Incidental appendiceal mass as the only manifestation of endometriosis

Appendiceal endometriosis is a rare condition that remains difficult to diagnose preoperatively. Herein, we present a case of appendiceal endometriosis presenting as a neuroendocrine tumor. A 34-year-old Caucasian woman was found to have an appendiceal mass with a small fluid collection on routine transvaginal ultrasound. The patient denied any symptoms. Features were consistent with those of a neuroendocrine tumour of the appendix. Laparoscopic appendectomy followed by histopathology revealed endometriosis with negative cytology for malignant cells. Preoperative characteristics of appendiceal tumours in women of childbearing age should be further investigated. Establishing clinical and surgical guidelines is the key to avoid invasive procedures and related adverse outcomes.

Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis

Background Appendiceal mass and abscess and its treatment are associated with significant morbidity and high costs. Still, the optimal treatment strategy is the point of debate. Therefore, this systematic review and meta-analysis aimed to compare overall complications between initial non-operative treatment (NOT) and early appendectomy (EA) in children with appendiceal mass and/or abscess. Methods Pubmed and Embase were searched. Only randomized controlled trials and prospective or historical cohort studies that compared NOT with EA in children with appendiceal mass or abscess in terms of complications were eligible for inclusion. Risk of bias was assessed. Primary outcome was the overall complication rate. Secondary, length of stay and readmission rate were investigated. A meta-analysis of overall complications associated with both treatment strategies was performed. Results 14 of 7083 screened studies were selected, including 1022 children in the NOT group and 333 in the EA group. Duration of follow-up ranged between four weeks and 12 years. Risk of bias was moderate in four and serious in 10 studies. NOT was associated with a lower overall complication rate (risk ratio (RR) 0.37 [95% confidence interval (CI) 0.21–0.65]). However, NOT led to increased length of stay (mean difference varied between 0.2 and 8.4 days) and higher readmission rate (RR 1.75 [95%CI 0.79–3.89]), although not significantly. Interval appendectomy after NOT was performed as a routine procedure in all but one study. This study found a recurrence rate of 34% in a group of 38 patients during a follow-up period of 3.4 ± 1.7 years. Conclusion NOT may reduce the overall complication rate compared to EA, but the evidence is very uncertain. As evidence is scarce, and of low level, and heterogeneity between studies is substantial, the results should be interpreted with caution. Large prospective studies are needed to determine the optimal treatment strategy for children with appendiceal mass and/or abscess.

Appendiceal Endometriosis Presenting as Possible Cecal Mass

Background Endometriosis is endometrial tissue located outside of the uterus. Endometriosis is rarely found in the appendix and can present very similar to acute appendicitis and is often indistinguishable on physical exam and imaging. The diagnosis is typically made after an appendectomy on pathology. Case Summary A 45-year-old female presented with right sided abdominal pain and CT revealed a possible cecal or appendiceal lesion. Colonoscopy revealed a submucosal non-obstructing cecal mass. In the operating room, the appendix was completely adherent to the cecum and a laparoscopic ileocecectomy was performed. Pathology revealed endometriosis of the appendix and cecum. Discussion Endometriosis of the appendix is a rare condition reported in less than 1% of females that is diagnosed after an appendectomy is performed for suspected appendicitis or other pathology. This diagnosis is made based on the finding of endometrial glands and stroma in the appendix. This can present as acute appendicitis or appendiceal or peri-appendiceal mass on imaging. When symptomatic, pain can align with the menstrual cycle and hemoperitoneum may be encountered intra-operatively. Treatment can be appendectomy, ileocecectomy, or right hemicolectomy if malignancy is suspected. In the patient we described, an ileocecectomy was performed with the intention of converting to a right hemicolectomy if the frozen section pathology had revealed malignancy. This case illustrates the importance of having a broad differential when diagnosing patients with abdominal pain, especially in women of childbearing age. Conclusion Appendiceal endometriosis should be considered in females of childbearing age with abdominal pain or cecal/appendiceal mass on imaging.

Appendiceal malakoplakia masquerading as a cecal mass

Appendiceal malakoplakia masquerading as a cecal mass is uniquely rare. The presence of an infiltrate of granular eosinophilic macrophages containing Michaelis–Gutmann bodies on histopathology is pathognomonic of malakoplakia. Cutaneous, gastrointestinal and most commonly urogenital malakoplakia is reported in association with an immunocompromised state, infectious, inflammatory and neoplastic processes. Presentation varies from microscopic disease to plaques, nodules, polypoid lesions and small masses. However, a cecal mass postea proven appendiceal malakoplakia deserves special attention. We could not find similar case reports in the English literature. The pathogenesis of malakoplakia is poorly understood, and it is unclear if it is a harbinger of malignancy, a precursor lesion or an inflammatory marker. In the setting of a dominant appendiceal mass, post-treatment endoscopic and tumor marker surveillance is paramount but, however, undefined in contemporary literature.

Giant Appendicolith: A Case Report and Review of the Literature

Acute appendicitis is one of the most prevalent causes of an acute abdomen. Although the cause of appendicitis is not completely understood, the theory of luminal obstruction is a popular belief, with appendicoliths being a common etiology. While appendicoliths are quite common, giant appendicoliths >2 cm are rare. Although previous reports cite only two or three other occurrences of giant appendicoliths, we found at least 11 reported cases in the literature. We present a young male diagnosed preoperatively on computed tomography to have a large appendiceal mass of 2.2 cm. This case is presented for the rarity of giant appendicoliths along with a review of the literature.

The effectiveness and appropriateness of Interval Laparoscopic Appendectomy on adult appendiceal mass, a retrospective cohort

Background: Appendiceal mass sometimes requires extended resection and difficult to treat postoperative complications. Interval appendectomy has been performed mainly in the field of pediatric surgery to avoid them. Recently, there are a few reports on interval laparoscopic appendectomy (ILA). We examined not only the safety and effectiveness of ILA for adult appendiceal mass (AAM), but also the appropriateness of ILA for which cases should be treated non-surgically for ILA or converted to surgical treatment. Methods: Among 956 appendectomies performed between April 2012 and March 2018, there were 49 cases of AAM, of which 34 cases underwent ILA; ILA group. The safety and efficacy of ILA were examined by comparing with 477 cases of adult uncomplicated appendicitis underwent laparoscopic appendectomy (LA); LA group. The appropriateness of ILA was examined by comparing with the remaining 15 cases of AAM; non-ILA group. Results: The ILA group had a longer operation time than the LA group, but the postoperative hospital stay was shorter, and no significant difference were found in the bleeding volume, the days required for oral intake of solid food, and the perioperative complications. Examining the factors for failure of non-surgical treatment or relapse of inflammation during interval period, higher WBC day3 / day0 was found to be an independent risk factor. Conclusion: ILA against AAM was almost as safe and effective as LA for adult uncomplicated appendicitis. WBC day3 / day0 may be effective as an objective parameter for judging the termination of non-surgical treatment for ILA. This determination to convert ineffective non-surgical treatment to surgical treatment earlier may reduce the burden on the patient.