|Year : 2017 | Volume
| Issue : 1 | Page : 13-16
Incidental appendectomy after esophageal bypass for treatment of dysphagia
SA Edaigbini1, M O A Samaila2, AA Liman2, WD Garba2
1 Division of Cardiothoracic Surgery, Ahmadu Bello University, Zaria, Nigeria
2 Department of Pathology, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||4-Apr-2018|
Dr. S A Edaigbini
Division of Cardiothoracic Surgery, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Background: The lifetime risk of acute appendicitis is 7-14%. Incidental appendectomy is defined as the removal of a clinically normal appendix during non-appendiceal surgery. Guidelines have tried to determine candidates for incidental appendectomy, but the practice continues to attract controversies. This paper presents our observation after appendectomy performed during oesophageal bypass/replacement procedures for treatment of dysphagia.
Patients and Method: The histology results of all who underwent oesophageal bypass/replacement patients for the treatment of dysphagia was trace from the patient's hospital records and histopathology register.
Results: A total of 28 patients underwent oesophageal bypass /replacement procedure between 2008 – 2015, during which 25 had incidental appendectomy. We were able to retrieve the histology of only 7 patients (3 males and 4 females). Of these, one male had a normal appendix another had lymphoid hyperplasia. Four patients had acute recurrent appendicitis (3 females with corrosive stricture and one male with HIV associated inflammatory stricture).
Conclusions: There is a high incidence of incidental appendicitis in patients with dysphagia justifying the need for incidental appendectomy as prophylaxis against future exploration which may put the conduit in harm's way.
Keywords: Appendicitis, incidental appendectomy, oesophageal bypass
|How to cite this article:|
Edaigbini S A, Samaila M O, Liman A A, Garba W D. Incidental appendectomy after esophageal bypass for treatment of dysphagia. Arch Int Surg 2017;7:13-6
|How to cite this URL:|
Edaigbini S A, Samaila M O, Liman A A, Garba W D. Incidental appendectomy after esophageal bypass for treatment of dysphagia. Arch Int Surg [serial online] 2017 [cited 2021 May 15];7:13-6. Available from: https://www.archintsurg.org/text.asp?2017/7/1/13/229183
| Introduction|| |
Incidental appendectomy is defined as the removal of a clinically normal appendix during nonappendiceal surgery. In the United States, the lifetime risk of appendicitis in males was put at 8.6% and 6.7% in women while 2.9% of men and 16% of women were expected to undergo incidental appendectomy. A higher incidence or risk appendicitis of 7–14% was; however, reported by Flum D. R. in the New England Journal of Medicine and Humes D.J. and Simpson J in the British Medical Journal., While the actual incidence is unknown in Nigeria, Duduyemi notes that the annual incidence varies between 22.1 and 49.8 new cases in different centers across the country., Alatise reported that acute appendicitis constitutes 15–40% of all surgical emergencies in most centers in the country. A study from the northern part of the country by Ahmed et al. puts the annual incidence to be about 2.6 per 100,000 population. In the index institution, Ahmed et al. reported a clinical diagnosis of acute appendicitis amongst 3717 patients admitted for abdominal surgical emergencies over a 5-year period with appendectomy constituting the major indication for surgery (50%). In most of these local studies no mention was made of incidental appendectomy except that by Njeze et al. Guidelines have tried to determine candidates for incidental appendectomy, but the practice continues to attract controversies.,,,,
This paper presents our observation after appendectomy performed during esophageal bypass/replacement procedures for treatment of dysphagia.
| Patients and Method|| |
This work was a product of the collaboration between the authors from two departments (Pathology and Surgery) of ABU Teaching Hospital Zaria, Nigeria. The histology results of all who underwent esophageal bypass/replacement surgery for the treatment of dysphagia was traced from the patients' hospital records and histopathology register. We routinely performed incidental appendectomy for all patients in whom the colon [Figure 1] was used as a replacement conduit after esophagectomy for carcinoma of the esophagus or after esophageal bypass for benign conditions in which the native esophagus is left in-situ and the neoesophagus (conduit) is tunnelled usually retrosternally through the anterior mediastinum.
|Figure 1: Mobilized left colon during oesophageal bypass for corrosive oesophageal stricture|
Click here to view
| Results|| |
A total of 28 patients underwent esophageal bypass/replacement procedure between 2008 and 2015, during which 25 had incidental appendectomy [Figure 2]. We could retrieve the histology of only seven patients (three males and four females). Of these, one male had a normal appendix another had lymphoid hyperplasia. While, five patients had acute recurrent appendicitis (four females with corrosive stricture and one male with HIV-associated inflammatory stricture [Figure 3], [Figure 4] and [Table 1].
|Figure 2: Total number of patients operated and the result of available histology|
Click here to view
|Figure 4: Recurrent acute appendicitis showing prominent lymphoid aggregates (Black Arrow –Right) and fibrosed mucosa( Black X - Left) - H and E stain, Mag ×10|
Click here to view
|Table 1: Available histology and the corresponding sex distribution of the patients|
Click here to view
| Discussion|| |
Esophageal bypass or replacement surgery is indicated when less aggressive techniques for restoration of normal swallowing are not feasible. These alternatives include esophageal dilatation, or resection of lesions with end-to-end esophageal anastomosis. The replacement or bypass procedure requires the use of conduits such as the patient's stomach or colon attached to a vascular pedicle [Figure 1]. These conduits are often laid in the midline, passed either through the anterior or posterior mediastinum to reach the proximal anastomosis (with the esophagus) in the thorax or the neck. This midline position of the conduit puts it in harm's way in future exploration and therefore forms the basis for our performance of incidental appendectomy during esophageal replacement or bypass surgeries. The high rate of emergency appendectomy and particularly complicated appendicitis in our subregion and in the index institution as reported by Ahmed et al. lends credence to this principle. This is even more so if future emergency exploration is undertaken by a different surgeon who is unaware of the “peculiar” position of the “neoesophagus” (conduit). Ahmad and Ahmad corroborating this view pointed in addition, that proponents of incidental appendectomy cited the technical ease and low morbidity of the procedure, no additional risk of anesthesia, high incidence of disease found in specimen, and elimination of confusion in future conflicting diagnosis. Also, the cost benefit of two operations in one setting is a major factor for recommending incidental appendectomy in low income population settings. Though only seven histology results of the 25 incidental appendectomy done could be retrieved, of these, five were pathological; giving a high incidence of 71.4% (five of seven). If the pathological appendix (5) is matched with the total incidental appendectomy in our study (25), it still gives a rate (20%) higher than the average life-time risk published in western literatures.,,, This may however not be a true reflection of the lifetime risk which would require a cross-sectional population based study for certainty. This brings us to the point that there is dearth of literature regarding incidental appendectomy and the pathological patterns observed in our locality. The study by Njeze et al., observed normal appendices for all 56 incidental appendectomy out of 152 appendectomies done. This study however, did not state the indications for the incidental as well all the 152 appendectomies that were done. Thus, comparing our findings with that of Njeze leaves one to wonder “is there a relationship between dysphagia and appendicitis?” Our literature search did not reveal any previous studies associating a higher risk of appendicitis with dysphagia. However, Kao et al. in a population-based case controlled study of 7,113 patients with appendicitis matched against 28,452 patients without appendicitis found a higher than normal incidence of prior gastroesophageal reflux disease (GERD). The reasons for this relationship was attributed to the occurrence of autonomic imbalance in these subsets of patients, dietary habits, and bacteria proliferation from the prolonged use of proton pump inhibitors (PPI) in patients with GERD. The only possible explanation if there is indeed a relationship between dysphagia and appendicitis would be related to altered immunity as a result of the malnutrition in these patients. While the appendix has been associated with the probability of conferring immunity as a result of increased incidence of colon cancer following excision, there is no documented evidence to the converse, that is, that a depressed immunity, predisposes to increased incidence of appendicitis. It is also possible that relative dehydration in this patients can lead to increased fecolith formation. Also, increased susceptibility to infection from the stasis above the obstruction, and chest infection from recurrent aspiration of regurgitated feeds, may have some role in this regard. These assertions however, require a more elaborate and well-structured research as that conducted by Kao et al. if it must be accorded greater merit. We regret the small number of analyzed specimen (7) relative to the total number of incidental appendectomy that was done. This attrition may be related to institutional challenges with record keeping or more likely the failure of the specimen to get to the histopathology laboratory due financial constraint on the part of the patient who may not appreciate the importance of this procedure despite adequate counselling.
| Conclusions|| |
There is a higher than normal incidence of appendicitis in patients with dysphagia justifying the need for incidental appendectomy as prophylaxis against future exploration which may put the conduit in harm's way. However, a more elaborate structured research is required to find out if there is any causal relationship between these entities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Addis DG, Shaffer N, Fowler BS, Tauxe RV. The Epidemiology of Appendicitis and Appendicectomy in the United States. Am J Epidemiol 1990;132:910-25.
Flum DR. Acute appendicitis - Appendectomy or the “antibiotics first” strategy. N
Engl J Med 2015;372:1937-43.
Humes DJ, Simpson J. Acute appendicitis. BMJ 2006;333:530-4.
Ahmed SA, Makama JG, Mohammed U, Sanda RB, Shehu SM, Ameh EA. Epidemiology of Appendicitis in Northern Nigeria; A 10-year Review. Sub-Saharan Afr J Med 2014;1:185-90. [Full text]
Duduyemi BM. Clinicopathological review of surgically removed appendix in Central Nigeria. AJM 2015;15:207-11.
Alatise OI, Ogunweide T. Acute Appendicitis: Incidence and Management in Nigeria. IFEMED Journal 2008;14:66-70.
Ahmed A, Dauda M, Garba S, Ukwenya Y. Emergency Abdominal Surgery in Zaria, Nigeria. SAJS 2010;48:59-62.
Njeze GE, Nzegwu MA, Agu KA, Ugochukwu AI, Amu C. A Descriptive Retrospective Review of 152 Appendectomies in Enugu Nigeria from January 2001-2009. Adv Biores 2011;2:124-6.
Ahmad M, Ahmad M. Incidental Appendectomy. Benefits at the Time of Total Abdominal Hysterectomy. Professional Med J 2012;19:647-51.
Song JY, Yordan E, Rotman C. Incidental Appendectomy During Endoscopic Surgery. JSLS 2009;13:376-83.
Fisher KS, Ross DS. Guidelines for therapeutic decision in incidental appendectomy. Surg Gynecol Obstet 1990;171:95-8.
Nockerts SR, Detmer DE, Fryback DG. Incidental appendectomy in the elderly? No. Surgery 1980;88:301-6.
Snyder TE, Selanders JR. Incidental appendectomy--yes or no? A retrospective case study and review of the literature. Infect Dis Obstet Gynecol 1998;6:30-7.
Kao LT, Tsai MC, Lin HC, Lee CZ. Association between Gastroesophageal Reflux Disease and Appendicitis: A Population-Based Case-Control Study. Sci Rep 2016;6:22430.
Wu SC, Chen WT, Muo CH, Ke TW, Fang CW, Sung FC. Association between Appendectomy and Subsequent Colorectal Cancer Development: An Asian Population Study. PLoS One 2015;10:e0118411.
Lamps LW. Beyond acute inflammation: A review of appendicitis and infections of the appendix. Diagn Histopathol 2008;14:68-77.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]