Appendix

Question 1

In the OR for lap appy for suspected acute appendicitis. Appendix is completely normal. What do you do?

Answer 1

• Evaluate the remaining abdomen and pelvis to looks for etiology of pain
  
  • Free fluid? Possible perforation
  • Search for Meckel’s
  • Look for stigmata of Crohn’s
    
    • Inflammation
    • Stricture
    • Creeping fat
  • Look at adnexa in females
    
    • TOA
    • Torsion
    • Endometriosis
    • Ruptured ovarian cyst
  • Assess for diverticulitis
  • If nothing, examine upper abdomen
    
    • Gallbladder
    • Stomach
    • Duodenum
• Excise the appendix to remove it from the differential diagnosis in the future

Question 2

You are doing a lap appy for suspected appendicitis when you notice that the patient has intraop findings of Crohn’s disease. What do you do with the appendix?

Answer 2

• Remove the appendix unless the base of appendix and the cecum are involved.
  
  • Peforming appendectomy in that scenario could lead to breakdown of staple line and fistula formation

Question 3

What are the three main types of appendecial carcinoma?

Answer 3

1. Carcinoid (most common - 65%)
2. Adenocarcinoma
3. Mucinous neoplasm

Question 4

What is a useful tumor marker for appendiceal carcinoid?

Answer 4

• Serum chromogranin A

Question 5

While performing a lap appy you see findings concerning for an appendiceal mass. What do you do?

Answer 5

Perform oncologic R hemicolectomy if:

• >2 cm OR
• Involves the base or mesoappendix

Otherwise perform appendectomy

Question 6

While performing a lap appy you appreciate perforation of the appendix with concerns for mucinous ascites. What is your plan?

Answer 6

The concern is that there was a mucinous neoplasm that ruptured. This is a concern because it can lead to pseudomyxoma peritonei. The following should be done:

• Complete appendectomy
• Send ascites for cytology
• Perform peritoneal lavage
• Pending final path, consider referral to center that performs cytoreductive surgery and HIPEC

Question 7

Pathology from appendectomy returns with findings of adenocarcinoma. How is this treated?

Answer 7

Appendiceal adneocarcinoma is treated like colonic adenocarcinoma.

• After staging, a formal oncologic right hemicolectomy needs to be performed

Question 8

Pathology from appendectomy returns with findings of carcinoid. How is this treated?

Answer 8

Tumor <1 cm

• No further treatment; observation

Tumor 1-2 cm

• IF lymphovascular invasion –> formal oncologic right hemicolectomy
• Otherwise no further treatment; observation

Tumor >2 cm

• Formal oncologic right hemicolectomy

Question 9

Pathology from appendectomy returns with findings of mucinous neoplasm. How is this treated?

Answer 9

IF margins (-), does not involve base or mesoappendix, <2cm

• THEN no further treatment; observation

Otherwise

• Formal oncologic right hemicolectomy

For aggressive/advanced disease (in addtion to R hemi):

• Consideration of cytoreductive surgery/HIPEC
• +/- chemo