Rajiv Gandhi University of Health Sciences, Bangalore s10

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

6. BRIEF RESUME OF THE INTENDED WORK: 6.1 Need for the study : The suspected acute appendicitis is the most frequent cause for emergency operations in visceral surgery, worldwide. The life time risk of acute appendicitis for men & women is 8.6% & 6.7% respectively, however, the lifetime risk of having an appendectomy is 12% for men and 25% for women. A reported 250,000 appendectomies are performed annually, with approximately 15% of these resulting in the removal of normal appendices.1

Matthyssens et al suggest that appendices should not routinely be sent unless there is obvious macroscopic abnormality at surgery. However a number of previous papers have found aberrant incidental findings to be more common, suggesting that this latter method has the potential to miss significant pathologies which may impact patient management.2 In addition to the findings of acute inflammation the excised appendix can be the site of a variety of neoplasms and unusual inflammatory conditions.3

Thus this study is undertaken to study all the diseases encountered in appendicectomy specimens.

6.2 Review of literature: Review of literature currently available show conformity in the opinion that the appendix was consistently recognized and described from around the beginning of 16th century and within a short span of time have been well documented by da Vinci, da Capri, Versalius and two centuries later by Morgagni. Fitz first described the sequence of inflammation/ perforation/ abscess formation and peritonitis.4 Acute appendicitis is the most common acute surgical condition of abdomen. Obstruction of lumen is the dominant factor. Although fecoliths are usual cause of obstruction some unusual factors like lymphoid hyperplasia, intestinal worms eg. Enterobius vermicularis, malignant or benign conditions (carcinoid, mucocele, adenocarcinoma etc) could be the reason. Tuberculous appendicitis (TBA) is a rare condition & commonly occur in the young. Results of all preoperative investigations are non-specific & the diagnosis is made only after histopathology.5

Appendiceal parasites (Enterobius vermicularis, taenia subspecies) can cause symptoms of appendiceal pain, independent of microscopic evidence of acute inflammation. The diagnosis of a parasitic infestation is generally achieved only after the pathologic examination of the resected appendices.1

A group of people have discussed about importance of increase in intraepithelial lymphocytes (IELs) in the mucosa of the appendix. In their study on 104 retrospective appendectomy specimens they reported 12 cases with intraepithelial lymphocytosis and concluded appendectomies with clinical signs of acute appendicitis, an increase in IELs is more likely related to parasitic infection.6

Appendiceal carcinoid tumours are found in 0.3-0.9 percent of patients undergoing appendicectomy.7 Carcinoids are the commonest tumor of appendix & are typically small, firm, circumscribed, yellow brown lesions. It is more frequently diagnosed incidentally after an operation for acute appendicitis & occasionally during other procedures.5

Epithelial tumors of appendix are mostly mucinous type which is characteristic of appendix but small fraction are nonmucinous & resemble colorectal neoplasia.8

A review study on 107 appendiceal mucinous neoplasms was conducted & classified them as low grade appendiceal mucinous neoplasm (LAMN), mucinous adenocarcinomas (MACAs) or discordant based on architectural & cytologic features.9 The histopathological diagnosis of 2,216 appendicetomy specimens was reviewed & found the following lesions of appendix-Acute appendicitis, lymphoid hyperplasia, carcinoid, adenocarcinoma, lymphoma, diverticulitis, periappendicitis, granulomatous inflammation, enterobius vermicularis infestation, fibrosis, luminal pus, fecolith, mucocele etc.3

6.3 Objectives of the study: 1. To study the histomorphology of different disease process affecting the appendix. 2. To correlate the clinical diagnosis with the histopathological findings.

7. MATERIALS AND METHODS: 7.1 Source of data: The source of data for the study are patients admitted or managed in surgical wards of Bapuji Hospital, Chigateri General Hospital, Women & Child hospital attached to JJMMC. Specimens of appendix received from other hospitals in and around Davangere will also be studied.

7.2 Method of collection of data (including sampling procedure, if any):

The appendicectomy specimens sent for histopathological examination to the department of pathology, JJMMC over a period of two years from Nov. 2007 to October 2009 constitute the material for the present study.

These specimens are received in 10% formalin. After adequate fixation over a period of 24-48 hours, the specimen will be subjected for thorough gross examination i.e. size, external appearance, wall thickness, nature of mucosa, luminal contents etc. will be noted down for each specimen respectively. Specimen will be sectioned at tip, body and base of appendix. After tissue processing representative bits stained with hematoxylin and eosin will be studied microscopically. Whenever necessary special stains like periodic acid-schiff stain (PAS) & Ziehl-Neelsen will be performed.

Patients history, general and physical examination details will be collected from hospital records.

Laboratory examination like Hb%, Total & Differential Leucocyte Counts, ESR, Blood Sugar, Blood Urea, Routine Urine examination will be done. X-ray and Ultrasound findings will be recorded.

Sample Size: Approximately 500 cases.

Inclusion criteria: All the lesions affecting appendix primarily sent separately are taken for the study.

Exclusion criteria: Appendix attached to right hemicolectomy specimens are excluded from the study.

7.3 Does the study requires any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly? Yes, The study requires investigations to be conducted on patients like

Routine investigations – Hb, TLC, DLC, ESR – Urine examination – Blood urea and Blood sugar – X-ray imaging of abdomen – USG abdomen

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, ethical clearance has been obtained.

8. LIST OF REFERENCES: 1) Aydin O. Incidental parasitic infestations in surgically removed appendices : a retrospective analysis. Diagnostic Pathology 2007;2:16 doi:10.1186/1746-1596- 2-16. Available at URL:http://www.diagnosticpathology.org/content/2/1/16.

2) Jones AE, Phillips AW, Jarvis JR, Sargen K. The value of routine histopathological examination of appendicectomy specimens. BMC Surgery 2007, 7:17 doi:10.1186/1471-2482-7-17. Available at URL:http://www.biomedcentral.com/1471-2482/7/17 .

3) Blair NP, Bugis SP, Turner LJ, Mac Leod MM. Review of the pathologic diagnosis of 2,216 appendectomy specimens. Am J Surg 1993;165:618-20.

4) Williams RA, Myers P. Pathology of appendix, Chapman & Hall Medicals, London : 1994;p.1-7.

5) Duzgun AP, Moran M, Uzun S, Ozmen MM, Ozer VM, Seckin S, Coskun F. Unusual findings in appendectomy specimens : Evaluation of 2458 cases & review of the literature. Indian J Surg 2004;66:221-6.

6) Deniz K, Sokmensuer LK, Sokmensuer C, Patiroglu TE. Significance of Intraepithelial lymphocytes in appendix. Pathol Res Pract Sept 2007;203(10):731- 5.

7) Goede C, Caplin ME, Winslet MC. Carcinoid tumour of the appendix. Br J Surg 2003;90:1317-22.

8) Carr NJ, Mc Carthy WF, Sobin LH. Epithelial Noncarcinoid Tumors and Tumor-Like lesions of the Appendix. Cancer 1995;75(3):757-68.

9) Misdraji J, Yantiss RK, Graeme-Cook FM, Balis UJ, Young RH. Appendiceal Mucinous Neoplasms, A Clinicopathologic Analysis of 107 cases. Am J Surg Pathol 2003;27(8):1089-103.