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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 33-35
Evaluating conservative treatment for acute appendicitis with lump formation


1 Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences Srinagar, Jammu and Kashmir, India
2 Department of Radiology, Sher-i-Kashmir Institute of Medical Sciences Srinagar, Jammu and Kashmir, India

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Date of Submission05-Aug-2010
Date of Acceptance13-Nov-2011
Date of Web Publication22-Feb-2012
 

   Abstract 

Background: Interval appendectomy after acute appendicitis with lump formation (phlegmon) remains controversial. We conducted this study to determine the risk of recurrent appendicitis following initial non-operative treatment for appendicitis, and evaluate factors associated with recurrence. Secondarily, we evaluate the efficacy of interval appendectomy versus no appendectomy. Materials and Methods: Patients who received conservative treatment for appendicitis with lump formation were prospectively studied from June 2006 to June 2008. These patients were followed for recurrence of appendicitis. Results: Of 763 patients with acute appendicitis some 220 patients had lump formation (28.8%). Median age was 28 years. Conservative treatment was successful in 213 (96.8%) patients. The rate of recurrence was 13.1%, all occurring within six months after the index admission. Mean follow-up was 26±18 months. Conclusion: Conservative treatment of appendicitis with lump formation is efficient and the recurrence rate is low. Routine interval appendectomy after initial conservative treatment for lump formation is not a cost-effective intervention and not recommended.

Keywords: Appendicitis, interval appendectomy, phlegmon

How to cite this article:
Malik AA, Wani ML, Wani SN, Parray FQ, NU, IfatIrshad. Evaluating conservative treatment for acute appendicitis with lump formation. J Emerg Trauma Shock 2012;5:33-5

How to cite this URL:
Malik AA, Wani ML, Wani SN, Parray FQ, NU, IfatIrshad. Evaluating conservative treatment for acute appendicitis with lump formation. J Emerg Trauma Shock [serial online] 2012 [cited 2019 Nov 15];5:33-5. Available from: http://www.onlinejets.org/text.asp?2012/5/1/33/93108



   Introduction Top


Management of acute appendicitis is purely surgical. However, in the setting of appendicitis with abscess or phlegmon, initial non-operative management has been shown to be safe and effective. [1],[2],[3] The treatment of appendicitis with phlegmon has been debated for more than 100 years. Conservative treatment is an established practice, but the necessity of interval appendectomy remains controversial. Advocates of interval appendectomy propose that appendectomy prevents recurrence and gives definitive treatment. [4],[5],[6] Appendectomy can also provide a definitive diagnosis, and may sometimes reveal an unexpected malignancy. However, another group of surgeons who oppose this policy [7],[8],[9] point out that the rate of recurrent appendicitis is around 6-20%, [7],[10],[11] and that the complication rate of interval appendectomy is not low (9-19%). [4],[11],[12] Furthermore, routine appendectomy may increase the cost for both patients and institutions. The aim of this study was to determine the risk of recurrent appendicitis following initial non-operative treatment for appendicitis, and evaluate factors associated with recurrence. Our hypothesis was that the risk of recurrent appendicitis is low and that interval appendectomy is not routinely indicated.


   Materials and Methods Top


Patients who received conservative treatment for appendicitis with lump formation were prospectively studied from June 2006 to June 2008. Detailed history with clinical examination was done in every patient. Baseline investigations viz complete blood count, liver function and kidney function was done in every patient. Computed tomography (CT) was done in every patient for confirmation of diagnosis. CT guided aspiration was done in seventeen patients. These patients had CT evidence of abscess. Every patient was treated with intravenous fluids, antibiotics (Third generation Cephalosporin, Amikacin and Metronidazole). Patients were only allowed orals after their condition improved clinically and biochemically. Patients were discharged home after complete resolution of symptoms.

Patients were followed up in outpatient department monthly for three months, bimonthly for another six months, and six monthly thereafter. If signs of recurrent appendicitis appeared (such as right lower quadrant pain, or tenderness with or without fever), CT was repeated and appendectomy was performed if recurrent appendicitis was confirmed. Data was collected and analyzed statistically using SPSS software.


   Results Top


A total of 763 patients with acute appendicitis were treated from June 2006 to June 2008. Out of them 220 (28.8%) patients presented with lump formation. They were diagnosed clinically and confirmed by CT scan. High rate of lump formation was because of late referral and due to poor health care facilities available in our state. Seven patients in this group (3.2%) were operated in the index admission as they did not respond to conservative treatment.

The remaining 213 patients were followed up regularly in the outpatient department. Mean follow up was 32 months. Out of the total; 115 of them were men and 98 were women. Median age was 28years (range 15-63 years). All patients had history of pain in the right lower abdomen. Most of the patients had classical history of pain, starting at the umbilicus then radiating to the right iliac region. Most of the patients (79.8%) had history of anorexia but nausea and vomiting was found in only 23.4% of patients. There was history of fever in 53.0% of the patients. All the patients had a lump palpable in the right iliac region on clinical examination. Right iliac region was tender in 84.5% of the patients [Table 1]. There was no clinical difference in the primary clinical presentation between the cases that later developed recurrence and the patients who did not had recurrence [Table 2].
Table 1: Clinical presentation of patients of appendicitis with lump formation

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Table 2: Clinical presentation of patients who later had recurrence

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Among 213 patients, 28 (13.1%) had recurrent appendicitis on follow-up and they were operated for the same. All these patients had recurrences within six months of the primary treatment [Figure 1]. Most recurrences were detected as emergencies; n=22 (10.3%). Few patients were detected on follow up; n=6 (2.8%).
Figure 1: Kaplan-Meier plot of the recurrence-free survival of the patients

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   Discussion Top


Lump formation after acute appendicitis is as a result of walled off perforation of appendix. Lump can be an inflammatory mass consisting of inflamed appendix, adjacent viscera, and greater omentum or a pus containing appendiceal mass. Although management of acute appendicitis is primarily surgical, management of appendicitis with lump is controversial for more than a century now. Ochsner [13] introduced the conservative treatment for fear of dissemination of infection with surgical intervention. McPherson and Kinmonth [14] reported that non-operative management of appendicitis with tumor formation achieved a 76% success rate and 0.8% mortality rate.

Currently, conservative treatment of appendicitis with lump formation is the preferred one. [7],[8],[11],[15] The success rate of conservative treatment of appendicitis with tumor formation ranges from 76% to 97%. [6],[14],[16],[17] CT- or ultrasound-guided drainage of an appendix abscess has made surgical drainage less common. [12],[16],[17] However, some surgeons still advocate early surgical intervention instead of conservative approach, [10],[16],[18] although this approach has been criticized because of possibility of spread of previously localized infection, injury to surrounding structures, and overall higher complication rate.

After successful conservative treatment the question arises whether or not to perform interval appendectomy. The morbidity of interval appendectomy ranges from 3.4% to 19% [4],[6],[11],[15],[19],[20],[21] which can be compared to the reported incidence of recurrent appendicitis after conservative treatment of an appendix mass that ranges from 0% to 20%. [4],[6],[7],[8],[10],[11],[12] The danger of recurrence is reported to be greatest during the first 6 months after the initial episode and minimal after 2 years. [8]

Hoffmann et al., [8] and Lai et al., [22] also suggested that routine elective appendectomy can be safely omitted in more than80% of patients. Two systematic reviews Andersson, Petzold [23] and Simillis et al., [24] in their studies also support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon.


   Conclusion Top


Conservative treatment is efficient in most patients with appendicitis with a phlegmone formation. The risk of recurrence is low, which does not motivate routine interval appendectomy after initial conservative treatment.

 
   References Top

1.Eriksson S, Granstrom L. Randomized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995;82:166-9.  Back to cited text no. 1
    
2.Oliak D, Yamini D, Udani VM, Roger JL, Arnell T, Hernan Vargas, et al. Initial non-operative management of periappendiceal abscess. Dis Colon Rectum 2001;44:936-41.  Back to cited text no. 2
    
3.Brown CV, Abrashimi M, Muller M, Velmahos G. Appendiceal abscess: Immediateoperation or percutaneous drainage? Am Surg 2003;69:829-32.  Back to cited text no. 3
    
4.Mosegaard A, Nielsen OS. Interval appendectomy. Acta Chir Scand 1979;145:109-11.  Back to cited text no. 4
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5.Friedell ML, Perez-Izquierdo M. Is there a role for intervalappendectomy in the management of acute appendicitis? Am Surg 2000;68:1158-62.  Back to cited text no. 5
    
6.Skoubo-Kristensen E, Hvid I. The appendiceal mass: Results of conservative management. Ann Surg 1982;196:584-7.   Back to cited text no. 6
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7.Engkvist O. Appendectomy a froid a superfluous routine operation? Acta Chir Scand 1971;137:797-800.  Back to cited text no. 7
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8.Hoffmann J, Lindhard A, Jensen H. Appendix mass: Conservative management without interval appendectomy. Am J Surg 1984;148:379-82.  Back to cited text no. 8
    
9.Ein SH, Shandling B. Is interval appendectomy necessary after rupture of an appendiceal mass? J Pediatr Surg 1996;31:849-50.  Back to cited text no. 9
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10.Foran B, Berne TV, Rosoff L. Management of the appendiceal mass. Arch Surg 1978;113:1144-5.  Back to cited text no. 10
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11.Thomas DR. Conservative management of the appendix mass. Surgery 1973;73:677-80.  Back to cited text no. 11
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12.Paull DL, Bloom GP. Appendiceal abscess. Arch Surg 1982;117:1017-9.  Back to cited text no. 12
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13.Ochsner AJ. The cause of diffuse peritonitis complicating appendicitis and its prevention. JAMA 1901;26:1747-54.  Back to cited text no. 13
    
14.McPherson AG, Kinmonth JB. Acute appendicitis and the appendix mass. Br J Surg 1945;32:365-70.  Back to cited text no. 14
    
15.Bagi P, Dueholm S. Nonoperative management of the ultrasonically evaluated appendiceal mass. Surgery 1987;101:602-5.  Back to cited text no. 15
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16.Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with apalpable mass. Ann Surg 1981;193:227-9.  Back to cited text no. 16
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17.Nguyen DB, Silen W, Hodin RA. Interval appendectomy in the laparoscopic era. J Gastro IntestSurg 1999;3:189-93.  Back to cited text no. 17
    
18.Vakili C. Operative treatment of appendix mass. Am J Surg 1976;131:312-4.  Back to cited text no. 18
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19.Yamini D, Vargas H, Bongard F, Klein S, Stamos MJ. Perforated appendicitis: Is it truly a surgical urgency? Am Surg 1998;64:970-5.  Back to cited text no. 19
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20.Willemsen P, Hoorntje LE, Eddes EH, Ploeg RJ. The need for interval appendectomy after resolution of an appendiceal mass questioned. Dig Surg 2002;19:216-20; discussion 221.  Back to cited text no. 20
    
21.Eriksson S, Styrud J. Interval appendicectomy: A retrospective study. Eur J Surg 1998;164:771-4; discussion 775.  Back to cited text no. 21
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22.Lai HW, Loong CC, Wu CW, Lui WY. Watchful waiting versus interval appendectomy for patients who recovered from acute appendicitis with tumor formation: A Cost-effectiveness Analysis. J Chin Med Assoc 2005;68:431-4.  Back to cited text no. 22
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23.Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg 2007;246:741-8.  Back to cited text no. 23
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24.Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 2010;147:818-29.  Back to cited text no. 24
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Correspondence Address:
Mohd Lateef Wani
Department of General Surgery and Allied Specialities, Sher-i-Kashmir Institute of Medical Sciences Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.93108

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