Appendiceal mass: Is interval appendicectomy “something of the past”?

Management of Inflammatory Phlegmon in Appendicitis: Comparing the Role of Emergency vs. Interval Appendectomy at a Single Institution

Background Acute appendicitis remains a common surgical pathology, with the accepted standard of care being appendectomy. However, in cases of acute appendicitis complicated by an inflammatory phlegmon, a dilemma remains regarding the best management options. The aim of our study was to examine the outcomes for patients with an appendiceal phlegmon, comparing emergency appendectomy with those who had initial conservative management followed by subsequent interval appendectomy. Methods We performed a retrospective analysis of all patients diagnosed with acute appendicitis with inflammatory phlegmon (January 2012 to December 2022), looking into the outcomes of patients managed with emergency appendectomy versus conservative management and subsequent interval appendectomy. Results A total of 127 patients were included in our study: 85 (66.9%) underwent emergency appendectomy, and 42 (33.1%) underwent interval appendectomy. Patients who underwent emergency appendectomy had a significantly shorter duration of symptoms compared to those undergoing interval appendectomy (two vs. seven days). Furthermore, there was a higher likelihood of either a partial cecectomy or ileocolic/right hemicolectomy in those undergoing emergency appendectomy (p=0.021). However, there was no difference in 30-day morbidity or mortality. Conclusion This study highlights the challenges in managing appendiceal phlegmons. We propose that interval appendectomies should be considered for patients who present with extensive phlegmonous appendicitis and a prolonged duration of symptoms.

Pediatric Appendectomy: Optimal Surgical Timing and Risk Assessment

Appendicitis is one of the most common pediatric surgical problems. In the older surgical paradigm, appendectomy was considered to be an emergent procedure; however, with changes to resident work hours and other economic factors, the operation has evolved into an urgent and deliberately planned intervention. This paradigm shift in care has not necessarily seen universal buy-in by all stakeholders. Skeptics worry about the higher incidence of complications, particularly intra-abdominal abscess (IAA), associated with the delay to appendectomy with this strategy. Development of IAA after pediatric appendectomy greatly burdens the healthcare system, incapacitates patients, and limits family functionality. The risk factors that influence the development of IAA after appendectomy were evaluated in 220 children admitted to a large urban teaching hospital over a recent 1.5-year period. Preoperative risk factors included in the study were age, sex, weight, ethnicity, duration and nature of symptoms, white cell count, and ultrasound or computed tomography scan findings (appendicolith, peritoneal fluid, abscess, phlegmon), failed nonoperative management, antibiotics administered, and timing. Intraoperative factors included were timing of appendectomy, surgical and pathological findings of perforation, open or laparoscopic procedure, and use of staple or Endoloop to ligate the appendix. Postoperative factors included were duration and type of antibiotic therapy. There were 94 (43%) perforated and 126 (57%) nonperforated appendicitis during the study period. The incidence of postoperative IAA was 4.5 per cent (nine of 220). Children operated on after overnight antibiotics and resuscitation had a significantly lower risk of IAA as compared with children managed by other strategies ( P < 0.0003). Of the preoperative factors, only the presence of a fever in the emergency department ( P < 0.001) and identification of complicated appendicitis on imaging ( P < 0.0001) were significant risk factors for postoperative abscess development. Perforated appendicitis carries a higher risk of development of IAA that is not reduced by an emergent operative or delayed nonoperative management strategy. The timing of appendectomy appears to be an extremely important factor in reducing the incidence of IAA after all presentations of appendectomy. The role of resuscitation and antibiotics in limiting the effects of the inflammatory cascade and development of laboratory markers that accurately measure the latter need to be the focus of further research in this field.

Comparison of treatment methods of appendiceal mass and abscess: A prospective Cohort Study

BACKGROUND

The aim of our prospective study is to compare and analyze the results of two treatment methods of appendiceal mass and abscess: emergency surgery and conservative treatment with and without interval surgery.

MATERIALS AND METHODS

74 Patients with the diagnosis of appendiceal mass or abscess were enrolled in this study. The patients were assigned into two groups: the emergency surgery group and the conservative management group. The conservative management group was subdivided into two groups: interval surgery group and the ambulatory follow-up observation group without interval surgery. Several clinical characteristics were determined and compared between the groups. Among patients who underwent surgery, the surgical methods, operation time, postoperative hospitalization period, and post-surgical complications were analyzed. In the ambulatory follow-up observation group, recurrence of appendicitis was assessed.

RESULTS

Comparison of the emergency surgery group and interval surgery group revealed that the interval surgery group was characterized by shorter operation time (P = 0.008), a smallernumber of postoperative complications (P = 0.02) and also shorter postoperative hospital stay (P = 0.009). In the ambulatory follow-up observation group, recurrence of appendicitis developed in 3 (13%) patients. US or CT-guided PCD was performed in all 3 patients on the conservative treatment stage. Comparing the interval surgery and recurrent appendicitis groups revealed statistically significant difference: operation time (P = 0.04) as well as postoperative hospital stay (P = 0.04) were shorter in recurrent appendicitis group. In 3 (4.1%) patients, the cause of the appendiceal mass was caecal cancer (2 cases) and Crohn's disease.

CONCLUSION

Conservative treatment without interval surgery seems to be the preferred method for treatment of appendiceal mass and abscess. Patients can be operated on only in case of recurrence of appendicitis. US or CT PCD of appendiceal abscess presents the risk-factor for the development of recurrence of appendicitis. CT and colonoscopy within 4-6 weeks after completing the conservative treatment is recommended to be performed in all patients.

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

A study on evaluation of laparoscopic surgical approach for pediatric appendix abscess

BACKGROUND

The main objective of this study was to investigate and compare chosen time laparoscopic surgery to traditional open surgery and to analyze whether laparoscopic surgery is safe and feasible for pediatric appendix abscess in emergency.

METHODS

This retrospective study consisted of three groups of patients designated as group A, group B, group C and the preoperative and postoperative clinical characteristics were analyzed and compared. Group A comprised of 63 patients of appendix abscess which has been treated by laparoscopic surgery from January 2011 to December 2014. Group B comprised of 60 patients who had undergone pediatric appendix abscess laparotomy and group C comprised of 35 cases who had undergone time-selective laparoscopic appendix ablation surgery after receiving anti-inflammatory treatment.

RESULTS

The average operation time during which all the appendix ablated successfully between group A and group B patients was not significantly different (P>0.05), meanwhile, operation time was significantly less for group C patients in comparison with group A patients (P<0.05). The incidence of postoperative complications among patients of group A was significantly lower than that of group B (P<0.05), while, these complications were similarly distributed between group A and group C (P>0.05). The duration of hospitalization among patients of group B (P<0.05) and group C (P<0.05) was significantly higher in comparison with group A patients.

CONCLUSIONS

As long as preoperative and perioperative periods are appropriately dealt with, laparoscopic surgery is safe and feasible to pediatric appendix abscess in emergency.

Early laparoscopic management of appendicular mass in children: Still a taboo, or time for a change in surgical philosophy?

INTRODUCTION:

Early appendicectomy has been found to be a safe and better alternative for management of appendicular mass in various studies in adults, while very few studies report such advantages in the paediatric population. We conducted this study to assess the safety, efficacy and need of early laparoscopic appendicectomy (ELA) in child patients with appendicular mass.

MATERIALS AND METHODS:

All patients with appendicular mass who underwent ELA at our institute between September 2011 and August 2014 were retrospectively reviewed. Appendicular mass was defined as a right iliac fossa mass in a case of acute appendicitis, diagnosed by clinical, laboratory and radiological evaluation, and palpation under anaesthesia, the patient being subjected to laparoscopic treatment.

RESULTS:

Forty-eight (48) patients were confirmed to have appendicular mass intraoperatively and were included in the analysis. There were 30 males and 18 females, with ages ranging 7-13 years (mean 9 years). In the present study, appendicular complications included appendicular abscess (62.5%), gangrenous appendicitis (25%), sloughed-out appendix (8.33%) and appendicular perforation (4.16%). The average operative time was 72 min (range 45-93 min). One case (1.92%) required conversion to open procedure due to failure of identification of the appendicular base of a sloughed-out appendix. Post-operative complications were found in 4 (7.69%) patients, of whom 3 (5.76%) had minor wound infection at the umbilical port site and 1 (1.92%) had post-operative pelvic abscess, which was managed with percutaneous aspiration.

DISCUSSION:

ELA avoids misdiagnosis, treats complicated appendicitis at its outset, and avoids complications and/or failure of non-operative treatment of a potentially lethal, diseased appendix. This approach is associated with minimal complications in experienced hands and is a safe and feasible option in children with appendicular mass.

Management of Appendiceal Mass and Abscess. An 11-Year Experience

The aim of our study is to compare the results of emergency surgery versus conservative treatment with interval surgery in patients diagnosed with appendiceal mass and abscess. A retrospective review of 48 patients with appendiceal mass and abscess treated from January 2002 to January 2013 at General Surgery Department of Kipshidze Central University Hospital was performed. Patients with emergency surgery were compared to patients treated by nonoperative management with interval surgery. Demographics, clinical profile, and operative outcomes were studied. The emergency surgery group included 25 patients, and the interval surgery group included 23 patients. The clinical characteristics of the emergency surgery and interval surgery groups were not statistically different. In the emergency surgery group, an open appendectomy was performed on 17 patients, and colonic resections (ileocecectomy or right hemicolectomy) were performed on 8 patients. In the interval surgery group, an open appendectomy was performed on 21 patients, and colonic resections were performed on 2 patients. There were no statistical differences in types of surgery, postoperative complications, operation time without colonic resections, and postoperative hospitalization period among these 2 groups. Operation time with colonic resections was of greater duration in the emergency surgery group than in the interval surgery group (P = 0.04). Both treatment methods for appendiceal mass and abscess have the same results. The surgeon must consider clinical symptoms and results of investigations in each particular case when choosing an appropriate treatment method. Prospective randomized controlled trials are required for comparing the results of all 3 treatment methods of appendiceal mass.

Inflammatory appendix mass in patients with acute appendicitis: CT diagnosis and clinical relevance

The purpose of our study was to analyze the clinical relevance of computerized tomography (CT) in providing the diagnosis of inflammatory appendix mass (IAM) in patients with acute appendicitis. The CT images of 134 patients were reviewed. Two groups of patients were made according to the presence (group 1; n = 21) or the absence (group 2; n = 113) of IAM. Clinical signs of patients, CT features, complications at surgery, and histological examinations were noted. Inter-observer agreement was assessed by using kappa statistics. Twenty-one patients presenting with CT features of IAM were diagnosed. An excellent inter-observer agreement (κ = 0.94) was assessed for the diagnosis of IAM. No significant statistical difference in the age distribution was observed between patients with IAM (mean age 55) and patients without (mean age 45) (p = 0.2232). No clinical sign showed a statistically significant association with the presence of IAM (p = 0.707) or with complication encountered at surgery (p = 0.180). Delay to CT examination was 5.4 days in patients presenting with CT features of IAM and of 1.7 days for patients presenting without (p = 0.0001). Conversely to acute appendicitis complicated by simple perforation (p = 0.153) or peri-appendicular abscess (p = 0.501), acute appendicitis presenting with IAM showed a statistically significant association with complications encountered at surgery (p = 0.0003) and the need for conversion to open surgery (p = 0.001). Performing CT in complicated acute appendicitis provides the diagnosis of IAM. Distinction of IAM appeared to be of clinical relevance, since immediate surgery in IAM was statistically associated with surgical complications and conversion to open surgery in our study.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

What is the optimal treatment for appendiceal mass formed after acute perforated appendicitis

We read with great interest the editorial article by Meshikhes AWN published in issue 25 of World J Gastroenterol 2011. The article described the advantages of emergency laparoscopic appendectomy compared with interval appendectomy as a new safe treatment modality for the appendiceal mass. The author concluded that the emergency laparoscopic appendectomy was a safe treatment modality for the appendiceal mass, and might prove to be more cost-effective than conservative treatment, with no need for interval appendectomy. However, we would like to highlight certain issues regarding the possibility of percutaneous catheter drainage to successfully treat the appendiceal mass, with no need for appendectomy, too.