|Year : 2017 | Volume
| Issue : 2 | Page : 71-75
Retrospective analysis of appendicectomy specimens: A tertiary care center-based study
Suhailur Rehman1, Asim Israr Khan1, Hena Ayyub Ansari1, Feroz Alam1, Shaista M Vasenwala1, Kiran Alam1, M Amanullah Khan2
1 Department of Pathology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
2 Department of Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
|Date of Web Publication||26-Jul-2017|
Department of Pathology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Acute abdominal pain in the right iliac fossa is the most common symptom of acute appendicitis for which appendicectomy is usually done. Histopathological examination of appendicectomy specimen reveals different causes of appendicitis which will decide further course of action.
Aims and Objectives: The aim of this study is to record the percentage of various pathologies of appendix, by carrying out a retrospective study of appendices excised in the past 2 years.
Materials and Methods: Three hundred and sixteen cases of appendicitis were taken and H and E sections of the specimens were reviewed.
Observation and Results: Out of 316 cases, there were 192 (60.8%) cases of acute appendicitis, 56 (17.7%) of periappendicitis, 1 (0.3%) of acute appendicitis with diffuse lymphoid hyperplasia, 7 (2.2%) of subacute appendicitis, 9 (2.8%) of recurrent appendicitis, 10 (3.2%) of obliterative appendicitis including one case of roundworm infestation, 25 (7.9%) of chronic appendicitis, 3 (0.9%) of mucocoele, 2 (0.6%) of mucinous neoplasm, 2 (0.6%) of carcinoid, 1 (0.3%) of adenocarcinoma, and 8 (2.5%) of normal appendix.
Conclusion: This study highlights the importance of histopathology as some of the rare malignancies of appendix as mucinous neoplasm, carcinoid, and adenocarcinoma can present with acute abdominal pain. Hence, careful histopathological examination of appendix and regional lymph nodes is mandatory with follow-up and endoscopy of the patient.
Keywords: Appendix, carcinoid, mucinous neoplasm, worm infestation
|How to cite this article:|
Rehman S, Khan AI, Ansari HA, Alam F, Vasenwala SM, Alam K, Khan M A. Retrospective analysis of appendicectomy specimens: A tertiary care center-based study. Saudi Surg J 2017;5:71-5
|How to cite this URL:|
Rehman S, Khan AI, Ansari HA, Alam F, Vasenwala SM, Alam K, Khan M A. Retrospective analysis of appendicectomy specimens: A tertiary care center-based study. Saudi Surg J [serial online] 2017 [cited 2017 Sep 24];5:71-5. Available from: http://www.saudisurgj.org/text.asp?2017/5/2/71/211607
| Introduction|| |
The appendix in human beings is supposed to be a functionless organ, but it is an important cause of morbidity and mortality because it is likely to become infected. Pain in the lower abdomen is a common cause of emergency admission, and acute appendicitis is one of the most common surgical causes of lower abdominal pain specifically in the right iliac fossa. Approximately 7% of individuals suffer an episode of acute appendicitis during their lifetime, occurring commonly in adolescents and young adults. The incidence of acute appendicitis roughly parallels that of lymphoid development, with peak incidence in the late teens and twenties.
Obstruction of the lumen of appendix is the dominant factor responsible for acute appendicitis. Fecaliths and lymphoid hyperplasia are the usual cause of obstruction. Other causes of obstruction could be intestinal worms, tumors, mucocele, granulomatous diseases, or other conditions.
An accurate preoperative diagnosis of acute appendicitis is not always possible. Clinical findings form the basis for diagnosis which may be further consolidated by blood tests such as white blood cell count and C-reactive protein. Even in this era of technology, appendicitis continues to be a clinical diagnosis. Many patients do not present classically because of the variation in the pathophysiological development of the disease and wide range of possible positions of appendix.
Early appendicectomy is the preferred management because misdiagnosis and delay in operation can lead to complications such as perforation and peritonitis. However, early diagnosis and emergency surgery can lead to increased number of negative appendectomies.
This retrospective study was performed to study the patterns of lesions (nonneoplastic and neoplastic) in the appendectomy specimens at this institution. In addition, an attempt was also made to find the rate of negative appendectomy at our center.
| Materials and Methods|| |
This is a retrospective cross-sectional study carried out at Jawaharlal Nehru Medical College and Hospital, Aligarh over a period of 2 years starting from August 2012 to July 2014.
Hospital records of all patients who were diagnosed as acute appendicitis and underwent appendectomy (either open or laparoscopic) were reviewed retrospectively. In each case, patients' age, sex, brief clinical history, physical examination, operative findings, and available relevant investigations recorded on the request forms were noted. Evaluation of the pathologists' reports and the microscopic slides of all those patients were carried out.
Patients who had undergone an operation for presumed acute appendicitis were included in the study. The results were statistically analyzed.
| Results|| |
In total, 316 appendectomies were performed with a clinical diagnosis of acute appendicitis during the study and were available for clinical and pathological analysis. Of these, there were 286 patients in whom emergency appendectomy was done, interval appendectomy was done in 25 cases, and 5 cases were of elective appendectomy.
Maximum numbers of appendectomies were performed in patients in their third decade. The youngest patient was 8 years old and the oldest was 69 years of age. Among these patients, 167 (52.8%) were male and 149 (47.2%) were female, with a male to female ratio of 1.1: 1. Age and sex distribution of patients with appendectomy is shown in [Table 1].
Most patients presented with multiple and overlapping clinical symptoms. The most common presenting symptom for which patients sought hospital admission was the right iliac fossa pain seen in 208 patients (65.8%), followed by fever in 58 (18.4%), and generalized pain abdomen in 50 (15.8%) patients. Other associated symptoms reported were nausea, vomiting, and anorexia.
On investigations, increased total leukocyte count (>11,000) was found in 274 patients (86.7%) and neutrophilia (neutrophils >75%) was seen in 291 patients (92.1%). There was no significant association between acute appendicitis and body temperature, hematocrit, and pus cells in urine.
The most common position of appendix as found recorded in the intraoperative notes was retrocecal in 151 cases (47.8%), and the least common was pelvic position seen in 8 cases (2.5%). The rate of negative appendectomies was 2.5% (8 out of 316 cases).
Details of histopathological findings of appendectomy specimens are shown in [Table 2].
Most common cause for which appendicectomy done was acute appendicitis (60.8%), followed by periappendicitis (17.7%). Obliterative appendicitis accounts for 3.2% of cases including one case of roundworm infestation [Figure 1]. Rare causes include mucocoele (0.9%), mucinous neoplasm (0.6%), carcinoid (0.6%), and nonmucinous adenocarcinoma (0.3%) [Figure 2], [Figure 3], [Figure 4].
|Figure 1: Enterobius vermicularis obstructing the lumen of appendix (H and E, ×10)|
Click here to view
|Figure 2: Mucinous neoplasm showing invasion of muscle layer of appendix by malignant mucinous glands (H and E, ×10)|
Click here to view
|Figure 3: Lymph node showing malignant mucin secreting glands and pools of mucin (H and E, ×10)|
Click here to view
The presenting complaint in one case of mucinous neoplasm was pain in right upper abdomen for 2 months (acute cholecystitis). Contrast-enhanced computed tomography and ultrasonography (USG) revealed mucocoele of appendix and 3 cm gallstone. Cholecystectomy and appendicectomy were done. Histopathological examination of appendix showed features of mucinous neoplasm. Dissected lymph node showed malignant mucinous glands with pools of mucin [Figure 2] and [Figure 3]. This was an incidental finding in a patient operated for cholecystectomy.
| Discussion|| |
Acute appendicitis is one of the most common general surgical conditions presenting in the emergency and its diagnosis is mostly based on the clinical manifestation of the patient. The patient usually presents with pain in the lower abdomen and it becomes necessary to rule out other possible surgical and nonsurgical causes of lower abdominal pain. The signs and symptoms associated with acute appendicitis have a sensitivity of 16%–100% and specificity of 36%–95%. Other diagnostic modalities which may be employed to aid in diagnosis are laboratory tests such as total and differential leukocyte count, plain abdominal radiographs, barium enema, and USG, but none of these proved to have a definite advantage over a careful clinical history and examination.,,
Increased total leukocyte count characterized by neutrophilia has been reported to be associated with the diagnosis of acute appendicitis. In this study, also neutrophilia (>75%) was found to be more associated with the diagnosis than leukocytosis (>11,000). The pain in the right iliac fossa in acute appendicitis showed a correlation with infiltration of neutrophils within the appendiceal wall.
Male patients undergoing surgery for lower abdominal pain had features of acute appendicitis (56.2%) on histopathology more than females (43.8%). In this study, the rate of negative appendectomies was more in female (75%) as compared to males. This was in accordance with many previous studies., This may be because of other causes of lower abdominal pain in females such as ovarian cysts, pelvic inflammatory disease, and ectopic pregnancy. In this study, it was found that young adults in their third decade, when presented with lower abdominal pain had more chances of having acute appendicitis than other age groups [Table 1]. Hence, early diagnosis and surgery should be considered in this group to avoid complications.
Histopathological examination of the appendix is necessary to confirm the diagnosis of acute appendicitis and to reveal additional findings that might not be evident clinically and intraoperatively but may change the course of further management of the patient. In the present study, emergency appendectomy was the preferred approach and was done in a maximum number of cases (90.5%), followed by interval appendectomy (7.9%) and elective appendectomy (1.6%). Deakin and Ahmed have also reported that in most cases, emergency appendectomy was the management of choice. In this study, the most common position of appendix was observed to be retrocaecal (47.8%). In contrast to this, Ahmed et al. reported pelvic position to be the most common position seen in 51.2% cases.
In this study of 316 appendectomy specimens, 303 (95.9%) turned out to be benign lesions and 5 (1.6%) cases were found to be malignant lesions [Table 2]. Blair et al., in their study, also reported that 80% of appendectomy cases on histopathology turned out to be involved by benign or inflammatory lesions. Only 8 (2.5%) cases were normal in this study in contrast to other studies which reported much higher negative appendicectomy rate ranging from 8.4% to 25%., Low rate could be due to various reasons such as the use of computed tomography or USG preoperatively for accurate diagnoses. Symptoms usually disappeared postoperatively even in patients with negative histopathology. It may have been probably due to early appendicitis at microcellular level.
The finding of chronic appendicitis reflects delay in seeking treatment and is common in developing countries. In western world, chronic appendicitis is very rare. In this study, 25 (7.9%) patients had chronic appendicitis [Table 2].
The present study revealed a few unusual pathologies in the appendicectomy specimens. Parasitic infestation is one of the causes of obstruction of the lumen of appendix leading to appendicitis. One case of worm infestation is reported in this study wherein Enterobius vermicularis was seen in the appendix obstructing the lumen on histopathology [Figure 1]. It may be effectively eradicated by antihelminthic treatment.
In this study, 3 (0.9%) cases of mucocele and 2 (0.6%) cases of mucinous neoplasm (mucinous adenocarcinoma) have been reported [Table 2]. A mucocele of the appendix is an obstructive dilatation of the lumen of appendix leading to abnormal accumulation of mucus. The incidence of mucocele as reported in previous literature ranges from 0.2% to 0.3% of all appendectomy specimens. Mucoceles are usually asymptomatic and are discovered as incidental findings on histopathology of appendectomy specimen removed for some other indication. One case of mucinous neoplasm which was the incidental finding seen in patient operated for cholecystectomy highlights the importance of exploration of the abdomen as a Pandora's Box and histopathological examination to rule out rare malignant pathology [Figure 2] and [Figure 3]. Appendectomy alone is the standard treatment for mucocele, but a mucinous neoplasm even confined to appendix requires a right hemicolectomy also.,
Carcinoid tumor [Figure 4] was diagnosed in 2 (0.6%) cases, and adenocarcinoma (nonmucinous type) was also reported in 1 (0.3%) case, this is consistent with figures from previous studies., Carcinoids are typically small, firm, circumscribed yellowish lesions and can produce appendicitis either by luminal obstruction or by releasing vasoactive inflammatory mediators such as five hydroxytryptamine, histamine, and kinin. Carcinoid syndrome was not observed in the patient in this study and the diagnosis was made after appendectomy and histological examination. Tumors of <1 cm are managed by appendectomy alone, but right hemicolectomy may be required for larger tumors.,,
Primary adenocarcinoma of the appendix is an extraordinarily rare but aggressive tumor with high frequency of ovarian metastasis for which bilateral oophorectomy has to be done. The treatment of choice is oncologic resection with right hemicolectomy.,
| Conclusion|| |
We conclude that although obstruction of appendiceal lumen due to fecaliths and lymphoid hyperplasia are the usual causes of acute appendicitis, sometimes unusual factors such as parasitic infestation and benign or malignant tumors may also be the cause of appendicitis. The presence of these would alter the further course of management.
This supports the fact that use of routine histopathologic examination although the specimen is macroscopically normal and is necessary because histopathology remains the gold standard method for confirming the primary diagnosis of acute appendicitis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Collins DC. 71,000 Human appendix specimens. A final report, summarizing forty years' study. Am J Proctol 1963;14:265-81.
Gough IR. A study of diagnostic accuracy in suspected acute appendicitis. Aust N
Z J Surg 1988;58:555-9.
Turner JR. The Gastrointestinal tract, In: Kumar V, Abbas A, Fausto N
(eds). Robins and Cotran Pathologic basis of disease. 8th
edn. Saunders: Philadelphia; 2010. p. 870-1.
Duzgan AP, Moran M, Uzun S, Ozmen MM, Ozer VM, Seckin S. et al
. Unusual findings in appendectomy specimens: Evaluation of 2458 cases and review of the literature. Indian J Surg 2004;66:221-6.
Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: Association with age and sex of the patient and with appendicectomy rate. Eur J Surg 1992;158:37-41.
Paydar S, Javidi Parsijani P, Akbarzadeh A, Manafi A, Ghaffarpasand F, Abbasi HR, et al.
Short-term outcome of open appendectomy in Southern Iran: A single center experience. Bull Emerg Trauma 2013;1:123-6.
Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA 1996;276:1589-94.
Campbell JP, Gunn AA. Plain abdominal radiographs and acute abdominal pain. Br J Surg 1988;75:554-6.
Brazaitis MP, Dachman AH. The radiologic evaluation of acute abdominal pain of intestinal origin. A clinical approach. Med Clin North Am 1993;77:939-61.
Wade DS, Marrow SE, Balsara ZN, Burkhard TK, Goff WB. Accuracy of ultrasound in the diagnosis of acute appendicitis compared with the surgeon's clinical impression. Arch Surg 1993;128:1039-44.
Ng KC, Lai SW. Clinical analysis of the related factors in acute appendicitis. Yale J Biol Med 2002;75:41-5.
Ricci MA, Trevisani MF, Beck WC. Acute appendicitis. A 5-year review. Am Surg 1991;57:301-5.
Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass – Is it necessary? Surgeon 2007;5:45-50.
Ahmed I, Asgeirsson KS, Beckingham IJ, Lobo DN. The position of the vermiform appendix at laparoscopy. Surg Radiol Anat 2007;29:165-8.
Blair NP, Bugis SP, Turner LJ, MacLeod MM. Review of the pathologic diagnoses of 2,216 appendectomy specimens. Am J Surg 1993;165:618-20.
Bergeron E, Richer B, Gharib R, Giard A. Appendicitis is a place for clinical judgement. Am J Surg 1999;177:460-2.
Hawthorn IE. Abdominal pain as a cause of acute admission to hospital. J R Coll Surg Edinb 1992;37:389-93.
Kumar V, Abbas AK, Fausto N, Mitchell RN. The oral cavity and gastrointestinal tract. In: Kumar V, Abbas AK, Fausto N, Mitchell RN, editors. Robbins Basic Pathology. 8th
ed. Philadelphia: Elsevier Inc.; 2007. p. 579-630.
Machado NO, Chopra P, Pande G. Appendiceal tumour – Retrospective clinicopathological analysis. Trop Gastroenterol 2004;25:36-9.
Bucher P, Mathe Z, Demirag A, Morel P. Appendix tumors in the era of laparoscopic appendectomy. Surg Endosc 2004;18:1063-6.
Cortina R, McCormick J, Kolm P, Perry RR. Management and prognosis of adenocarcinoma of the appendix. Dis Colon Rectum 1995;38:848-52.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]