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The appendiceal mass. Results of conservative management

Article  in  Annals of Surgery · December 1982

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Ivan Hvid
Oslo University Hospital


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The Appendiceal Mass

Results of Conservative Management


During a ten-year period 193 patients with an appendiceal From the Department of Surgery, County Hospital,
mass-and subsequently proved postinflammatory changes of University of Aarhus, Aarhus, Denmark.
the appendix-were treated conservatively. The course was
uneventful in 88%. Twelve per cent underwent delayed surgical
intervention caused by complications with one death. Elective
appendectomy was performed after three months with a com- antibiotic treatment changed through the period. Peni-
plication rate of 3.4%. In comparison with series with early
operation the conservative management seems to carry a lower cillin and streptomycin were given to most patients dur-
morbidity. The value of elective appendectomy is discussed. ing the first years; later on only patients with high tem-
perature or fever spikes received antibiotics. In later
r HE PRIMARY TREATMENT of an appendiceal mass years ampicillin and metronidazole were the preferred
or abscess may be either nonoperative or consist first-choice antibiotics. The patients stayed in hospital
of surgical drainage plus appendectomy if possible. until the mass was reduced to a small nontender lump
Whatever method is preferred, the question of interval or had disappeared. As a rule interval appendectomy
appendectomy becomes pertinent in most cases. Recent was contemplated to take place three months after the
reports on operative management suggest a high rate of end of primary hospitalization.
complications." 2 This has prompted the authors to re- All patients files from the period 1970 to 1979 car-
view the results of appendiceal abscess treated during rying a diagnosis of appendiceal abscess were reviewed.
the last decade in this department, where the treatment As the authors were interested in the outcome of con-
for many years has been nonoperative followed by a servative treatment, not in diagnostic problems, only
scheduled appendectomy. patients with confirmed sequelae of appendicular in-
flammation are reported in this study, criteria for en-
Methods and Patients tering being clear macroscopic or microscopic pathology
or both in addition to the above mentioned clinical find-
Appendiceal abscess was diagnosed in patients with ings. Two hundred and two patients were identified for
a history of fever and right lower quadrant pain when review. The institution serves a predominantly urban
a mass could be felt in the right lower quadrant or by area with approximately 150,000 inhabitants. The mean
rectal examination. Mature female patients had a gyne- incidence of appendiceal mass with verified sequelae of
cologic examination on admission, and repeatedly if appendicitis was thus 13 per year per 100,000 inhabit-
necessary, to rule out inflammatory or neoplastic disease ants.
of the internal genital organs. Bed rest was obligatory
until subsidence of fever, significant reduction of ESR, Results
and reduction of the size of the palpable mass. Naso-
gastric suction and intravenous fluids were used when Age and sex distribution of the 202 patients (92 males
the patient was nauseated or showed other signs of in- and 110 females) is shown in Figure 1. The youngest
testinal paralysis. Opium for constipation was widely patient was three years and the eldest 86 years old.
used in the first years of the period. The attitude toward Maximum incidence was in the second decade. Sixty-
five patients (32.2%) had symptoms prior to admission
for three days or less, and 82 (40.6%) had a history of
Reprint requests: E. Skoubo-Kristensen, M.D., Department of Sur- one week or more (Fig. 2).
gery, Aarhus Amtssygehus, DK-8000 Aarhus C, Denmark. All but nine patients presented with an abdominal or
Submitted for publication: January 12, 1982. pelvic mass identified at the admission or during the
0003-4932/82/1100/0584 $01.00 © J. B. Lippincott Company
first days in hospital. The nine patients are included in
the study because an abscess was found at a primary
operation in seven cases and at interval appendectomy
in two cases.
Most patients (93%) had elevated ESR. WBC was not
routinely taken. Temperature did not exceed 38 C in
13% of the patients, while 55% experienced febrile ep- ta
isodes with temperature above 39 C.
Antibiotics in various combinations were adminis-
tered to 138 patients (68.3%) as part of the primary treat- 0

ment. -o

The treatment is summarized in Table 1. Nine pa- E

tients were primarily operated on in suspicion of another -z
diagnosis. Three patients had nothing further done after
recognition of the appendiceal mass, leaving the masses
to spontaneous resolution, and two patients were treated
by appendectomy without drainage. Four patients had
a right hemicolectomy performed because of difficulty
in differentiating the mass from a malignant lesion. Sub- 1 2 3 4 5 6 7 or more Days
sequent histologic examination gave evidence of inflam- FIG. 2. Duration of symptoms before admission to hospital.
mation in every case, but confirmed a neoplastic disease,
a benign carcinoid, in one case only.
perforation of the abscess to the peritoneal cavity. This
Nonoperative treatment was started in 193 patients complication is very serious and often fatal; the devel-
of which 170 patients (88%) experienced an uneventful opment in this case was long and difficult.
course and were discharged after median 13 days of
hospitalization (interquartile range: 10-17 days, range: Recurrences
3-52 days).
In 23 patients (1 1.9%) a delayed operation was nec- Before the scheduled appendectomy, 12 out of the
essary because of complications during conservative 170 patients discharged after conservative treatment
treatment, as listed in Table 2. An 86-year-old woman were readmitted to hospital with a recurrent mass in
died a few days after surgical drainage, as a result of a eight cases and acute appendicitis without a mass in four
large retroperitoneal and abdominal abscess-in fact the cases, a recurrence rate of 7.1% within three months.
only death in the series-a mortality rate of 0.5%. An- One patient with the appendix mass during pregnancy
other patient developed a fecal fistula that persisted for did not come to appendectomy after delivery as rec-
seven months until surgical closure. A third patient had ommended, but returned with a recurrent mass after 15
a reoperation the day after the tubulation because of months. Eight patients were again treated nonopera-
tively with resolution of the mass. Five patients under-
went an uncomplicated appendectomy.
Interval Appendectomy
El 6' N= 92 A total of 179 patients underwent an interval appen-
35 dectomy, out of which six patients experienced com-
c 30 9 N= 110 plications, a rate of 3.4%. Four patients had wound in-
fections, one had recurrent abscess and fistula, and one
25 had small bowel obstruction. Median time in hospital


E 15 TABLE 1. Treatment of Patients with an Appendiceal Mass


;z No. of
Treatment Patients
Primarily operated 9
Completed nonoperative treatment 170
0 10 20 30 40 50 60 70 80 90 Age in years Delayed operated 23
Total 202
FIG. 1. Age and sex distribution.
586 SKOUBO-KRISTENSEN AND HVID Ann. Surg. November 198f

TABLE 2. Delayed Surgical Intervention in 23 Unsuccessful Conservatively Treated Cases

No. of
Patients Indication Treatment Secondary Complications
6 Small bowel obstruction All lysis + appendectomy 1 Douglas abscess + pleuropneumonia
(+ drainage 2, - drainage 4) 1 bleeding gastric ulceration
- gastrectomy - subphrenic abscess
8 Sepsis + unresolved abscess All drainage + elective appendectomy 1 diffuse peritonitis after drainage operation
1 fecal fistula
6 Unresolved abscess All drainage + 5 elective appendectomy 1 death
3 Suspicion of perforation of abscess 1 appendectomy 1 subphrenic abscess
(1 verified) I drainage + app.
1 drainage + elective app.

for this procedure was five days (interquartile range: 5- been reported in children.7'8 In the old-age group, all did
7 days, range: 3-40 days). well in Thomas' study,5 but in the present study five out
Microscopic examination of the removed appendices of seven patients past 70 years of age underwent a de-
revealed seven with mucocele and two with benign car- layed operation because of failure of the conservative
cinoid tumors. Simple inflammatory changes were management.
found in 154 specimens. The microscopy was normal The mortality has been decreasing through this cen-
in three cases and was not done in 13 cases, but in these tury. In this series there was one death (0.5%), and no
cases macroscopic changes consistent with previous peri- fatalities connected to interval appendectomy. Mortal-
appendiceal inflammation was recorded at the opera- ity in recent studies on operative treatment is
tion. equally low.",2'4
The authors consider resorting to operation after start-
Discussion ing conservative treatment to be a complication, which
amounted to 12% in this series. In a recent paper by
Reports on conservative vs. early operative treatment Jordan et al.2 on surgical treatment, the overall com-
of appendiceal mass and abscess are difficult to compare plication rate was 36%, but about 50% in the abscess
and, certainly, no single prospective and randomized group, and 21% in the group with phlegmons. This study
trial has been carried out to clarify the possible superi- is comparable to the authors', the criterion for entering
ority of any of these treatment plans. One main problem the study being appendicitis with a palpable mass. In
in comparing existing retrospective results is the lack of another study of surgical drainage, the complication rate
consistency in using the terms appendiceal mass and was 28%.' These figures may suggest that conservative
appendiceal abscess. As emphasized by McPherson and treatment carries a lower morbidity, yet Foran et al.
Kinmonth,3 the two terms are not synonymous, appen- showed no significant complications and good results
diceal mass thus signifying a palpable lump around an with either form of therapy,9
inflamed appendix, that at operation might turn out to One advantage generally accepted with operative
be either a phlegmon with adherent adjacent organs or treatment is a somewhat shorter stay in hospital. The
a definite abscess. Studies of conservative management median total stay (including exacerbations and admit-
deal with both conditions, while most studies of early tance for interval appendectomy) in the 193 conserva-
operation deal with the stage of abscess formation. Clin- tively treated cases was 21 days. With early operation
ically it is not possible in most cases to distinguish with Bradley and Isaacs found an average hospital stay of 17
certainty between the two conditions, but in two recent days for primary operative treatment, and five days for
reports about half of the patients presenting with a mass interval appendectomy, while Jordan et al. found an
proved to have phlegmons at surgery.24 In this way it average hospital stay of 16 days.
becomes uncertain to what extent definite abscesses re- The benefit of interval appendectomy has been ques-
solve spontaneously or need incision. It remains to -be tioned in several recent studies. 10-2 The argument is
shown if ultrasonography might clarify this point as pro- that therapeutic gain (avoidance of recurrences, identi-
posed.2 fication of malignant, and potentially malignant lesions)
Eighty-eight per cent of the patients in this study did is minimal (about 10% of patients) and contrasting to
well on conservative treatment, which is in accordance an unduly high rate of complications to the appendec-
with other investigators.3'5'6 A similar success rate has tomy (13-19%). However, there is a wide variation in
Vol. 196 * No. 5 APPENDICEAL MASS 587

the rate of recurrent appendicitis after an attack of ap- References

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1978; 113:130-132.
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