ABSTRACT
Objective:Material and Methods:
Results:
Conclusion:
Key Words:
To evaluate the justification for conservative treatment of appendicular mass without interval appendicectomy.
This study was conducted at the department of surgery Postgraduate Medical Institute HMC Peshawar. It was a descriptive study including all those patients who presented with appendicular mass from January 2000 to December 2005. These patients were treated conservatively.
Patients who responded to conservative treatment were sent home and were followed for months for any recurrent attack. Patients who did not respond to conservative treatment, were explored after further investigation. Patients who had recurrent attack in the follow up were offered appendicectomy. No patient was offered interval appendicectomy.
Total number of the patients included in the study was 125. Patients responded to conservative treatment were 88% (n=110). Failure of conservative treatment occurred in 12% (n=15). Out of these, abscess formation occurred in 8% (n=10) who responded well to open drainage with out appendicectomy while 4% (n=5) were explored after CT abdomen. Appendicitis was found in 2 cases (1.6%), ileoceacal tuberculosis, colonic tumour and appendicular tumour in 1 case each (0.8%). All patients except for the 5 cases already explored were followed up for 18 months. Recurrent attack of acute appendicitis occurred only in 8.33% (n=10/120) and appendicectomy was performed on these patients.
Conservative management is effective in the majority of the patients. Randomized control trial is needed to study the real need of interval appendicectomy.
Appendiceal mass, Conservative management, Appendicular Abscess, Interval Appendicectomy.
INTRODUCTION
C l a s s i c a l m a n a g e m e n t ' i n v o l v e s i n i t i a l conservative treatment with broad-spectrum Interval appendicectomy has been definedantibiotics and intravenous fluid until the as ”appendicectomy in asymptomatic patient after
inflammatory mass resolves. The patient is resolution of inflammatory appendix mass with 1 t h e n o f f e r e d i n t e r v a l a p p e n d i c e c t o m y conservative treatment” Appendicular mass is a following resolution of symptoms.
common surgical clinical entity encountered in 2-
M o r e r e c e n t l y t h e n e e d f o r i n t e r v a l 6 % o f t h e p a t i e n t p r e s e n t i n g w i t h a c u t e
appendicectomy has been questioned, by a appendicitis. It forms a spectrum of disease
number of authors adopting an entirely ranging from an inflamed appendix walled off by
conservative approach with out interval
the omentum (an appendicular phlegmon) to a 3
appendicectomy.
large collection of pus surrounded by adherent and
inflamed omentum (an appendiceal abscess). 2 A t h i r d a p p r o a c h i n v o l v e s p e r f o r m i n g M a n a g e m e n t o f a n a p p e n d i c u l a r m a s s i s immediate appendicectomy during the initial controversial with three general approaches.' admission prior to resolution of the mass.2
l
l
l
CONSERVATIVE TREATMENT OF APPENDICULAR MASS WITHOUT INTERVAL APPENDICECTOMY:
IS IT JUSTIFIED?
Department of Surgery Postgraduate Medical Institute,
Hayatabad Medical Complex and Lady Reading Hospital, Peshawar
Safir Ullah, Mumtaz Khan, Siddique Ahmad, Naeem Mumtaz
describe the advantages of avoiding the need for interval appendicectomy, and the exclusion of other pathologies simulating to an c mass.
Advocates of interval appendicectomy describe the advantages of avoiding recurrence of symptoms a n d t h e m i s d i a g n o s i s o f a n i n t e r v a l appendicectomy mass. They suggest interval appendicectomy is less hazardous and challenging o p e r a t i o n , c o m p a r e d w i t h i m m e d i a t e appendicectomy during the initial admission.
Proponents of an entirely conservative approach c l a i m a p p e n d i c e c t o m y, w h e t h e r i n t e r v a l o r immediate, is unnecessary. 3
Total number of patient included in our study was 125. Female to male ratio was 2:3. Age distribution was 14 to 65 years with mean age of 31.92+ 14.24 years. Complete resolution after conservative treatment occurred in 88% (n=110) patients. Abscess formation occurred in 8% (n=10) patients. Clinically and ultrasonically abscess formation was confirmed in these cases and was drained retroperitonialy under general anaesthesia.
They made good recovery and were included in series of those who responded to the conservative treatment for follow up as shown in table no.1.
P a t i e n t s w h o r e s p o n d e d p u r e l y t o This study was planned to evaluate the conservative management and patients who j u s t i f i c a t i o n f o r c o n s e r v a t i v e t r e a t m e n t o f
underwent open drainage of abscess along with a p p e n d i c u l a r m a s s w i t h o u t i n t e r v a l
conservative treatment were followed for 18 appendicectomy in our patients. m o n t h s f o r r e c u r r e n c e a n d n o i n t e r v a l appendicectomy was offered. Recurrent attack of acute appendicitis occurred only in 8.33%
This descriptive study was conduced at the (n=10/120) patients with in 1 year of follow up. st
department of surgery Postgraduate Medical Clinically the presentation was mild in these cases.
Institute Hayatabad Medical Complex, Peshawar. It Appendicectomy was performed on these patients included all those patients who presented with as shown in (Table-2). There was failure of appendicular mass from January 2000 to December complete resolution in 4% (n=5) patients. Clinical 2005. The sampling was purposive. Clinical data assessment including ultrasound abdomen of these of every patient was recorded on a proforma. cases did not show evidence of appendicular Baseline investigations including ultrasound were abscess. CT abdomen was performed on these performed. CT abdomen were done in few cases. cases and were explored. Appendicectomy was performed in 2 cases. Peroperative suspicion of These patients were put on conservative
pathologies other than appendix was noted in 03 treatment which included: soft diet, i/v antibiotic,
cases (2.4%). Limited right hemicollectomy was i/v fluid, pulse/temperature record, marking of the
done in 2 cases (1.6%) with the suspicion of I m, mass, noting the response of the mass to treatment
leocaecal tuberculosis and carcinoid tumour of with daily examination. Patients who responded to
a p p e n d i x a n d f o r m a l e x t e n d e d r i g h t conservative treatment were sent home and were
hemicollectomy in one case (0.8%) with the followed for 18 months. Patients with abscess
suspicion of colonic tumour. Later on the formation, confirmed clinically and ultrasonically,
suspected pathologies were confirmed by biopsy were treated with open drainage by retroperitoneal
reports as shown in table No.3.
approach under general anesthesia. These cases w e r e a l s o f o l l o w e d a l o n g w i t h t h o s e w h o responded to conservative treatment. Cases who
At the beginning of the 20 century, th
did not respond to treatment and clinical and
O s c h n e r ( 1 9 0 1 ) p r o p o s e d n o n - o p e r a t i v e ultrasound did not show any evidence of abscess
management for the appendix mass. This approach 4
formation, were explored after CT abdomen.
involved the administration of intravenous fluids Different pathologies found were dealt with
and antibiotics whilst keeping the patient starved.
accordingly. Data was collected and manually
The aim of this approach was to achieve resolution analyzed for descriptive statistics.
MATERIAL AND METHODS
DISCUSSION
of the mass and an asymptomatic patient. This has 8.33% (n=10) with in one year time. The attacks
5 were mild. These cases underwent appendicectomy.
been found effective in the majority of patients.
They made good recovery. Mean incidence of We followed the same regimen in our study and
recurrent appendicitis in a number of international 88% (n=110) responded to conservative treatment
6 studies was 13.7% (rang 0-20%). Most recurrence which is comparable to Adalla study in which
7 occurred with in the first two years and the attacks 87% responded but lower than Kumar et al where
12-15
were mild.
the response was 95%.
Analysis of our study and other available We noted abscess formation in 8% (n=10)
3 , 5 , 1 6 - 1 8
8 s t u d i e s m a k e s t h e r o l e o f i n t e r v a l while Jeffery et al found in 7.45% cases. We
a p p e n d i c e c t o m y l e s s i m p o r t a n t . C l a s s i c a l drained the abscess retroperitonialy under general
8 m a n a g e m e n t i n v o l v e s p e r f o r m i n g i n t e r v a l anaesthesia. Jeffery et al performed radiological
appendicectomy following resolution of the mass guided percutaneous drainage of abscess under
and symptoms. This approach dates to the local anesthesia. They noted recurrence of abscess
beginning of the 20th century when Murphy 17
in 2 cases and the success rate was 90%. We found
p r o p o s e d e l e c t i v e i n t e r v a l a p p e n d i c e c t o m y no recurrence of abscess after open drainage.
9 following successful conservative management.
Similarly Yamini et al found 97% success rate
Recently the value of interval appendicectomy has with conservative treatment associated with
been questioned, with the majority of authors percutaneous drainage of appendicular abscess. In
advocating an entirely conservative approach our study 4% (n=5) cases showed no response.
1 8 - 2 1
where possible. The principal reasons for Ultrasound abdomen and clinical assessment did
justifying interval appendicectomy are firstly to not confirm abscess formation in these cases. CT
prevent recurrence of acute appendicitis and abdomen was done before exploration. Two cases
secondly to avoid misdiagnosing an alternative were found to be of acute appendicular mass and
22-25
pathology such as a malignancy. Most of the appendicectomy was done by senior surgeon. One
26-29
case was found to be of ileoceacal tuberculosis and studies provide good evidence, firstly, that the limited right hemicollectomy was done. One case risk of recurrent acute appendicitis following turned out to be right sided colonic tumour and successful conservative management is low;
another one appendicular tumour(carcinoid). between 5% and14%. Secondly in the minority of Formal right hemicollectomy was performed for patients whose symptoms do recur, this usually colonic tumour and limited right hemicollectomy occurs with in first year of the initial attack.
6 Thirdly, recurrence of appendicitis following for carcinoid tumour of appendix. Adala , Nitech et
5 10 11
conservative management is usually associated al , Dexon et al and Kaminski et al found failure
with a milder clinical course amenable to both of conservative treatment in 12%, 6%, 5%, and 3%
operative and non-operative approaches. Fourthly respectively in their studies. Patients of these
studies with no response to conservative treatment were investigated in detail including CT abdomen before exploration. No other pathologies except appendicitis were found. Appendicectomy was performed on these cases.
In our study we followed all those patients (n=120) who responded to conservative treatment including those who developed abscess and were treated with open drainage associated with conservative treatment for eighteen months.
Recurrent attacks of acute appendicitis occurred in Table 2
Percentage 110
10
120 10/120
88%
8%
96%
8.33%
FOLLOW UP
Characteristics Frequency
(n=125) Patients responded purely to conservative
treatment & were followed for 18 months Patients with abscess formation responded to open drainage along with conservative treatment.
Total No. of patients who are followed for 18 months.
Patients with recurrence of acute appendicitis.
Histology Report Frequency
(n=125) %age
Table 3
HISTOLOGY OF UNRESOLVED MASS
Acute appendicitis Ileocaecal tuberculosis Colonic tumour Appendicular tumour Total
2 1 1 1 5
1.6%
0.8%
0.8%
0.8%
4%
an appendix mass are serious. It is, therefore e s s e n t i a l t o e x c l u d e o t h e r d i a g n o s e s w i t h
3-5,32,33
investigation. Analysis of a number of studies shows almost similar complications of interval appendicectomy to as that of appendicectomy performed for acute appendicitis. Eriksson and styrud found comparable complications rates for 1
both types of appendicectomy (13% verus10%).
I n i t i a l c o n s e r v a t i v e m a n a g e m e n t i s successful in the vast majority of patients with an appendix mass. The indications for interval appendicectomy are to exclude an alternative diagnosis, following recurrence of symptoms after successful conservative management and if the patient is unwilling to take the low risk of recurrence. However randomized control trial is n eed ed to s tu d y th e r eal n eed o f in ter v al appendicectomy in patients presenting with an appendix mass.
CONCLUSION
REFERENCES
the severity of recurrent appendicitis. Am J Surg 2003;186: 718-22.
11. Kaminski A, Liu 11, Applebaum H, Lee SL, Haigh PI. Routine interval appendicectomy is n o t j u s t i f i e d a f t e r i n i t i a l n o n o p e r a t i v e treatment of acute appendicitis. Arch Surg 2005;140:897-901.
12. Skoubo-Kristensen E, Hvid I. The appendiceal mass: Results of conservative manament. Ann Surg 1982;196: 584-7.
13. Foran B, Berne TV, Rosoff L. Management of the appendiceal mass. Arch Surg 1978;113:
1144-5.
14. J o r d a n J S , K o v a l c i k P J , S c h w a b C W.
Appendicitis with a palpable mass. Ann Surg 1981;193:227-9.
15. Tingstedt B, Bexe-Lindskog E,Ekelund M, Andersson R. Management of appendiceal masses. Eur J Surg 2002;168:579-82.
16. Friedell ML, Perez-Izquierdo M. Is there a role for interval appendicectomy in the 1. Eriksson S, Styrud J. Interval appendicectomy:
management of acute appendicitis? Am Surg A retrospective study. Eur J Surg 1998;
2000;66:1158-62.
164:771-4.
17. Murphy JB. Two thousand operations for 2. S c h e i n M . T h e n e e d f o r i n t e r v a l
appendicitis. Am J Med Sci 1904;128: 187 appendicectomy: How many times do we need
to kill the gimmick? Dig Surg 2002; 19:221-2. 18. Verwaal VJ Wobbes T,Goris RJA. Is there still a place for interval appendicectomy? Dig Surg 3. Willemsen PJ, Hoorntje LE, Eddes EH, Ploeg
1993; 10:285-8.
RJ. The need for interval appendicectomy after
resolution of an appendiceal mass questioned. 19. Marya SK, Garg P, Singh M, Gupta AK, Singh Dig Surg 2002; 19: 216-20. Y. I s a l o n g d e l a y n e c e s s a r y b e f o r e a p p e n d i c e c t o m y a f t e r a p p e n d i c e a l m a s s 4. Oschner AJ. The cause of diffuse peritonitis
formation? A preliminary report. Can J Surg complicating appendicitis and its prevention.
1993;36:268-70.
JAMA 1901;26:1747.
20. De U, Ghosh S. Acute appendicectomy for 5. Nitecki S, Assalia A, Schein M. Contemporary
appendicular mass: A study of 87 patients.
management of the appendiceal mass. Br J
Ceylon Med J 2002;47:117-8.
Surg 1993;80: 18-20.
21. A r n b j o r n s s o n E . M a n a g e m e n t o f t h e 6. A d a l l a S A . A p p e n d i c e a l m a s s : I n t e r v a l
Appendiceal Abscess. Curr Surg1984;41:4-9.
appendicectomy should not be the rule. Br J Clin Prac 1996;50:168-9.
22. Bradley EL, Isaacs J, Appendiceal Abscess 7. Kumar S, Jain S. Treatment of appendiceal Revisited. Arch Surg 1978;113 (2):130-2.
23. Ahmed I, Deakin D, Parsons S. Appendix 29. Bagi P Dueholm S, Karstrup S. Percutaneous mass: Do we know how to treat it? Ann R drainage of appendiceal abscess. An alternative Coll Surg Engl 2005;87: 191-5. to conventional treatment. Dis Colon Rectum
1987;30:532-5.
24. Lewin J, Fenyo G, Engstrom L. Treatment of
a p p e n d i c e a l a b s c e s s . A c t a C h i r S c a n d 30. Lasson A, Lundagards J, Loren I, Nilsson PE.
1988;154:123-5.
Appendiceal abscess: Primary percutaneous 25. Thomas DR. Conservative management of the d r a i n a g e a n d s e l e c t i v e i n t e r v a l
appendix mass. Surgery 1973;73:677-80. appendicectomy. Eur J Surg 2002;168:264-9.
26. Bagi P Dueholm S. Nonoperative management 31. Oliak D, Sinow R, French S, Vikram VM, of the ultrasonically evaluated appendiceal Stamos MJ. Computed tomography scanning mass. Surgery 1987;101:602-05. for the diagnosis of perforated appendicitis.
27. O l i a k D , Ya m i n i D , U d a n i V. I n i t i a l Am Surg 1999;65:959-64.
nonoperative management for periappendiceal
32. B r o w n C V R , A b r i s h a m i M , M u l l e r M , abscess. Dis Colon Rectum 2001;44:936-41.
Velmahos GC. Appendiceal abscess: Immediate 28. Oliak D, Yamini D, Udani R, Lewis RJ, Vargas operation or percutaneous drainage? Am
H , A r n e l l T, S t a m o s M . N o n o p e r a t i v e Surg2003;69:829-32.
management of perfotated appendicitis with
33. Vakili C. Operative treatment of appendix o u t p e r i a p p e n d i c e a l m a s s . A m J S u r g
mass. Am J Surg 1976;131:312-4 2000;179:177-81.
Address for Correspondence:
Dr. Safir Ullah Department of Surgery, Hayatabad Medical Complex, Peshawar – Pakistan.
E-Mail : [email protected]
