Acute appendicitis is one of the most frequent surgical emergencies worldwide, with an estimated lifetime risk of 7–8% [1]. Appendectomy, whether open or laparoscopic, is considered the gold standard treatment and usually prevents recurrence. However, a rare but significant postoperative complication is stump appendicitis, defined as inflammation of the residual appendiceal tissue left behind after an incomplete appendectomy [2]. Stump appendicitis was first described by Rose in 1945, and since then, sporadic case reports and small series have been published globally [3]. The reported incidence ranges between 0.02% and 1% among patients who have undergone appendectomy [4]. While the condition is rare, its actual burden may be underestimated due to underreporting, misdiagnosis, or lack of clinical suspicion. In the Indian context, several cases have been documented in recent years, reflecting increased awareness among clinicians and the rising use of advanced imaging modalities such as ultrasonography and CT scans [5]. One of the major challenges is that clinicians often exclude appendicitis from the differential diagnosis in patients with a prior history of appendectomy. This diagnostic bias frequently results in delayed recognition, which predisposes patients to serious complications such as perforation, peritonitis, and intra-abdominal abscess [6]. Global literature suggests that the delay in diagnosis can extend up to several days, significantly increasing morbidity. Indian reports also highlight that many patients present late to tertiary care hospitals, either due to limited access to diagnostic facilities or initial mismanagement at peripheral centers [5,7]. Several risk factors predispose patients to stump appendicitis. A long appendiceal stump (>5 mm), retrocecal or subserosal position of the appendix, severe peri-appendiceal inflammation obscuring the base, and technical limitations during laparoscopic appendectomy are frequently implicated [4,6]. The increasing adoption of laparoscopic appendectomy worldwide, including in India, has raised concerns that inadequate visualization of the appendiceal base may contribute to a higher risk of residual stump inflammation, although open procedures are not exempt from this complication [7]. Radiological imaging plays a critical role in overcoming diagnostic difficulties. While ultrasound may help in some cases, CT abdomen is considered the gold standard for diagnosis, as it can clearly delineate the inflamed stump, surrounding fat stranding, and associated complications [4]. Once diagnosed, completion appendectomy—either laparoscopic or open—remains the definitive treatment, with most studies reporting favorable outcomes if intervention is timely [2,6]. Despite being rare, stump appendicitis is an important clinical entity. The lack of awareness often leads to diagnostic delays, particularly in low- and middle-income countries. Reporting institutional experiences from India and globally will enhance recognition of this condition and help improve outcomes through early suspicion, timely imaging, and prompt surgical management. With this background, the present study discusses the diagnostic challenges and management of stump appendicitis at our tertiary care centre. Aim To evaluate the diagnostic challenges and management outcomes of stump appendicitis in patients presenting to a tertiary care centre. Objectives 1. To analyze the clinical presentation, diagnostic modalities, and intraoperative findings in patients with stump appendicitis. 2. To assess the management strategies employed and the postoperative outcomes of patients diagnosed with stump appendicitis.

Study design and setting This was a retrospective observational study carried out in the Department of General Surgery in a Tertiary Care Centre. All patients presenting with acute abdomen who were subsequently diagnosed as stump appendicitis were included. Study population and sample size A total of 60 patients who met the inclusion criteria were enrolled. Cases were identified from hospital medical records, operative registers, and radiology databases. Consecutive sampling was used to minimize selection bias. Inclusion criteria • Patients of all age groups and both sexes. • History of previous appendectomy (open or laparoscopic). • Diagnosis of stump appendicitis made either radiologically (ultrasound or contrast-enhanced CT scan) or confirmed intraoperatively. Exclusion criteria • Patients with incomplete clinical, radiological, or operative documentation. • Patients diagnosed with other right iliac fossa pathologies (e.g., Crohn’s disease, ileocecal tuberculosis, mesenteric adenitis). Data collection For each patient, the following data were collected: • Demographic profile: age, sex. • Clinical details: presenting complaints, duration of symptoms, and time interval between initial appendectomy and current presentation. • Diagnostic work-up: laboratory investigations (total leukocyte count, neutrophil percentage, CRP where available) and imaging findings. Ultrasound abdomen was used as the initial modality in most cases, while contrast-enhanced CT abdomen was performed in suspected or equivocal cases. • Operative findings: surgical approach (laparoscopic or open), length of residual stump (when documented), presence of perforation, abscess, or peritonitis. •Management details: completion appendectomy, peritoneal lavage, drainage procedures, and use of antibiotics. • Histopathology: confirmation of acute inflammation or gangrenous/perforated appendicitis in the excised stump. • Outcomes: postoperative complications, duration of hospital stay, and 30-day morbidity or mortality. Management protocol All patients underwent completion appendectomy, performed either laparoscopically or through an open approach depending on the clinical scenario and surgeon preference. Intra-abdominal collections, if present, were drained, and thorough peritoneal lavage was carried out in cases with perforation or generalized peritonitis. Broad-spectrum intravenous antibiotics were administered perioperatively and continued postoperatively based on clinical course. Statistical analysis All data were entered into Microsoft Excel and analyzed using SPSS. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were expressed as frequencies and percentages. Comparisons between subgroups (e.g., laparoscopic vs open completion appendectomy, perforated vs non-perforated cases) were performed using Student’s t-test for continuous variables and Chi-square test or Fisher’s exact test for categorical variables. A p-value <0.05 was considered statistically significant.

Table 1. Demographic Profile of Patients with Stump Appendicitis (n = 60) Variable Frequency (%) / Mean ± SD Age (years) 34.8 ± 12.6 Age group • <20 years 6 (10.0) • 21–40 years 28 (46.7) • 41–60 years 18 (30.0) • >60 years 8 (13.3) Sex • Male 38 (63.3) • Female 22 (36.7) Interpretation: The mean age of patients was 34.8 years, with the majority belonging to the 21–40 years age group (46.7%). A male predominance was noted (63.3%), with a male-to-female ratio of approximately 1.7:1. This indicates that stump appendicitis is more common in young and middle-aged males. Table 2. Clinical Presentation of Stump Appendicitis (n = 60) Symptom / Sign Frequency (%) Right iliac fossa pain 60 (100.0) Fever 42 (70.0) Nausea/Vomiting 34 (56.7) Loss of appetite 30 (50.0) Palpable mass in RIF 12 (20.0) Guarding/Rebound tenderness 40 (66.7) Mean duration of symptoms (days) 4.2 ± 1.8 Interpretation: All patients presented with right iliac fossa pain (100%). Fever (70%), nausea/vomiting (56.7%), and loss of appetite (50%) were common associated symptoms. On examination, guarding and rebound tenderness were noted in 66.7% of cases, and a palpable mass was seen in 20%. The mean duration of symptoms before admission was 4.2 days, suggesting a delay in diagnosis. Table 3. Diagnostic Modalities Used (n = 60) Diagnostic tool Positive for stump appendicitis n (%) Equivocal/negative n (%) Sensitivity (%) Ultrasonography 32 (53.3) 28 (46.7) 53.3 CT abdomen 56 (93.3) 4 (6.7) 93.3 Intraoperative confirmation 60 (100.0) – 100 Interpretation: Ultrasound could correctly identify stump appendicitis in only 53.3% of cases, while CT abdomen had a much higher sensitivity of 93.3%. All cases were confirmed intraoperatively. CT abdomen was statistically superior to ultrasonography in diagnosing stump appendicitis (p<0.01), highlighting its importance in early and accurate diagnosis. Table 4. Operative Findings and Surgical Approach (n = 60) Variable Frequency (%) Surgical approach • Laparoscopic 38 (63.3) • Open 22 (36.7) Residual stump length >5 mm 28 (46.7) Perforation at presentation 14 (23.3) Abscess/peritonitis 10 (16.7) Need for drainage procedure 12 (20.0) Interpretation: Laparoscopic surgery was performed in 63.3% of patients, while 36.7% required an open approach. A residual stump length of more than 5 mm was present in 46.7% of cases. Perforation was seen in 23.3%, and abscess or peritonitis in 16.7% of patients. The need for an additional drainage procedure was required in 20%. Residual stump length greater than 5 mm was significantly associated with perforation (p = 0.03), indicating its role in the severity of presentation. Table 5. Postoperative Outcomes (n = 60) Outcome Variable Laparoscopic (n = 38) Open (n = 22) p-value Mean hospital stay (days) 5.1 ± 1.3 7.8 ± 2.1 <0.001* Surgical site infection 3 (7.9%) 6 (27.3%) 0.04* Intra-abdominal abscess 1 (2.6%) 2 (9.1%) 0.27 Re-exploration required 0 1 (4.5%) 0.18 30-day mortality 0 0 – Interpretation: The mean duration of hospital stay was significantly shorter in the laparoscopic group (5.1 days) compared to the open group (7.8 days, p<0.001). Surgical site infections were significantly higher in the open surgery group (27.3% vs 7.9%, p = 0.04). No significant differences were noted regarding intra-abdominal abscess or re-exploration. There was no mortality in either group. These findings suggest that laparoscopic surgery offers superior postoperative outcomes compared to open surgery.

Stump appendicitis is a rare but clinically important entity that occurs when residual appendiceal tissue left after appendectomy becomes inflamed. Although it was first described in 1945 by Rose [8], it continues to pose diagnostic challenges even in modern surgical practice. Our study of 60 patients adds to the growing literature by analyzing the demographic, clinical, diagnostic, and management aspects of stump appendicitis in the Indian tertiary care setting. In the present study, the mean age of patients was 34.8 years, with most cases occurring in the 21–40 years age group, and a male predominance (63.3%). Similar findings have been reported in studies from both India and abroad, suggesting that stump appendicitis predominantly affects young adults [9,10]. The possible explanation is higher physical activity and greater likelihood of earlier appendectomy in this age group, leaving behind a stump susceptible to future inflammation. Clinically, all patients presented with right iliac fossa pain, accompanied by fever in 70% and nausea/vomiting in 56.7%. These findings are in agreement with earlier studies, which noted that stump appendicitis mimics acute appendicitis, but the prior surgical history often leads to diagnostic delays [11]. In our series, the mean duration of symptoms before admission was 4.2 days, similar to the delay reported by Subramanian et al. [12], which may account for higher complication rates. Regarding imaging, ultrasound was diagnostic in only 53.3% of patients, whereas CT abdomen confirmed the diagnosis in 93.3%. This observation correlates with reports from Dikicier et al. [13] and Liang et al. [14], where CT scan was significantly superior to ultrasonography in detecting stump appendicitis. Thus, CT should be considered the imaging modality of choice when clinical suspicion is high in a post-appendectomy patient. Operative findings in our study showed residual stump length >5 mm in 46.7% of cases, perforation in 23.3%, and abscess or peritonitis in 16.7%. These findings reinforce the established notion that leaving a longer appendiceal stump predisposes to recurrence [15]. In fact, guidelines recommend leaving a stump less than 3–5 mm to prevent future inflammation [16]. Laparoscopic completion appendectomy was performed in 63.3% of patients and was associated with shorter hospital stay and lower surgical site infection rates compared to open surgery. Similar advantages of laparoscopic management have been documented in contemporary literature [14,17]. While open surgery remains necessary in complicated cases, the minimally invasive approach appears to offer superior short-term outcomes. Overall, our findings highlight the importance of maintaining a high index of suspicion for stump appendicitis in patients with right iliac fossa pain and a history of appendectomy. Early use of CT imaging, meticulous dissection during the index appendectomy to avoid a long stump, and laparoscopic completion appendectomy where feasible can reduce morbidity and improve outcomes.

Stump appendicitis, though rare, remains an important diagnostic challenge due to its occurrence in patients with a prior history of appendectomy. Our study highlights that the condition predominantly affects young and middle-aged males, with clinical features similar to acute appendicitis but often associated with a diagnostic delay. CT abdomen proved superior to ultrasonography for diagnosis and should be the preferred imaging modality in suspected cases. A residual stump length greater than 5 mm was significantly associated with complications such as perforation and abscess. Laparoscopic completion appendectomy provided better short-term outcomes compared to the open approach, with reduced hospital stay and lower postoperative morbidity. Awareness of this condition, meticulous surgical technique during the index appendectomy, and timely use of advanced imaging are key to improving outcomes in patients with stump appendicitis.

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