engleski

Morphometric analysis of vascular clefts in children with symptoms of acute appendicitis and negative appendectomy

Objective: Many cases of clinically suspected acute appendicitis show no microscopic signs of acute inflammation. Negative appendectomy rates differ greatly, partly due to various criteria used by different institutions to define acute appendicitis. In our practice, we have noticed that many of the negative appendectomy specimens contain prominent vascular clefts. The objective of this study was to determine the possible signifi cance of vascular clefts, which has not been investigated yet. Our hypothesis was that vascular clefts are early, as yet unrecognized signs of acute appendicitis. Methods: We conducted a retrospective study by searching for patients who had negative appendectomy at the Zagreb Children’s Hospital (2014-2019). There were 151 patients aged 1-18 years, 124 of which were included in the study group and 27 in the control group. Vascular clefts, if present, were measured microscopically. Statistical analysis was performed using Kolmogorov-Smirnov, Kruskal-Wallis, Mann Whitney, χ2 and Spearman’s rank correlation tests. The level of statistical signifi cance was set at p<0.05. Results: Out of the 124 patients included in the study group, 50.8% were female (n=63) and 49.2% were male (n=61). Mean age of the patients was 11.5 years and median 12 years. Negative appendectomy specimens showed prominent vascular clefts in 94 of 124 (75.8%) study group patients. Vascular cleft width varied between 140 and 1751 μm. Twelve (9.7%) specimens showed no signs of vascular clefts, and 18 specimens had partial vascular clefts that did not penetrate muscular wall of the appendix and consequently could not be measured. We also showed that there was a statistically signifi cant difference between the number of appendices that contained fecaliths in their lumina in the study group as compared to the control group (p<0.01). Discussion: Negative appendectomies are still a problem in the 21st century medical practice. Although many cases of clinically suspected acute appendicitis microscopically show no signs of inflammation, in some cases symptoms may regress after appendectomy has been performed, even if there are no histopathologic signs of inflammation. In everyday practice, we noticed that in cases of acute suppurative or phlegmonous appendicitis, a dense infl ammatory infi ltrate is often seen passing through prominent vascular clefts, which we defi ne as fi ssures of the muscular layer of the bowel (or in this case appendiceal) wall through which blood vessels and peripheral nerve branches pass on their way to and from the bowel. We tried to determine the possible signifi cance of these vascular clefts. We collected 124 negative appendectomy specimens from the archives of our Department of Pathology and Cytology, all of which were removed from pediatric patients at the Zagreb Children’s Hospital due to clinically suspected acute appendicitis. None of the 124 appendices met our criteria for acute appendicitis. We found that 94 of 124 (75.8%) negative appendectomy specimens showed vascular clefts. We also calculated the Zagreb Children’s Hospital negative appendectomy rate during the 5-year period, which was 9%. Conclusion: Our results show that prominent vascular clefts in the muscular layer of the appendiceal wall are frequently found in negative appendectomy specimens. These clefts could be implicated in the pathophysiology of acute appendicitis and might be one of the fi rst signs of acute appendicitis.

appendix ; appendicitis ; vascular cleft ; negative appendectomy rate

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