Right hemicolectomy does not confer a survival advantage in patients with mucinous carcinoma of the appendix and peritoneal seeding

BACKGROUND: Traditionally epithelial malignancies of the appendix with or without carcinomatosis have been treated by right hemicolectomy. Recent accumulation of a large number of patients with this disease has enabled a re-evaluation of this surgical judgement. METHODS: Clinical data on 501 patients with epithelial malignancy of the appendix were collected prospectively. All patients had peritoneal seeding at the time of referral and were treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy. The main independent variable for statistical analysis was the surgical procedure used to resect the primary cancer (appendicectomy alone versus right hemicolectomy). Nineteen other clinical and pathological variables were considered as control variables. The endpoint for all analyses was survival. RESULTS: Median follow-up after the initial diagnosis was 4 years. The rate of regional lymph node positivity was 5.0 per cent. When the incidence of lymph node metastasis was determined by histological type, it was statistically significantly higher in intestinal (66.7 per cent) than in mucinous (4.2 per cent) tumours (P < 0.001). The presence of lymph node metastases had no influence on prognosis (P = 0.155). The surgical procedure (appendicectomy alone versus right hemicolectomy) had an influence on patient survival by univariate analysis (P < 0.001), but not by multivariate analysis (P = 0.258). CONCLUSION: Right hemicolectomy does not confer a survival advantage in patients with mucinous appendiceal tumours with peritoneal seeding. These data suggest that right hemicolectomy should be avoided unless metastatic involvement of the appendiceal or distal ileocolic lymph nodes is documented by biopsy, or the resection margin is inadequate.     

Carcinoid tumour of the appendix: problems of diagnosis and treatment

Carcinoids (neuroendocrine tumours) are considered the most common primary appendiceal neoplasm. Primary appendiceal tumours are uncommon. Routine histopathological examination of appendicectomy specimens is justified given the not infrequent incidental finding of appendiceal tumours. In cases of appendicitis in the elderly, the index of suspicion for epithelial tumours of the appendix should be raised. Moreover, once the diagnosis of an adenomatous lesion is made, colonoscopic examination of the entire large bowel is mandatory given the frequency of synchronous colorectal neoplasia in our population. In our study, we review 3 cases of carcinoid tumor of the appendix and describe their presentation, treatment and outcome. They are often diagnosed incidentally after histopathological examination of the vermiform appendix submitted in the course of the management of another clinical diagnosis. Appendectomy is appropriate for lesions < 1 cm but for lesions over 2 cm in diameter there is a significant increase in metastatic spread and thus right hemicolectomy is required in such cases. Appendiceal carcinoid tumours are found in 0,3 - 0,9 per cent of patients undergoing appendicectomy. Controversy exists over the management following appendicectomy, especially with regard to the role of right hemicolectomy in patients with tumours smaller than 2 cm in diameter.     

Carcinoid tumour of the appendix

BACKGROUND: Appendiceal carcinoid tumours are found in 0.3-0.9 per cent of patients undergoing appendicectomy. Controversy exists over the management following appendicectomy, especially with regard to the role of right hemicolectomy in patients with tumours smaller than 2 cm in diameter. METHODS AND RESULTS: The literature pertaining to the behaviour of appendiceal carcinoids was reviewed in order to formulate indications for right hemicolectomy. Metastatic disease from appendiceal carcinoids is a rare occurrence, but is more common when lesions are larger than 2 cm in diameter. The risk-benefit balance of right hemicolectomy needs to be better defined, and an improved understanding of tumour cell biology may aid prognostic accuracy and decision-making. CONCLUSION: There is limited evidence on which to base clear indications for right hemicolectomy in patients with a diagnosis of appendiceal carcinoid. Acceptable indications are carcinoids larger than 2 cm in size, any high-grade malignant carcinoid (including those with a high mitotic index), mesoappendiceal invasion, lesions at the base of the appendix with tumour-positive margins, and goblet cell adenocarcinoid tumours.     

Surgical attitude towards carcinoid tumour of the appendix. Review of the literature

Carcinoid tumours of the gastrointestinal tract are most frequently located at the appendix. We report two cases: In the first case, we realized a simple appendicectomy. In the second case, two weeks after the appendicectomy was performed, according to the histological characteristics of the tumoral specimen, the patient underwent a laparoscopic right hemicolectomy with regional lymphadenectomy. In both cases, 5-HIAA (5 HydroxyIndolAceticAcid) is assayed regularly and remains normal.     

Surgical Attitude towards Carcinoid Tumour of the Appendix Review of the Literature

Carcinoid tumours of the gastrointestinal tract are most frequently located at the appendix. We report two cases: In the first case, we realized a simple appendicectomy.

In the second case, two weeks after the appendicectomy was performed, according to the histological characteristics of the tumoral specimen, the patient underwent a laparoscopic right hemicolectomy with regional lymphadenectomy. In both cases, 5-HIAA (5 HydroxyIndolAceticAcid) is assayed regularly and remains normal.     

Surgical management of primary appendiceal malignancy

Aim Primary appendiceal neoplasms are rare, with carcinoid being more common than carcinoma. Preoperative diagnosis is infrequent. We report a series of 24 primary appendiceal neoplasms treated over a 5‐year period. Method All primary appendiceal neoplasms diagnosed in a university teaching hospital between April 2003 and June 2008 were identified from the prospective histopathology database. Patient records were reviewed for clinical, operative and pathological data. Results Fourteen carcinomas and 10 carcinoids were identified in the 5‐year period. The former presented at median age 55.8 years with median symptom duration of 35 days, compared with 48 years and 3 days, respectively, for carcinoids. An abdominal mass was commoner in carcinomas (8/14 vs 1/10). Six patients with carcinoma underwent appendicectomy followed by completion right‐hemicolectomy, two of whom had residual disease; seven underwent primary right‐hemicolectomy and one had abscess drainage. Five patients with appendiceal carcinoma died of the disease during a median follow‐up of 633 (256–1158) days. Six patients underwent appendicectomy for acute appendicitis, one had a primary right‐hemicolectomy for a caecal mass. Three had a subsequent right‐hemicolectomy for a high‐risk carcinoid. An appendiceal carcinoid was an incidental finding in three right‐hemicolectomy specimens removed for other indications. No metastases or deaths were recorded at median follow‐up 451 (51–975) days. Conclusion Appendiceal carcinomas follow a more protracted clinical course than carcinoids, which usually present as acute appendicitis. Caution is needed when diagnosing simple appendicitis in older patients with longer symptom duration, particularly if a mass is present. Patients with appendiceal carcinoma should be offered completion right‐hemicolectomy. Carcinoma has a poor prognosis.     

Carcinoid tumor of the appendix. A not especially rare entity]

Carcinoid tumors arise from neuroendocrine system and one of their preferred sites is the appendix. Most of appendiceal carcinoids almost always are clinically silent and are incidentally found at histological examination. For this reason, histological examination of the appendix is recommended in every case of the appendicectomy. Prognostic factors are: tumor stage, histologic pattern and differentiation. The authors present 6 cases of appendiceal carcinoid tumor, clinically silent and found at histologic examination (3 cases of appendicectomy for acute appendicitis, 3 cases of appendicectomy associated with abdominal surgical interventions for other pathology) and compare their experience with the most recent literature on this subject. The conclusion is drawn that the size of this tumor is the main factor that surgeons must consider for the choice of surgical treatment. Incidental, clinical silent, small (less than 2 cm in size) appendiceal carcinoid tumors can be treated by appendicectomy, and they do not need follow-up. Greater (more than 2 cm in size) appendiceal carcinoid tumors, in young patients must be treated with a right hemicolectomy and they need follow-up (periodically radiological, ultrasonographic and endoscopic examinations, tumor markers) because there is the possibility of recurrence or metastases.     

Clinicopathological features and the outcome of surgical management for adenocarcinoma of the appendix

AIM:To present a comprehensive analysis of incidence,clinicopathological features,appropriateness of surgical procedures,and survival for adenocarcinoma of the appendix.METHODS:A retrospective case analysis was conducted for the 10-year period 1998-2008.All patients diagnosed with adenocarcinoma of the appendix were analyzed for their demographics details,clinical features,tumor incidence and characteristics,tumor stage,surgical procedures performed,and their survival.RESULTS:Nine thousand three hundred and twentythree patients underwent appendectomies during the study period,and of these,10 (0.1%:8 men and 2 women with a mean age of 53.1 years,age range 21-83 years) were found to have primary adenocarcinoma of the appendix.Appendicular neoplasia was not suspected pre-operatively in any of the patients.Six (60%) patients underwent secondary right hemicolectomy.Four (40%) cases had appendectomy alone,and two of them died,whereas all those who underwent right hemicolectomy are alive and disease free.Five (50%) were reported to have grade 1 disease,three (30%) grade 2,and two (20%) grade 3 with mean survival of 34,48,and 22 mo,respectively.Six (60%) patients presented with advanced disease (Duke’s C and D).At the end of follow up (mean period:37.9 mo),eight patients are alive and disease free at the end of follow up.Overall mean survival was 36.3 mo (conf idence interval;16%-56%) with 41.3 and 16 mo for men and women,respectively.Mean survival for those with and without lymph node involvement was 33.6 and 40.2 mo,respectively.Right hemicolectomy gave better results than appendectomy alone,although the difference was not statistically signif icant due to the small number of cases.CONCLUSION:Adenocarcinoma of the appendix is extremely rare neoplasm with varied presentations,and is usually advanced when diagnosed.Right hemicolectomy is the treatment of choice for such tumors.     

Mucinous cystadenoma of the appendix

Mucinous neoplasms of the Appendix are rare conditions, usually diagnosed intraoperatively or postoperatively on the pathology report. They have an association with colonic and ovarian neoplasms, and spillage can result in pseudomyxoma peritonei. While appendicectomy is adequate treatment for cystadenomas, cystadenocarcinomas require a right hemicolectomy. Open approach is recommended for the surgical treatment of these lesions.     

Laparoscopic appendicectomy: a training model for laparoscopic right hemicolectomy?

OBJECTIVE: To analyse the outcome of laparoscopic appendicectomy and right hemicolectomy and see if the surgical approach to the former can be applied to the latter. METHOD: A prospective electronic laparoscopic database identified 330 appendicectomies and 78 right hemicolectomies (using this approach) between 1996 and 2005. RESULTS: Three hundred and thirty patients (188 males: median age 38 years, range 17-74 years) underwent laparoscopic appendicectomy; 270 (82%) were performed by trainees (higher surgical trainee 71%, basic surgical trainee 12%). The median operative time for trainees was 35 min (14-75 min) with a conversion rate 2%. There were no intra-operative complications. The postoperative complication rate excluding minor wound infection (5.5%) was 1.5%. There were no deaths. The median hospital stay was 2 days (1-15 days). The 30-day readmission rate was 1%. Seventy-eight patients (23-93 years) underwent laparoscopic right hemicolectomy during 2004/5; trainees performed parts thereof in the majority or all of the surgery in 25 cases. The median operation time was 55 min: trainees 115 (65-145 min). There was one conversion. The median hospital stay was 4 days (2-23 days) falling to 3 for the last 20 operations (1-8 days). There were two readmissions for wound sepsis and small bowel obstruction and three deaths (3.8%): anastomotic leak (one), C difficile infection leading to renal failure (one) and duodenal perforation (one). CONCLUSION: Laparoscopic appendicectomy is a safe, predictable, easily learnt operation and an ideal model for learning the skills and principles required for more advanced laparoscopic colorectal interventions and in particular, right hemicolectomy.     

Carcinoid of the appendix. A case report

A case of a young male operated on for acute appendicitis due to a carcinoid of the base is reported. Since the tumor was infiltrating the resection margin of the appendix, the patient was later treated with a right hemicolectomy. Carcinoid tumor is unusual, but can be encountered several times during the career of a surgeon (1/200-300 appendicectomy). The tumor is more frequent in women (2-4:1), located at the tip of the appendix (62-78%) and has a diameter less than 1 cm in 70-95% of cases. It is more frequently diagnosed incidentally after an operation for acute appendicitis and occasionally during other procedures (colectomy, cholecystectomy, salpingectomy). Liver metastases are rare (< 2%), related to the dimension of the primitive tumor (21-100% when > 2 cm) and can cause a "carcinoid syndrome": flush, diarrhea bronchoconstriction, cardiac valve disease. Diagnosis is made by the pathologist and staging by conventional radiologic procedures (TAC, US), dosage of neuroendocrine mediators such as 24 hours urinary 5-HIAA. Nowadays 111In-octreotide scintigraphy (SRS) has an 86% sensitivity to detect the carcinoid and is useful for staging and for planning a surgical intervention. Simple appendectomy is adequate treatment for appendiceal carcinoids less than 1 cm in diameter. Adequate treatment for tumors greater than 2 cm is right hemicolectomy. A point of controversy is what to do for tumors in the 1 to 2 cm range. It seems that appendectomy alone is sufficient except in those cases when mesoappendiceal invasion is identified. When surgical margins after appendectomy are not free of tumor, additional surgery seems warranted. Carcinoid tumor of the appendix has a good prognosis with a 5-year-survival rate, of 85.9-100%. When liver metastases are encountered octreotide can relieve symptoms and sometimes the progression of the disease.     

结肠癌侵犯十二指肠的手术方式探讨

目的探讨结肠癌侵犯十二指肠的手术方式,评估临床疗效。 方法回顾性分析第四军医大学附属西京医院2013年1月至2014年12月收治的结肠癌侵犯十二指肠患者共26例,结合患者不同的临床特点及手术方式进行生存分析。 结果根治性右半结肠切除术8例,根治性右半结肠切除术+十二指肠壁缺损间断全层缝合术10例,右半结肠切除、空肠十二指肠端侧吻合+空肠Roux-en-Y吻合、空肠营养管造瘘术4例,右半结肠切除、胰十二指肠切除术1例,根治性右半结肠切除、胃窦及球部切除、胃空肠吻合术1例,横结肠-回肠侧侧吻合术2例。术后除1例发生横结肠回肠吻合口瘘,未发生十二指肠瘘、胰瘘等严重并发症,12个月生存率84.6%,30个月生存率76.9%。 结论结肠癌侵犯十二指肠时,术前影像学评估、合理的手术方式选择和积极的外科处理将有助于减少术后并发症,提高临床疗效,改善预后。     

Conservative approach is feasible in the management of acute diverticulitis of the right colon

Background: Acute diverticulitis of the caecum and ascending colon is uncommon. Controversies abound as regards the optimal surgical treatment, ranging from appendectomy, diverticulectomy to right hemicolectomy. The aim of the present paper was to review treatment strategy followed by a critical appraisal. Methods: The case notes of 30 patients with acute diverticulitis of the right colon who were treated at the United Christian Hos­pital, Hong Kong from 1992 to 1998 were systematically reviewed. The data were subjected to statistical analysis. Results: The median age was 34 years, with a male:female ratio of 1:1.15. All patients presented with acute right lower abdominal pain and localized rebound tenderness. All were diagnosed preoperatively as having appendicitis. The mean duration of symptoms was 2 days (range: 1–6 days). Two treatment groups were identified. Group A (n = 16; 53%) received appendicectomy alone, while group B (n = 14; 47%) underwent diverticulectomy in addition to appendicectomy, including one patient with perforated diverticulitis. Overall, there was no procedure‐related morbidity or mortality. Both groups received a similar duration of broad‐spectrum anti­biotics. All the patients were interviewed by phone after operation to detect any recurrence of symptoms, with a median follow‐up interval of 34 months (range: 11–78 months). There was no recurrence of symptoms in group A, which received appendicectomy and antibiotics. The only difference was operative time. Conclusion: For non‐perforated diverticulitis of the right colon, appendicectomy and intravenous antibiotics without diverticulectomy is the preferred treatment strategy.     

Primary carcinoma of the appendix.

Primary adenocarcinoma of the appendix is rare and less than 200 cases are on record. The present material consisted of 20 cases collected from different hospitals. The cases are described in respect of sex and age-distribution, symptoms, treatment and prognosis. Of 7 patients with malignant mucocele, 6 subjected to appendectomy only, were still alive 5 years after the operation. Of 12 patients with colonic type of adenocarcinoma, 3 had been treated with appendectomy only. Of these, 2 were still alive 5 years after the operation. The remaining 9 patients had undergone right hemicolectomy. Only one of them was alive 5 years after the operation. A compilation of a further 39 cases garnered from the literature, however, showed that 60% had survived at least 5 years after right hemicolectomy, compared with 46% after appendectomy alone. Appendectomy alone is probably a sufficiently radical operation for malignant mucocele provided the tumor has not grown through the submucosa and that it is confined to the tip of the appendix. Right hemicolectomy is indicated for the colonic type of adenocarcinoma.     

Adenocarcinoma of the appendix. A multicenter study from AURC

Thirty-two patients with primary adenocarcinoma of the appendix were studied in this collective review. Diagnosis was never suspected preoperatively. Immediate operation was performed in 21 patients with a diagnosis of acute appendicitis. At operation, tumor of the appendix was only identified in 50 percent of the 32 patients. One patient with an obstructing tumor and peritoneal involvement died postoperatively. Estimated survival rate was 46% at five years. Probability of survival was unrelated to the histologic tumor type but significantly correlated with the extent of tumor spread. Right hemicolectomy led to a significant increase in survival compared with appendectomy alone and to a significant decrease in risk of recurrence. In Dukes' B2 and C patients, differences in the survival curves were in favor of right hemicolectomy. In patients with pseudomyxoma peritonei, long-term survival was obtained by repeated laparotomy with resection of mucinous material. Our results indicate that, in good risk patients, right hemicolectomy performed as first or second operation, provides better results than appendectomy alone.     

Inflammation of the residual appendix stump: a systematic review

Aim A systematic review of the literature was undertaken to examine reported cases of stump appendicitis (SA) to determine the relationship between SA and the original operative strategy (open vs laparoscopic), and to evaluate the clinical features and diagnosis. Method A Pub‐med search was conducted to identify cases of appendicitis of a residual stump following appendicectomy. Two original cases of SA following laparoscopic appendicectomy treated in our own hospitals are also included in the analysis. Sixty cases of SA reported in the English medical literature were analysed. Results The interval from the original appendicectomy ranged from 4 days to 50 years. SA followed appendicectomy in 58% of open and 31.6% of laparoscopic procedures. SA was frequently misdiagnosed as constipation or gastroenteritis, with a significant delay to surgery. Computerized tomography diagnosed SA in 46.6% of cases. Perforation with gangrene of the stump occurred in 40%. Conclusion Stump appendicitis is rare. It may complicate open or laparoscopic appendicectomy. A high level of suspicion should be maintained in any patient with right sided abdominal pain and a history of prior appendicectomy.     

Primary adenocarcinoma of the appendix presenting with fresh bleeding per rectum: A case report

IntroductionPrimary adenocarcinoma of appendix is a rarely diagnosed malignancy accounting for less than 6% of appendiceal neoplastic lesions and less than 0.5% of all gastrointestinal malignancies. It is mostly diagnosed as an incidental finding after appendicectomy.Case summaryAn 81 year old male patient presented with bleeding per rectum in a background of previous rectal polyp, hypertension, diabetes and hypothyroidism. CECT of whole abdomen findings revealed thickening at the appendix and base of the caecum. Colonoscopy showed a sessile polypoid growth at appendicular orifice, at the base of the caecum. Laparoscopy confirmed the clinical suspicion of appendicular carcinoma and laparoscopy assisted radical right hemicolectomy was performed. Final histopathology revealed well differentiated adenocarcinoma of the appendix with no lymph node involvement (pT3N0M0).DiscussionPatients with primary adenocarcinoma of the appendix present with features similar to acute appendicitis whereas anaemia or fresh bleeding per rectum is a rare presentation. Surgery is the mainstay of treatment, the extent of which will depend upon the stage. Tumours staged as T1 may be managed by appendicectomy alone provided the base is free and there are no lymphadenopathies. T2 or above require right hemicolectomy as chances of lymph node metastasis are high. Nodal involvement warrants the need for adjuvant chemotherapy. Distant metastasis to the peritoneum or liver and lungs is very rare.ConclusionWhile investigating unexplained anaemia or bleeding per rectum, full colonoscopic examination up to the appendicular orifice is important and if required, should be combined with CT scan of abdomen, to clinch the rare but possible and potentially curable diagnosis of appendicular carcinoma.     

Carcinoid tumours of the appendix

Appendicular carcinoid tumours in 147 patients are presented. Two patients had evidence of metastatic spread at the time of presentation. Both patients had primary tumours less than 2 cm in diameter. Size remains the most reliable guide to the malignant potential of these tumours. If, after simple appendicectomy, a carcinoid tumour is found with a post-formalin fixation diameter greater than 1.5 cm then a subsequent right hemicolectomy should be considered.     

腹腔镜右半结肠癌切除术后中长期随访分析研究

目的探讨影响腹腔镜右半结肠癌切除术后患者生存时间的因素。方法收集并回顾性分析2004年2月至2011年3月间北京大学第三医院普通外科经腹腔镜施行右半结肠癌切除术患者的病例资料和随访资料．运用Kaplan—Meier法计算生存率并进行单因素分析，利用Cox比例风险模型进行多因素分析。结果164例腹腔镜右半结肠癌切除术患者中，中转开腹12例（7-3％）。围手术期并发症发生率为18．9％（31／164）。中位随访时间为27（5～85）个月。全组5年总体生存率为81．5％。5年无瘤生存率为75．7％，5年肿瘤相关生存率为78．7％。单因素分析和多因素分析结果均显示．TNM分期及中转开腹对患者生存时间的影响有统计学意义（P〈0．05）。结论TNM分期及中转开腹是影响腹腔镜右半结肠癌切除术后患者生存时间的独立因素。     

腹腔镜右半结肠癌根治术177例临床分析

目的:探讨腹腔镜下右半结肠癌根治术的安全性及远期疗效。方法:回顾分析2002年2月至2009年3月间177例行腹腔镜下右半结肠癌D3根治术病人的临床资料,研究其手术安全性及近远期疗效。结果:本研究病人的平均手术时间(132.6±35.7)min,术中出血(94.2±34.1)mL,术后肠道排气时间、恢复流质饮食时间、术后住院天数分别为(2.13±0.74)d、(3.21±0.45)d、(10.35±2.72)d;平均切除标本长度(17.32±8.26)cm,淋巴结清扫数目(15±8)枚。中转开腹5例(2.82%),腹腔镜手助切除4例(2.26%)。并发症24例(13.56%)。术后随访39(12～97)个月,随访期内发现1例戳创孔肿瘤种植,局部复发5例(2.82%),远处转移7例(其中肺转移2例,肝转移4例,骨转移1例)。累计生存率、无病生存率及肿瘤相关生存率分别为83.69%、80.43%及83.14%。Dukes A期、B期、C期的5年生存率分别为93.23%、76.47%、66.67%。结论:腹腔镜右半结肠癌根治术是安全且符合肿瘤根治原则的,并能获得令人满意的近、远期疗效。