Appendicular Mass: A Conservative Approach

ISSN: 2091-2331 (PRINT) 2091-234X (ONLINE) Journal of Nobel Medical College Available Online: w w w .nepjol.info, w w w .nobelmedicalcollege.com.np Volume 5, Number 2, Issue 9, Aug.-Dec. 2016, 47-50 Original Article Appendicular Mass: A Conservative Approach Ashok Koirala1 * , Dipendra Thakur1 , Sunit Agrawal1, Kamal Raj Pathak1, Manoj Bhattarai2, and Abhilasha Sharma3 1 Department of General and Minimally Invasive Surgery, Nobel Medical College Teaching Hospital, Biratnagar 2 Department of Radiology, NMCTH, Biratnagar 3 Department of Microbiology, B.P. Koirala Institute of Health Sciences, Dharan Received:30 th September, 2016;Revised after peer-review :28 th Oct ober, 2016;Accepted:22 th November, 2016 Abstract Introduction Appendicular mass is one of the most common complicat ions follow ing acut e appendicitis and seen in 2-6% of the patients. The treatment of appendicular mass is cont roversial w ith three general approaches. The aim of this study is to evaluat e outcome of conservat ive approach. Material & Methods A retrospect ive analysis of the patients managed w ith appendicular mass from 1st January to 31 st December 2014 w as carried out in NMCTH, Birat nagar. A total of 173 pat ients w ith diagnosis of appendicular mass admit ted in emergency and OPD of our hospital w ere studied. All age groups and both sex w ere included. Results Out of 496 patients w ith appendicitis, 173 patients [34.87% ] w ere diagnosed w ith appendicular mass. Age range of the patient in the study varied betw een 4-84 years and maximum pat ient s found in the age group of 21-30 years. Onset of symptoms w as betw een 2-6 days and greater number of patients reporting betw een 5-6 days. During study period 10(5.7% ) pat ient s came w it h recurrence, 9 [5.2% ] developed abscess, 35(20.23%) pat ient s came for interval appendicectomy, w hereas 119 [68.78% ] failed to come for a follow up. Conclusion Our study concluded that the appendicular mass can be managed successfully by conservative approach, although few complications may arise w hich can be managed by surgical intervention. Key words: Appendicular mass, Conservative approach, Interval appendicectomy. masses include a spectrum of clinical Introduction Acute appendicitis is one of the most present at ions superseded by pathological common acute surgical conditions of the processes ranging from localized abdomen and is encountered in 2 – 6% of collections of pus (peri-appendicular patients [1]. The appendicular mass usually abscesses) to inf lamed appendices w hich develops follow ing an attack of acut e have become adherent to the omentum and appendicitis and is the end result of a surrounding viscera to form a phlegmon. w alled-off appendicular perforation and The def initive treat ment of acut e represent s a pathological spectrum ranging appendicitis is appendicectomy. If timely appendicectomy is not done, the patient s from phlegmon to abscess [2,3]. These * Corresponding Author: Dr. Ashok Koirala, Lect urer | E-mail: [email protected] 476 Ashok Koirala, et .al., Journal of Nobel Medical College develop a mass in the right iliac fossa (Appendicular mass) as one of the early complications [4,5]. Management of an appendicular mass is controversial w it h three general approaches usually employed[6,7]. ' Classical management ' involves initial conservative management w ith broad spectrum antibiot ics and intravenous fluid until the inflammatory mass resolves. Patients are of fered interval appendicectomy 4-6 w eeks lat er, believing that an early appendicectomy in these cases is hazardous, time consuming and may lead to life threatening complicat ions such as fecal fistula[8-10]. Semi conservative approach involves performing immediate appendicectomy during the initial admission af ter resolution of the inflammatory mass or ent irely conservative approach w ithout interval appendicectomy. Of these, the advantage of Classical management technique is ef fect ive in the majorit y of patient s. It helps to prevent recurrence of acut e appendicitis and avoids misdiagnosing an alt ernat ive pat hology such as malignancy [11-14]. Therefore, the present study w as undertaken w ith the aim to evaluate the outcome of conservative approach follow ed by interval appendicectomy so as to achieve complete resolution of the inflammatory mass and the disappearance of symptoms in the pat ient before any surgical intervention. Material and Methods A ret rospect ive study regarding the patients managed w ith appendicular mass, w as conducted in Department of General Surgery, Nobel Medical College and Teaching Hospital, Biratnagar, from 1 st January 2014 to 31 st December 2014, af ter taking ethical clearance from Institut ional Review Committee. Among the total 496 pat ients w ith appendicitis admitted in hospital, 173 pat ients w ere diagnosed w ith appendicular mass. All the age group and both the sex w ere included in the study. The appendicular mass w as either diagnosed on the basis of physical examinat ion or on radiological evaluation. All the pat ient s w ith the diagnosis of appendicular mass w ere managed w it h standard conservative approach of Ochsner Sherren regimen follow ed by interval appendicectomy af ter 4-6 w eeks. Parameters included in the study w ere demographic data, incidence, age group, durat ion of symptoms, length of hospital stay, complications, recurrence of appendicitis, rat e of elect ive appendicectomy and follow ups. Data w ere analyzed w ith SPSS softw are. Results A total of 496 patients w ith appendicitis w ere managed in our hospital during the study period. Among them, 173 patient s diagnosed w ith appendicular mass w ere included for analysis. Therefore, tot al incidence of appendicular mass w as 34.87% . Out of them female pat ient s w ere 107 and male patients w ere 66. Therefore female: male rat io w as 1.62:1. Age range of the pat ient included in the study varied betw een 4-84 years and the median age w as 30 [As depicted in table 1]. The patient had onset of the symptoms betw een 2-6 days, w ith greater number of pat ient s reporting betw een 5-6 days [45.08% ] [As show n in Table 2]. Overall length of hospital stay varied betw een 215 days w ith an average of 4-5 days. During conservative treatment 9[5.2%] developed appendicular abscess. Among them 6 cases w ere managed w ith ultrasound guided drainage w hile 3 cases needed laparotomy drainage and appendicectomy. Recovery w as seen in all the managed cases. During study period 10 [5.7% ] cases returned w ith repeat attack of acut e appendicitis and all of them underw ent successful appendicectomy. * Corresponding Author: Dr. Ashok Koirala, Lect urer | E-mail: [email protected] 486 Ashok Koirala, et .al., Journal of Nobel Medical College Similarly, 35 [20.23%] patients returned for interval appendicectomy at the duration of 6 w eeks to 10 months. All of them underw ent appendicectomy, although t here w as difficulty in finding appendix during surgery in few cases. Ot her 119[68.78% ] patients failed to come for follow up. Table 1.Age distribution Age group No of patients 1-10 7 11-20 49 21-30 33 31-40 24 41-50 20 51-60 15 61-70 12 71-80 10 81-90 3 Table 2. Duration of symptoms at presentation Duration of No of Incidence % symptoms patients < 48 hrs 9 5.2 3-4 days 35 20.3 5-6 days 78 45.08 > 6 days 51 29.4 Discussion Acute appendicitis is a very common surgical cause of acut e abdomen. With prolongation of duration of symptoms, in some pat ients, appendicular mass develops [15]. In the present study appendicular mass w as found in 34.87% w hereas other study conducted in different places the incidence ranges from 2-6%[1]. The incidence is found to be higher in our study, as reason may be the late presentation of the patients from the areas w here emergency medical facilities are not available or may be due to financial problem or ignorance w here patient s either do not seek medical advice or take the analgesics over the counter. The maximum patients in this study,i.e. 49 (28.32% ) w ere bet w een the age group of 11 – 20 years, how ever the age varied from 4 - 84 years suggesting any age group prone to develop mass. The female to male rat io is 1.62:1 w hich is in contrast to other studies w here male predominance is found. Majority of the pat ient s w ho present ed w ith lump had symptoms betw een 5-6 days. In other studies, it w as found to be 3-4 days. Reason might be the patient in our region coming from distant places and habit of getting treat ment by local pract itioner [16]. During the conservative management, appendicular abscess may develop in few cases [17]. In the present study, appendicular abscess developed in 9[5.2%] of the pat ients w ho w ere managed w ith either ultrasound guided drainage or laparot omy drainage and successful appendicectomy. Failure of conservat ive management has been reported in 2-3% of cases w ith urgent explorat ion [17]. In our study, 10 [5.7% ] cases returned w ith repeat at tack of acute appendicitis and all of them underw ent successful appendicectomy. Similarly, 35 [20.23%] patients returned for interval appendicectomy at the duration of 6 w eeks to 10 months. All of them underw ent appendicectomy, although there w as difficulty in finding appendix during surgery in few cases. Other 119[68.78%] pat ient s failed to come for follow up; actual cause for it could not be found. Reason might be either the patient s fully recovered and did not find a need to seek medical advice, or the patients w ent to other cent ers. A meta-analysis conducted over a 13 years period, including 1012 pat ient s concluded that the interval appendicectomy w as not justified, as the majority [95%] of the pat ient s managed conservatively w ill not develop recurrence[3]. The success rate of initial conservative management varies betw een * Corresponding Author: Dr. Ashok Koirala, Lect urer | E-mail: [email protected] 496 Ashok Koirala, et .al., Journal of Nobel Medical College 76-97%. In our study out of 173 patient s 9[5.2% ] developed abscess. Remaining patients w ere managed conservatively. So our success rate of conservative management w as 94.8 % comparable to other studies[18]. According to t he results of our study, most of the patients w ere managed successfully by conservative approach w ith only few needing surgery for complications. Conclusion It can be concluded that the appendicular mass can be managed successfully by conservative approach, how ever few complications may arise w hich may need urgent surgical exploration. Although there w ere few limitations of the study that has to be considered for future, is that it has been conducted in a single center, w ith small sample size and there w as no evidence regarding the pat ients w ho failed to come for a follow up. References : [1]. [2]. [3]. [4]. [5]. [6]. [7]. [8]. Hogan MJ, Appendiceal abscess drainage, Techniques in vascular and interventional radiology. 6:4 (2003) 205-14. 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