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The appendiceal mass. Results of conservative management

Article  in  Annals of Surgery · December 1982

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The Appendiceal Mass
Results of Conservative Management
ERIK SKOUBO-KRISTENSEN, M.D., IVAN HVID, M.D.
During a ten-year period 193 patients with an appendiceal
mass-and subsequently proved postinflammatory changes of
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-
plication rate of 3.4%. In comparison with series with early
operation the conservative management seems to carry a lower
morbidity. The value of elective appendectomy is discussed.
r HE PRIMARY TREATMENT of an appendiceal mass
or abscess may be either nonoperative or consist
of surgical drainage plus appendectomy if possible.
Whatever method is preferred, the question of interval
appendectomy becomes pertinent in most cases. Recent
reports on operative management suggest a high rate of
complications." 2 This has prompted the authors to re-
view the results of appendiceal abscess treated during
the last decade in this department, where the treatment
for many years has been nonoperative followed by a
scheduled appendectomy.
Methods and Patients
Appendiceal abscess was diagnosed in patients with
a history of fever and right lower quadrant pain when
a mass could be felt in the right lower quadrant or by
rectal examination. Mature female patients had a gyne-
cologic examination on admission, and repeatedly if
necessary, to rule out inflammatory or neoplastic disease
of the internal genital organs. Bed rest was obligatory
until subsidence of fever, significant reduction of ESR,
and reduction of the size of the palpable mass. Naso-
gastric suction and intravenous fluids were used when
the patient was nauseated or showed other signs of in-
testinal paralysis. Opium for constipation was widely
used in the first years of the period. The attitude toward
Reprint requests: E. Skoubo-Kristensen, M.D., Department of Sur-
gery, Aarhus Amtssygehus, DK-8000 Aarhus C, Denmark.
Submitted for publication: January 12, 1982.
0003-4932/82/1100/0584 $01.00 © J. B. Lippincott Company
584
From the Department of Surgery, County Hospital,
University of Aarhus, Aarhus, Denmark.
antibiotic treatment changed through the period. Peni-
cillin and streptomycin were given to most patients dur-
ing the first years; later on only patients with high tem-
perature or fever spikes received antibiotics. In later
years ampicillin and metronidazole were the preferred
first-choice antibiotics. The patients stayed in hospital
until the mass was reduced to a small nontender lump
or had disappeared. As a rule interval appendectomy
was contemplated to take place three months after the
end of primary hospitalization.
All patients files from the period 1970 to 1979 car-
rying a diagnosis of appendiceal abscess were reviewed.
As the authors were interested in the outcome of con-
servative treatment, not in diagnostic problems, only
patients with confirmed sequelae of appendicular in-
flammation are reported in this study, criteria for en-
tering being clear macroscopic or microscopic pathology
or both in addition to the above mentioned clinical find-
ings. Two hundred and two patients were identified for
review. The institution serves a predominantly urban
area with approximately 150,000 inhabitants. The mean
incidence of appendiceal mass with verified sequelae of
appendicitis was thus 13 per year per 100,000 inhabit-
ants.
Results
Age and sex distribution of the 202 patients (92 males
and 110 females) is shown in Figure 1. The youngest
patient was three years and the eldest 86 years old.
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
one week or more (Fig. 2).
All but nine patients presented with an abdominal or
pelvic mass identified at the admission or during the
VOl. 196 * NO. 5 APPENDICEAL MASS 585
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
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-
sequent histologic examination gave evidence of inflam-
mation in every case, but confirmed a neoplastic disease,
a benign carcinoid, in one case only.
Nonoperative treatment was started in 193 patients
of which 170 patients (88%) experienced an uneventful
course and were discharged after median 13 days of
hospitalization (interquartile range: 10-17 days, range:
3-52 days).
In 23 patients (1 1.9%) a delayed operation was nec-
essary because of complications during conservative
treatment, as listed in Table 2. An 86-year-old woman
died a few days after surgical drainage, as a result of a
large retroperitoneal and abdominal abscess-in fact the
only death in the series-a mortality rate of 0.5%. An-
other patient developed a fecal fistula that persisted for
seven months until surgical closure. A third patient had
a reoperation the day after the tubulation because of
45
40
El 6' N=
35
c 30 9 N= 110
a)
25
0
-z
1 2 3 4 5 6 7 or more Days
FIG. 2. Duration of symptoms before admission to hospital.
perforation of the abscess to the peritoneal cavity. This
complication is very serious and often fatal; the devel-
opment in this case was long and difficult.
Recurrences
Before the scheduled appendectomy, 12 out of the
170 patients discharged after conservative treatment
were readmitted to hospital with a recurrent mass in
eight cases and acute appendicitis without a mass in four
cases, a recurrence rate of 7.1% within three months.
One patient with the appendix mass during pregnancy
did not come to appendectomy after delivery as rec-
ommended, but returned with a recurrent mass after 15
months. Eight patients were again treated nonopera-
tively with resolution of the mass. Five patients under-
went an uncomplicated appendectomy.
Interval Appendectomy
92 A total of 179 patients underwent an interval appen-
dectomy, out of which six patients experienced com-
plications, a rate of 3.4%. Four patients had wound in-
fections, one had recurrent abscess and fistula, and one
had small bowel obstruction. Median time in hospital

1K

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

Li

;z No. of
10
Treatment Patients
5
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
9

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-
7 days, range: 3-40 days).
Microscopic examination of the removed appendices
revealed seven with mucocele and two with benign car-
cinoid tumors. Simple inflammatory changes were
found in 154 specimens. The microscopy was normal
in three cases and was not done in 13 cases, but in these
cases macroscopic changes consistent with previous peri-
appendiceal inflammation was recorded at the opera-
tion.
Discussion
Reports on conservative vs. early operative treatment
of appendiceal mass and abscess are difficult to compare
and, certainly, no single prospective and randomized
trial has been carried out to clarify the possible superi-
ority of any of these treatment plans. One main problem
in comparing existing retrospective results is the lack of
consistency in using the terms appendiceal mass and
appendiceal abscess. As emphasized by McPherson and
Kinmonth,3 the two terms are not synonymous, appen-
diceal mass thus signifying a palpable lump around an
inflamed appendix, that at operation might turn out to
be either a phlegmon with adherent adjacent organs or
a definite abscess. Studies of conservative management
deal with both conditions, while most studies of early
operation deal with the stage of abscess formation. Clin-
ically it is not possible in most cases to distinguish with
certainty between the two conditions, but in two recent
reports about half of the patients presenting with a mass
proved to have phlegmons at surgery.24 In this way it
becomes uncertain to what extent definite abscesses re-
solve spontaneously or need incision. It remains to -be
shown if ultrasonography might clarify this point as pro-
posed.2
Eighty-eight per cent of the patients in this study did
well on conservative treatment, which is in accordance
with other investigators.3'5'6 A similar success rate has
been reported in children.7'8 In the old-age group, all did
well in Thomas' study,5 but in the present study five out
of seven patients past 70 years of age underwent a de-
layed operation because of failure of the conservative
management.
The mortality has been decreasing through this cen-
tury. In this series there was one death (0.5%), and no
fatalities connected to interval appendectomy. Mortal-
ity in recent studies on operative treatment is
equally low.",2'4
The authors consider resorting to operation after start-
ing conservative treatment to be a complication, which
amounted to 12% in this series. In a recent paper by
Jordan et al.2 on surgical treatment, the overall com-
plication rate was 36%, but about 50% in the abscess
group, and 21% in the group with phlegmons. This study
is comparable to the authors', the criterion for entering
the study being appendicitis with a palpable mass. In
another study of surgical drainage, the complication rate
was 28%.' These figures may suggest that conservative
treatment carries a lower morbidity, yet Foran et al.
showed no significant complications and good results
with either form of therapy,9
One advantage generally accepted with operative
treatment is a somewhat shorter stay in hospital. The
median total stay (including exacerbations and admit-
tance for interval appendectomy) in the 193 conserva-
tively treated cases was 21 days. With early operation
Bradley and Isaacs found an average hospital stay of 17
days for primary operative treatment, and five days for
interval appendectomy, while Jordan et al. found an
average hospital stay of 16 days.
The benefit of interval appendectomy has been ques-
tioned in several recent studies. 10-2 The argument is
that therapeutic gain (avoidance of recurrences, identi-
fication of malignant, and potentially malignant lesions)
is minimal (about 10% of patients) and contrasting to
an unduly high rate of complications to the appendec-
tomy (13-19%). However, there is a wide variation in
Vol. 196 * No. 5 APPENDICEAL MASS
the rate of recurrent appendicitis after an attack of ap-
pendiceal abscess. Bauer reviewed the earlier literature
in 1933, and found the frequency to vary between 10%
and 46%, but only 9.7% in his own study with a long
follow-up.'3 In a contemporary study Engkvist reported
a recurrence rate of 7% with a follow-up period from
three to 15 years. Generally quite many recurrences take
place within the first months of the convalescence, and
cannot be prevented unless the interval before elective
appendectomy is a few weeks. On the other hand the
inflammatory changes may not have subsided at that
time, and more complications to this procedure might
be anticipated. In this series the rate of complications
was low, 3.4%, and it seems that some of the compli-
cations noted by others are so harmless that interval
appendectomy should not be rejected on that account.
The following conclusions were made: (1) conserva-
tive management of appendiceal mass is successful in
most cases and the complication rate seems lower than
with early operative treatment; and (2) complications
to elective appendectomy can be kept to a minimum,
but the therapeutic gain of this procedure remains ques-
tionable.
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587
References
1. Bradley EL, Isaacs J. Appendiceal abscess revisited. Arch Surg
1978; 113:130-132.
2. Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpable
mass. Ann Surg 1981; 193:227-229.
3. McPherson AG, Kinmonth JB. Acute appendicitis and the ap-
pendix mass. Br J Surg 1945; 32:365-370.
4. Vakili C. Operative treatment of appendix mass. Am J Surg 1976;
131:312-314.
5. Thomas DR. Conservative management of the appendix mass.
Surgery 1973; 73:677-680.
6. Lehman EP, Parker WH. The treatment of intraperitoneal abscess
arising from appendicitis. Ann Surg 1938; 108:833-856.
7. Gierup J, Karpe B. Aspects on appendiceal abscess in children
with special reference to delayed appendectomy. Acta Chir
Scand 1975; 141:801-803.
8. Janik JS, Ein SH, Shandling B, Simpson JS, Stephens CA. Non-
surgical management of appendiceal mass in late presenting
children. J Pediat Surg 1980; 15:574-576.
9. Foran B, Berne TV, Rosoff L. Management of the appendiceal
mass. Arch Surg 1978; 113:130-132.
10. Engkvist 0. Appendectomy a froid a superfluous routine opera-
tion? Acta Chir Scand 1971; 137:797-800.
11. Bulow S, Christoffersen I, Olsen JH. Appendectomi a froid.
Ugeskr Lag 1977; 139:1120-1122.
12. Mosegaard A, Nielsen OS. Interval appendectomy, a retrospective
study. Acta Chir Scand 1979; 145:109-111.
13. Bauer G. Zur Behandlung der Appendicitis-Peritonitis. Acta
Chir Scand 1933; Suppl 24:486-495.