Appendiceal Phlegmon Research Articles

Significance of Histopathology of Appendectomy Specimens: Analysis From a Teaching Hospital of Pakistan.

Background Histopathology of a tissue specimen plays a crucial role in formulating the final diagnosis of any disease. It confirms whether the histopathological findings are in correspondence with the clinical diagnosis and thus suggests an optimal management plan. Standard surgical practices guide that every human tissue specimen must undergo postoperative tissue analysis unless indicated otherwise. Objective To determine the significance of histopathology in determining the final diagnosis of appendectomy specimens. Materials and methods This retrospectiveclinical studyconducted in May 2022 included 100 patients operated for appendectomy from January 1, 2021, to December 31, 2021, in the emergency room of the Department of General Surgery, Unit-III, Lahore General Hospital, Lahore. Data were retrieved from patients' records and the picture archiving and communication system (PACS). A Google Forms-based pro forma(Google, Mountain View, CA) was generated to include the demographic details, clinical manifestations, and histopathology reports of the patients. Descriptive analysis was completed using a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA). Results Fifty-two patients were females out of the total 100. The mean age at presentation was 23.02 ± 12.02 years. Of the samples, 54% were not sent for histopathology. Among the remaining ones, 27% of cases were proven to be acute appendicitis. Alvarado score was 7-10 in 50% of patients. Other lesions proven by histopathology were appendiceal phlegmon (4%), perforated appendix (4%), mucocele (1%), carcinoid tumor (1%), tuberculosis (1%), and adenocarcinoma (1%). Conclusions Histopathological analysis is the gold standard for the tissue diagnosis of a disease. The high percentage of the samples not sent for histopathology is alarmingsince the appendix is not only a site for inflammatory pathologies but for neoplastic lesions as well. This practice depicts that the incidence of non-inflammatory pathologies is being ignored by healthcare professionals and there is a dire need to emphasize the significance of acquiring histopathology reports for the specimens of appendectomy in all circumstances.

Metastatic gastric adenocarcinoma with appendiceal phlegmon: a case report

BackgroundGastric carcinoma is one of the most frequent malignancies worldwide. Gastric cancer metastasis to the appendix is uncommon in incidence, and has been rarely described in acute-appendicitis-related literature reviews. In this presented case, we have reported a rare case of appendiceal phlegmon, due to a diagnosis of metastatic gastric adenocarcinoma with uncommon symptoms.Case presentationA 79-year-old Caucasian male presented to the emergency department with history of weakness, anorexia, lethargy, and mood changes for 2 months. Abdominopelvic computed tomography showed an abscess in right iliac muscle. After percutaneous drainage of the abscess and 6 weeks antibiotic therapy, an appendectomy was done for the patient. Histopathologic findings revealed the involvement of the appendiceal wall by adenocarcinoma, most probably with gastrointestinal origin. Gastric cancer was confirmed later by upper endoscopy and pathologic report.ConclusionsAlthough the presence of tumor in appendectomy specimens is rare, and metastasis to appendix is even rarer, it should be considered as a cause of appendicitis, especially in elderly patients.

A rare case of appendiceal tip complete attachment to a sigmoid diverticulum: An appendiceal phlegmon case report.

IntroductionAppendiceal phlegmon is defined as an inflammatory mass, consisting of the inflamed appendix, enclosed by adjacent viscera and the greater omentum in 2 % to 10 % of patients with acute appendicitis.Case presentationA 24-year-old female presented to the hospital with chief complaints of fever, nausea, vomiting, and pain over the right lower quadrant of the abdomen for two days. In the local examination, tenderness and rebound tenderness were detected. Ultrasonography and abdominal CT scan indicated appendiceal phlegmon. After seven weeks of receiving a course of antibiotics with complete resolution of her symptoms, she underwent elective laparoscopic appendectomy. During surgery, the appendiceal tip was completely attached and fused to a sigmoid diverticulum, which has not been reported elsewhere. The appendix was completely removed, and the patient was discharged from the hospital in a good general condition after two days.DiscussionAcute appendicitis can cause serious complications, such as ruptured appendix, abscess, or phlegmon. In most cases, inflammation and infection resolve by antibiotic administration. In some cases perforation of the inflamed appendix and local abscess or diffuse peritonitis formation, which requires immediate percutaneous drainage or surgery as indicated. Theoretically, the inflamed appendix can cause adhesive damage to the adjacent organs; however, there is no particular report on this type of damage.ConclusionThis rare case suggests that during phlegmon formation and related inflammation, other complications such as fistula formation, are theoretically expected.

Thigh and iliopsoas abscess as a rare presentation of perforated mucinous appendix carcinoma. A case report.

Classic presentation of appendicular neoplasms in early stage includes appendicitis-like symptoms. For mucinous adenocarcinoma, it presents at an average age of 60 years, this is why when they present these symptoms a high index of suspicion must be maintained. Only one case has been reported of an appendiceal neoplasm with a thigh abscess. We present a 65-year-old with a preoperative diagnosis of an appendiceal phlegmon with and iliopsoas and thigh abscess. Percutaneous drainage and thigh drainage were initially performed. Due to persisting fever and increased abdominal symptoms, 48 h postoperative hours, on multidisciplinary discussion, exploratory laparoscopy was decided, finding the iliac abscess and a perforated appendix. Right hemicolectomy was performed, revealing a mucinous appendicular carcinoma. Conservative management of a mass or appendiceal abscess has a high success rate and low complication rate during the initial period but despite this, some patients must undergo emergency surgery. Right hemicolectomy was performed because of the large inflammatory compromise and adhesions of the appendix and caecum and a more conservative approach could not be performed due to the deformation of anatomic structures. This has been a complex case, not only for its different approaches but also because of its singularity of presentation, this is why it has to be taken into account the group age that it has to be dealt with, clinical presentation, anamnesis, etc. There are no guidelines for the management of this disease but it is unquestionable that multidisciplinary management leads to better outcomes. • Only one case has been reported of an appendiceal neoplasm with a thigh abscess. • The classic presentation of appendicular neoplasms includes appendicitis-like symptoms. • We performed a right hemicolectomy and thigh abscess drainage. • No guidelines exist but multidisciplinary management leads to better outcomes.

Nonoperative management of appendicitis in children.

Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.

Is Emergency Appendicectomy Better Than Elective Appendicectomy for the Treatment of Appendiceal Phlegmon?: A Review.

Appendiceal phlegmon is considered to be sequelae to acute appendicitis which presents as an appendiceal mass composed of the inflamed appendix, the adjacent bowel loops, and the greater omentum. The definitive diagnosis can be obtained by a CT scan of the abdomen. Though conservative management was the most practiced approach, recent studies have shifted the trends towards immediate appendicectomy for the management of appendiceal phlegmon. Thus, the management of appendiceal phlegmon has been debatable. Evidence to support this review was gathered via the PubMed database as this database uses the Medline, PubMed Central, and NLM databases and also offers a quick diverse search with up-to-date citations and numerous open-access free articles focused on Medicine. We did not include other databases like Google Scholar, Embase, and Scopus due to its limited access to free articles, recent articles, and citation information. Search terms used were combinations of "Appendicitis," "Appendiceal phlegmon", "Appendiceal phlegmon (AND) appendicectomy ". The resultant studies were reviewed and cross‐referenced for additional reports. Emergency appendicectomy is defined as appendicectomy carried out during the same, initial admission. An elective or interval appendicectomy is an appendicectomy carried out four to six weeks after the initial episode at a later admission. The interval is bridged by antibiotics and conservative management. Emergency appendicectomy is considered to have a higher rate of complications when compared to conservative management for appendiceal phlegmon. However, interval appendicectomy requires multiple re-admissions, leads to delayed diagnosis of any underlying pathology, and an increased risk of recurrent appendicitis. In our review, we aimed to compare and contrast the effectiveness of the different treatment modalities available for appendiceal phlegmon. Though the meta-analyses showed an increased association of complications with emergency appendicectomy, they included studies conducted before the laparoscopic era. Emergency appendicectomy decreases the financial burden, re-admission rate, and aids in the early diagnosis of any underlying pathology. In the laparoscopic era, we can consider the shifting trends towards emergency appendicectomy for the management of appendiceal phlegmon.

Appendiceal phlegmon in adults: Do we know how to manage it yet?

A Best Evidence Topic in general surgery was written according to a structured protocol. The question addressed was ‘Appendiceal phlegmon in adults: Do we know how to manage it yet?‘. Altogether 217 papers were found on Ovid Embase and Medline, 334 on PubMed and 13 on the Cochrane database using the reported search. From the screened articles, 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the best management method is conservative only treatment without interval appendicectomy. These patients must be followed up, including colonoscopy and/or CT imaging as indicated, to investigate for conditions such as inflammatory bowel disease or malignancy masquerading as appendicitis.

Nonoperative management of appendiceal phlegmon or abscess in children less than 3\xa0years of age

BackgroundIn children less than 3 years of age, there is little experience in the nonoperative management of appendiceal phlegmon or abscess (APA), especially in APA with an appendicolith. The purposes of this study were to evaluate the effects of an appendicolith and the success rate of nonoperative management for APA in these young children.MethodsChildren younger than 3 years of age with APA who underwent attempted initial nonoperative treatment between January 2008 and December 2016 were reviewed. Based on the presence or absence of an appendicolith on admission ultrasonography examination or computed tomography scan, children were divided into two groups: appendicolith group and no appendicolith group.ResultsThere were 50 children who met the study criteria. Among 50 children, three children failed to respond to nonoperative treatment because of aggravated intestinal obstruction or recurrent appendicitis within 30 days of admission. The overall success rate for nonoperative management of APA was 94% (47/50) in children younger than 3 years old. The rate of diarrhea and CRP levels were higher in the appendicolith group than that of the no appendicolith group (P < 0.05). However, the success rate and the hospital length of stay for nonoperative treatment in the appendicolith group and the no appendicolith group were similar without statistical significance.ConclusionAPA with or without an appendicolith can have nonoperative management without immediate appendectomy in children less than 3 years old.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess.

Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial. To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality. We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials. We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities. It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy.Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.

Minimally Invasive Interval Appendectomy for Perforated Appendicitis With a Periappendiceal Abscess.

See Article on Page 105-110 Acute appendicitis is the one of the most common conditions requiring surgical intervention, and an appendiceal abscess or phlegmon has an incidence rate of about 3.8% among patients with a perforated appendicitis [1]. An immediate appendectomy for the treatment of a periappendiceal abscess (PAA) or phlegmon is technically demanding with adhesive loops of the bowel and a distorted anatomy, and the appendiceal stump is difficult to close due to the presence inflamed tissues [2]. In actual practice, not infrequently, even an early laparoscopic surgery will be converted to a more extensive open surgical procedure, such as an ileocecal resection or a right hemicolectomy, due to technical problems or distorted anatomy [3]. In the management of perforated appendicitis with a well-defined abscess and an inflammatory phlegmon seen on an image study, an alternative treatment may be nonsurgical management, including intravenous antibiotics and selective percutaneous drainage. Currently, a treatment widely accepted among surgeons is initial nonoperative management followed by an interval appendectomy rather than an immediate appendectomy, but the management of the appendiceal mass remains a matter of major controversy in current practice. However, many surgeon still agree that an interval appendectomy is to be preferred because the risk for recurrent acute appendicitis is reported to be about 10% and because a definite diagnosis needs to be established to rule out any underlying malignancy [4,5]. The advantage of the interval appendectomy is that the operation is performed at a time when peritoneal contamination has been resolved, potentially resulting in fewer intraoperative and/or postoperative complications. Although this advantage has led to the widespread application of drainage/interval appendectomy, published data describing how these patients fare during the interval between percutaneous abscess drainage and minimally invasive surgery are rare. The superiority of an early laparoscopic appendectomy (LA) over an interval LA has been shown in some reports on patients with a well-formed abscess [6,7]. This pilot randomized trial found no major differences in outcomes when comparing an early LA with an interval LA [6]. In another randomized study on appendiceal phlegmon, Blakely et al. [7] concluded that, compared to an interval LA, an early LA significantly reduced the time away from normal activities and the rates of overall adverse events and had a conversion rate comparable to that of an open appendectomy. Schurman et al. [8] also reported that their patients managed with an interval LA were likely to suffer a more negative impact on their quality of life than those managed with an immediate LA. Based on these studies, the issue of whether an interval LA is superior to an early LA for the treatment of an appendiceal phlegmon remains a topic of debate. As experience with the single-incision technique grows, the role of immediate surgery in the treatment of patients presenting with an abscess deserves to be reconsidered. Conservative management followed by a single-incision laparoscopic interval appendectomy using a multichannel single port appears feasible and safe for the treatment of patients with acute perforated appendicitis with a PAA, as this study shows [9]. However, this study has several limitations, including its retrospective nature, small number of patients, and lack of data on surgical outcomes such as quality of life and pain or cosmesis for both single-port and multiport surgeries. Therefore, further large-scale comparative studies are needed to prove the advantages of this procedure by comparing the outcomes for initial nonoperative management followed by an interval appendectomy to the outcomes for an early laparoscopic appendectomy in patients with perforated appendicitis and a PAA.

A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See?

Patients with appendiceal abscess or phlegmon have been traditionally managed with antibiotics and radiologically guided drainage of the abscess. Many studies have questioned the need for interval appendectomy. A systematic review of the nonsurgical treatment of patients with an appendiceal abscess or phlegmon was undertaken. The rate of recurrence after nonsurgical management, morbidity and length of hospital stay was measured. PubMed and Cochrane databases were queried to identify 21 studies reporting the morbidity of nonsurgical treatment of appendiceal phlegmon or abscess, and five studies reporting the morbidity of performing interval appendectomy. Repeat nonsurgical management was compared with that of performing interval appendectomy. The studies included a total of 1943 patients, of which 1400 patients were managed nonsurgically and 543 patients underwent interval appendectomy. Nonoperative treatment had a mean recurrence of 12.4 per cent, a morbidity of 13.3 per cent, and the length of hospital stay was 9.6 days. The mean morbidity rate and length of hospital stay for patients who underwent interval appendectomy was 10.4 per cent and 5.0 days, respectively. Interval appendectomy and repeat nonoperative management in case of recurrence are associated with similar morbidity; however, elective interval appendectomy implies additional operative costs to prevent recurrence in one of eight patients.

Appendiceal phlegmon mimicking intussusception on ultrasound: correspondence between sonographic and operative findings

Little is known about the possibility that ruptured appendicitis may produce a false sonographic appearance of intussusception. We present here a case of a periappendiceal phlegmon mimicking ileocolic intussusception on ultrasound in a 3.5-year-old girl and provide a surgico-anatomic explanation on the basis of the intraoperative findings for the false sonographic image. CT imaging was used to make the diagnosis. Intraoperatively, it was revealed that the cecum and sigmoid, which were adherent to each other with pseudomembranes, formed an intestinal mass around the appendix. Accordingly, the appendicolith at the center of the phlegmon was responsible for the central echogenicity, and the surrounding cecum and sigmoid for the external hypoechoic and hyperechoic rings of the target-sign appearing mass on the preoperative ultrasound. Such an understanding of the etiology of the false sonographic image may help to increase awareness and avoid misdiagnosis.

Nonoperative Management of Appendiceal Phlegmon or Abscess with an Appendicolith in Children

BackgroundThe optimal treatment of appendiceal phlegmon or abscess with an appendicolith is controversial. This study aimed to evaluate outcomes and prognosis of nonoperative management of appendiceal phlegmon or abscess with an appendicolith in children. MethodsFrom 2007 to 2011, 105 children with appendiceal phlegmon or abscess who were treated nonoperatively without interval appendectomy were reviewed. Average follow-up of subjects was 2.4 years. Data were compared between subjects with and without an appendicolith or persistent presence and disappearance of an appendicolith. ResultsThe success rate for nonoperative therapy for appendiceal phlegmon or abscess with appendicolith was 95.9 %. The risk of recurrent appendicitis in appendiceal phlegmon or abscess with appendicolith (19.1 %) was higher than that without appendicolith (8.9 %, P = 0.132). The rate of appendicolith disappearance during follow-up was 80.9 %. The persistent presence of an appendicolith was associated with a significantly higher recurrence rate (66.7 %) compared with appendicolith disappearance (7.9 %, P < 0.05). ConclusionAppendiceal phlegmon or abscess with an appendicolith can be managed nonoperatively, and most appendicoliths can be resolved. Persistent presence of an appendicolith is a significant risk factor for recurrent appendicitis. Interval appendectomy is recommended for persistent presence of appendicolith, but is not indicated in cases without appendicolith or appendicolith disappearance.

The button cecostomy for management of fecal incontinence.

The antegrade continence enema (ACE), administered through a continent cutaneous appendicocecostomy, has been used to successfully achieve reliable evacuation and fecal continence in patients with myelomeningocele. However, as originally described, it is not suitable in patients without an appendix or those requiring urologic reconstruction with appendix. We report the use of a standard gastrostomy button in the cecum to create a continent cecostomy in five patients with fecal incontinence. Four underwent simultaneous urologic reconstruction, including two artificial urinary sphincter (AUS) implantations. At a mean of 28 months' follow-up, all five patients are continent of stool. One ACE button has been converted to an ileal Malone cecostomy at the patient's request. Complications included one appendiceal phlegmon requiring exploration and three superficial wound infections, one at a cecostomy site, responsive to antibiotics and local care. There were no AUS infections. The button cecostomy is an effective alternative to standard ACE procedures. It is particularly useful in those who require creation of an appendicovesicostomy for attainment of urinary continence.

Inflammatory cecal masses in patients presenting with appendicitis.

An unexpected inflammatory cecal mass of uncertain etiology encountered during surgery for presumed appendicitis poses a dilemma to the surgeon when deciding the appropriate operative management. A retrospective study was performed to review the pathology and surgical management of this condition. Among 3224 patients who had emergency surgery for a diagnosis of acute appendicitis between January 1990 and December 1997, a group of 52 patients (1.6%) underwent either ileocecal resection or right hemicolectomy for an inflammatory cecal mass of uncertain etiology. The final pathologic diagnosis was cecal diverticulitis in 26 patients (50%), appendiceal phlegmon or abscess in 21 patients (40%), cecal carcinoma in 3 patients (6%), tuberculosis in 1 patient (2%) and schistosomiasis in another patient (2%). Altogether 34 patients underwent ileocecal resection, and 18 patients underwent right hemicolectomy, including the 3 patients with cecal carcinoma. Ileocecal resection was associated with a shorter mean operative time (144 vs. 201 minutes; p < 0.001), a lower morbidity rate (3% vs. 22%; p = 0.043), and a shortened mean postoperative hospital stay (6.8 vs. 11.2 days; p = 0. 011) than right hemicolectomy. There was no mortality in either group. In conclusion, most inflammatory cecal masses are due to benign pathologies and could be managed safely and sufficiently with ileocecal resection. Careful intraoperative assessment including examination of the resected specimen is essential to exclude malignancy, which would require right hemicolectomy.

Evaluation of right hemicolectomy for unexpected cecal mass.

Ileocecal mass is occasionally encountered unexpectedly by surgeons operating for presumed appendicitis. A five-year retrospective study was performed to review the management of this problem. Thirteen patients were identified who had had right hemicolectomy performed for unexpected mass in which neoplasm, diverticular disease, or inflammatory bowel disease could not be differentiated from severe appendicitis at laparotomy. Seven patients (group 1) had a final pathologic diagnosis of appendiceal phlegmon. The other patients (group 2) had Crohn's disease, typhlitis, or neoplasm. Right hemicolectomy was performed with a morbidity of 7% and mortality of 7% in all patients. This procedure is acceptable for unexpected cecal mass.