الدكتور جليل العبيدي من رموز الأطباء العراقيين المعاصرين
Early appendectomy in appendicular mass
Dr. Jaleel Hussein Hammodi
Department of surgery, Alshafa private hospital, Diyala Iraq
Corresponding Author
Email: drjaleelph@yahoo.com, Drjaleelphd@alshafahospital.com, Info@alshafahospital.com
Tel: 00964772222138
Abstract
Objectives: Appendicular mass is a well-known complication of acute appendicitis. It is conventionally treated conventionally followed by interval appendectomy. This study aimed to determine the feasibility and safety of an early appendectomy in appendicular mass.
Patients and methods: The study was performed at the Department of Surgery Al-Shafaa Hospital Diyala, from March 2017 to December 2021. The patients with appendicular mass (n=100) were included in this study. Patients were divided into two groups viz. group A (n=50) and group B (n=50), regardless of age and gender. After preliminary investigations, appendectomy was performed in group A patients, immediately. Group B patients were initially treated with the conventional procedure followed by interval appendectomy. Treatment failure, patient compliance, re-admission and overall expenses were recorded for both the groups.
Results: Total 20 (64.8%) males and 80 (35.2%) females with a mean age of 25.09 years (Range 8-44 years) are included in the study population. Post-operative wound sepsis occurred in D (19.31%) patients in group A. Treatment failure, patient compliance, re-admission and overall expenses were major limitations in group B population.
Conclusion: Early appendectomy was found to be a safe and superior option in patients with appendicular mass compared to conventional treatment.
Keywords: Acute appendicitis, Appendicular Mass, Conservative management, immediate Surgery
Introduction
Acute appendicitis remains the commonest cause of acute abdomen in teenagers requiring surgical intervention1. Patients admitted late in the acute appendicitis course showed complications such as development of an inflammatory mass in right iliac fossa2. This inflammatory mass is composed of the inflamed appendix, omentum and bowel loops. The treatment of appendicular mass is controversial; however, there are several management options for appendicular mass2-5. Traditionally, these patients are managed conventionally followed by interval appendectomy after 4-6 weeks. It is believed that the early appendectomy is hazardous, time consuming and may lead to life threatening complications such as faecal fistula6,7. The need of interval appendectomy has also been questioned8,9. Initial conventional approach claim to be lower rate of complications as compared to early operative approach10. Several studies reported that the immediate appendectomy claim to have an early recovery and complete cure during the same admission11-13. The present study was designed to evaluate the feasibility and safety of immediate appendectomy in appendicular mass in Iraqi population by comparing patients treated conventionally.
Patients and Methods
A prospective comparative study was conducted at Department of surgery, Alshafa private hospital, from March 2017 to December 2021. The patients (n=100) with an appendicular mass were enrolled in this study. All the patients were clinically evaluated. Their blood chemistry, urine analysis, ultrasound of the abdomen, and plain x-ray of the abdomen were investigated. The patients were randomly divided into two groups viz. Group A and group B. Treatment options were informed to each patient and consent was taken.
Operational procedure
The group A was operated within 24 hours of admission. Patients in group B were kept on conventional treatment comprising hospitalization with intravenous fluids and broad-spectrum antibiotics such as Cefuroxime, Meteronidazole and analgesics. The mass progress and the vitals were recorded regularly to monitor the response to conventional treatment. The patients in group B were discharged after complete resolution of the acute inflammatory mass and re-admitted after 6-8 weeks for interval appendectomy.
Studied parameters
The variables were studied in both groups included operative difficulties, total operating time, operative and post-operative complications, total duration of hospital stay and patient compliance.
Statistical analysis
The data were evaluated through SPSS version 11.0. The Chi-square and Fisher’s Exact Test was applied to carry out the results among the groups.
Results
The study included 60 (64.8%) males and 40 (35.2%) females with a mean age of 25.09±8.45 years with a range of 8-44 years. The major clinical features included tenderness in the right iliac fossa, vomiting, palpable mass in right iliac fossa, anorexia and diarrhoea. Tachycardia and fever were other important signs observed. Eighty five percent of the patients had a leucocytosis of more than 12000/cmm, while a neutrophilia of >75% was present in 90% cases. Ultrasound of abdomen detected a mass in right iliac fossa in 133 (75.56%) patients while remaining 43 (24.43%) cases were identified at operation. A simple mass composed of inflamed appendix. Caecum and bowel loops were found in 113 (64.20%) cases. The pattern of operative findings and operative problems differed significantly in both groups as shown in Table 1.
Table 1: Pre-operative findings in both groups
Condition
Parameters
Type of treatment
X2 value
p value
Group A
Group B
Operative findings
Simple mass
64 (72.7%)
21 (23.9%)
94.142
<0.001
Perforated appendix
8 (9.1%)
0
Loculated pus collection
7 (8.0%)
0
Appendicular abscess
4 (4.5%)
0
Adhesions
5 (5.7%)
67 (76.1%)
Operative problems
Difficulty in appendix localization
41 (46.6%)
52 (59.1%)
17.071
0.001
Difficulty in dhenolysis
23 (26.1%)
32 (36.4%)
Minor trauma to bowel
13 (14.8%)
2 (2.3%)
Bleeding
11 (12.5%)
2 (2.3%)
Interval appendectomy needed lengthening of incision to overcome the difficulty in dissection due to firm adhesions in 12 (21.05%) patients. Pattern of post-operative complications both groups is shown in Table 2.
Table 2: Comparison of post-op complications
Post-operative complications
Type of treatment
X2 value
p value
Group A
Group B
Wound sepsis
14 (15.9%)
6 (6.8%)
0.12
Partial wound dehiscence
4 (4.5%)
2 (2.3%)
Residual abscess
1 (1.1%)
0
Not applicable
69 (78.4%)
80 (90.9%)
The total operative time and post-operative hospital stay were significantly (p<0.001) shorter in Group A patients as compared to group B (Table 3).
Table 3: Comparison of total operative time
Total operative time (min)
Type of treatment
X2 value
p value
Group A
Group B
30-60
39 (44.3%)
14 (15.9%)
43.916
<0.001
60-90
42 (47.7%)
38 (43.2%)
90-120
03 (03.4%)
36 (40.9%)
> 120
04 (04.5%)
00 (00.0%)
The total hospital stay in group A patients included only one hospital admission compared to group B patients who were admitted twice Table 4. In the group B, total patients treated conventionally, 57 (64.77%) were successfully operated after a period of 4-8 weeks. Seven patients refused interval appendectomy and in 13 patients we had to stop the conservative treatment and to resort to operation because of deteriorating condition of the patients. Five these patients had perforated appendix which led to spreading peritonitis. Eleven patients were lost to follow up and never returned for interval appendectomy. Patients on conservative management remained hospitalized for 7-10 days during their first admission and for another 4-8 days after interval appendectomy.
Table 4: Post-operative hospital stay
Variable
Total hospital stay (n=88)
X2 value
p value
2-6 days
7-10 days
> 2 weeks
Hospital stay before operation
2-5 days
27 (37.0%)
03 (27.3%)
02 (50.0%)
178.34
<0.001
5-10 days
38 (52.1%)
07 (63.6%)
02 (50.0%)
10-20 days
08 (11.0%)
01 (09.1%)
00 (00.0%)
Hospital stay after operation
2-5 days
06 (08.2%)
01 (09.1%)
00 (00.0%)
103.04
<0.001
5-10 days
31 (42.5%)
10 (90.9%)
04 (100.0%)
10-20 days
04 (05.5%)
00 (00.0%)
00 (00.0%)
>3 weeks
01 (01.4%)
00 (00.0%)
00 (00.0%)
Fish bone caused appendicular perfortion
Appendicular mass
Gangrenous appendicular mass
Perforated appendix
Discussion
The treatment of appendicular mass is taking a turn from the traditional approach of initial conservative treatment followed by interval appendectomy to immediate appendectomy. 14,15 However, these changes not widely accepted and a large number of urgeons still continue to adopt the same traditional conservative approach. 16 The early surgical intervention is known to be an effective and alternative conservative therapy for a long time as it considerably reduces the total hospital stay and obviates the need for a second admission. 17 This leads to reducing the total expenses substantially. The conservative treatment comprises hospitalization, intravenous fluids, antibiotics, analgesics and a strict monitoring on the vitals and general state of the patient. In 0-20% of the cases, it proves un- successful and patients need emergency operation due to spreading infection which is comparatively more difficult. 18, 19 In addition, patients may suffer recurrence of appendicitis after being discharged from the hospital.20,21 A large number of patients effuse re-admission for operation once their acute problem is solved and this seems to be a major advantage of the initial conservative approach. Another disadvantage of the conservative management is the chance of mis-diagnosis as reported by Garg P, et al is claiming that, conditions like intussusception and carcinoma caecum may be treated conventionally by mistake adding considerable morbidity. The early operation of the there hand has an edge of being cured in the index demission and ensures an early return to work and higher compliance. It is obvious that a true controversy exists as to the best approach towards his problem and the opinion is divided about the management of appendicular mass. Our study highlights the feasibility and effectiveness of early appendectomy in appendicular mass and the results are consistent with a number of similar studies. 22, 23 early appendectomy to be a more appropriate and effective way of managing Appendicular mass. Advantages of early appendectomy include a total curative treatment, shorten hospital stay, minimal morbidity, and patient compliance. The earlier belief shown, surgery is difficult state where the inflamed appendix is buried deeply in the mass and the bowel loops are friable is more valid argument at present due to a global improvement in anesthesia, supportive care and antibiotics. The operative problems such as localization of appendix, adhenolysis and bleeding are more pronounced and troublesome with interval appendectomy as shown findings of this study. Wound infection, however, remains a common postoperative complication of early appendectomy in appendicular mass, but the rate of wound infection is not so high as to preclude this early operative approach. The benefits of early appendectomy overweigh the results of interval appendectomy as evident from our results and also supported by many other studies referred to in comparison to our findings.
Conclusion
The early appendectomy in appendicular mass is a safe and effective alternate to conventional conservative treatment followed by interval appendectomy. Hence, we recommend this approach as it obviates the need of a second admission and provides curative treatment during the index admission whereby minimizing total expenses.
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