Intact Appendix Research Articles

Endoscopic submucosal dissection of a large cecal tumor extending into the appendiceal orifice in a patient with intact appendix.

Video 1Endoscopic submucosal dissection of a cecal laterally spreading tumor-granular type extending into the appendiceal orifice.

Split appendix catheterizable urinary channels are at no higher risk of undergoing revision compared to channels made with the intact appendix

To assess long-term APV and split-appendix MACE durability and to compare split and intact appendix APVs in a large patient cohort. This retrospective cohort study included consecutive patients ≤21 years old undergoing an APV at our institution (1990-2019). Main outcomes were stomal and subfascial revisions. Kaplan Meier survival and Cox proportional hazards analysis were used. A total of 339 patients underwent APV creation at a median 7.4 years old (41% female vs. 59% male; 37% umbilical stoma vs. 63% other). In total, 36 patients underwent a stomal revision and 19 a subfascial revision (median channel follow-up 6.3 years). On survival analysis, the risk of stomal revision of the APV was 9.1% at 5 years, 12.6% at 10 years and 16.5% at 15 years. Risk of subfascial revision of the APV was 5.1% at 5 years, 7.0% at 10 years and 8.2% at 15 years. A split-appendix APV was performed in 118 (34.8%) of 339 patients. They had a shorter follow-up compared to those with an intact APV (5.1 vs. 7.0 years, p=0.03). After correcting for differential follow-up time, there was no significant difference between groups for stomal revisions (HR 1.11, p=0.76) or subfascial revisions (HR 0.80, p=0.67, Figure). Risk of APV stomal revision was independent of stomal location and age at surgery (p≥0.37). Similarly, risk of subfascial APV revision was independent of stomal location and age at surgery (p≥0.18). Risk of stomal revision for split-appendix MACE channels was 16.2% at 5, 10 and 15 years (similar to split-appendix APV and all APVs, p≥0.26). Risk of MACE subfascial revision was 5.5% at 5 years, 5.5% at 10 years and 14.7% at 15 years (similar to split-appendix APV and all APVs, p≥0.36). We focused on surgical complications, as these entail the highest morbidity, however, we did not assess non-surgical, percutaneous or endoscopic management which also impact long-term outcome and patient quality of life. We did not compare the outcomes of the split-appendix MACE to an intact-appendix MACE cohort, as this patient population was not captured in this review. The split-appendix technique has durable long-term results for both the APV and MACE channels, which are comparable to the technique utilizing the intact appendix. Channel complications occur over the channel's lifetime, as 1 in 8 APVs in the entire cohort underwent a stomal revision and 1 in 14 APVs underwent a subfascial revision at 10 years after surgery.

Split appendix Mitrofanoffs have higher risk of complication than intact appendix or monti channels

Many patients with certain conditions require catheterizable channels for bladder and bowel management. There are a variety of accepted techniques for creating these channels; the split appendix technique enables the use of this organ for both procedures, obviating the need for more complex surgical procedures. Studies comparing outcomes across catheterizable channel types are limited. The aim of this study was to compare the urinary channel complication rates of the split appendix, intact appendix and transverse ileal tube (Monti) channels. We hypothesized that complication rates would be the same across all channel types. We retrospectively reviewed consecutive patients who underwent surgical creation of a urinary continent catheterizable channel. We recorded demographics, underlying diagnosis, body mass index, stoma location, surgical techniques, and surgical revisions. The primary outcome was complication (stenosis, leakage, or both) with or without surgical revision, and to compare the three different catheterizable channel types using time to event analysis. From January 2014-July 2018, 107 patients underwent creation of a continent catheterizable urinary channel; 86 (80.4%) patients also underwent simultaneous procedure for antegrade bowel management. The mean age was 7 years; 66 (60.8%) were females. Intact appendices were used in 46 (43.0%), Monti channel in 25 (23.4%), and split appendix technique in 36 (33.6%). The corresponding complication rates with or without surgical revision was 21.7%, 36.0%, and 47.2%, respectively. The only independent factor associated with increased risk of complication was the split appendix technique; these channels were more than twice as likely to require surgical revision with an adjusted hazard ratio of 2.32 (Table 4). The majority of revisions in all groups were skin level (58.3%). The most common indication for surgical revision was stenosis (55.6%). This analysis shows a statistically significant increase in risk of all complications, including an increase in need for surgical revision, in patients who underwent split appendix technique for simultaneous bladder and bowel catheterizable channels. This finding should be balanced with the fact that a bowel anastomosis is not required in cases where individuals need both a bowel and bladder catheterizable channel. This study is unique in its separation of split and intact appendix channels, and inclusion of patients experiencing complications that have not yet required surgical revision. Limitations of this study include its retrospective design, inclusion of a single institution, and the lack of consistency in documenting baseline appendiceal length. Split appendix catheterizable channels have a higher rate of channel complications than other techniques. The authors acknowledge that the split appendix technique has been proven feasible and effective, however recognize that it may not be appropriate for all patients and include counseling of the risks of its use.

Analysis of Clinical Characteristics of Low-Grade Appendiceal Mucinous Neoplasm (LAMN): A Retrospective Cohort Study of 51 LAMN Patients

Introduction Low-grade appendiceal mucinous neoplasm (LAMN) is a rare disorder. There is no consensus on the prognosis and management of LAMN. Materials and methods We reviewed 51 consecutive patients with LAMN from 2013 to 2018. We divided our patients into two groups. The first is patients with an intact appendix. The second group comprises patients with the potential to develop a malignant condition. Comparisons of serum tumor markers between two groups were performed. Survival curves were estimated. Univariate and multivariate Cox proportional hazards were computed for 46 patients with median follow-up of 2.7 years. Results Comparison of patients in two groups revealed significant differences in the mean level and abnormal ratio of CA125 (p < 0.001, p < 0.001), CA19-9 (p = 0.04, p = 0.04), and CEA (p = 0.001, p = 0.02). Eight patients had relapsed by the last follow-up in the second group. Patients with normal CEA had significantly longer disease-free survival (DFS) time than those with abnormal CEA (p = 0.04). CA19-9 exhibited a significant association with DFS (HR = 5.72, p = 0.02) in the Univariate Cox proportional hazards. Discussion The prognosis of LAMN is related to serum tumor markers, the surgical procedure and the pathology.

NEGATIVE APPENDECTOMY

Acute appendicitis is the most common surgical emergency. Despite advancesin diagnostic techniques, an accurate pre-operative diagnosis may still pose a challenge tothe clinicians. Therefore, even today we are facing a high rate of negative appendectomy.The current study explores this aspect of a common and important disease. Objectives: Toknow the percentage of negative operative findings in acute appendicitis in our hospital thatdrains wide area of population from lower socioeconomic strata. Patients and methods: Thisprospective cross-sectional study was conducted at Department of Surgery, Lady ReadingHospital, Peshawar within two years from 1-1-2009 to 31-12-2010. This study included 673cases undergoing appendectomy. All the patients operated for clinical diagnosis of acuteappendicitis over the study period were included. Their history, clinical features, and resultsof investigations were noted. Gross examination of intact appendix specimen, and on-tablecross sectional inspection of appendix was made; and were correlated with histopathologicalfindings (as gold standard). Results: The study included 673 patients. There were 478 males(70%), and highest number of patients was in second decade of life. On gross examination,545 (81%) appendices were swollen, 531 (79%) were reddened due to inflammation; 63 (9.4%)were gangrenous; and 50 (7.5%) had perforated; while in 128 patients (19%) the appendix wasnormal looking with shiny surface. Fibrino-purulent exudate in the peri-appendeceal regionwas noticed in 253 (37.6%) patients. The cut section of appendix showed wall abscess in 474(70.4%) cases, and mucosal ulceration in 325 (48.2%). Necrotic foci in mucosa were seen in188 (27.6%) cases, and in 61 cases (9%) the necrosis was extending through the wall up toserosa. Histopathology revealed marked acute inflammation in 416 (61.8%) cases, moderateinflammation in 92 (13.7%), and mild inflammation in 47 (6.9%); while in 118 cases the appendixhad no evidence of inflammation (giving negative appendectomy rate of 17.5%). Negativeappendectomy rate in females was 29.2% compared to 12.7% in males. Probable alternatediagnoses are also addressed. Conclusions: The negative appendectomy can be avoidedin many cases if ultrasound facilities were available during odd hours of patient presentation.Similarly, the rate of negative appendectomy can be further reduced in adults, especially femalesaround puberty and reproductive age, by the provision of laparoscopy during emergency hoursof the day.

Appendectomy: a risk factor for colectomy in patients with Clostridium difficile

BackgroundThe appendix, considered an intestinal microbiota reservoir, may be protective against the risk of fulminant Clostridium difficile infection. MethodsRetrospective analysis was performed in patients with C. difficile infection at St. Francis Medical Center from 2007 to 2011. Outcome of infection and history of appendectomy were compared. Statistical analysis was by chi-square and multivariate logistic regression. ResultsIn total, 507 patients were hospitalized for C. difficile. Of 388 patients with intact appendix, 20 (5.2%) developed fulminant infection and required colectomy, whereas of 119 patients with previous appendectomy, 13 (10.9%) required colectomy. An increased severity of disease, indicated by increased rate of colectomy, occurred for the group with a history of appendectomy (P = .03). Age and sex were adjusted by multivariant regression (P = .05). ConclusionsAppendectomy may be a risk factor for increased severity of C. difficile infection. Although the mechanism is unknown, further studies are warranted.

V2-07 CONTINENT RIGHT COLON RESERVOIR USING CUTANEOUS APPENDICOSTOMY

You have accessJournal of UrologyReconstruction1 Apr 2014V2-07 CONTINENT RIGHT COLON RESERVOIR USING CUTANEOUS APPENDICOSTOMY Mehrdad Alemozaffar, Hamed Ahmadi, and Siamak Daneshmand Mehrdad AlemozaffarMehrdad Alemozaffar More articles by this author , Hamed AhmadiHamed Ahmadi More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1005AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There are a subset of patients who are not appropriate candidates for orthotopic neobladder (ONB) and still want to have a continent urinary reservoir. We present our technique of continent cutaneous right colon pouch using a catheterizable submucosally embedded appendicostomy. METHODS Of 1964 patients diagnosed with bladder cancer undergoing radical cystectomy at our institution, 97 patients underwent continent right colon reservoir urinary diversion. Contraindications for ONB were non-functional and/or tumor involvement of urethra or bladder neck, history of pelvic radiation, and small bowel pathology with extensive involvement of the ileum. RESULTS We demonstrate our technique for continent right colon reservoir using the appendix as an efferent catheterizable continence mechanism. The ascending and proximal trasverse colon are detubularized and folded to form the reservoir component of the urinary diversion. (Figure 1) The ureters are anastomosed to the terminal ileum which acts as the afferent limb with the intact native ileocecal value providing the anti-reflux mechanism. The appendix is then tunneled submucosally with preservation of the mesentery in a flap-value technique to act as the continent catheterizable mechanism. (Figure 2) CONCLUSIONS A continent cutaneous right colon reservoir, with the terminal ileum receiving the ureters, and the use of the appendix as the continent catheterizable ostomy is a reasonable alternative for cutaneous urinary diversion when an intact appendix is present. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e359-e360 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Mehrdad Alemozaffar More articles by this author Hamed Ahmadi More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Association Between Appendectomy and Clostridium difficile Infection

BackgroundRecent theory proposes that the appendix functions as a reservoir for commensal bacteria, and serves to re-inoculate the colon with normal flora in the event of pathogen exposure or purging of intestinal flora. If true, we reasoned that flora from a normal appendix could provide protection against Clostridium difficile. We conducted this investigation to examine the protective effect of an intact appendix and test the hypothesis that prior appendectomy will be more common among patients with a positive test for C. difficile as compared with patients who test negative.MethodsWe contacted patients who had undergone C. difficile testing and asked them whether or not they had a prior appendectomy. Using their responses and results from Toxin A & B EIA tests, we calculated the difference in appendectomy rates between those who tested positive for C. difficile, and those who tested negative. We considered a positive 15% absolute difference to represent a significant increase in appendectomy rate.ResultsWe enrolled 257 patients. Among the 136 who tested positive for C. difficile, 27 (19.9%) had prior appendectomies, while among 121 patients testing negative for C. difficile, 38 (31.4%) had prior appendectomies, yielding a difference in appendectomy rates of -11.6% (95% Confidence Interval: -21.6% to -0.9%).ConclusionsThe rate of prior appendectomy was actually lower among patients with a positive C. difficile test as compared to those with a negative test. Conversely, patients who tested positive for C. difficile were more likely to have an intact appendix than those who tested negative. These results suggest that rather than being protective, an intact appendix appears to promote C. difficile acquisition, carriage, and disease.KeywordsClostridium difficile; Appendix; Appendectomy; Microbial reservoir; Infection

Continent right colon reservoir using a cutaneous appendicostomy

Introduction Although orthotopic reconstruction has become the preferred form of lower urinary tract reconstruction after cystectomy there remains a select group of patients who are not appropriate for an orthotopic neobladder substitute. A continent cutaneous reservoir provides an alternative means to store urine and protect the upper urinary tract without the need for a urostomy appliance. We report our surgical technique of a continent cutaneous right colon reservoir using a catheterizable submucosally embedded appendicostomy. Technical considerations The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy incorporates the ascending and proximal transverse colon, which are detubularized and folded to form the reservoir component of the urinary diversion. The terminal ileum acts as the afferent limb, with the intact native ileocecal valve providing the antireflux mechanism. The continence catheterizable mechanism incorporates the submucosally tunneled appendix with preservation of the mesentery in a flap-valve technique. Conclusions The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy is a reasonable alternative for cutaneous urinary diversion when an intact appendix is present, with good functional results and excellent continence.

The appendix and IBD: Appendectomy does not protect against ulcerative colitis

It is now almost 9 years since Gilat et al. (I), in their international study of childhood factors in IBD, noted the rarity of appendectomies in patients with ulcerative colitis (UC) compared with their control population. The authors had “no ready explanation” of their finding and did not mention it in their summary. This clear-cut report evoked little interest, and most clinical epidemiologists concentrated on the relationship between IBD and cigarette smoking and sucrose consumption. The more recent report (in 1994) of Rutgeerts et al. (2), who were apparently unfamiliar with the older study confirming the rarity of appendectomy in UC, has revived interest in this finding because of the unequivocal title of their article, “Appendectomy Protects Against Ulcerative Colitis” and the suggestion that removal of the appendix might be a useful procedure because “the relative risk of developing UC with an intact appendix exceeds the risk factor associated with smoking.” As a result, the literature now contains six studies on the subject, four full reports, two in abstract form (including one of our own), letters to the Editor, commentary, and editorials, etc.

Case Reports: Functional Replacement of Bladder and Urethra After Cystectomy for Bladder Cancer in a Female Patient

ABSTRACTWe describe a new concept for female bladder replacement introducing an ileocecal pouch with the intact appendix vermiformis used as an orthotopic neourethra. Based upon the results of preceding experimental studies this procedure was performed on a woman with the diagnosis of focal invasive bladder cancer. Eight months after the operation the patient is completely continent and back to work. This new type of urinary diversion with improved body image can be offered to female patients undergoing cystectomy for bladder cancer.

Case Reports

We describe a new concept for female bladder replacement introducing an ileocecal pouch with the intact appendix vermiformis used as an orthotopic neourethra. Based upon the results of preceding experimental studies this procedure was performed on a woman with the diagnosis of focal invasive bladder cancer. Eight months after the operation the patient is completely continent and back to work. This new type of urinary diversion with improved body image can be offered to female patients undergoing cystectomy for bladder cancer.

Appendectomy protects against ulcerative colitis

Background/Aims: Defining risk factors for ulcerative colitis (UC) is important to better understand the pathogenesis of this idiopathic disease. One factor modulating the disease is smoking. A pilot study showed the absence of appendectomy in the medical history of patients with ulcerative colitis. The aim of the present case control study was to compare the relative risk of developing UC after appendectomy with the relative risk of developing UC with an intact appendix. Methods: One hundred seventy-four (84 females and 90 males, mean age 34.9 years) consecutive UC patients examined at our inflammatory bowel disease clinic or hospital ward, were included. Fifty-six had pancolitis (32%) and 118 (68%) suffered from left-sided colitis. The control group consisted of 161 consecutive patients examined at the orthopedic clinic (86 females and 75 males, mean age 40.9 years). Results: Two parameters, absence of appendectomy and smoking, were closely related to the development of UC. Before the onset of UC, only 1 of the 174 patients (0.6%) had undergone an appendectomy. Of the 161 controls, 41 (25.4%) had undergone an appendectomy. The difference between the two groups was highly significant with an odds ratio of 59.1 (95% Cl, 18–189; P < 0.001). The relative risk of getting the disease associated with nonsmoking was 2.95 (95% Cl, 1.69 – 5.17). Conclusions: Appendectomy is a protective factor against UC.

Coiled-spring sign of the cecum in acute appendicitis.

A concentric ring appearance of the cecal mucosa on a barium enema is a distinctive but nonspecific radiographic finding that has been termed the vortical, whirlwind, or coiled-spring sign. It can be caused by inversion of a postappendectomy stump and transient intussusception of the intact appendix in asymptomatic patients. The sign has also been reported with mucoceles, carcinoma, and endometriosis of the appendix, but there has been little mention of it in connection with acute appendicitis. The records of 18 patients with a coiled-spring sign and nonfilling of the appendix were reviewed. Acute appendicitis was proven in 14 of 18. In five of these 14, this sign was the only finding accompanying nonfilling of the appendix. On review of 53 cases of pathologically proven acute appendicitis studied by preoperative barium enema, 14 had a coiled-spring sign. The coiled-spring sign is nonspecific but can be produced by acute appendicitis, where it may be the only positive sign accompanying nonfilling of the appendix.

SPREADING PERITONITIS COMPLICATING ACUTE PERFORATIVE APPENDICITIS

Approximately 300,000 persons in the United States will be operated on this year for acute appendicitis and its complications. Twenty thousand of these will die at an average age of 27 years. Fewer than 2,000 will die of acute appendicitis. More than 17,000 will die of peritonitis. Of the 300,000 persons operated on, nearly 195,000 will have an intact appendix; the serous coat will be unruptured. The mortality will be less than 1 per cent. Of the 300,000, it is estimated that 105,000 will have peritonitis at the time of their admission to the hospital and approximately 1 of every 6 of these will die; 63,000 will have local peritonitis and approximately 3 per cent, or 1 in 30, will die; 42,000 will have spreading peritonitis and more than 15,000, or 1 in every 3, will die. Over 80 per cent of those who die will die of spreading peritonitis.