JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 7, Number 6, December 1997

Mary Ann Liebert, Inc.

Brief Clinical Report

Stump Appendicitis: A Case Report
VICTOR Z. ERZURUM, M.D.,1 KARTHIKESWHAR KASIRAJAN, M.D.,1 and
MASUD HASHMI, M.D., F.A.C.S.12

ABSTRACT

Residual appendicitis is a rare event that occurs when there is incomplete resection of the
organ. A recent report suggested that this may be a complication of laparoscopic surgery.1
Following a case of stump appendicitis in a young patient, we thoroughly reviewed the lit-
erature and found that most reported cases have occurred in open appendectomy. Aware-
ness of the existence of this uncommon condition will help in the early diagnosis and prompt
treatment of this pathology.

CASE REPORT

An 11-year-old girl presented with a 24-h history of right lower quadrant pain radiating to the lower back.
Her medical history included an open appendectomy 8 months prior. Physical examination found that the
child had a fever of 102.6°. Her abdomen was diffusely tender with rebound and guarding over the right
lower quadrant. Her white blood count was 19,000 with a significant left shift. Urinalysis and abdominal
radiograph showed no pathology. Computerized tomographic scan of the abdomen showed an inflamma-
tory mass in the right lower quadrant with the possible appendicular stump evident (Fig. 1). Emergency ex-
ploratory open laparotomy revealed a perforated 3.5-cm appendical stump and a retrocecal abscess, both of
which were removed and drained. The patient had an uneventful recovery and was discharged on day five.

DISCUSSION

Stump appendicitis is a rarely encountered condition that can occur when the appendix is not resected
at its base. There have been 16 cases recorded in the literature since the first description appeared in
1945.1_n The patients ranged in age from 11 to 53 years, with an average age of 37.6 years. The time
interval from original appendectomy to recurrent appendicitis ranged from 2 months to 21 years. Most
patients experienced a ruptured appendiceal stump at the time of surgery. The longest residual stump
length was 4.5 cm2 (Table 1).
It has been suggested that, with the increased use of laparoscopic appendectomy, there might be an in-

1
Department of Surgery, Western Reserve Care System, Youngstown, Ohio 44501.
2Northeastern Ohio Universities College of Medicine, Rootstown, Ohio 44272.

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 ERZURUM ET AL.

FIG. 1. Computerized tomographic scan of the abdomen showing an inflammatory mass in the right lower quadrant.
The arrowhead points to the stump of retained appendix.

crease in the incidence of stump appendicitis.1-3 With 11 of the 17 cases occurring after open procedures,
however, it is clear that stump appendicitis is not exclusive to laparoscopic appendectomy.5-11
In the past decade, the number of cases resulting from open and closed procedures was equal (n 5). =

Despite the increasing use of laparoscopy, most recent cases were open procedures. Thus, the inflamma-
tory changes associated with acute appendicitis may obscure the appendiceal anatomy during either proce-
dure. To prevent the recurrence of appendicitis, complete removal of the appendix is essential. This can be

Table 1. Cases of Stump Appendicitis Reported in the Literature

Age Primary
Study (years) Sex Stump (cm) Time past surgery

Milne and Bradbury (1996)1 25 Male 3.2 18 months Laparoscopic

Wright and Diaco (1994)2 35 Male 4.5 2 months Laparoscopic
Wright and Diaco (1994)2 48 Male 4.0 8 months Laparoscopic
Devereaux et al. (1994)3 49 Male 2.0 9 weeks Laparoscopic
Feigen et al. (1994)4 26 Male Not reported 1 year Laparoscopic
Rose (1945)5 23 Male 5.1 1 year Open
Rose (1945)s 40 Male 5.1 2 years Open
Baumgardner (1948)6 55 Male None found 3 months Open
Seigel (1954)7 51 Female 1.3 14 years Open
Greene et al. (1958)8 27 Female Not reported 13 years Open
Greene et al. (1958)8 42 Female Not reported 16 years Open
Greene et al. (1958)8 53 Female Not reported 20 years Open
Harris (1989)9 26 Male Not reported 10 years Open
Thomas et al. (1994)10 53 Female 1.5 21 years Open
Sommerville and Lavelle (1996)11 Unknown Unknown Not reported Not reported Open
Sommerville and Lavelle (1996)11 Unknown Unknown Not reported Not reported Open
Erzurum et al. (this study) 11 Female 3.5 8 months Open

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 STUMP APPENDICITIS

accomplished either by dissecting and ligating the recurrent appendiceal artery as a marker of the appen-
diceal base, as recommended by Greene,8 or by following the taenia coli of the cecum down to the appen-
dix, as recommended by Wright.2
The exact preoperative diagnosis of stump appendicitis can be extremely difficult. In the nine cases re-
ported during this decade, only six discussed the diagnostic approach for identifying the pathology. Three
diagnoses were made by lower gastrointestinal study, diagnostic laparoscopy, and during exploratory lap-
arotomy.2j* Three cases, including this report, were diagnosed with computerized tomographic scan.210 We
found the scan helpful in making the early preoperative diagnosis and allowing operative treatment to be
limited to stump appendectomy. It is concluded that any patient who has undergone appendectomy, open
or laparoscopic, and presents with symptoms similar to appendicitis should be evaluated for residual ap-

pendicitis.

REFERENCES

1. Milne AA, Bradbury AW: "Residual" appendicitis following incomplete laparoscopic appendicectomy. Br J Surg
1996;83:217.
2. Wright TE, Diaco JF: Recurrent appendicitis after laparoscopic appendectomy. Int Surg 1994;79:251-252.
3. Devereaux DA, McDermott JP, Caushaj PF: Recurrent appendicitis following laparoscopic appendectomy. Dis
Colon Rectum 1994;37:719-720.
4. Feigin E, Carmon M, Szold A, Seror D: Acute stump appendicitis. Lancet 1993;341:757.
5. Rose TF: Recurrent appendiceal abscess. Med J Aust 1945;32:659-662.
6. Baumgardner LO: Rupture of appendiceal stump three months after uneventful appendectomy with repair and re-
covery. Ohio State Med J 1949;45:476-477.
7. Siegel SA: Appendiceal stump abscess: A report of stump abscess twenty-three years post appendectomy. Am J
Surg 1954;88:630-632.
8. Greene JM, Peckler D, Schumer W, Greene El: Incomplete surgical removal of the appendix: Its complications. J
Int Coll Surg 1958;29:141-146.
9. Harris CR: Appendiceal stump abscess ten years after appendectomy. Am J Emerg Med 1989;7(4):411—412.
10. Thomas SE, Denning DA, Cummings MH: Delayed pathology of the appendiceal stump: A case report of stump
appendicitis and review. Am Surg 1994;60:842-844.
11. Somerville PG, Lavelle MA: "Residual" appendicitis following incomplete laparoscopic appendicectomy. Br J Surg
1996;83:869.

Address reprint requests to:

Victor Erzurum, M.D.
Research Department
Western Reserve Care System
500 Gypsy Lane
Youngstown, OH 44501

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This article has been cited by:

1. Bryan M. Burt, Patrick J. Javid, Stephen J. Ferzoco. 2005. Stump Appendicitis in a Patient with Prior Appendectomy.
Digestive Diseases and Sciences 50:11, 2163-2164. [CrossRef]
2. Brian P Watkins, Shanu N Kothari, Jeffrey Landercasper. 2004. Stump Appendicitis. Surgical Laparoscopy, Endoscopy &
Percutaneous Techniques 167-171. [CrossRef]
3. Rafik Shalaby, Abdo Arnos, Ahmed Desoky, Abdel-Hady Samaha. 2001. Surgical Laparoscopy, Endoscopy & Percutaneous
Techniques 11:1, 22-27. [CrossRef]
4. Rafik Shalaby, Abdo Arnos, Ahmed Desoky, Abdel-Hady Samaha. 2001. Laparoscopic Appendectomy in Children:
Evaluation of Different Techniques. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 11:1, 22-27. [CrossRef]