Appendiceal Specimens Research Articles

Through Different Lenses: A Retrospective Analysis of the Agreement Between Laparoscopic and Histopathological Evaluations of the Appendix.

Appendicectomy is the most frequently performed emergency general surgical procedure. Previous research has highlighted discrepancies between initial intraoperative laparoscopic diagnoses and subsequent histopathology reports following appendicectomy. In the United Kingdom (UK), routine histopathological examination is the established practice, ensuring precise diagnosis of appendiceal specimens. This retrospective analysis aims to compare intraoperative laparoscopic assessments of the appendix with corresponding histopathology findings. We conducted a retrospective analysis of 418 consecutive emergency laparoscopic appendectomies at Peterborough City Hospital in the UK between April 2018 and June 2019 for suspected appendicitis. Intraoperative findings were compared with histopathological examination outcomes using kappa statistics. Of the 418 appendectomies analysed, we found a substantial agreement between surgeons and pathologists (kappa = 0.71, P < 0.001) in detecting overall abnormalities of appendices. This agreement was also high for detecting inflamed appendices (kappa = 0.72, P< 0.001). However, of the six neoplastic lesions confirmed in the pathologists' final report, only two were suspected during laparoscopy. While laparoscopic assessments of the appendix demonstrate a statistically significant and improved agreement with histopathological findings in detecting abnormal and inflamed appendices, the ability of surgeons to identify neoplasia appears suboptimal based on our small sample of neoplasia cases. The data strongly support the continued practice of routine histopathological examination following appendicectomy due to its crucial role in avoiding missed diagnoses and ensuring better patient outcomes.

Pathologic Analysis of Twenty-one Appendices From Children With Multisystem Inflammatory Syndrome Compared to Specimens of Acute Appendicitis: A Cross-sectional Study.

Multisystem inflammatory syndrome in children (MIS-C) is a rare, severe complication of coronavirus disease 2019, commonly involving the gastrointestinal tract. Some children with MIS-C undergo appendectomy before the final diagnosis. There are several hypotheses explaining the pathomechanism of MIS-C, including the central role of the viral antigen persistence in the gut, associated with lymphocyte exhaustion. We aimed to examine appendectomy specimens from MIS-C patients and assess their pathologic features, as well as the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigens. In this cross-sectional study we included 21 children with MIS-C who underwent appendectomy. The control group included 21 sex- and age-matched children with acute appendicitis (AA) unrelated to SARS-CoV-2 infection. Histologic evaluation of appendiceal specimens included hematoxylin and eosin staining and immunohistochemical identification of lymphocyte subpopulations, programmed cell death protein-1 (PD-1) and SARS-CoV-2 nucleocapsid antigen. Appendices of MIS-C patients lacked neutrophilic infiltrate of muscularis propria typical for AA (14% vs. 95%, P < 0.001). The proportion of CD20+ to CD5+ cells was higher in patients with MIS-C (P = 0.04), as was the proportion of CD4+ to CD8+ (P < 0.001). We found no proof of SARS-CoV-2 antigen presence, nor lymphocyte exhaustion, in the appendices of MIS-C patients. The appendiceal muscularis of patients with MIS-C lack edema and neutrophilic infiltration typical for AA. SARS-CoV-2 antigens and PD-1 are absent in the appendices of children with MIS-C. These findings argue against the central role of SARS-CoV-2 persistence in the gut and lymphocyte exhaustion as the major triggers of MIS-C.

Unraveling the Unusual Pathological Findings of Appendiceal Lesions: A Cross-sectional Study from Tertiary Care Centre in Chengalpattu, Tamil Nadu, India

Introduction: The appendix, once considered a vestigial structure, is now recognised as a site of diverse pathologies beyond simple appendicitis through a systematic analysis of published literature and case studies. The diagnosis of appendiceal lesions is still a clinical phenomenon and a constant struggle. The gold standard for diagnosing appendiceal lesions, however, is meticulous histopathological examination. Aim: To determine the histopathological distribution of all the appendiceal lesions and to identify the rare and unusual histopathological findings in appendectomy specimens received at a tertiary care Centre. Materials and Methods: A cross-sectional study was conducted in the Department of Pathology at Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Chengalpattu, Tamil Nadu, India for a duration of 10 years, from August 2013 to August 2023. From the histopathological records of 832 appendectomies, 40 specimens with unusual histopathological findings were identified and analysed in this study. Relevant recorded data from all the appendiceal specimens reported during the study period, with special reference to age, sex, and histopathological findings, were retrieved and evaluated retrospectively. Corresponding slides and specimens were reviewed. The data were presented in the form of frequency tables and percentages. The analysis was done using Statistical Package for Social Sciences (SPSS) software version 20.0. Results: Out of 832 appendectomy specimens, there were 485 (58.29%) cases of acute appendicitis, 244 (29.33%) cases of chronic appendicitis, 59 (7.09%) cases of subacute appendicitis, and 4 (0.48%) cases of gangrenous appendicitis. Unusual histopathology findings were noted in 40 cases (4.81%). These include 17 cases of appendiceal neuroma, eight cases of Xanthogranulomatous appendicitis, seven cases of Enterobius vermicularis, three cases of Low-grade Appendiceal Mucinous Neoplasm (LAMN), one case of appendiceal Neuroendocrine Tumour (NET), one case of Goblet Cell Adenocarcinoma (GCA), one case of metastatic squamous cell carcinomatous deposit in the appendix, one case of urothelial rests in the appendix, and one case of appendiceal lipoma. Conclusion: In this study, 4.81% of patients had atypical appendiceal lesions. A complete histopathological examination of appendectomy specimens increases the chances of discovering unusual lesions of the appendix. Ultimately, this comprehensive analysis will contribute to future improvements in clinical management and prognostication, fostering better patient outcomes.

Active surveillance for low-grade appendiceal mucinous neoplasm (LAMN).

Due to the scarcity of low-grade appendiceal mucinous neoplasm (LAMN), there is an absence of systematized guidelines concerning its management, especially after incidental finding on an appendiceal specimen. In this study, we evaluate the active surveillance (AS) strategy adopted for a series of patients diagnosed with LAMN on resection specimens who were considered to have a low risk of pseudomyxoma progression. Thirty patients were included between April 2014 and July 2021, with a female majority and a median follow-up period of 3.1 years. The inclusion criteria were as follows: LAMN diagnosis on appendiceal specimens, confirmed in an expert center, limited extra-appendiceal mucin resected and localized around the appendix, normal biology (CEA, CA199, CA125) and normal abdominopelvic MRI. AS included physical exam (trocar scar), biology and MRI, 6months postoperatively, then yearly for 10 years. As an initial surgery, 77 % had an appendectomy as their initial intervention, 17 % had a cecectomy, and 6 % had a right colectomy. After follow-up, 87 % of patients showed no sign of disease progression by MRI, while 13 % progressed to PMP. MRI performed in the first postoperative year predicted the disease prognosis in 97 % of patients. The AS strategy, based on MRI, is a valid option after incidental LAMN diagnosis.

Incidence, Clinicopathological Features and Oncologic Outcome of Appendiceal Neoplasms: A Single-Center Cohort Study

Appendiceal tumors represent a large amalgam of different tumor lineages. The continuous evolution in their pathological classifications has led to some variable recommended attitudes over time. The aim of this study is to review the incidence, clinicopathological characteristics, therapeutic approach and oncological results in this type of tumor at our institution. This is a single-centre retrospective cohort study. Every pathologic report catalogued as an appendiceal specimen was reviewed for a time period of 5 years (2013–2017) at our institution. Demographic, clinical, pathological and oncologic follow-up data were recorded. A descriptive study of the sample was completed. A total of 1434 appendiceal specimens was analyzed. Appendiceal neoplasms incidence was 3.2%. Epithelial tumors were the predominant histological subtype, making up 68% of the cases. Low-grade appendiceal mucinous neoplasia and neuroendocrine tumors were the most frequent neoplasms with malignant potential, with 13 and 6 cases, respectively. In more than 80% of neoplasia cases, the definitive treatment was appendectomy. Mortality cases were related to tumors with a very poor prognosis and an advanced stage. All patients had adequate oncological follow-up. Although it is still quite rare, the incidence of appendiceal tumors is increasing with an epidemiological change in favor of mucinous neoplasms currently predominating. Therefore, it is necessary to know and use an updated anatomo-pathological classification in order to provide correct treatment in the first or second surgical stage, as well as the correct follow-up of patients.

Appendiceal neoplasms: Suspected findings and reports of 14 cases.

Neoplastic lesions of the vermiform appendix are still considered to be rare, some studies suggest that appendix cancer may be on the rise, with an estimated incidence of 0.08-0.1% of all appendiceal specimens. The lifetime incidence of malignant appendiceal tumors ranges from 0.2 to 0.5%. Our study is applied at the Department of General Surgery at tertiary training and research hospital; 14 patients who had appendectomy or right hemicolectomy between December 2015 and April 2020 were evaluated. The mean age of the patients was 52.3 ± 15.1 (range, 26-79) years. Gender of the patients were: five (35.7%) men and nine (64.3%) women. The clinical diagnosis was appendicitis without suspected findings in 11 (78.6%), appendicitis with suspected findings (appendiceal mass, etc.) in three (21.4%) of the patients, and there is no patient with asymptomatic or other rare findings. Surgeries applied for the patients were: nine (64.3%) underwent open appendectomy, four (28.6%) underwent laparoscopic appendectomy, and one (7.1%) underwent open right hemicolectomy. Histopathologic results were as follows: five (35.7%) neuroendocrine neoplasm, eight (57.1%), noninvasive mucinous neoplasm, and one (7.1%) adenocarcinoma. While diagnosis and management of appendiceal pathology, surgeons should be familiar with suspected findings of appendiceal tumors and discuss them with patients to the possibility of histopathologic results.

Potential therapeutic effects of ethyl pyruvate in an experimental rat appendicitis model

BackgroundPathophysiology of appendicitis is associated with the underlying inflammatory processes. Ethyl pyruvate (EP) has potent antioxidant and anti inflammatory properties. In this study, we aimed to investigate the effects of EP on the treatment of appendicitis and to examine whether adding EP to the antibiotic treatment could increases the effectiveness of the treatment in a rat appendicitis model. MethodThirty two Wistar rats, which had previously created appendicitis, were randomly divided into 4 groups: Group 1 (0.1 ml saline solution), Group 2 (15 mg/kg ceftriaxone), Group 3 (50 mg/kg EP), Group 4 (EP 50 mg/kg + ceftriaxone 15 mg/kg). In all groups, saline solution, ceftriaxone and EP were administered intraperitoneally and the same procedure was repeated twice a day for the following five days. On day 6, the rats underwent relaparotomy and then intraabdominal findings were recorded. Histopathological examination and interleukin 6 (IL 6) level were performed on appendiceal specimens. ResultsIntra abdominal adhesion score was significantly lower in Group 4 than in Group 1. Total inflammation score was significantly lower in Group 2 than in Group 1 and was significantly lower in Group 4 than in Group 3 and 1. IL 6 level was significantly lower in Group 4 than in Group 3 and 1. ConclusionWe found that adding EP to the antibiotic therapy increased the efficacy of the treatment in the rat appendicitis model. Further studies are required to apply our findings to the clinical setting.

Incidental Appendiceal Tumors During Appendectomy: A 19-year Retrospective Review at a Municipal Hospital

Introduction: Appendectomy is the most common emergency surgical procedure. While non-operative management (NOMA) has gained popularity, particularly during the COVID pandemic, there is concern that NOMA might miss appendiceal tumors, including malignant ones. We sought to investigate the incidence and distribution of appendiceal tumors among appendectomy patients to determine its impact on the decision to pursue NOMA. Methods: We conducted a retrospective review of 1694 appendectomies for acute appendicitis at our institution between January 2001 and December 2019, to identify pathology-confirmed neoplasms in appendiceal specimens. Results: We identified 24 tumors among 1694 cases, with an incidence of 1.43% and average age of 48.7 years. This included 9 Low Grade Appendiceal Mucinous Neoplasms (LAMNs), 6 neuroendocrine tumors (NETs), 6 Mucoceles without adenoma, and one each of adenocarcinoma, endometrioma, and neurofibroma. The incidence in our sample had a bimodal distribution, with peaks in the 2nd and 5th decades of life. Twenty cases were managed by appendectomy alone, with only 4 requiring colectomy. 4 of 24 cases with tumors (16.66%) also had appendicoliths while 343 of 1670 (20%) without neoplasms had appendicoliths. Conclusion: Appendiceal tumors were rare in our series, and most were cured with appendectomy alone. LAMNs and NETs were the most common tumors identified. All patients under 40 had relatively benign disease, and overall tumor incidence had a bimodal distribution, similar to other series. Incidence of appendicoliths was unaffected by the presence of tumor. We conclude that NOMA is a safe alternative to surgery in patients under 40.

Appendiceal inflammation in colectomy is independently correlated with early pouchitis following ileal pouch anal anastomosis in ulcerative colitis and indeterminate colitis

BackgroundAppendiceal inflammation in colectomy is one of the histologic predictors of pouchitis in ulcerative colitis (UC) following ileal pouch anal anastomosis (IPAA). Fecal calprotectin level has been shown to increase 2 months prior to the onset of pouchitis. We evaluated whether inflammation and calprotectin expression in appendiceal specimens correlate with early-onset pouchitis in UC and indeterminate colitis (IC). Materials and methodsIPAA (2000-2018) cases with appendix blocks available in colectomy specimens were identified (n = 93, 90 UC, 3 IC). Histologic features thought to predict pouchitis were evaluated. The degree of appendiceal inflammation was scored. Calprotectin immunostain was performed on the appendix blocks and the extent of mucosal staining was quantified. Electronic medical records were reviewed for demographics, smoking history, clinical pouchitis, time of onset of pouchitis, and clinical and endoscopic components of the Pouchitis Disease Activity Index (PDAI) score. Follow-up pouch biopsies were reviewed and scored to generate histologic PDAI score, when available. ResultsAmong the patients with clinical pouchitis (n = 73), moderate to severe appendiceal inflammation independently correlated with earlier pouchitis compared to no/mild inflammation (median time to pouchitis 12.0 vs. 23.8, log rank p = 0.016). Calprotectin staining correlated with inflammatory scores of the appendix (Spearman's rho, r = 0.630, p < 0.001) but not with early pouchitis (p > 0.05). ConclusionsThe presence of moderate to severe appendiceal inflammation at the time of colectomy was associated with a shorter time to pouchitis following IPAA. Calprotectin immunostain may be used to demonstrate the presence of inflammation in the appendix but its role in predicting early pouchitis remains limited.

Appendiceal Neoplasms: Diagnosis, Management and Follow-up

Appendicectomy is one of the most performed surgical procedures. Neoplasms of the appendix are identified in approximately 1% of appendiceal specimens, and the incidence seems to be rising. The aim of this review was to summarize the current data on these neoplasms, focusing on the recent classification, clinical manifestations, management, and follow-up of such patients, which remain under debate. A literature search was performed using the database PubMed. The keywords used were related to appendiceal neoplasms, mucocele, pseudomyxoma peritonei and treatment. Records without abstracts, case reports, opinion articles and experimental studies were excluded. The appendix tumors can be classified between epithelial or nonepithelial. The epithelial variant is composed by mucinous neoplasms, nonmucinous adenocarcinoma, and signet ring cell tumors; instead, neuroendocrine tumors, lymphoma, and sarcoma are included in nonepithelial neoplasia. Goblet cell carcinoids share characteristics of both epithelial and nonepithelial tumors. The clinical presentation can be variable and the algorithm for evaluation and treatment is complex. Treatment is based on stage and histology. Our intention is to clarify some questions and help the surgeon in operative decisions, treatment strategies, and patient counseling. Doi: 10.28991/SciMedJ-2021-0303-9 Full Text: PDF

S1840 An Interesting Case of a Polyp in an Inaccessible Location: A Tubulovillous Adenoma Found in the Appendiceal Orifice

INTRODUCTION: Primary adenocarcinoma of the appendix is a rare malignancy that accounts for less than 0.5% of all gastrointestinal malignancies. Of all appendiceal polyps, malignant adenomas of the appendix make up less than 0.1% of cases. We present an unusual case of a tubulovillous adenoma found in the appendix during a colonoscopy for evaluation of lower gastrointestinal bleed. CASE DESCRIPTION/METHODS: An 82-year-old man with a prior history of diverticular hemorrhage presented for complaints of hematochezia. A colonoscopy performed for evaluation revealed multiple diverticula. Incidentally, a 10 mm sessile polyp was seen at the appendiceal orifice extending into the appendiceal lumen. Biopsy of the lesion revealed tubulovillous adenoma. Patient subsequently underwent appendectomy and partial cecectomy. Pathology of the appendiceal specimen revealed a tubulovillous adenoma with moderate dysplasia. Citing age and personal reasons the patient has declined surveillance colonoscopy. He remains on aspirin for chemoprevention of further colonic polyps. DISCUSSION: Colonoscopy is the gold standard for screening and detection of neoplastic polyps to prevent their progression to carcinoma. Given the anatomy of the appendix and the difficulty of evaluating lesions extending into the appendiceal orifice, visualizing such lesions presents a tremendous challenge for endoscopists and are often missed during routine colonoscopy. While extremely rare, appendiceal polyps are often discovered accidentally during an appendectomy or incidentally at autopsy. Embryologically, the appendix is derived from the cecum and is thus histologically similar to colorectal tissue. 4.1% of patients with colorectal cancer also have synchronous appendiceal neoplasms. Recommended treatment is with appendectomy and, for malignant lesions, right hemicolectomy with subsequent surveillance colonoscopy. Overall five-year survival rate for appendiceal adenocarcinoma is 18.7%. However, this number jumps to 43.7% following curative resection. The difficulty of visualizing the appendix during colonoscopy has made detection of appendiceal neoplasms challenging. Furthermore, the association of colorectal cancer with appendiceal neoplasms and its favorable prognosis following resection, has placed an even greater emphasis on thorough visualization of the appendix during routine colonoscopy.Figure 1.: Sessile Polyp at the Appendiceal Orifice extending into Lumen.Figure 2.: Sessile Polyp at the Appendiceal Orifice extending into Lumen.

S1684 Appendiceal Adenomatous Mucocele Masquerading as Right-Sided Colonic Diverticulitis

INTRODUCTION: Appendiceal mucoceles (AM) are found in 1% of appendiceal specimens. AM are often incidental imaging findings and are often not visible on routine colonoscopy. They are usually asymptomatic, but can present with right lower quadrant (RLQ) pain, palpable mass, weight loss and altered bowel habits- often mimicking appendicitis. We present a rare case of adenomatous AM masquerading as right sided diverticulitis. CASE DESCRIPTION/METHODS: 56 yo man with GERD, chronic constipation, and prior colonic adenomas presents with 48 hrs of non-bloody diarrhea, RLQ pain and fever of 101F; denies chills, nausea, vomiting. Exam: soft, non-distended abdomen, hypoactive bowel sounds, RLQ tenderness with mild rebound. Labs: mild leukocytosis. Imaging: CT A/P shows cecal wall thickening and fat stranding consistent with right sided diverticulitis, no evidence of appendicitis. Patient responded to ciprofloxacin and metronidazole, but presented 2 months later with intermittent RLQ pain, similar but less severe to initial presentation. Colonoscopy revealed an appendiceal rim with a 10 mm adenomatous appearing polyp prolapsing from deep in the orifice; no right sided diverticula were visualized. Patient underwent appendectomy with partial cecectomy and recovered well. Surgical pathology revealed a 1.5 cm adenomatous polyp of the appendix. DISCUSSION: There are various classification systems for AM. The PSOGI consensus criteria describes eight distinct lesion categories: adenoma, serrated polyp, LAMN (low grade neoplasm of the appendix), HAMN (high grade appendiceal mucinous neoplasm), mucinous adenocarcinoma, signet ring cell low differentiated adenocarcinoma, signet ring cell carcinoma and adenocarcinoma. Surgical resection is critical to ascertain lesion type and develop adjunctive therapy and follow up. AM may result in pseudomyxoma peritonei, a fatal condition of copious mucinous or gelatinous ascites. Thus, regardless of classification, surgical resection is indicated for all appendiceal polyps. Initial imaging studies misdiagnosed our patient with right sided diverticulitis. However, colonoscopy with direct mucosal visualization revealing an adenomatous polyp extruding from the appendiceal orifice facilitated the correct diagnosis of AM. Therefore, although rare, appendiceal neoplasms should be considered in cases of RLQ pain and imaging suggestive of acute inflammatory response; colonoscopy is essential for ongoing RLQ pain and presumed right sided diverticulitis to rule out both colonic and appendiceal neoplasms.Figure 1.: Appendiceal polyp.

Systematic review and meta-analysis of the association between diverticulosis of the appendix and neoplasia.

Diverticula of the appendix (DA) are infrequent and their clinical implications are often overlooked. Several studies have found a significantly increased prevalence of neoplasms in appendiceal specimens with diverticula. Despite the potential clinical implications, there is a paucity of literature. A systematic review and meta-analysis was performed to evaluate the prevalence of DA and its association with neoplasia. A systematic search of literature (Cochrane, EMBASE, PubMed and Medline) reporting the prevalence of DA and association with neoplasia was performed in November 2019. Relevant articles were assessed in accordance with the PRISMA guidelines. Risk of bias assessment was carried out using modified Newcastle-Ottawa scale. Meta-analysis with risk ratio and random-effects model was performed using RevMan. The initial search identified 1122 potential articles of which 11 were appropriate for quantitative analysis. The prevalence rate of DA was 1.74%. The mean age of patients with DA and those without DA was 41.2 and 33.9 years, respectively. The ratio of male to female was 1.8:1. The prevalence of neoplasia in specimens without DA versus those with DA was 1.28% and 26.94%, respectively. Only four studies addressed the prevalence of locoregional neoplasia in the setting of DA compared to control. Meta-analysis with random-effects model demonstrated that pooled risk ratio was 25.46 (95% confidence interval 12.77-50.75, P < 0.00001). The strong association with neoplasia in this meta-analysis reinforces the clinical significance of DA. Surgeons, pathologists and radiologists should be mindful of this uncommon pathology and consider individualized patient management, until further evidence can direct clinical guidelines for the management of patients with DA.

Appendiceal Endometriosis: Is Diagnosis Dependent on Pathology Evaluation? A Prospective Cohort Study

To evaluate the diagnosis of appendiceal endometriosis (AppE) in coincidental appendectomy specimens using standard versus modified histopathologic analysis. Prospective analysis of 300 consecutive patients undergoing coincidental appendectomy at the time of a primary gynecologic procedure. Academic tertiary referral hospital in the northeastern United States. Women aged 22 to 52 years undergoing gynecologic surgery for the management of endometriosis or chronic pelvic pain between 2013 and 2015. Each appendix specimen underwent standard pathologic analysis with 4 sections performed. Modified pathologic analysis, consisting of standard analysis plus serial sectioning and complete evaluation of the appendix and mesoappendix, was then performed. The first pathologist reviewed all the slides to render a diagnosis. The slides of the subjects with abnormal pathology were rereviewed. On rereview, the diagnosis was confirmed, and the data on which protocol, standard or modified, achieved the diagnosis was rendered. The pathologist performing the second review was blinded to whether the slides from the standard or modified histopathology protocol achieved the original diagnosis. This allowed each specimen to serve as its own control. The primary outcome is the detection of AppE. The standard analysis identified endometriosis in 7.7% (n = 23) of appendiceal specimens, whereas the modified analysis identified endometriosis in 10.0% (n = 30; odds ratio 1.3; confidence interval, 1.1-1.7; p = .01). When all pathology findings were combined, the standard analysis identified abnormal pathology in 9.3% (n = 28) of the specimens, whereas the modified analysis identified abnormal pathology in 12.3% (n = 37; odds ratio 1.4; confidence interval, 1.1-1.7; p <.01). Other abnormal appendiceal pathology identified in this study included polyps, neuroendocrine tumors, and acute appendicitis. The average number of slides required for the standard analysis was 1.4 compared with 4.9 slides for the modified analysis. At this institution, the average increase in the cost of slide production for the modified protocol was $12.07. Modified pathologic analysis resulted in a significantly higher rate of diagnosis of endometriosis and abnormal pathology in coincidental appendectomy performed during a primary gynecologic procedure for endometriosis and/or chronic pelvic pain. The use of a standard pathologic protocol likely contributes to underdiagnosis of AppE. The implementation of a modified histopathologic protocol should be considered for improving diagnosis rates of appendiceal pathology in coincidental appendectomy specimens.

Risk factors for appendiceal neoplasm and malignancy among patients with acute appendicitis.

Non-operative management of acute uncomplicated appendicitis has shown promising results but might carry the risk of delayed diagnosis of premalignant or malignant appendiceal tumors found by chance in 0.7-2.5% of appendiceal specimen after appendectomy. Purpose of this study was to analyze whether appendiceal tumors are associated with a complicated appendicitis and to determine risk factors for appendiceal neoplasm and malignancy in patients with acute appendicitis. We performed a retrospective analysis of 1033 adult patients, who underwent appendectomy for acute appendicitis from 2010 to 2016 at the University hospital Erlangen. Data included patients' demographics; comorbidities; pre-, intra- and postoperative findings; and histopathological results. Complicated appendicitis was defined in the presence of perforation or abscess. Appendiceal neoplasm respectively malignancy rate was 2.8% respectively 1.5%. Using univariate analysis, we identified seven risk factors at least for appendiceal neoplasm or malignancy: age, ASA, C-reactive protein, appendiceal diameter, perforation, intraoperative perithyphilitic abscess, and complicated appendicitis. Risk for appendiceal neoplasm or malignancy was 4.4% respectively 2.7% in complicated acute appendicitis compared to 2.0% respectively 1.0% in uncomplicated appendicitis (p = 0.043 respectively p = 0.060). In multivariate analysis, age ≥ 50years and a diameter of the appendix in the sonography ≥ 13mm were independent risk factors predicting the presence of appendiceal neoplasm and malignancy. Among patients with appendicitis, there are relevant risk factors predicting appendiceal tumors, especially age and appendiceal diameter in sonography. But the identified risk factors have a low sensitivity and specificity, so obtaining a confident preoperative diagnosis is challenging.

1565 Goblet Cell Carcinoid: An Unusual Presentation of Acute Abdominal Pain

INTRODUCTION: Goblet Cell Carcinoid (GCC) is a rare neoplasm comprising 0.3-0.9% of appendectomy specimens and less than 14% of all malignant masses of the appendix. While abdominal pain is a common presenting complaint of GCC, rarely does it manifest as an acute perforated appendicitis, as depicted in the case below. CASE DESCRIPTION/METHODS: A 66 year old male with a medical history of hypertension, heart failure, endocarditis, chronic alcoholic pancreatitis presented with RLQ pain 3 days prior with associated fevers, chills, nausea, vomiting and maroon colored stools. His vitals were stable with exam notable for diffuse lower abdominal tenderness and no rebound tenderness. Labs demonstrated a mild leukocytosis of 11.7 and negative blood cultures. CT abdomen and pelvis revealed a small appendiceal abscess and acute appendicitis for which he was treated with intravenous fluids and antibiotics, then was discharged on day 3 with oral antibiotics. 7 days later, he was readmitted with intractable nausea and vomiting. Repeat CT revealed mild improvement in acute appendicitis with labs notable for a leukocytosis of 14 for which he was restarted on antibiotics. Six days later, he underwent a laparoscopic appendectomy as repeat CT was concerning for persistent appendicitis with necrosis (Figure 1). Intra-operatively, the appendix was found to be ruptured. Pathology of appendiceal specimen revealed GCC (Figure 2). His hospital course was also complicated by septic shock and respiratory failure requiring intubation, and acute tubular necrosis requiring hemodialysis. The patient eventually improved and underwent a staging right hemicolectomy which identified lymphovascular invasion and node positivity (Figure 3). DISCUSSION: GCC, a rare appendiceal malignancy of both neuroendocrine and glandular histological features, accounts for less than 5% of all primary tumors of the appendix. Presentation varies from no symptoms to overt gastrointestinal bleeding, with acute appendicitis as the most common initial manifestation. While GCC is of a more aggressive phenotype compared to its benign carcinoid tumor counterpart, prognosis is generally favorable. However in 15-30% of cases, metastasis to the ovaries, pelvis, abdominal cavity, ribs, vertebra and lymph nodes has been observed. Surgery is typically the treatment of choice with tumors &lt;2 cm confined to the appendix requiring only an appendectomy. For larger tumors with nodal involvement, right hemicolectomy within 3 months after appendectomy followed by chemotherapy is warranted.

Appendiceal Neoplasms.

Appendiceal neoplasms are identified in 0.9 to 1.4% of appendiceal specimens, and the incidence is increasing. It has long been professed that neuroendocrine tumors (formerly carcinoids) are the most common neoplastic process of the appendix; recent data, however, has suggested a shift in epidemiology. Our intent is to distill the complex into an algorithm, and, in doing so, enable the surgeon to seamlessly maneuver through operative decisions, treatment strategies, and patient counseling. The algorithm for evaluation and treatment is complex, often starts from the nonspecific presenting complaint of appendicitis, and relies heavily on often subtle histopathologic differences.

Appendectomy at Gynecologic Surgery: Feasibility and Outcomes in a High Risk Gynecologic Population—Revealing a High Rate of Incidental Appendiceal Cancer

Objective: Appendectomy during gynecologic surgery is not performed routinely by most providers, even in patients with pelvic pain complaints or with gynecologic malignancies. Appendectomy, concordant with cancer debulking, can optimize surgical outcomes, and, in patients with pelvic pain, can help diagnose pathologic etiology for those symptoms. With a lifetime rate of appendicitis of 7%–9%, incidental appendectomy can reduce risk for future complications of appendicitis. Design: A retrospective chart review of all patients operated on from April 2012 to July 2016 was performed. Materials and Methods: Data were abstracted to include: age; body mass index; route and indication for surgery; final pathology; complications; and feasibility. Statistics were calculated, using Excel 2007 and the R Project. Results: Charts for 920 patients were reviewed. Of these, charts for 69 patients were excluded due to extraperitoneal procedures; 110 patients had prior appendectomies. There were no complications. In the remaining charts, there were 14 incidental appendiceal primary cancers, 54 metastatic gynecologic cancers wherein appendectomy contributed to optimal debulking, 15 cases of acute appendicitis, and 8 appendiceal specimens with endometriotic implants. Conclusions: Incidental appendectomy is a safe and feasible procedure for both laparoscopic and open abdominal–pelvic procedures. There was a high rate of incidental primary appendiceal cancers, at 2.97%. There was also a high rate of other pathologies, including metastatic tumors, endometriosis, and appendicitis. Removing the appendix during gynecologic surgery can reduce the risks for present and future gastrointestinal cancer, and appendicitis with rupture, as well as contributing to high-quality surgical care in patients with cancer and pelvic pain. (J GYNECOL SURG 33:145)

Composition of the cellular infiltrate in patients with simple and complex appendicitis

BackgroundIt is now well established that there are two types of appendicitis: simple (nonperforating) and complex (perforating). This study evaluates differences in the composition of the immune cellular infiltrate in children with simple and complex appendicitis. Materials and methodsA total of 47 consecutive children undergoing appendectomy for acute appendicitis between January 2011 and December 2012 were included. Intraoperative criteria were used to identify patients with either simple or complex appendicitis and were confirmed histopathologically. Immune histochemical techniques were used to identify immune cell markers in the appendiceal specimens. Digital imaging analysis was performed using Image J. ResultsIn the specimens of patients with complex appendicitis, significantly more myeloperoxidase positive cells (neutrophils) (8.7% versus 1.2%, P < 0.001) were detected compared to patients with a simple appendicitis. In contrast, fewer CD8+ T cells (0.4% versus 1.3%, P = 0.016), CD20 + cells (2.9% versus 9.0%, P = 0.027), and CD21 + cells (0.2% versus 0.6%, P = 0.028) were present in tissue from patients with complex compared to simple appendicitis. ConclusionsThe increase in proinflammatory innate cells and decrease of adaptive cells in patients with complex appendicitis suggest potential aggravating processes in complex appendicitis. Further research into the underlying mechanisms may identify novel biomarkers to be able to differentiate simple and complex appendicitis.

Parasites in the Etiology of Pediatric Appendicitis

Appendicitis is the most common cause of operation in the children. Fekalit, lymphoid hyperplasia, parasites and foreign bodies are accused as the causes of appendicitis. In this study, we wanted to evaluate that the role of parasitic infections in pediatric appendicitis. Histopathological results of the patients who underwent operations for acute appendicitis between January 2008 and 2014 were evaluated. The patients who have parasite in appendiceal specimens were detected and parasites were recorded. Fourteen of 846 patients underwent appendectomy, were classified as parasitic appendicitis. Enterobius vermicularis was observed in 12 and Taenia spp. was observed in 2 patients, Three children with appendicitis had parasitic infection in pathological examination. Two of them were Enterobius vermicularis, and one was Taenia spp. Enterobius vermicularis is the most common parasites in appendiks. Parasites often cause abdominal pain at right lower quadrant without any inflammation in the appendiks. However, parasites are responsible for some appendicitis as an etiologic factor. In our study, 0.39% of patients with appendicitis, parasites were also detected. As a result, we think that right lower quadrant pain and the incidence of appendicitis will reduce by time with the diagnosis and treatment of parasites.