Clinical significance of appendiceal diverticulum: a significant marker for appendiceal neoplasia in Australian patients.

INTRODUCTION: Diverticula of the appendix (DA) have a reported incidence of up to 2.1%. They are primarily detected incidentally, through imaging and intraoperative or histologic diagnosis. This study's objective was to examine the prevalence of DA, and its relationship with inflammation and neoplasia, as well as review the literature with respect to clinical outcomes and ability to identify DA preoperatively. METHODOLOGY: A retrospective search of all patients undergoing an appendicectomy for right lower quadrant pain at a single institution between 2004 and 2017 was conducted. Histopathology reports for evidence of DA, location of the DA, presence of inflammation, and any relationship between DA and neoplasms (adenoma, carcinoma, carcinoid, lymphoma, and mucinous neoplasm) within the appendix were reviewed. Clinical notes, operative records, and preoperative imaging were also reviewed. RESULTS: Two thousand seven hundred eleven patient were included in the study, with a mean age of 34 years, with acute appendicitis found in 82.5%. 31.6% of patients with DA had associated inflammation of the DA. DA was present in 57 patients (2.1%), with 55 patients in the total cohort having neoplasia (2.0%). Patients with DAs were ten times more likely to have appendicular neoplasm than patients without a DA (17.5 vs 1.8%; p < 0.0001, OR 11.8 95%, CI 5.6-24.8). CONCLUSION: This is the first Australian study demonstrating DAs are a significant marker of appendiceal neoplasm. Appendicectomy in all incidentally discovered diverticulum should be considered. Due to a paucity of data, research is required into this area to assess for the need for endoscopy following diagnosis.

Unusual presentation of left sided acute appendicitis in elderly male with asymptomatic midgut malrotation.

INTRODUCTION: Acute appendicitis in the setting of midgut malrotation is uncommon. Midgut malrotation commonly presents within the first month of life. A minority remain asymptomatic and may present with concomitant abdominal pathology making diagnosis difficult. PRESENTATION OF CASE: This paper reports a rare case of a 73-year-old male diagnosed with acute appendicitis and asymptomatic MM .The patient underwent a laparoscopic appendectomy, but had an unplanned return to theatre for washout of post-operative intra-abdominal haematoma. DISCUSSION: Midgut malrotation is commonly described by the stringer classification and type 1a is the most common in adults. There have only been a handful of documented cases of acute appendicitis with midgut malrotation occurring in the adult population. Previous delay in diagnosis has led to a delay in definitive management. Both laparoscopic and open surgery has been used in the past. CONCLUSION: Acute appendicitis with malrotation should be considered in elderly patients presenting with atypical signs and symptoms. Imaging offers significant advantage for timely and definitive management.