Management of Appendiceal Mass: Controversial Issues Revisited

J Gastrointest Surg (2008) 12:767–775 DOI 10.1007/s11605-007-0399-1 Management of Appendiceal Mass: Controversial Issues Revisited Abdul-Wahed N. Meshikhes Received: 3 August 2007 / Accepted: 16 October 2007 / Published online: 13 November 2007 # 2007 The Society for Surgery of the Alimentary Tract Abstract Purpose Although appendix mass occurs in 10% of patients with acute appendicitis, its surgical management is surrounded with controversy. This article reviews some of the controversial issues in the management of appendix mass. Methods A search of the English literature was conducted for “appendiceal mass,” “interval appendicectomy,” and “laparoscopic appendicectomy” and manual cross-referencing. Results and Conclusion The majority of the studies were small and retrospective. Emergency appendicectomy for appendix mass is emerging as an alternative to conventional conservative treatment. It is feasible, safe, and cost-effective, allowing early diagnosis and treatment of unexpected pathology. However, the appropriate timing for emergency surgery is not clear. After successful conservative management, interval appendicectomy is not necessary and can safely be omitted, except in patients with recurrent symptoms. In patients over 40 years of age, other pathological causes of right iliac mass must be excluded by further investigations (colonoscopy and computerized tomography scan), and a close follow-up is needed. Laparoscopic appendicectomy whether in emergency or interval settings is feasible and safe and should replace the conventional open method. Large prospective, randomized controlled trials are lacking, and therefore, such trials are needed to scientifically compare emergency surgery vs conservative management without interval appendicectomy. Keywords Appendiceal mass . Interval appendicectomy . Laparoscopy Introduction Acute appendicitis is the most common surgical emergency. It may be complicated by the development of an appendiceal mass in 2–10% of cases.1,2 This mass results from a walledoff appendiceal perforation and represents a wide pathological spectrum ranging from an inflammatory mass that consists of the inflamed appendix, some adjacent viscera, and the greater omentum (a phlegmon) to periappendiceal abscess.3 Fever and leucocytosis are common, but the mass A.-W. N. Meshikhes (*) Department of Surgical Specialties, King Fahad Specialist Hospital, Dammam 34111, Saudi Arabia e-mail: [email protected] may be missed clinically in the obese and in those with marked tenderness and rigidity at presentation. Hence, it may first be detected when the patient is already under anesthesia for emergency appendicectomy, posing a dilemma for trainee surgeons. Ultrasonography has been advocated as the diagnostic modality of choice, revealing the diagnosis in 72% of cases, but computerized tomography (CT) scan is superior2. Some management issues has been surrounded with controversy with no general agreement among surgeons; a recent questionnaire study of 67 consultant and specialist registrar surgeons in the Mid-Trent region of England showed no agreed consensus on the management of appendiceal mass.4 Another more recent questionnaire survey of 90 consultant general surgeons in England revealed that 53% of surgeons perform interval appendicectomy routinely at 6 weeks to 3 months, mainly because of concerns about recurrence.5 This article discusses some of those controversial management issues and draws management recommendations based on a review of the available English literature. 768 J Gastrointest Surg (2008) 12:767–775 Methods A Medline search of the English literature was conducted using the Medical Search Headings and keywords: “appendiceal mass,” “interval appendicectomy,” and “laparoscopic appendicectomy.” Further articles were obtained from manual crossreferencing of the literature reviewed. Case reports and articles with less than five patients were excluded. Conservative Vs Emergency Treatment of Appendix Mass The surgical management of acute appendicitis presenting with appendiceal mass remains controversial. The standard treatment that was introduced by Ochsner6 in 1901, advocating conservative regimen, has proved popular over the years and has been shown to be safe and effective.1,7–13 It allows the acute inflammatory process to subside in more than 80% of the cases before interval appendicectomy is performed some 8–12 weeks later.7–13 Failure to respond may, however, be encountered in 10–20% of the patients with development of appendiceal abscess that can be drained percutaneously or if multiloculated via an extraperitoneal approach. Furthermore, while waiting for interval appendicectomy after discharge, up to 46% of the patients may develop recurrent symptoms of appendicitis that require readmission.1–3 Also, before the planned interval appendicectomy, delayed emergency surgery becomes necessary in 15% of the cases.1,14 The most serious criticism is the fear of missing an unexpected pathology such as Crohn’s disTable 1 The Argument For and Against Conservative and Emergency Surgery Approaches Conservative approach ease, ileo-cecal tuberculosis, and most importantly, cecal malignancy in 8–15% of the cases.10,15 Early emergency surgery is feasible and as safe as the non-operative approach and is associated with shorter hospital stay,16–22 with the advantage that unexpected cecal pathology will be treated. The only disadvantage of emergency surgery is that, in some cases, the inflammatory condition may be mistaken for malignancy necessitating ileo-cecal resection or right hemicolectomy with its attendant morbidity and mortality.23 The extent of resection will depend on whether the pathology is inflammatory or malignant, which may be difficult to decide during surgery, even with intraoperative frozen section. Ileo-cecal resection was found to be associated with a significantly shorter mean operative time (144 vs 201 min; p<0.001), lower morbidity rate (3 vs 22%; p= 0.043), and shorter mean postoperative hospital stay (6.8 vs 11.2 days; p=0.011) than right hemicolectomy.23 The arguments for and against conservative and emergency operative managements are summarized in Table 1. Emergency Surgery for Appendix Mass In the 1970s, early surgery for appendix mass was shown to be safe, associated with shorter hospital stay and without major morbidities.16,17 However, acceptance by the surgical community remained cautious. In nine articles (Table 2) on emergency surgery for appendix mass with a total of 340 patients [123 (36%) children], there was general agreement that emergency surgery for appendix mass is feasible, safe, cost-effective, Advantages Disadvantages Safe Failure rate and recurrent symptoms in 5–46% Delayed emergency surgery in non-responders is hazardous Costly (long HS, intravenous antibiotics, analgesia, etc.) IA may be needed; this requires second admission Has complication rate of 12–23% May be difficult especially if delayed Differentiation between inflammatory and malignant masses may be difficult (FS may be necessary) Unnecessary ileo-cecal resection may be performed. May have higher complication rate than IA Allows acute episode to settle Good response in >91% Emergency Surgery Safe, feasible and cost-effective Acceptable operative time No need for another admission IA Interval appendicectomy, FS frozen section, HS hospital stay No need for IA Deals with pathology and other unexpected pathology rapidly No need for close follow-up and investigations J Gastrointest Surg (2008) 12:767–775 Table 2 List of Articles on Emergency Surgery for Appendiceal Mass (n=9) Author Year Number of LA vs OA Comments patients 1976 34 OA Foran et al.17 1978 13 OA Marya et al.18 1993 30 OA 2002 Samuel et al.19 (children) De and Ghosh20 2002 82 OA 87 OA Tingstedt et al.14 2002 43 OA Senpati et al.21 2002 10 LA Erdogan et al.13 (children) Goh et al.22 (children) 2004 19 OA 2005 22 LA Total, 9 articles 1976–2005 n=340 Vakili LA Laparoscopic appendicectomy, OA open appendicectomy, HS hospital stay 769 16 associated with reduced hospital stay, with minimal morbidity but no mortality and with more or less comparable infection and operating time to that performed after conservative treatment.16–23 Two studies13,14, however, found early surgery to be associated with high complication rate of 26%, and therefore, conservative approach was advocated instead. In a prospective nonrandomized study, Samuel et al.19 showed early surgical intervention to be more beneficial over the conservative approach in a cohort of 82 children, especially in terms of hospital stay (4.8 vs 13.2 days; p< 0.05).19 At a mean of 4.3 weeks, recurrent symptoms were seen in 19 (39.6%) patients of the conservative group.19 Furthermore, periappendiceal abscesses and adhesions were found at interval appendicectomy in 38 (79%) and 39 (81.3%), respectively, compared to 100% in those who underwent emergency surgery.16,19,21 In another controlled clinical trial, 30 patients with appendix mass treated by early surgery were compared with 26 patients who were treated conservatively.18 The two groups had similar infection rate (17 vs 18%), mean operating time (38.7 vs 35.2 min), and mean hospital stay (15 vs 19 days). Furthermore, 15% of patients in the conservative group developed episodes of recurrent acute symptoms while waiting for interval appendicectomy, and their return to work was delayed.18 In a retrospective study of 87 patients presenting with appendix mass who underwent emergency appendicectomy within 24 h of admission, the mean operative time was 65 min, and only 29% developed minor wound infections and majority 2 LA Early surgery is safe, feasible, has short HS, and has no major morbidity Early surgery has shorter HS than the conservative approach Early surgery is safe, feasible, and cost-effective. It has comparable infection rate, operating time, and hospital stay to conservative approach Early surgery is beneficial, but IA is needed for those treated conservatively Early surgery is associated with low cost, low morbidity, and short HS Early surgery is associated with complications. Conservative approach is advocated Early LA is feasible and safe. It has equal operative time and HS to that of non-mass appendicitis Early surgery has a high complication rate (26.3%) Early LA has no morbidity or mortality. It has longer operative time (103 vs 87 min) than LA for non-mass cases 2 studies14,13 out of 9 were against emergency surgery of patients (81.6%) were discharged within 7 days. It was concluded that emergency surgery is feasible and associated with low morbidity.20 The timing of emergency surgery is very important, as delayed emergency surgery is expected to be difficult and hazardous. In a recent prospective randomized controlled trial, appendicectomy performed after the appendix mass had resolved was shown to be associated with longer operative time, higher incidence of adhesions, higher incidence of incision extension, and more postoperative complications than interval appendicectomy.24 On the other hand, others argue that emergency surgery is difficult and associated with high complication rate that approaches 26%.13,14 In a comparison of the outcome of 50 patients treated conservatively and 43 who were operated on for appendiceal abscess, complications were found to be common among patients who were operated on, but 4 (8%) of the patients treated conservatively had another pathology detected during follow-up.14 In an evaluation13 of 19 children who were operated on immediately and 21 children who were managed by interval appendectomy, the mean hospital stay was similar (8.7 vs 8.9 days), but the complication rate was higher in the emergency group (26%). Appendectomy could not be done in one patient who required another laparotomy 8 weeks later. In the conservative group, however, two patients (8.6%) failed to respond and another two returned with perforated appendicitis.13 Furthermore, those who were treated conservatively in both 770 studies needed close follow-up and investigations to exclude other ileo-cecal pathology, which may be encountered in the conserved cases. However, both studies were retrospective and contained a small number of patients. In conclusion, most reported literature on emergency surgery advocated this approach as safe, feasible, and cost-effective. Interval Appendicectomy: Is It Necessary? Another controversial issue is the need for interval appendicectomy (IA) after successful conservative treatment. A survey of 663 surgeons in North America revealed that IA is routinely performed by 86% of the surveyed surgeons.25 The most cited reason is the risk of recurrent appendicitis, which is reported to occur in 21–37% of the cases.10,19,25,26 Another recent questionnaire survey of 90 consultant general surgeons in England (response rate of 78%) revealed that 53% of surgeons perform IA routinely at 6–12 weeks mainly because of concerns about recurrence.5 This argument of recurrent appendicitis has been questioned, as the risk that is greatest during the first 2 years occurs in less than 20% of cases, and the risk becomes minimal after the first 2 years of the initial episode.1,3,10,17 Hence, more than 80% of patients can be spared the morbidity of a surgical intervention. Also, the study from the Mid-Trent region, UK, showed that less than 25% manage asymptomatic appendix mass without IA.4 It is of interest to find in this survey that specialist registrars are less likely to offer patients IA after successful conservative management (p<0.05).4 A prospective non-randomized study of 48 IA specimens showed 37 (77%) appendices to have a patent lumen, whereas only 11 (23%) showed fibrosis and obliteration of appendicular lumen.19 This fact has led some authors to advocate IA for patients who have undergone successful conservative treatment. However, this means subjecting 23% of patients to unnecessary IA that necessitate a second admission and is not entirely free of complications; the reported complication rate is 12–23%.2,7,8,12,27 In another large retrospective study of 233 patients (108 males, 125 females), the histological examination of the IA specimen showed a normal appendix without signs of previous inflammation in 30% of cases,2 which argues against routine IA. Moreover, a recent large retrospective population-based cohort study of 1,012 patients treated initially conservatively showed that only 39 patients (5%) developed recurrent symptoms after a median follow-up of 4 years with males sex having slight influence on recurrence, but neither age nor type of appendicitis had such an influence.25 It is, therefore, concluded that IA after initial successful conservative treatment is not justified and should be abandoned.25 Lower recurrence rate of 2% has been reported by others2 with the risk becoming minimal after 2 years of the initial J Gastrointest Surg (2008) 12:767–775 episode.3 Also, a recent prospective randomized controlled trial showed that patient treated conservatively without IA had the shortest hospital stay and duration of work days lost.24 Furthermore, only 10% of the patients developed recurrent appendicitis during a median follow-up period of more than 33 months. This overwhelming evidence argues strongly against IA after successful conservative treatment of appendix mass. Moreover, in 30 patients presenting with appendix mass, 3 required emergency appendicectomy within 48 h of admission, and another 2 underwent an interval appendicectomy for recurrent symptoms after 2 and 3 months. The remaining 25 (83%) patients did not require any intervention over a mean follow-up of 15.5 months.28 Therefore, it was concluded that IA should not be the rule in every patient presenting with appendiceal mass.28 Karaca et al. treated 17 children with appendiceal mass out of 866 patients with acute appendicitis (1.96%) conservatively with triple antibiotics for a week.29 The mean hospital stay was 9.7 days, and mass regression was confirmed on repeat ultrasonography. They were followed up by clinical examination and ultrasound for 1–60 months; 11 patients underwent barium enema also. Ultrasonography demonstrated complete disappearance of the mass, and barium enema revealed normal appendix in 10 out of 11 patients. No recurrent appendicitis was detected during follow-up of 1–7 years. It was concluded that conservative treatment is feasible with no need for IA.29 In another experience of ten pediatric patients who were treated conservatively with intravenous triple antibiotic therapy for a week, one returned after 2 months with perforated appendicitis that required emergency appendicectomy. The other nine remained well and asymptomatic at 6 months to 13 years. Based on this small experience, the authors argued against IA.30 However, a week of intravenous triple antibiotics in hospital29,30 and repeated ultrasonography29 is certainly not cost-effective and necessitated the stay of children and one of their parents in the hospital.29,30 A recent retrospective review of 106 patients (89 males, 76 females) with a mean age of 53.6 (range, 7–89) years also found that recurrent symptoms after conservative treatment occurred in 25.5% of the cases with most of the recurrences (83%) occurring within the first 6 months. Moreover, very few will benefit from prevention of recurrent symptoms if IA is performed after 6 to 12 weeks. An interesting finding also was that complication rates for appendicectomy performed before or after recurrence of symptoms were equal at 10%. However, 17 patients (10.3%) had their diagnosis changed after follow-up or surgery with 5 patients (3%) found to have colon cancer. It was, therefore, concluded that performance of colonoscopy or barium enema is essential in patients who are treated conservatively and that IA can only benefit less than 20% of J Gastrointest Surg (2008) 12:767–775 771 patients, another argument against routine IA.31 In terms of costs, IA is also not a cost-effective approach, as it increases the cost per patient by 38% compared with followup and appendectomy only if recurrence occurs.32 If no IA is to be performed after successful conservative treatment, the fear of missing hidden pathologies such as Crohn’s disease, tuberculosis, or cancer that masquerade as an appendiceal mass remains an important issue. This can be excluded by barium enema or colonoscopy, which should be performed especially in patients aged 40 years or more after the acute episode has subsided.10,29 However, there is no general consensus as to the right time to perform such an investigation. Timing is important as incompletely resolved appendix mass may mimic cecal carcinoma on barium enema, giving false positive results. Colonoscopy augmented by CT scan is far superior in excluding cecal pathology. Such investigations can be performed safely after 6–8 weeks.33–35 Table 3 summarizes the published articles on conservative approach and advocating IA, whereas Table 4 lists the articles that argue against IA after conservative treatment. high morbidity.24 Failure rate of conservative treatment in the reported literature is variable, ranging from 8.5– 15.5%.7–14,17,34 Much higher rate of 46% has also been reported.1,2 In the author’s unit, such scenario may be encountered in less than 20% of cases, and in more than 95% of appendix masses discovered upon palpation of the abdomen under general anesthesia, the appendix was easily removed by immediate open appendicectomy with minimal morbidity (unpublished data). Hence, under such circumstances, it is justifiable to proceed with the planned operation, but the presence of a senior colleague is mandatory. Appendix Mass in the Laparoscopic Era Horwitz has discouraged performance of laparoscopic appendicectomy (LA) in children with complicated appendicitis caused by the increased risk of intraabdominal abscesses.36 This fear was, however, later dismissed by other workers who advocated LA as a good alternative to open method.37 LA in management of patients with appendiceal mass was first reported by Vargas et al. who performed laparoscopic IA at 6–12 weeks after successful conservative treatment in 12 patients. The procedure was conducted successfully and safely in 11 out of 12 cases with a median hospital stay of 1 day and no perioperative morbidity.38 Since then, an increase in percentage of IAs performed by the laparoscopic method from 30 to 85% has been noted,39 and the total operating time of the laparoscopic IA did not differ from that of the interval open method (95 vs 103 min), but the hospital stay was much shorter in the interval laparoscopic group (0.55 vs 3.07 days, p<0.001).39 First Encounter Under Anesthesia A common scenario is when a surgical trainee first discovers the appendix mass when the patient is relaxed under general anesthesia for an emergency appendicectomy. Such scenario may be encountered in 55% of cases.1 Although reversal of anesthesia has been advocated to give conservative treatment a chance, it runs the risk of ‘failure’ with the subsequent need for delayed emergency operation, which is often difficult, hazardous, and associated with Table 3 Articles Advocating Interval Appendicectomy (n=9) Cons Conservative, IA interval appendicectomy, HS hospital stay Author Year Total no. Cons Remarks Skoubo-Kristensen and Hvid8 1982 193 169 Shipsy and O’Donnell1 Vargas et al.36 1985 1994 77 12 69 12 Ericksson and Styrud26 1998 38 38 Friedell and Perez-Isqierdo11 Gillick et al.12 2000 2001 5 427 5 411 Erdogan et al.13 2004 40 21 Owen et al.39 2006 36 36 Conservative followed by IA is advocated IA has 3.4% complication rate Conservative followed by IA is advocated Conservative treatment is safe and effective Laparoscopic IA is safe HS is 3 days Postoperative complications, 13% One had appendiceal base cancer IA is advocated after conservative treatment Complication of IA 2.3% Conservative followed by IA is advocated Conservative is safe IA is recommended Laparoscopic IA can be safely performed in children Laparoscopic IA is associated with a short HS Laparoscopic IA has minimal morbidity and scarring 772 Table 4 Articles Against Interval Appendicectomy (n=11) J Gastrointest Surg (2008) 12:767–775 Reference Year Total no. Cons I.A Thomas27 Foran et al.17 1973 37 1978 43 33 30 Hoffmann et al.10 1984 44 44 Bagi and Duetolm9 1984 40 37 Ein and Shandling30 Adala28 Gahukamble et al.32 Karaca29 1996 1996 2000 2001 10 30 59 17 10 27 59 17 Tingstedet et al.14 2002 83 50 Willemsen2 2002 233 233 Lai et al.31 2006 165 165 Cons Conservative, IA interval appendicectomy, FU follow-up Nguyen et al. compared 38 adult patients with appendiceal mass who underwent interval LA with 15 patients who underwent open IA. It was found that there was no difference in the operative time between the two groups, and moreover, the hospital stay was shorter in the laparoscopic group.37 Senapati et al. also reported their experience with emergency LA in ten patients with appendiceal mass and compared them to patients who had LA for non-mass-forming appendicitis. There was no difference between the two groups in terms of operative time (median, 45 vs 40 min, p=0.085) and postoperative hospital stay (median, 2 vs 2 days). It was concluded that early emergency LA for appendiceal mass is feasible and safe, obviates the need for a second hospital admission, and also avoids misdiagnoses.21 In another study comparing a group of 17 patients (aged 16–60 years) with appendiceal mass who were treated conservatively followed by interval LA at an average of 4.9 months later and a second matched group of 15 patients who underwent immediate appendicectomy, there was no difference between the two groups in the operative time and complication rate.40 In a recent retrospective study of 35 children who underwent interval LA after a median interval of 93 days (range, 34–156 days), the median operative time was 55 min (range, 25–120 min), and the median length of stay for interval LA was 1 day (range, 1–3 days) and without any complications.41 Remarks 31 0 IA is associated with complications Conservative approach has longer hospital stay than emergency surgery. It may miss other pathology (10%) and run the risk of symptom recurrence. Patients need to be closely examined to exclude other hidden pathology 0 Conservative without IA is advocated This eliminates morbidity and the expense of appendicectomy in 80% of cases 0 2 patients had delayed diagnosis of other pathology (cecal cancer and Crohn’s disease) Conservative group needs closer FU 0 No need for IA 0 No need for IA 32 No need for IA if appendiceal lumen is obliterated 0 IA is unnecessary, but follow-up with ultrasonography or barium enema is needed 0 4 (8%) had tumor. Conservative is advocated. However, FU is necessary to exclude other pathology. No need for IA 233 In IA, 30% normal appendix. Complication 18%. Once all other pathology is excluded no need for IA 70 Minimal benefit from routine IA FU colonoscopy or barium enema is essential. Colon cancer diagnosed in 10.3% In summary, in the era of laparoscopy, there is an increase in percentage of interval appendicectomies performed laparoscopically. LA can be conducted safely and successfully in early emergency surgery for appendiceal mass and in the interval setting after successful conservative treatment with a short hospital stay and minimal morbidity, analgesia, and scarring. The operative time and hospital stay are comparable to those of LA performed for non-mass-forming appendicitis. Table 5 summarizes the articles published on LA for appenidceal mass. Management Recommendation Based on the available evidence, which comprises mainly of small retrospective rather than prospective non-randomized studies and only one small prospective randomized controlled trial, what should now be recommended for the management of an appendix mass in the era of laparoscopy? With the advent of LA, early emergency appendicectomy has emerged as an attractive management option,21,40 as it is feasible, safe, and associated with significantly much lower wound-related complications.21,42 If this approach is to become a standard, the fear of missing or delaying the diagnosis of other pathologies will be eliminated, and the overall hospital stay will certainly be reduced. However, one should accept the odd occasion when an ileo-cecal J Gastrointest Surg (2008) 12:767–775 Table 5 Articles on Laparoscopic Appendicectomy for Appendiceal Mass (n=6) ELA Emergency laparoscopic appendicectomy, ILA interval laparoscopic appendicectomy, HS hospital stay, ORT operative time, OIA open interval appendicectomy 773 Reference Year No. of patients ELA ILA Comments Vargas et al.38 Nguyen et al.39 1994 1999 12 adults 53 adults 0 0 12 38 (vs 15 OIA) Senapati21 2002 10 adults 10 0 Gibeily et al.40 Goh et al.22 2003 2005 32 adults 22 children 15 22 17 0 Owen et al.39 2006 35 children 0 35 ILA is safe with no morbidities No difference in ORT HS is shorter after ILA Comparable ORT and HS to LA in non-mass No difference in ORT and HS Longer ORT and HS than non mass appendicitis LA can be safely performed with minimal morbidity and scarring 164 (107 adults; 57 children) 37 90 Total, 6 resection is performed in difficult cases and for masses mistaken for malignancy. Also, once this approach is widely accepted, the debate on whether or not to perform IA will eventually vanish. Nevertheless, larger prospective randomized multi-center clinical trials are needed to establish the safety of emergency appendicectomy for appendix mass and also the safety of omitting IA in those treated conservatively. Such studies should look into the possible differences—if any—in the management of appendiceal masses in various age groups (pediatric vs adults) and different sexes (males vs females). Although Andersson et al.43 reported no adverse effects on fertility in 9,840 Swedish women aged under 15 years when they underwent appendicectomy for perforated appendix, the possibility of increased infertility in females with appendiceal masses treated conservatively should also be studied to see if emergency surgery is more beneficial in affected females to make stronger argument for emergency management, at least, in females. From the reviewed literature, for surgeons adopting conservative management, IA can be safely omitted, and other pathologies are excluded by colonoscopy, which may be augmented by CT scanning. This helps to avoid a second hospital admission and a surgical procedure, which is Appendiceal Mass Emergency (Early) surgery OA Recommended Management Algorithm for Appendiceal Mass Conservative Approach Watchful observation: LA Failure to respond Successful Emergency (Delayed) surgery Discharge OPD F-U Recurrence OA No recurrence LA <40 years >40 years I.A OA: open appendicectomy, LA: laparoscopic appendicetomy, F-U: follow-up, I.A: interval appendicectomy, CT: computed tomography. Colonoscopy +/ - CT No I.A Pathology present No pathology Figure 1 Recommended management algorithm for appendiceal mass. Treat or operate 774 associated with some complications. However, IA is still reserved for patients with recurrent symptoms and can be performed safely by laparoscopic means. A suggested algorithm of appendiceal mass management is shown in Fig. 1. Conclusion For the time-being—based on the available evidence—the management of appendiceal mass can either be nonoperative (conservative) or operative (emergency appendicectomy). Emergency appendicectomy (laparoscopic or open) for management of appendiceal mass is gaining popularity and is advocated, as it is safe, feasible, and cost-effective. For surgeons adopting conservative approach to appendiceal mass, IA can safely be omitted provided there is no recurrence of symptoms, and all other pathological causes of right iliac fossa mass has been thoroughly excluded by close follow-up and investigations such as colonoscopy and CT scan, especially in patients aged 40 years and over. For patients with recurrent symptoms after successful conservative treatment, laparoscopic IA is recommended. 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