Sessile Serrated Adenoma of the Appendix and Perforated Cecal Lymphoma in a Nonagenarian on Novel Anticoagulant Undergoing Emergent Surgery: The Challenges, Decision Making and Management of a Rare Case

Abstract

A 92-year-old male with significant past medical history of atrial fibrillation, congenital heart disease, coronary artery disease (CAD), deep vein thrombosis (DVT), hyperlipidemia (HLD), hypertension (HTN), myocardial infarction (MI), and peripheral vascular disease presented to emergency department (ED) with shortness of breath and right sided chest pain. He was hypotensive and tachycardic with right upper and lower quadrant tenderness on clinical examination. Initial pulmonary embolism (PE) protocol CT scan was negative for pulmonary embolism but revealed a large 13 cm mass in right lower quadrant (RLQ) with adjacent free peritoneal air and fluid, suspicious for perforated cecal neoplasm or abscess. He received activated prothrombin complex concentrate (PCC) for emergent reversal of apixaban and taken emergently for exploratory laparotomy, where he underwent an extended right hemicolectomy with end ileostomy and a long Hartmann's. The ileocecal lesion was large and extended from the terminal ileum to almost the hepatic flexure. Histopathology revealed high-grade B-cell lymphoma involving the terminal ileum, cecum, ascending colon, appendix, and mesenteric lymph nodes. The specimen also contained a serrated sessile appendicular adenoma. We discuss urgent/emergent surgeries in nonagenarians with multiple comorbidities on novel oral anticoagulant (NOAC) as well as the indications of palliative surgery in these patient groups. We also discuss synchronous serrated adenoma along with the perforated high-grade lymphoma in the same patient.

Sessile serrated adenoma of the appendix: literature review and clinical cases

“…et al наблюдали в своей практике зубчатую аденому, которая во время колоноскопии выглядела как субмукозное образование устья аппендикса с центральным вдавлением "vulcano sign", а микроскопически распространилась на всю длину червеобразного отростка [12]. В 2018 году Adhya A. K. и Misra P. обнаружили сидячую зубчатую аденому в аппендиксе при рутинной обработке материала, поступившего от пациента с острым аппендицитом [13], Biswas S. и соавторы описали сидячую зубчатую аденому аппендикса в сочетании с перфоративной лимфомой слепой кишки у мужчины 92 лет [14], Sato K. с коллегами опубликовали материалы 69-летнего пациента с острым перфоративным аппендицитом и сидячей зубчатой аденомой червеобразного отростка, осложнившиеся перитонитом и множественными пиогенными абсцессами печени [15].…”