.: Stump appendicitis seven years after appendectomy. APSP J Case Rep, 2013; 4(2): 33. 19. Suarez-Moreno R, Ponce-Pérez LV, Vera-Rodriguez F, MargainParedes MA, et al.: Appendiceal stump appendicitis. Cir Cir, 2012; 80(4): 385-88. 20. Parameshwarappa S, Rodrigues G, Prabhu R, Sambhaji C: Stump appendicitis following Laparoscopic Appendectomy. Sultan Qaboos Univ Med J, 2011; 11(1): 112-14. 21. Bu-Ali O, Al-Bashir M, Samir HA, Abu-Zidan FM: Stump appendicitis after laparoscopic appendectomy: Case report. Ulus Travma Acil Cerrahi Derg, 2011; 17(3):267-68. 22. O’Leary DP, Myers E, Coyle J, Wilson I: Case report of recurrent acute appendicitis in a residual tip. Case J, 2010; 3:14. 23. Al-Dabbagh AK, Thoman NB, Haboubi N: Stump appendicitis. A diagnostic dilemma. Tech Coloproctol, 2009; 13(1): 73-4. 24. Cases Baldò MJ, Campillo Soto A, Mengual Ballester M, Parlorio de Andrés E, et al.: Stump appendicitis: Report of two cases and review of literature. Rev Esp Enferm Dig, 2009; 101(7): 514-16. 25. Gasmi M, Fitouri F, Sahli S, Jemai R, et al.: A stump appendicitis in a child: A case report. Ital J Pediatr, 2009; 35(1): 35. 26. Lin CT, Kuo SM, Wu CC, Jao SW: Unusual right upper quadrant stump appendicitis. Z Gastroenterol, 2009; 47(9):819-21. 27. Patel RP, Kan JH: Stump appendicitis. Pediatr Radiol, 2009; 39(3): 306. Published online (EP) 7 April 2014 - Ann. Ital. Chir 7 S. Papi, et al. 28. Jacombs A, Webb G, Leibman S: Right iliac fossa pain 10 years after appendectomy and the diagnosis of stump appendicitis. ANZ J Surg, 2008; 78(8): 711-12. appendicitis following incomplete laparoscopic appendectomy. Acta Chir Belgl, 2003; 103:517-18. 50. Chikamori F, kuniyoshi N, Shibuya S, Takase Y: Appendiceal stump abscess as an early complication of laparoscopic appendectomy: Report of a case. Surg Today, 2002; 32: 919-21. 30. Mente O, ZeybeK N, Oysul A, Onder SC, et al.: Stump appendicitis, rare complication after appendectomy: Report of a case. Ulus Travma Acil Cerrahi Derg, 2008; 14(4): 330-32. 51. Nahon P, Nahon S, Hoang JM, Traissac L: Stump appendicitis diagnosed by colonoscopy. Am J Gastroenterol, 2002 J; 97(6): 1564-565. 31. Osime CO, Moses MI: Stump appendcitis. A rarely considered diagnosis. Am J Case Rep, 2008; 10: 52-4. 52. Moissinac K, To BC, Gul YA, Liew NC: Appendicitis despite previous appendectomy. Trop Doct, 2001; 31: 217. 32. Truty MJ, Stulak JM, Utter PA, Solberg JJ: Appendicitis after appendectomy. Arch Surg, 2008; 143(4):413-15. 53. Baldisserotto M, Cavazzola S, Cavazzola LT, Lopes MH, et al.: Acute edematous stump appendicitis diagnosed preoperatively on sonography. AJR, 2000; 175(2):503-04. pi a ST dig AM ita l e PA d i VI so ET la AT let t A u ra 29. Waseem M, Devas G: A child with appendicitis after appendectomy. J Emerg Med, 2008; 34(1):59-61. 33. Guisasola Iñiguez A, Leunda Iruretagoyena M, Villanueva Mateo A, Nogués Pérez A: Appendicitis of the appendicular stump. A new observation. An Pediatr (Barc), 2007; 66(5):539-40. 34. Rodriguez Hermosa JI, Roig Garcìa J, Puig Alcàntara J, Codina Cazador A: Stump appendicitis: A rare entity. Rev Esp Enferm Dig, 2007; 99(4): 244-45. 35. Carcacìa ID, Vàzquez JL, Iribarren M, Pardellas H: Preoperative diagnostic imaging in stump appendicitis. Radiologia, 2007; 49(2): 133-35. 36. Oshio TIH, Takano S: Retrocecal abscess caused by residual appendix and remains of appendicolithiasis after laparoscopic appendectomy; case report of a child. J Jap Soc Ped Radiol, 2007; 23:33-38. 37. Liang MK, Lo HG, Marks JL: Stump appendicitis: A comprehensive review of literature. Am Surg, 2006; 72(2):162-66. 38. Uludag M, Isgor A, Basak M: Stump appendicitis is a rare delayed complication of appendectomy: A case report. World J Gastroenterol, 2006; 12(33): 5401-403. 39. Shaun M, Gifford MC, Bowman J, Perry B, et al.: Right lower quadrant pain in a young adult male. Curr Surg, 2006; 63: 318-21. 40. Aschkenasy MT, Rybicki FJ: Acute appendicitis of the appendiceal stump. J Emerg Med, 2005; 28(1):41-3. 41. Roche-Nagle G, Gallagher C, Kilgallen C, Calswell M: Stump appendicitis: A rare but important entity. Surgeon, 2005; 3(1): 53-4. 42. Burt BM, Javid PJ, Ferzoco SJ: Stump appendicitis in a patient with prior appendectomy. Dig Dis Sci, 2005; 50(11): 2163-164. co 43. Watkins BP, Kothari SN, Landercasper J: Stump appendicitis: Case report and review. Surg Laparosc Endosc Percutan Tech, 2004; 14(3): 167-71. 54. Gupta R, Gernshiemer J, Golden J, Narra N, et al.: Abdominal pain secondary to stump appendicitis in a child. J Emerg Med, 2000; 18(4):431-33. 55. Rao PM, Sagarin MJ, McCabe CJ: Stump appendicitis diagnosed preoperatively by computed tomography. Am J Emerg Med, 1998; 16(3):309-11. 56. Walsh DC, Roediger WE: Stump appendicitis. A potential problem after laproscopic appendectomy. Surg Laparosc Endosc, 1997; 357-58. 57. Milne AA, Bradbury AW: Residual appendicitis following incomplete laparoscopic appendectomy. Br J Surg, 1996; 83: 217. 58. Erzurum VZ, Kasirajan K, Hasmi M: Stump appendicitis: A case report. J Laparoendosc Adv Surg Tech A, 1997; 7(6): 389-91. 59. Greenberg JJ, Esposito TJ: Appendicitis after laparoscopic appendectomy: A warning. J Laparoendosc Surg, 1996; 6:185-87. 60. Demartines N, Largiader J: Residual appendicitis following incomplete laparoscopic appendectomy. Br J Surg, 1996; 83:148. 61. Deveraux DA, McDermott JP, Caushaj PF: Recurrent appendicitis following laparoscopic appendectomy. Report of a case. Dis Colon Rectum, 1994; 37:719-20. 62. Filipi de la Palavesa MM, Vaxmann D, Campos M, Tuchmann C, et al.: AppendiceAl stump abscess. Abdom Imaging, 1996; 21: 6566. 63. Thomas SE, Denning DA, Cummings MH: Delayed pathology of he appendiceal stump: A case report of stump appendicitis and review. Am Surg, 1994; 60:842-44. 64. Wright TE, Diaco JF: Recurrent appendicitis after laparoscopic appendectomy. Int Surg, 1994; 79:251-52. 44. Clark J, Theodorou N: Appendicitis after appendectomy. J R Soc Med 2004; 97:543-44. 65. Feigin E, Carmon M, Szold A, Seror D: Acute stump appendicitis. Lancet 1993; 341:757. 45. Gordon R, Bamehriz F, Birch DW: Residual appendix producing small bowel obstruction after laparoscopic appendectomy. Can J Surg, 2004; 47:217-18. 66. Harris CR: Appendiceal stump abscess ten years after appendectomy. Am J Emerg Med, 1989; 7:411-12. 46. De U, De Krishna K: Stump appendicitis. J Indian Med Assoc, 2004; 102(6):329. 47. Hirano YSJ, Kinoshita S, Tatsuzawa Y, Kawaura Y: Stump appendicitis with lipohyperplasia of the ileocecal valve: Report of a case. Indian J Surg, 2004; 66:367-69. 48. Durgun AV, Baca B, Ersoy Y, Kapan M: Stump appendicitis and generalized peritonitis due to incomplete appendectomy. Tech Coloproctol, 2003; 7(2):102-04. 49. Marcoen S, Onghena T, Van Loon C, Vereecken L: Residual 8 Ann. Ital. Chir - Published online (EP) 7 April 2014 67. Greene JM, Peckler D, Schumer W, Greene EI: Incomplete surgical removal of the appendix; its complications. J Int Coll Surgm 1958; 29:141-46. 68. Siegel SA: Appendiceal stump abscess: A report of stump abscess 23 years post appendectomy. Am J Surg, 1954; 88:630-32. 69. Baumgardner L: Rupture of appendiceal stump three months after uneventful appendectomy with repair and recovery. Ohio State Med J, 1949; 45:476-77. 70. Kanona H, Al Samaraee A, Nice C, Bhattacharya V: Stump appendicitis: A review. Int J Surg, 2012; 10 (9):425-28.