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META-ANALYSIS

Nonsurgical Treatment of Appendiceal Abscess or


Phlegmon
A Systematic Review and Meta-analysis
Roland E. Andersson, PhD, MD,*† and Max G. Petzold, PhD‡

Objective: A systematic review of the nonsurgical treatment of


patients with appendiceal abscess or phlegmon, with emphasis on
T he inflammation in acute appendicitis may sometimes be
enclosed by the patients own defense mechanisms, by the
formation of an inflammatory phlegmon or a circumscribed
the success rate, need for drainage of abscesses, risk of undetected
serious disease, and need for interval appendectomy to prevent
abscess, often presenting some days after the onset of symp-
recurrence.
toms as a palpable mass.
Summary Background Data: Patients with appendiceal abscess or
The management of these patients is controversial.1
phlegmon are traditionally managed by nonsurgical treatment and
Immediate appendectomy may be technically demanding
interval appendectomy. This practice is controversial with propo-
because of the distorted anatomy and the difficulties to close
nents of immediate surgery and others questioning the need for
the appendiceal stump because of the inflamed tissues. The
interval appendectomy.
exploration often ends up in an ileocaecal resection or a
Methods: A Medline search identified 61 studies published between
right-sided hemicolectomy due to the technical problems or a
January 1964 and December 2005 reporting on the results of
suspicion of malignancy because of the distorted tissues.
nonsurgical treatment of appendiceal abscess or phlegmon. The
The traditional management of these patients is non-
results were pooled taking the potential clustering on the study-level
surgical treatment followed by interval appendectomy to
into account. A meta-analysis of the morbidity after immediate
prevent recurrence. The need for interval appendectomy after
surgery compared with that after nonsurgical treatment was per-
a successful nonsurgical treatment has recently been ques-
formed.
tioned as the risk of recurrence is relatively small.2–7
Results: Appendiceal abscess or phlegmon is found in 3.8% (95%
After successful nonsurgical treatment of an appen-
confidence interval (CI), 2.6 – 4.9) of patients with appendicitis.
diceal mass, the true diagnosis is uncertain and an underlying
Nonsurgical treatment fails in 7.2% (CI: 4.0 –10.5). The need for
diagnosis of cancer or Crohn’s disease may be delayed. Some
drainage of an abscess is 19.7% (CI: 11.0 –28.3). Immediate surgery
authors therefore advocate immediate surgery with a right-
is associated with a higher morbidity compared with nonsurgical
sided hemicolectomy if needed, as the definitive treatment
treatment (odds ratio, 3.3; CI: 1.9 –5.6; P ⬍ 0.001). After successful
with acceptable morbidity.8 –12
nonsurgical treatment, a malignant disease is detected in 1.2% (CI:
Recently, the conditions for conservative management
0.6 –1.7) and an important benign disease in 0.7% (CI: 0.2–11.9)
of these patients has changed due to the development of
during follow-up. The risk of recurrence is 7.4% (CI: 3.7–11.1).
computerized tomography (CT) and ultrasound (US), which
Conclusions: The results of this review of mainly retrospective
has improved the diagnosis of enclosed inflammation and
studies support the practice of nonsurgical treatment without interval
made drainage of intra-abdominal abscesses easier. New
appendectomy in patients with appendiceal abscess or phlegmon.
efficient antibiotics have also given new opportunities for
nonsurgical treatment of appendicitis.
(Ann Surg 2007;246: 741–748) This report aims at reviewing the results of nonsurgical
treatment of patients with enclosed appendiceal inflamma-
tion, with emphasis on the success rate, the need for drainage
of abscesses, the risk of undetected serious disease, and the
need for interval appendectomy to prevent recurrence.

From the *Department of Surgery, University Hospital, Linköping, Sweden; MATERIALS AND METHODS
†Department of Surgery, County Hospital Ryhov, Jönköping, Sweden;
and ‡Nordic School of Public Health, Göteborg, Sweden. A Medline search with the profile “appendicitis AND
Correspondence: Roland Andersson, PhD, MD, Department of Surgery, (expectant OR expectantly OR nonsurgical OR nonsurgically
County Hospital Ryhov, SE 551 85 Jönköping, Sweden. E-mail: roland. OR conservative OR conservatively OR interval appendec-
andersson@lj.se. tomy OR froid OR mass OR resolving OR phlegmon)”
Reprints will not be available from the author.
Copyright © 2007 by Lippincott Williams & Wilkins identified 546 references, written in English, German, French,
ISSN: 0003-4932/07/24605-0741 Spanish, Italian, Swedish, Norwegian, or Danish, between
DOI: 10.1097/SLA.0b013e31811f3f9f January 1964 and December 2005. Based on the title and the

Annals of Surgery • Volume 246, Number 5, November 2007 741


Andersson and Petzold Annals of Surgery • Volume 246, Number 5, November 2007

TABLE 1. Studies Reporting the Proportion of Patients With Appendicitis Who Developed Enclosed Inflammation
No. With No. With Enclosed
Study Definition of Diagnosis Age Appendicitis Inflammation
Jordan et al, 198125 Palpable mass All 806 45 (5.6)
Thomas, 197326 Palpable mass All 501 37 (7.4)
Willemsen et al, 20027 Palpable mass All 2325 233 (10.0)
Gahukamble et al, 199327 Palpable mass Children 1853 66 (3.6)
Gästrin et al, 196928 Palpable mass Children 3191 59 (1.8)
Janik et al, 198029 Palpable mass Children 2589 37 (1.4)
Puri et al, 198130 Palpable mass Children 3677 158 (4.3)
Samuel et al, 200231 Palpable mass Children 740 82 (11.1)
Shipsey and O’Donnell, 198532 Palpable mass Children 834 77 (9.2)
Arnbjörnsson E, 198433 Palpable mass Adults 2214 48 (2.2)
Bradley and Isaacs, 197834 Palpable mass or abscess found at All 2621 68 (2.6)
exploration
Gibeily et al, 200335 Palpable mass or abscess/phlegmon shown All 313 32 (10.2)
by CT and ⬎2 d duration of symptoms
Hsia et al, 199536 Palpable mass and abscess shown by CT/US All 263 18 (6.8)
and ⬎3 d duration of symptoms
Karp et al, 198637 Palpable mass with no signs of peritonitis Children 485 12 (2.5)
and ⬎5 d duration of symptoms
Erdogan et al, 200538 Palpable mass or abscess/phlegmon shown Children 939 40 (4.2)
by US or at exploration
Elmore et al, 198721 Abscess found at exploration Children 233 10 (4.3)
Befeler, 196439 Abscess found at exploration Adults 586 49 (8.4)
Bufo et al, 199840 Abscess/phlegmon shown by CT or US or at Children 190 87 (45.8)
operation
Oliak et al, 200141 Abscess shown by CT Adults 2150 88 (4.1)
Kaminski et al, 200542 Patients with a discharge diagnosis of All 32.938 1.012 (3.1)
appendicitis without appendectomy
Pooled results Clinical diagnosis — 55.593 5.1 (3.5–6.8)
Diagnosis made with CT or US — 3.855 14.2 (⫺1.4 to 29.8)
Overall — 59.448 3.8 (2.6–4.9)
Values inside parentheses indicate percentages.

abstracts, potential reports were selected and the full text was mass or a circumscribed abscess by CT, US, or at surgical
analyzed to identify original studies that reported results after exploration of the abdomen. The analyses of the studies are
nonsurgical treatment for appendiceal phlegmon or abscess. where possible grouped according to how the diagnosis is done.
A total of 74 such original reports were identified. Seven of Failure of nonsurgical treatment is defined as the pa-
these were excluded because of double publishing.4,13–18 tients who are operated with appendectomy during the same
Another 5 studies were excluded because they reported re- hospital stay after an initial period of nonsurgical treatment.
sults from less than 10 patients.19 –23 One study from rural The proportion of patients treated with drainage is the pa-
Nigeria was judged not applicable to the western society.24 tients who had drainage of an abscess without appendectomy,
After these exclusions, there remain 61 studies for analysis. either percutaneously or by surgical exploration. The mor-
bidity includes postoperative infectious complications, intes-
Definitions tinal fistula, small bowel obstruction, and recurrence after
The analysis of the studies is hampered by incom- initially successful nonsurgical management. The length of
plete definitions and lack of information regarding the hospital stay on the primary hospital admission, at recurrence,
diagnosis and treatment, how the patients were selected for and at elective appendectomy is analyzed separately, if pos-
nonsurgical treatment, and the definition of failure of this sible. The risk of recurrence is analyzed from studies that did
treatment. The term “perforated appendicitis” is often used not apply interval appendectomy.
to describe a palpable appendiceal mass, an appendiceal
phlegmon, or a localized abscess without distinction. In Statistical Methods
this review, all these conditions are brought together as For all analyses, potential clustering on the study-level
appendicitis with enclosed inflammation. In the studies, the is taken into account via random coefficient (normal distri-
diagnosis of enclosed inflammation is made by the findings of bution) modeling. For confidence intervals (CIs) and statisti-
a palpable mass at clinical examination before or after anes- cal tests of differences, a logistic link is used for binary
thesia has been given, or by the findings of an inflammatory outcomes and an identity link is used for continuous out-

742 © 2007 Lippincott Williams & Wilkins


Annals of Surgery • Volume 246, Number 5, November 2007 Nonsurgical Treatment of Appendix Mass

TABLE 2. Results of Nonsurgical Management of Patients With an Enclosed Appendiceal Inflammation and the Numbers
With a Different Definite Diagnosis at Follow-Up, According to How the Diagnosis Was Made
Other Diagnoses at Follow Up
Study Age No. Pts. Drainage of Abscess Treatment Failure Malignant Benign
Palpable mass
Arnbjornsson, 198433 Adults 27 0 (0.0) 6 (22.2) 1 1
Foran et al, 197846 Adults 30 1 (3.3) 3 (10.0) 2 1
Hurme and Nylamo, 19953 Adults 69 0 (0.0) 5 (7.2) 1 3
Lewin et al, 198847 Adults 115 14 (12.2) 3 (2.6) 0 0
Thomas, 197326 Adults 37 2 (5.4) 1 (2.7) 0 0
Bülow et al, 197748 All 148 0 (0.0) 0 (0.0) 5 0
Engkvist, 197149 All 47 15 (31.9) 0 (0.0) 1 2
Gomez-Lorenzo et al, 198750 All 106 4 (3.8) 5 (4.7) 0 0
Hoffmann et al, 198451 All 59 10 (16.9) 2 (3.4) 2 1
Hoffmann et al, 199152 All 28 0 (0.0) 0 (0.0) 1 0
Marya et al, 199353 All 61 0 (0.0) 2 (3.2) 0 0
Mosegaard and Nielsen, 19792 All 79 3 (3.8) 0 (0.0) 4 4
Ein and Shandling, 20054 Children 96 63 (66.0) 5 (0.0) 0 0
Gahukamble et al, 199327 Children 59 2 (3.4) 0 (0.0) 0 0
Gahukamble and Gahukamble, 200054 Children 59 0 (0.0) 5 (8.5) 0 0
Gästrin and Josephson, 196928 Children 29 3 (10.3) 6 (20.7) 0 0
Gierup and Karpe, 197555 Children 52 13 (25.0) 0 (0.0) 1 1
Gillick et al, 200156 Children 411 27 (6.6) 18 (4.4) 0 0
Janik et al, 198029 Children 37 6 (16.2) 1 (2.7) 0 0
Karp et al, 198637 Children 12 0 (0.0) 0 (0.0) 0 0
Powers et al, 198157 Children 48 0 (0.0) 16 (33.3) 0 0
Puri et al, 198130 Children 31 2 (6.5) 0 (0.0) 0 0
Shipsey and O’Donnell, 198532 Children 77 4 (5.2) 4 (5.2) 0 0
Pooled results — — 9.5 (3.3–15.8) 5.8 (2.5–9.2) — —
Drained periappendiceal abscess
vanSonnenberg et al, 198758 All 17 17 (100) 0 (0.0) 0 0
Lasson et al, 200259 All 24 24 (100) 0 (0.0) 1 0
Pooled results — — 100% 0% — —
Abscess or phlegmon diagnosed by imaging
Bagi and Dueholm, 198760 Adults 40 17 (42.5) 3 (7.5) 0 0
Dixon et al, 200361 Adults 237 63 (26.6) 7 (2.9) 3 of 66 2 of 66
Brown et al, 200362 All 68 59 (86.8) 3 (4.4) 0 0
Gibeily et al, 200335 All 17 3 (17.6) 0 (0.0) 0 0
Hsia et al, 199536 All 18 0 (0.0) 10 (55.6) 0 0
Jeffrey et al, 198863 All 61 28 (45.9) 6 (9.8) 1 0
Paull and Bloom, 198264 All 42 32 (76.2) 0 (0.0) 2 0
Tingstedt et al, 20026 All 50 9 (18) 1 (2.0) 3 1
Bufo et al, 199840 Children 41 0 (0.0) 7 (17.1) 0 0
Erdogan et al, 200538 Children 21 0 (0.0) 0 (0.0) 0 0
*Kogut et al, 200144 Children 101 0 (0.0) 22 (21.8) 0 0
Samuel et al, 200231 Children 57 10 (17.5) 9 (15.8) 1 0
Weber et al, 200365 Children 25 6 (24.0) 9 (36.0) 0 0
Pooled results — — 27.6 (12.0–43.2) 13.0 (4.5–21.5)
Flegmone
*Garg et al, 199743 All 40 0 (0.0) 0 (0.0) 0 0
Karaca et al, 20015 Children 17 0 (0.0) 0 (0.0) 0 0
*Kumar and Jain, 200445 All 60 0 (0.0) 0 (0.0) 0 0
Adalla, 199666 All 30 0 (0.0) 3 (10.0) 0 1
Pooled results — — 0% 2.5 (⫺2.4 to 7.3) — —
Palpable mass or preoperatively found abscess
Bradley and Isaacs, 197834 All 55 48 (87.3) 0 (0.0) 0 0
Skoubo-Kristensen and Hvid, 198267 All 193 15 (7.8) 8 (4.1) 2 0
Pooled results — — 47.5 (⫺30.5 to 125.4)% 2.6 (⫺1.4 to 6.5) — —
Pooled results Table 2 — — 19.7 (11.0–28.3) 7.2 (4.0–10.5) 1.2 (0.6–1.7)% 0.7 (0.2–11.9)%
Values inside parentheses indicate percentages.
*Prospective studies.

© 2007 Lippincott Williams & Wilkins 743


Andersson and Petzold Annals of Surgery • Volume 246, Number 5, November 2007

5.1% (CI: 3.5– 6.8)兴, P ⫽ 0.048. It is also more common in


children than in adults as shown by the trend of 8.8% (CI:
0.6 –17.0) in children, 6.5% (CI: 4.2– 8.7) in patients of all
ages, and 4.8% (CI: 1.3– 8.4) in adults (P ⬍ 0.001).
Failure Rate of Nonsurgical Treatment and
Need for Drainage of Abscess
The results of primary nonsurgical treatment for en-
closed appendiceal inflammation are reported in 44 studies,
of which 3 are prospective (Table 2).43– 45 All studies report
a low-failure rate for nonsurgical treatment without appen-
dectomy, 4 of them even without giving antibiotics treatment.
The failure rate for all the studies in Table 2 is 7.2% (CI:
4.0 –10.5). No difference is seen in the failure rate depending
on the definition of the diagnosis, the age of the patients, or
between the prospective and the retrospective studies.
The proportion of patients in need for drainage of an
abscess is strongly related to how the diagnosis is made, with
100% in studies of patients selected because of a drained
FIGURE 1. Meta-analysis of the morbidity of nonsurgical abscess, 47.5% (CI: ⫺30.5 to 125.4) in patients with a
compared with that of immediate surgical treatment of con-
“palpable mass or preoperatively found abscess,” 27.6% (CI:
tained appendiceal inflammation.
12.0 – 43.2) in patients with an “abscess or phlegmon diag-
nosed by CT or US,” 9.5% (CI: 3.3–15.8) in patients with a
comes. In the analyses, percentages also were considered as palpable mass and no need for drainage in studies of patients
continuous in a few cases ending up with CIs outside 0% to with a phlegmon diagnosed by CT or US (P ⬍ 0.001). There
100%. For the meta-analysis, random-coefficient models is no association between the need for drainage and the
based on the DerSimonian and Laird method are used with patients’ age.
the estimate of heterogeneity being taken from the inverse
variance fixed effect model. Immediate Surgical Treatment Compared With
All analyses were done using Stata version 9.2. Given Nonsurgical Treatment
CIs are on the 95% level and a significant difference is stated The results of immediate surgical compared with those
on the 5% level. of nonsurgical treatment, eventually followed by interval
appendectomy, have been reported in 19 retrospective studies
RESULTS (Table 4 and Fig. 1). No details are presented about how the
selection between the 2 treatments was done.
Proportion of Patients With Appendicitis Who In these studies, nonsurgical treatment fails in 7.6%
Develop Enclosed Appendiceal Inflammation (CI: 3.2–12.0), which is close to the result of 7.2% (CI:
The proportion of all patients with appendicitis treated 4.0 –10.5) in the larger analysis in Table 2. The risk of
for enclosed inflammation is reported in 20 studies with a recurrence is 7.2% (CI: 3.2–11.0), which is slightly lower
total of 59.448 patients (Table 1). According to these studies, than the result of 7.4% (CI: 3.7–11.0) in the analysis of
the proportion of enclosed inflammation is 3.8% (CI: 2.6 – studies that did not practice interval appendectomy (Table
4.9). Enclosed inflammation is more common in studies 3). The mean length of stay after immediate surgery
where the diagnosis is based on CT or US than in studies compared with that after nonsurgical treatment was more
based on clinical diagnosis 关14.2% (CI: ⫺1.4 to 29.8) vs. than 1 day longer in 7 and more than 1 day shorter in 6

TABLE 3. Recurrence After Nonsurgically Treated Appendicitis in Studies That Did Not Practice Interval Appendectomy
Study Age Diagnosis No. Pts. Follow-Up (y) Recurrences
66
Adalla, 1996 All Phlegmon 30 Mean 1.3 (range 0.5–3) 2 (7.5)
Bagi and Dueholm, 198760 Adults Palpable resistance 40 Median 3.8 (range 0.4–9.3) 3 (7.5)
Ein Shandling, 19964 Children Palpable resistance 10 (range 0.5–13) 1 (10)
Engkvist, 197149 All Palpable resistance 41 (range 3–15) 3 (7.3)
Hoffmann et al, 198451 All Palpable resistance 59 (range 0.5–22) 9 (18.4)
Kaminski Liu, 200542 All Discharge diagnosis of appendicitis 864 Median 4 (range 0.5–12) 39 (5)
without appendectomy
Karaca et al, 20015 All Phlegmon 17 (range 1–7) 0 (0.0)
Pooled results — — 1.061 7.4 (3.7–11.0)
Values inside parentheses indicate percentages, unless specified otherwise.

744 © 2007 Lippincott Williams & Wilkins


TABLE 4. Results of Immediate Appendectomy and Primary Nonsurgical Treatment
Immediate Appendectomy Conservative Treatment
Authors
No. Hospital Stay Delayed Hospital Recommended
Study Age Pts. Hemicolectomy Morbidity (d) Nos. Failure Recurrence Diagnoses Morbidity Stay (d) Management
Palpable mass
Gomez-Lorenzo All 89 3 infl 48% 12.0 106 9 (8%) 14 (15%) — 13% 9.5 Cons
et al, 198750
Hoffmann et al, All 19 1 infl 53% 8 28 0 (0%) 2 (7%) — 7% 10 Cons
199152
Foran et al, 197846 Adults 13 1 infl, 1 CD 0% 7.5 30 4 (13%) 4 (15%) 2ca,1CD 23% 11 —

© 2007 Lippincott Williams & Wilkins


Arnbjornsson, Adult 21 1 ca, 1 CD 57% 6.5 27 6 (22%) 5 (24%) 1ca,1CD 30% 11 Immediate
198433
Lewin et al, 198847 Adults 95 5 infl, 1 ca 34% 12 98 3 (3%) 1 (1%) — 1 (⫹18)% 11 (⫹9) Cons
Hurme and Nylamo Adults 78 1 infl, 1 CD 28% 69 6 (9%) 0 (0%) 1ca,3CD 0% Cons
et al, 19953
Gästrin and Children 30 — 47% 15 29 6 (21%) 0 (0%) — 0% 11 (⫹6) Cons
Josephson,
196928
Powers et al, Children 100 — 22% 12.3 48 0 (0%) 0 (0%) — 8% 12.3* Cons
198157
Annals of Surgery • Volume 246, Number 5, November 2007

Puri et al, 198130 Children 16 — 69% 32.3 38 0 (0%) 1 (3%) — 24% 19.1 (⫹8.7) Cons
Karp et al, 198637 Children 88 — 6.8% 11.3 12 0 (0%) 1 (8%) — 8 (⫹8)% 12.5 (⫹4.8) Cons
Abscess or phlegmon
Paull et al, 198264 All 17 24% 14.9 42 0 (0%) 2 (5%) 1 ca 17 (⫹10)% 14.7 Cons
Tingstedt et al, All 43 5 infl 63% 7 (⫹2) 50 1 (2%) 4 (8%) 14% 5 (⫹1.5) Cons
20026
Gibeily et al, All 15 — 30% 7.8 17 0 (0%) 1 (6%) — 24% 6.1 (⫹2.5) Cons
200335
Oliak et al, 200141 Adults 67 — 38% 9.0 88 5 (6%) 7 (8%) — 22 (⫹9)% 9.0 Cons
Brown et al, Adults 36 — 67% 14.8 (⫹0.5) 68 3 (4%) 2 (3%) — 19% 9 (⫹1.7) Cons
200362
Bufo et al, 199840 Children 46 — 21% 6.2 41 7 (17%) 0 (0%) — 0 (⫹5)% 4.2 (⫹1.4) Cons
Samuel et al, Children 24 — 17% 4.8 57 9 (16%) 19 (40%) — 33% 10.7 (⫹2.6) Immediate
200231
Weber et al, Children 71 — 28% ⬃7 25 9 (36%) 0 (0%) — 12% ⬃10 Cons
200365
Erdogan et al, Children 18 — 22% 8.7 22 0 (0%) 2 (9%) — 9% 8.9 (⫹2.9) Cons
200538
Pooled results — — — 35.6 (26.9–44.2)% — — 7.6 (3.2–12.0)% 7.2 (3.2–11.0)% — 13.5 (8.8–18.1)% — —
⫹11.0
(5.5–15.4)

The causes for hemicoelctomy and delayed diagnosis are: infl indicates inflammation; CD, Crohn’s disease; and ca, cancer. Morbidity from the interval appendectomy is given within parentheses. Length of hospital stay relates
to the first admittance. Hospital stay for complications or interval appendectomy is given within parentheses.
*Hospital stay including all admittances.

745
Nonsurgical Treatment of Appendix Mass
Andersson and Petzold Annals of Surgery • Volume 246, Number 5, November 2007

studies. The reported data were too sparse for a formal Primary Nonsurgical Treatment Followed by
statistical analysis of the length of stay. Right-sided hemi- Delayed or Interval Appendectomy or Without
colectomy for suspicion of a malignant disease or for Appendectomy
technical reasons, but where only inflammatory changes The results of primary nonsurgical treatment followed
could be found at histopathologic examination, was re- by delayed appendectomy during the same hospital stay
ported in 17 of a total 493 adult patients. In all but 3 of the compared with those of interval appendectomy are reported
studies, the authors conclude that nonsurgical treatment is in 2 prospective, randomized trials and 1 retrospective study
to be recommended. (Table 5).43– 45,53 Delayed appendectomy is associated with
Immediate surgery is associated with morbidity in morbidity in 18.2% (CI: 7.7–28.7) compared with that in
35.6% (CI: 26.9 – 44.2) compared with that in 13.5% (CI: 12.4% (CI: 0.3–24.5) after interval appendectomy. The return
8.8 –18.1) with nonsurgical treatment and an additional to work took longer time for patients treated with interval
11.0% (CI: 5.5–15.4) after interval appendectomy (Table 4). appendectomy, mainly because the patients wanted to have
The risk of morbidity after immediate surgery compared with the planned interval appendectomy done before they were
that after nonsurgical treatment for the individual studies and willing to return to work.
a meta-analysis are given in Figure 1. Because of the heter- One prospective study randomized patients to primary
ogeneous results between the studies (heterogeneity test, P ⬍ nonsurgical treatment followed by delayed or interval or no
0.001), the meta-analysis is made according to a random appendectomy.45 The group with nonsurgical treatment with-
effects model. Surgical treatment is associated with a higher out appendectomy had the lowest morbidity and the shortest
morbidity with an odds ratio of 3.31 (CI: 1.95–5.61, P ⬍ length of stay. The authors’ conclusion was a recommenda-
0.001) according to the meta-analysis. A funnel plot did not tion for nonsurgical treatment with delayed appendectomy in
show any signs of publication bias. the 2 former studies, mainly because of the longer time to
Only 3 of 19 studies show a (nonsignificant) lower return to work with interval appendectomy, and nonsurgical
morbidity after immediate surgery. In the study by Foran et treatment without appendectomy in the latter study.
al, this is due to the combination of an unusual low morbidity
in the group of patients that had immediate surgery (0%) and
a relatively high proportion of missed diagnoses in the group The Risk of Missing Other Diagnoses
that received nonsurgical treatment (10%).46 In the small A total of 31 malignant and 17 benign diseases were
study by Karp et al, the slightly higher morbidity after identified during follow-up in 2771 patients (Table 2). Four
nonsurgical treatment is caused by only 1 patient who had a of these patients were under the age of 40 years—2 children
recurrence.37 In the study by Samuel et al, this is due to an had a carcinoid in the appendix, one 26-year-old woman had
unusual high frequency of recurrence, described as intermit- ovarian carcinoid, and one 25-year-old patient had gastric
tent abdominal pain or signs of a persistent appendiceal cancer. The remaining patients were all older than 40 years.
abscess at the planned interval appendectomy.31 A malignant disease was detected during follow-up in
The majority of the studies practiced elective interval 1.2% (CI: 0.6 –1.7). This risk was related to age at diagnosis
appendectomy after successful nonsurgical treatment. The with 0.2% (CI: 0.0 – 0.5) in children, 1.8% (CI: 0.9 –2.8) in
morbidity of interval appendectomy was reported in 5 studies studies of all ages, and 1.4% (CI: 0.1– 0 2.7) in adults (P ⬍
with a pooled value of 11.0% (CI: 5.5–15.4; Table 4). The 0.001). There was no difference in relation to how the
age of the included patients had no influence on the results. diagnosis was done.

TABLE 5. Comparison of Results of Nonsurgical Treatment With Delayed Versus Interval or No Appendectomy
Authors Conclusion
Study Treatment No. Pts. Morbidity Hospital Stay (d) About Best Treatment
Kumar and Jain, 200445 Nonsurgical ⫹ delayed op 20 30% 21.4 (8.5) Nonsurgical only
Prospective study Patients with No nonsurgical ⫹ interval op 20 0% 14.7 (2.9)*
phlegmon
All ages Nonsurgical only 20 0% 4.9 (1.5)
Garg et al, 199743 Prospective Nonsurgical ⫹ delayed op 20 10% 18.3 Nonsurgical ⫹ delayed op
study patients with palpable
mass
All ages Nonsurgical ⫹ interval op 20 15% 19.3
53
Marya et al, 1993 Retrospective Nonsurgical ⫹ delayed op 32 17% 15 Nonsurgical ⫹ delayed op,
study patients with palpable because of earlier return
mass to work
All ages Nonsurgical ⫹ interval op 29 21% 19.1*
Pooled results Nonsurgical ⫹ delayed op 72 18.2 (7.7–28.7) — —
Nonsurgical ⫹ interval op 69 12.4 (0.3–24.5)
*Length of hospital stay including all admittances.

746 © 2007 Lippincott Williams & Wilkins


Annals of Surgery • Volume 246, Number 5, November 2007 Nonsurgical Treatment of Appendix Mass

An important benign disease, mainly Crohn’s disease, The results must be interpreted with caution as they are
was detected in 0.7% (CI: 0.2–11.9) during follow-up after mainly based on retrospective case series and only 3 small
nonsurgical treatment (Table 2). This risk was related to age prospective randomized studies.
with 0.1% (CI: ⫺0.1 to 0.3) in children, 0.8% (CI: 0.0 –1.6)
in all ages, and 1.5% (CI: 0.1–2.9) in adults (P ⬍ 0.001; CONCLUSIONS
Table 2). There was no difference in relation to how the In patients with suspicion of contained appendiceal
diagnosis was done. inflammation, based on a palpable mass or long duration of
The Risk of Recurrence symptoms, the diagnosis should be confirmed by imaging
The risk of recurrence was estimated from 7 studies that techniques. The patient should receive primary nonsurgical
did not apply interval appendectomy. During follow-up, there treatment with antibiotics and drainage of abscesses as
were 58 recurrences in a total of 1061 patients (Table 3). The needed. After successful nonsurgical treatment, no interval
pooled estimate of the risk of recurrence was 8.9% (CI: appendectomy is indicated, but the patient should be in-
4.4 –13.3). The majority of recurrences occurred within 6 formed about the risk of recurrence. The risk of missing
months after the initial hospital stay. another underlying condition is low, but motivates a fol-
low-up with a colon examination and/or a CT scan or US,
especially in patients above the age of 40 years. However, the
DISCUSSION results should be interpreted with caution as it is mainly based
Circumscribed appendiceal inflammation is common on retrospective studies and only 3 small randomized trials.
and often undiagnosed preoperatively. The diagnosis can be
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Andersson and Petzold Annals of Surgery • Volume 246, Number 5, November 2007

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