Epiploic Appendages Research Articles

Treatment of Epiploic Appendigitis Using Laparoscopic Electrocautery Technique

Clinical Image: A 57-year-old female presented to the emergency department with a two-day history of left lower quadrant abdominal pain. Vital signs and results of a complete blood count and basic metabolic panel were unremarkable. Abdominal exam was significant for localized left lower quadrant peritonitis. Computed tomography of the abdomen and pelvis showed diffuse fatty infiltration and mild peritoneal thickening in the left abdomen suggestive of omental infarct/fat necrosis (Figure 1). Patient was treated conservatively using NSAIDS with no success. Laparoscopy revealed large infarcted epiploic appendage adhered to the anterior abdominal wall along with the greater omentum (Figure 2). After the epiploic appendage was separated from the anterior abdominal wall and greater omentum, torsion of its vascular pedicle was seen (Figure 3). The vasculature was divided with laparoscopic electrocautery device and the specimen was removed from the abdomen (Figure 4). Her pain improved immediately following the surgery. She was discharged home the next day

Acute Epiploic Appendagitis of the Vermiform Appendix: Typical Computed Tomographic Image with Pathologic Correlation

Epiploic appendages can become ischemic and infarcted, which can present acute abdominal pain that mimics other diseases, such as diverticulitis or appendicitis. Particularly, inflammation of an epiploic appendage attached to the vermiform appendix is a very rare cause of acute abdominal pain, and it is difficult to diagnose this condition preoperatively. We present a case of epiploic appendagitis of the vermiform appendix that was identified with a typical radiologic image and was pathologically confirmed. In addition, we review the literature of similar cases and analyze the clinical and radiologic features of EA of the vermiform appendix.

Recurrent Epiploic Appendagitis Mimicking Appendicitis and Cholecystitis

Epiploic appendagitis (EA) is a rare cause of acute abdominal pain caused by inflammation of an epiploic appendage. It has a nonspecific clinical presentation that may mimic other acute abdominal pathologies on physical exam, such as appendicitis, diverticulitis, or cholecystitis. However, EA is usually benign and self-limiting and can be treated conservatively. We present the case of a patient with two episodes of EA, the first mimicking acute appendicitis and the second mimicking acute cholecystitis. Although recurrence of EA is rare, it should be part of the differential diagnosis of acute, localized abdominal pain. A correct diagnosis of EA will prevent unnecessary hospitalization, antibiotic use, and surgical procedures.

Torsion of epiploic appendices: An uncommon cause of acute abdomen

Torsion of epiploic appendices: An uncommon cause of acute abdomen

Epiploic Appendagitis: The Great Intestinal Imitator

Introduction: Acute abdominal pain is a common complaint for patients presenting to the Emergency Room and often caused by diverticulitis or appendicitis. Herein we present a case of a young patient with epiploic appendagitis (EA) initially diagnosed as acute diverticulitis. Case Report: A 22-year-old Caucasian male with no significant past medical history presented to the hospital with acute onset sharp, intermittent left lower abdominal pain. He denied having any associated symptoms. His physical examination demonstrated moderate left lower quadrant tenderness. He had normal white blood cell count and comprehensive metabolic panel. Imaging studies included a CT scan of the abdomen which was initially read as circumferential inflammation of the descending colon suggestive of diverticulitis and possible microperforation. The next day the patient was much improved and a history of abdominal trauma while playing hockey was elicited. A review of the CT scan with radiology suggested pathognomonic findings for EA and patient was discharged home. Discussion: Epiploic appendages are small peritoneal fat pouches located around the colon supplied by one or two small end arteriole accompanied by a single venule. Inflammation and ischemia of the epiploic appendages commonly occur as a result of vascular pedicle torsion. Less commonly reported causes include venous thrombosis. Two retrospective studies reported that men (70%) were affected more than women with an age range of 26-75 years[1,2]. Because this disorder involves the sigmoid colon, descending colon and caecum, symptoms can imitate diverticulitis and appendicitis. EA, however, is associated with relatively mild pain without any associated systemic findings. Systemic inflammatory responses are often lacking and CT scan findings are considered pathognomonic. Classic findings on CT scan are described as a pericolonic ovoid mass with rim attenuation and pericolonic fat stranding. A central hyperdense dot sign is also considered specific and represents venous thrombosis. Calcification can be seen on follow-up studies and represent old infarcts. EA is a self-limited disorder managed conservatively with nonsteroidal anti-inflammatory agents. As in our case, it is important to ensure that the imaging studies are reviewed by an experienced radiologist. Recognition of this condition is very important to avoid unnecessary surgical interventions.Figure 1Figure 2

Earlobe-like peritoneal appendage near the angle of His: a useful landmark for demarcating the lateral margin of the gastric cardia

The gastric cardia-the small area around the cardiac orifice including the abdominal esophagus-is an important target area for abdominal and thoracic surgeries, especially for laparoscopic procedures. In this study of 28 cadavers, a peritoneal earlobe-like appendage near the angle of His was identified as a useful indicator of the lateral margin of the abdominal esophagus, which is otherwise obscure because the peritoneum continues to the diaphragm without definite demarcation of this margin. This structure, which appears equivalent to the epiploic appendages, was commonly found to be present (in 22/28, 78.6% of the 28 cadavers) and was 4-21mm×6-40mm×1-4mm in size, triangular, round, or leaf-like in shape, contained fat, and was on an imaginary line along which the lesser omentum adheres to the lesser curvature and continues to the diaphragm (18/22, 81.8%). This indicator is associated with the lesser omentum and is part of the gastrophrenic ligament, and could serve as a useful indicator of the margin of the gastric cardia, thus aiding surgeons performing laparoscopic surgery in this region.

The Enigmatic Fallopian Tube: A More Common Cause of Catheter Malfunction than Previously Recognized

Successful performance of peritoneal dialysis (PD) depends on a properly functioning PD catheter. Catheter malfunction remains a significant cause of technique failure, especially early in the course of therapy. Common causes of catheter malfunction include catheter displacement, omental or bowel wrapping, and fibrin clots. Less commonly, various intraperitoneal structures have been reported to lead to obstruction, including appendices epiploicae of sigmoid colon and the fallopian tube. Peritoneal dialysis catheter blockage due to fimbriae of the fallopian tube is being recognized as an important cause of catheter malfunction in females due to the increasing availability of diagnostic laparoscopy. We report 5 episodes of catheter malfunction in 4 patients on PD from a single center as a result of obstruction by the fallopian tube.

Radiology of epiploic appendages: acute appendagitis, post-infarcted appendages, and imaging natural history.

Our aim was to demonstrate the imaging characteristics of epiploic appendages in native, acute inflamed/ischemic and post-infarcted states through retrospective imaging analysis, with clinical and pathologic correlation, and to discuss clinical implications. Cases were gathered mostly retrospectively and reviewed for inclusion based on established diagnostic criteria. Radiology report text search was used to find cases, using terms "epiploic," "appendage," "appendagitis," and "peritoneal body." Data records included patient demographics, relevant clinical data, lesion size, location and apparent imaging composition, and the presence of change or stability in features over multiple studies. Pathologic and clinical data were sought and assessed for correlation. Imaging studies of 198 individuals were included (mean age 50, range 9-95), with a total of 228 lesions: 63 acute and 165 non-acute presentations. All included subjects had CT imaging and some had lesions visible on radiographs, MRI, PET/CT, and sonography. 23 subjects had more than one studied lesion. In addition to classic acute appendagitis, more frequently encountered are post-infarcted appendages either in situ along the colon, adhered to peritoneal or serosal surfaces, or freely mobile in the peritoneum as loose bodies. The majority of the non-acute varieties are recognizable due to peripheral calcification that develops over time following ischemic insult. Multiple cases demonstrated the imaging natural history and confirmed pathologic basis for imaging findings. In summary, acute and post-infarcted epiploic appendages have characteristic imaging appearances and natural history which should provide correct diagnosis in most cases. Incidental post-infarcted epiploica are more commonly encountered than acute presentations.

Epiploic appendagitis masquerading as incarcerated left inguinal hernia

Epiploic appendagitis is a rare condition resulting from acute inflammation of an epiploic appendage. This condition occurs usually within the abdominal cavity and is frequently misdiagnosed; as an unexpected hernia content, it is a very rare entity. We herein report the case of a 38-year-old male patient with a known left inguinal hernia who presented acutely with a painful left inguinal mass. Emergent surgical exploration was mandatory to rule out a possible incarcerated bowel loop; it revealed a hernia sac containing a 3 cm thick, swollen, inflamed and incarcerated epiploic appendage of healthy sigmoid colon. The patient recovered after resection of the epiploic appendage and a tension-free hernioplasty.

Value of laparoscopy in appendix epiploica infarction – A report of four cases

Inflammation of the appendix epiploica is a rare condition which may lead to torsion and eventually infarction. It is almost always never diagnosed clinically. Our four patients were young females presenting with right lower quadrant abdominal pain and nausea. The white cell counts were marginally elevated in all four patients. Clinically, we suspected appendicitis or Meckel’s diverticulitis. Laparoscopy revealed a normal appendix with infarction of the epiploic appendix which was easily excised using ultracision shears. The appendix epiploica has no known function. Inflammation of the appendix epiploica is called appendagitis. Appendagitis and torsion will mimic appendicitis or acute abdomen. This condition usually responds to antibiotic therapy, but surgery is indicated if infarction occurs. There are very few reports of laparoscopy in surgery for appendix epiploica. Our patients were managed laparoscopically with a good outcome. The benefits of laparoscopy include avoidance of laparotomy and reduced morbidity.

開腹歴のない上行結腸の腹膜垂による絞扼性イレウスの1例

開腹歴のない上行結腸の腹膜垂による絞扼性イレウスの1例

A Rare Cause of Abdominal Pain: Primary Epiploic Appendagitis (PEA)

Karin Agrisi; Primer Epiploik Apendajitis; Tomografi Abstract Primary epiploic appendagitis (PEA) is a rare disease caused by torsion or spontaneous thrombosis of the central vein that drains epiploic appendages (EA). Primary Epiploic Appendagitis (PEA) is an ischemic infarction. Although PEA is a self-limiting disease and does not require surgical intervention in most cases, it may mimic diseases that require surgical intervention or aggressive medical therapy, such as appendicitis, diverticulitis, or cholecystitis. In order to avoid unnecessary surgical intervention, PEA should be kept in mind when patients present with acute abdominal pain. In this report, we present a PEA case admitted with abdominal pain.

Excision of small intestine epiploic appendage: Over-estimated or not?

Dear Editor, Epiploic appendages (EA) are pedunculated enlarged fat structures of mesentery found mostly along the transverse and sigmoid colon, but rarely at jejunum and ileum. While many colonic epiploic appendagitis have been reported due to complications, such as torsion, obstruction, venous thrombosis and inflammation, there are only few reports on preoperative diagnosis of small intestine EA and recommendations on uncomplicated lesions found incidentally at laparotomy (1-3). We describe a case of 58-year-old woman with medical history of sigmoid resection with Hartmann procedure due to sigmoid torsion. She presented with diffuse interloop adhesions and EA of ileum at re-laparotomy. Physical examination revealed tenderness near colostomy opening. All biochemical tests and abdominal ultrasound were normal. Based on the previous history we decided to close the colostomy. During the laparotomy, we found multiple interloop adhesions and an ileum segment with three pedunculated EA sized 4-5 cm (Figure 1) with no evidence of complications on macroscopic examination. Colostomy was reversed and end-to-end colorectal anastomosis was performed. We decided to excise the EAs because of the risk for torsion or strangulation of small intestine (Figure 2). The EAs were reported on histopathology as adipose tissue. The patient was discharged after 7 days with no postoperative complications. Small intestine EA is a rare condition, initially described by Mittal et al. in 1981(3). To our LETTER TO EDITOR Open Access

Excision of small bowel epiploic appendage:Over-estimate or not?

Excision of small bowel epiploic appendage:Over-estimate or not?

Laparoscopic Vesicovaginal Fistula Repair with Limited Cystotomy: A Rewarding Treatment Option.

Vesicovaginal fistula (VVF) is the most common type of urogenital fistula. Gynecologic surgery is the most common cause associated with it. Laparoscopic approach for VVF repair gives the benefit of minimally invasive surgery with principles similar to open transabdominal approach. We retrospectively reviewed data of 13 patients who underwent laparoscopic vesicovaginal repair at our department from December 2012 to December 2014. Transperitoneal transvesical laparoscopic vesicovaginal repair using 4 ports was performed in all cases. Small cystotomy was performed instead of classical bivalving of the bladder. In most of the cases, the sigmoid epiploic appendix was used for augmentation. Per urethral catheter was kept for 10days. In all patients, the procedure was successfully completed. Repairs were performed between 8 and 28weeks (mean 15.8±5.7) following the injury. All fistulas were at supratrigonal region. Fistula size ranged from 1 to 3.5cm (mean 2.2±0.9). Mean operative time was 157±29.8min (range 110-210), and estimated blood loss was 73.8±18.2ml (range 45-110). Average hospital stay was 4.6days. In the postoperative period, three patients had urinary tract infection, which was treated with oral antibiotics. Apart from these, no major complications were seen. Follow-up time ranged from 4 to 27months (mean 15.7). During the follow-up, no patient had recurrence or voiding symptoms. Laparoscopic transabdominal transvesical VVF repair with limited cystotomy and sigmoid epiploic appendix flap coverage can be performed safely with short operative time, good success rate, less morbidity, and quick convalescence.

A New Device to Prevent Irregular Adsorption of Fatty Tissue While Using an Irrigation-suction Instrument for Laparoscopic Surgery: Divided Silicone Drain Tip.

Background:While using an irrigation-suction instrument for laparoscopic surgery, irregular adsorption of fatty tissue may damage the tissue or obstruct continuous sucking. A new device made up of a divided silicone drain tip to prevent irregular adsorption was reported.Materials and Methods:A cigarette-type silicone drain was cut 4 cm in length. It was slipped over the instrument to cover the side holes, leaving 1.0 to 1.5 cm free from the end of the instrument. It was fixed by means of 1-0 silk above the side holes. Finally, the free tip was divided vertically into 4 even pieces like octopus arms.Results:This device could prevent the irregular adsorption of fatty tissue (greater and lesser omentum, or epiploic appendices) and could suck saline, fresh, and coagulated blood almost continuously.Conclusions:This simple and easy device facilitated the prevention of irregular adsorption of fatty tissue while using an irrigation-suction instrument for laparoscopic surgery.

A Novel Technique for Laparoscopic Salvage of CAPD Catheter Malfunction and Migration: The Santosh-PGI Hanging Loop Technique.

CAPD catheter malfunction is a common problem. Obstruction due to wrapping by appendices epiploicae of sigmoid colon has been rarely reported in literature. We report a case of CAPD catheter malfunction caused by catheter tip migration and obstruction by appendices epiploicae that was successfully managed by laparoscopic hanging loop technique. This case report highlights the ease with which epiplopexy can be performed and catheter tip migration can be prevented by this innovative laparoscopic procedure.

Torsion of Fatty Appendage of Falciform Ligament: Acute Abdomen in a Child.

Torsion of the fatty appendage of the falciform ligament is an extremely rare condition that leads to severe abdominal pain and raised inflammatory markers. It can be recognised on ultrasound or CT scan. The pathophysiology is the same as that involved in the more common torsion and/or infarction of the greater omentum or epiploic appendages. The condition is best managed conservatively with anti-inflammatory analgesia, and the early recognition of this type of torsion may prevent unnecessary operative intervention to look for a source of abdominal pain. There have been five reported adult cases of a torted fatty appendage of the falciform ligament identified on ultrasound and CT scan, but no paediatric cases. We report a case of torsion of the fatty appendage of the falciform ligament in a ten-year-old boy and describe its imaging characteristics on CT scan.

An unusual cause of acute abdomen – epiploic appendagitis: report of two cases

Epiploic appendices, first described in 1543 by Vesalius, are fatty structures which are attached through the length of the colon and consisted of visceral peritoneum. Epiploic appendicitis is an uncommon and self-limiting disease. In this report, we aimed to present two patients with epiploic appendicitis.

単孔式腹腔鏡下手術にて治療したS状結腸腹膜垂による腸閉塞の1例

単孔式腹腔鏡下手術にて治療したS状結腸腹膜垂による腸閉塞の1例