3. DISCUSSION :
Stump appendicitis is one of the rare delayed complications of
appendectomy first described in 2 patients by Rose in 1945. The
incidence of stump appendicitis is about 1 in 50 000 cases even though
the real incidence is probably higher due to underestimating of this
entity. A modern review found 160 cases reported in surgical literature
[2].
Stump appendicitis can occur in patients after both laparoscopic and
open appendectomy, the interval between initial appendectomy and repeat
presentation ranging from 4 days to 50 years [3–5] (10 months for
our patient).
Many risk factors are reported in the litterature : at least
theoretically, there is the potential for an increased incidence of
stump appendicitis in laparoscopic surgery due to the lack of a
3-dimensional perspective, and the absence of tactile feedback [5].
However, a review of the literature by Subraman et al. showed more cases
occurred after open appendectomy, implying that the laparoscopic
technique may not be a major factor [6]. Remnant appendix tissue
> 5 mm in length and retrocecal position are also risk
factors for fecalitis and stump appendicitis [7].
The presenting symptoms of stump appendicitis are basically
indistinguishable from those of primary appendicitis. They include pain
that starts periumbilically and wanders to the right lower quadrant and
is associated with anorexia, nausea, and vomiting [5,8], but no sign
is specific. History of appendectomy and non-specificity of clinical
signs may confuse diagnosis and delay management.
The CT findings of stump appendicitis may not be entirely specific and
include cecal wall thickening, free or loculated fluid in the right
paracolic gutter, and infiltration of the surrounding fat. If the
remnant stump is of sufficient length, it might be visualized as a
tubular, thick-walled, fluid-filled, enhancing structure with or without
an adjacent fluid collection, much like typical acute appendicitis
(before initial appendectomy) [2,9]. In the era of laparoscopy a
diagnostic laparoscopy may prove to be the next diagnostic and
therapeutic option in case of ambiguity [10,11]. However some
authors suggest that abdominal Ultra-sound may well have a high accuracy
in establishing the diagnosis of stump appendicitis [4].
Surgical resection seems to be the treatment of choice in the reported
cases. The choice of either laparotomy or laparoscopy depends on various
factors like the patient’s clinical condition and the local expertise
and resources [5,12]. A more extensive operation should generally
not be required as long as the appendiceal stump can be readily
identified and the cecum itself does not show evidence of a significant
amount of inflammation. Some authors suggest an appendiceal critical
view similar to that described for cholecystectomy [6].