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Villous adenoma of the distal appendix
Case reports
185
Villous adenoma of the distal appendix J. V. Taylor*, M. G. Thomas*, S. Kellyt and R. Sutton* Department of*Surgerl, and tDepartment o/" Histopathology Royal Liverpool University and Broadgreen Hospitals NHS Trust, Liverpool, UK
Villous adenoma confined to the distal appendix has not been previously reported in conjunction with acute apendicitis. The presence of an adenonm indicates a need for further investigation due to an association with neoplasia elsewhere.
KO' words: acute appendicitis; villous adenoma of appendix; post-operative screening.
I ntroduction
Villous adenomas of tile appendix are rare' and are mostly located in the proxinwl appendix, perhaps arising l¥om adjacent caecal mt, cosa.-" Wc report a case of villous adenoma of the distal appendix. idcntilicd oll histological exarnination [bllowing appendectomy for acute appendicitis. This location indicates that it arose from the appendicular mucosa per st'. not from tile colonic mucosa and that it was not a causal factor of the appendicitis.
been coincidental, arising from the uppendicular mucosa, distal to the area of inflammation. If the lesion is excised completely and there are no features suggestive of malignancy, appendectomy is appropriate, with further extended resection indicated only if there are signs of malignancy or incomplete excision.-"
Case history A 71-year-old mall was admitted with a 2-day history of right ili.'lc fossa pain, exacerbated by movement and associated with vomiting. Oil examination he had a fever of 38.6°C and was tender with guarding in the right lilac fossa. Rectal examination showed an enlarged benign prostate but no tenderness. The white blood cell count was raised at 14.3 × 10'Tml. A provisional diagnosis of acute appendicitis was made and appendectomy performed, and an inllamed, pus-filled appendix was removed. Subsequent histological examination of the resccted specimen showed a villous adenoma of the distal appendix (Fig. I), with mild cellular atypia, but no signs of inv:tsion. The proximal appendix was largely destroyed, although areas of preserved m u c o s a showed a normal structure. In view of the unexpected histological findings, colonoscopy was subsequently performed, but demonstrated no further pathology of tile large bowel.
Discussion Tile rarity of appcndicular adenomas appears to result from the predeliction of adenomas to affect the left side of the colon 3 and the small surface area of tile appendiculur mucosa, which is large bowel in type. Only one case of villous adenoma confined to the distal appendix has been previously reported. 4 Indeed, it has never been reported to occur in association with acute appendicitis, unlike adenoma of the proximal appendix, which may sometimes cause signilicant luminal obstruction.' In our case tile t,denoma appears to have
Correspondence to: Mr R. Sutton, Department of Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK.
Fig. I. Villous adenoma of the appendix showing acute inflammatory changes. Magnification, × 630, reproduced here at 75"/,,.
Case reports
186
There is also a recognized association between adenomas of the appendix and both benign and malignant neoplasia elsewhere in the body, particularly the large bowel) Therefore, colonoscopy should be performed routinely if an appendicular adenoma is identified after appendectomy. 7
References 1. Morrison JG, Llanera PP, Potts JR, III. Preoperative colonoscopic diagnosis of villous adenoma of the appendix. Report of a case and review of the literature. Dis Colon Rectum 1988; 31: 398-400. 2. Hameed K. Villous adenoma of the vermiform appendix. Arch Path 1966: 81: 465-8.
3. Gillespie PE, Chambers TJ, Chan KW, Doronzo F, Morson BC, Williams CB. Colonic adenomas--a colonoscopic survey. Gut 1979; 20: 240-5. 4. Sadahiro S, Ohruva T, Yamada Y, Saito T, Akatsuka S. A case of cecocolic intussusception of the appendix with villous adenoma. Dis Colon Rectum 1991; 34: 85-8. 5. Munk JF. Villous adenoma causing acute appendicitis. Br J Surg 1977; 64: 593-5. 6. Wolff M, Ahmed N. Epithelial neoplasms of the vermiform appendix [exclusive of carcinoids] II. Cystadenomas, papillary adenomas and adenomatous polyps of the appendix. Cancer 1976; 37:2511-22. 7. Deans GT, Spence RAG. Neoplastic lesions of the appendix. Br J Surg 1995; 82: 299-306.
Accepted for publication 11 December 1995
Umbilical port metastasis from gallbladder carcinoma after laparoscopic cholecystectomy A. J. Karayiannakis and M. J. Knight Pancreaticobiliary Unit, St George's Hospital, London, U K
A case of gallbladder carcinoma is presented where metastatic tumour developed at the abdominal wall port site following laparoscopic cholecystectomy.
Key words: gallbladder carcinoma; laparoscopic cholecystectomy; metastasis.
Introduction Laparoscopic cholecystectomy has rapidly gained widespread acceptance in the treatment of symptomatic cholelithiasis. Gallbladder carcinoma is found in 1-2% of all cholecystectomies performed and many of these are unsuspected in the pre-operative period) We report here a patient with gallbladder carcinoma, unsuspected before and during laparoscopic cholecystectomy, in whom a metastasis developed in the umbilical cannula site through which the gallbladder was removed. Case report A 59-year-old woman presented to the referring hospital with recurrent biliary colic. There was no history of jaundice and her liver function tests were normal. Abdominal ultrasonography confirmed the presence of cholelithiasis with no indication of tumour. She underwent an elective laparoscopic cholecystectomy using the four-trocar technique. The operation was uneventful and
Correspondence to: M. J. Knight, St George's Hospital, London SW 17 0QT, UK.
the gallbladder was removed intact, although with some difficulty, through the umbilical incision. There was no macroscopic evidence of tumour in the excised gallbladder. However, histological e x a m i n a t i o n revealed a well-differentiated adenocarcinoma invading the serosa. There was no vascular, lymphatic or perineural invasion and the resection margins were clear. The patient presented 3 months later complaining of a painful periumbilical swelling. A ' biopsy of the swelling confirmed metastatic adenocarcinoma from the gallbladder. Computed tomography showed that this was the only site of recurrence (Fig. I).
Discussion The presence of a wound metastasis so early after the operation in the absence of systematic dissemination suggests tumour inoculation during the procedure. This complication is not specific to laparoscopic cholecystectomy. Tumour seeding has been described after diagnostic fine-needle aspiration and laparoscopy for the diagnosis and staging of other intra-abdominal malignancies.-''3 However with the well-known difficulties in the pre-operative diagnosis of gallbladder carcinoma and the widespread use of laparoscopic cholecystectomy such a complication will inevitably become more frequent. In a review of the literature, we found several other cases of
185
Villous adenoma of the distal appendix J. V. Taylor*, M. G. Thomas*, S. Kellyt and R. Sutton* Department of*Surgerl, and tDepartment o/" Histopathology Royal Liverpool University and Broadgreen Hospitals NHS Trust, Liverpool, UK
Villous adenoma confined to the distal appendix has not been previously reported in conjunction with acute apendicitis. The presence of an adenonm indicates a need for further investigation due to an association with neoplasia elsewhere.
KO' words: acute appendicitis; villous adenoma of appendix; post-operative screening.
I ntroduction
Villous adenomas of tile appendix are rare' and are mostly located in the proxinwl appendix, perhaps arising l¥om adjacent caecal mt, cosa.-" Wc report a case of villous adenoma of the distal appendix. idcntilicd oll histological exarnination [bllowing appendectomy for acute appendicitis. This location indicates that it arose from the appendicular mucosa per st'. not from tile colonic mucosa and that it was not a causal factor of the appendicitis.
been coincidental, arising from the uppendicular mucosa, distal to the area of inflammation. If the lesion is excised completely and there are no features suggestive of malignancy, appendectomy is appropriate, with further extended resection indicated only if there are signs of malignancy or incomplete excision.-"
Case history A 71-year-old mall was admitted with a 2-day history of right ili.'lc fossa pain, exacerbated by movement and associated with vomiting. Oil examination he had a fever of 38.6°C and was tender with guarding in the right lilac fossa. Rectal examination showed an enlarged benign prostate but no tenderness. The white blood cell count was raised at 14.3 × 10'Tml. A provisional diagnosis of acute appendicitis was made and appendectomy performed, and an inllamed, pus-filled appendix was removed. Subsequent histological examination of the resccted specimen showed a villous adenoma of the distal appendix (Fig. I), with mild cellular atypia, but no signs of inv:tsion. The proximal appendix was largely destroyed, although areas of preserved m u c o s a showed a normal structure. In view of the unexpected histological findings, colonoscopy was subsequently performed, but demonstrated no further pathology of tile large bowel.
Discussion Tile rarity of appcndicular adenomas appears to result from the predeliction of adenomas to affect the left side of the colon 3 and the small surface area of tile appendiculur mucosa, which is large bowel in type. Only one case of villous adenoma confined to the distal appendix has been previously reported. 4 Indeed, it has never been reported to occur in association with acute appendicitis, unlike adenoma of the proximal appendix, which may sometimes cause signilicant luminal obstruction.' In our case tile t,denoma appears to have
Correspondence to: Mr R. Sutton, Department of Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK.
Fig. I. Villous adenoma of the appendix showing acute inflammatory changes. Magnification, × 630, reproduced here at 75"/,,.
Case reports
186
There is also a recognized association between adenomas of the appendix and both benign and malignant neoplasia elsewhere in the body, particularly the large bowel) Therefore, colonoscopy should be performed routinely if an appendicular adenoma is identified after appendectomy. 7
References 1. Morrison JG, Llanera PP, Potts JR, III. Preoperative colonoscopic diagnosis of villous adenoma of the appendix. Report of a case and review of the literature. Dis Colon Rectum 1988; 31: 398-400. 2. Hameed K. Villous adenoma of the vermiform appendix. Arch Path 1966: 81: 465-8.
3. Gillespie PE, Chambers TJ, Chan KW, Doronzo F, Morson BC, Williams CB. Colonic adenomas--a colonoscopic survey. Gut 1979; 20: 240-5. 4. Sadahiro S, Ohruva T, Yamada Y, Saito T, Akatsuka S. A case of cecocolic intussusception of the appendix with villous adenoma. Dis Colon Rectum 1991; 34: 85-8. 5. Munk JF. Villous adenoma causing acute appendicitis. Br J Surg 1977; 64: 593-5. 6. Wolff M, Ahmed N. Epithelial neoplasms of the vermiform appendix [exclusive of carcinoids] II. Cystadenomas, papillary adenomas and adenomatous polyps of the appendix. Cancer 1976; 37:2511-22. 7. Deans GT, Spence RAG. Neoplastic lesions of the appendix. Br J Surg 1995; 82: 299-306.
Accepted for publication 11 December 1995
Umbilical port metastasis from gallbladder carcinoma after laparoscopic cholecystectomy A. J. Karayiannakis and M. J. Knight Pancreaticobiliary Unit, St George's Hospital, London, U K
A case of gallbladder carcinoma is presented where metastatic tumour developed at the abdominal wall port site following laparoscopic cholecystectomy.
Key words: gallbladder carcinoma; laparoscopic cholecystectomy; metastasis.
Introduction Laparoscopic cholecystectomy has rapidly gained widespread acceptance in the treatment of symptomatic cholelithiasis. Gallbladder carcinoma is found in 1-2% of all cholecystectomies performed and many of these are unsuspected in the pre-operative period) We report here a patient with gallbladder carcinoma, unsuspected before and during laparoscopic cholecystectomy, in whom a metastasis developed in the umbilical cannula site through which the gallbladder was removed. Case report A 59-year-old woman presented to the referring hospital with recurrent biliary colic. There was no history of jaundice and her liver function tests were normal. Abdominal ultrasonography confirmed the presence of cholelithiasis with no indication of tumour. She underwent an elective laparoscopic cholecystectomy using the four-trocar technique. The operation was uneventful and
Correspondence to: M. J. Knight, St George's Hospital, London SW 17 0QT, UK.
the gallbladder was removed intact, although with some difficulty, through the umbilical incision. There was no macroscopic evidence of tumour in the excised gallbladder. However, histological e x a m i n a t i o n revealed a well-differentiated adenocarcinoma invading the serosa. There was no vascular, lymphatic or perineural invasion and the resection margins were clear. The patient presented 3 months later complaining of a painful periumbilical swelling. A ' biopsy of the swelling confirmed metastatic adenocarcinoma from the gallbladder. Computed tomography showed that this was the only site of recurrence (Fig. I).
Discussion The presence of a wound metastasis so early after the operation in the absence of systematic dissemination suggests tumour inoculation during the procedure. This complication is not specific to laparoscopic cholecystectomy. Tumour seeding has been described after diagnostic fine-needle aspiration and laparoscopy for the diagnosis and staging of other intra-abdominal malignancies.-''3 However with the well-known difficulties in the pre-operative diagnosis of gallbladder carcinoma and the widespread use of laparoscopic cholecystectomy such a complication will inevitably become more frequent. In a review of the literature, we found several other cases of