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Management of appendicular lump: early exploration vs conservative management.

Introduction

Acute appendicitis is the most common acute surgical condition of the abdomen. The definitive treatment of acute appendicitis is appendicectomy. If timely appendectomy is not done, 2-6% of the patients develop a mass in the right iliac fossa (Appendicular lump) as one of the early complications. [1,2] The conventional conservative treatment followed by delayed appendectomy in patients with appendicular mass is well recommended. Majority of the times appendicular lump resolve after conservative management but some 10-20% of such patients fail to respond and require urgent and more difficult operation. [1]

Moreover 7-46% of the patients suffer a recurrence of acute appendicitis or appendicular mass following discharge from the hospital after successful conservative treatment of appendicular mass. Misdiagnosis is another problem. Condition such as caecal carcinoma in middle aged or elderly, intussusceptions in children and ileocaecal tuberculosis at any age may mimic appendicular mass. [1-7] With the availability of modern operative & anesthesia facilities and to avoid the uncertain natural course and misdiagnosis, an early exploration of the appendicular mass is recommended. This shortens the hospital stay, cures and diagnoses the disease and obviates the need of a second hospital admission with no added morbidity and mortality. [1,8,9] In this modern era where facilities and expertise of laparoscopic surgery is available, laparoscopic appendicectomy for both complicated (appendicular lump) and uncomplicated appendicitis is recommended where possible which further lessen morbidity. Based on these studies, the present study was done with objective of comparison of early exploration versus conservative management of appendicular lump.

Materials and Methods

A prospective study was conducted in the department of Surgery of Rohilkhand Medical College & Hospital, Bareilly, UP from December 2009-January 2012. A total of 632 patients with appendicular lump and acute appendicitis were admitted over a period of Three years. All age groups and both sexes were included. Any patients whose diagnosis was changed after initial diagnosis of appendicular lump were excluded from the study. Through clinical examination was done. Complete blood count, ESR, Urinalysis, urea, Creatinine and electrolyte, plane X-ray abdomen and ultrasonography of abdomen and other investigations as per need of the patients were done.

Patients were divided randomly in two groups, each containing 31, in group one early surgical exploration was done. In group two, conservative approach with OCHSNER SHERREN REGIME was adopted followed by interval appendectomy. Comparison of outcome between two groups was done.

Results

The outcome of present study as tabulated in tables 1 to 7. There was not a big difference in post-operative wound sepsis in each group. Patients in group II developed residual abscess which was not seen in group I. One patient in group I developed faecal fistula that was treated successfully with conservative treatment. 3 (9.67%) patients in group II developed adhesive intestinal obstruction while one in group I. Chest complication were more in group II due to prolonged hospital stay. Eight patients (25.8%) in group II failed to respond to conservative treatment where intervention was done rather in a difficult situation.

Two (6.45%) of patients in group II lost to follow-up. One patient in group II was ultimately diagnosed as iliocecal tuberculosis which had been treated as appendicular mass. Eight patients in group II needed readmission for recurrent acute appendicitis or appendicular mass again. 26 patients of group I had hospital stay less than three days and none more than one weak. On the other hand, 23 patients in group II had hospital stay more than one weak and none less than three days.

Discussion

Acute appendicitis is a very common surgical cause of acute abdomen. With prolongation of duration of symptoms, in some patients appendicular lump developed which is an inflammatory mass composed of inflamed appendix, caecum, omentum, terminal ileum and mesoappendix at times sigmoid, right tubes and overies in females. [1,2] This has been attributed to a protective mechanism of body to prevent the spread of infection. In our study, we found that the incidence of the appendicular lump was 9.81% and this is comparable with other author's study varying from 2-6%. [2]

The maximum patients 30 (48.38%) in this study were between the age group of 21-30 years. However the age varied from 11 years to 59 years suggesting any age group prone to develop lump, but common in younger age groups. The male to female ratio of 1.82:1 is also comparable with another study. [1]

Majority of the patients who presented with lump had symptoms between 3 to 4 days. However some even presented with symptoms for 14 days.

The history of shifting of pain in 91.94% of patients, the gastrointestinal upset in the form of nausea, vomiting, decreased appetite; loose stools or constipation in 93.55% of the patients in this study is comparable with other studies. [1] Sixty percent of the patients were febrile. The presence of supurative, gangrenous or perforated appendix with abscess in the appendicular mass corresponds with literature. [11]

The wound sepsis was found in 2 cases in group I while 3 in group II is also comparable with another study where wound sepsis was 10% in non-perforated and 20% in gangrenous perforated appendix. The other complication such as failure of conservative treatment, misdiagnosis, readmission for recurrent acute appendicitis and lost to follow up are noted less in early exploration. [11]

The short hospital stay of less than three days in 80% of the patients in group I is comparable with another study. [11]

Conclusion

The traditional method of conservative management of appendicular lump is well known. The patients are managed on OCHSNER SHERREN REGIME and stays in hospital for 7-10 days. All the patients do not respond uniformly. In a significant number of patients, the regimen fail and surgical intervention has to be made rather in a difficult situation. Misdiagnosis in the form of iliocaecal tuberculosis, carcinoma of caecum and intussusception is another enigma.

Now with the availability of better anaesthesia, good antibiotics and better surgical expertise, the appendicular mass of any duration can be explored early. It confirms the diagnosis, cures the problem, reduces the cost of management, shortens the sickness period and hospital stay with reasonably satisfactory outcome.

References

[1.] Ali S, Rafique HM. Appendicular mass; Early exploration vs conservative management. Professional Med J Jun. 2010;17(2):180-4.

[2.] Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpable mass. Ann Surg. 1981;193(2):227-9.

[3.] Wade DS, Marrow SE, Balsara ZN, Burkhard TK, Goff WB. Accuracy of ultrasound in the diagnosis of acute appendicitis compared with the surgeon's clinical impression. Arch Surg. 1993;128(9):1039-44

[4.] O'Connell PR. The Verniform apprndix. In: Williams NS, Bullstrode CJK, O'Connell PR, (editors). Bailey and Love's Short practice of surgery. 25th edi. London: Hodder Arnold. 2008. p. 1204-18.

[5.] Eryilmaz R, Sahin M, Savas MR. Is interval appendectomy necessary after conservative treatment of appendiceal masses? [Article in Turkish]. Ulus Travma Acil Cerrahi Derg. 2004;10(3):185-8.

[6.] Oliak D, Yamini D, Udani VM, Lewis RJ, Vergas H, Arnell T, et al. Non-operative management of perforated appendicitis without periappendiceal-mass. Am J Surg. 2000;179(3):177-81.

[7.] Garg P, Dass BK, Bansal AR, Chitkara N. Comparative evaluation of conservative management versus early surgical intervention in appendicular mass. J Indian Med Assoc. 1997;95(6):179-80.

[8.] Arshad M, Aziz LA, Qasim M, Talpur KAH. Early appendectomy in appendicular mass. JAMC 20(1):70-2.

[9.] Taj MH, Qureshi SA. Early surgical management of appendicular mass; J Surg Park. 2006;11(2):52-6.

[10.] Senapathi PS, Bhattacharya D, Ammori BJ. Early laparoscopic appendectomy for appendicular mass. Surg Endosc 2002;16(12):1783-5.

[11.] William RCN, Whitelaw DE. General surgical operations. 1st ed. UK: Elsevier Books Customer Service. 2006. p. 111.

Source of Support: None

Conflict of interest: None declared

Chandra Pandey (1), Ram Kesharwani (1), Chandra Chauhan (1), Manmohan Pandey (2), Purnima Mittra (3), Pramod Kumar (4), Arshad Raza (1)

(1) Department of Surgery, Rohilkhand Medical College, Bareilly, Uttar Pradesh, India

(2) Department of Medicine, Rohilkhand Medical College, Bareilly, Uttar Pradesh, India

(3) Department of Pathology, Rohilkhand Medical College, Bareilly, Uttar Pradesh, India

(4) Department of Radiology, Rohilkhand Medical College, Bareilly, Uttar Pradesh, India

Correspondence to: Chandra Pandey (cppandey19@yahoo.com)

DOI: 10.5455/ijmsph.2013.230820131

Received Date: 14.07.2013

Accepted Date: 23.08.2013
Table-1: Age Distribution

Age Group    Frequency (n=62)         %

11-20               11              17.75
21-30               30              48.39
31-40               16              25.80
41-60               5               8.07
>60                 0                00

Table-2: Gender Distribution

Gender        Frequency (n=62)       %

Male                 40            64.53
Female               22            35.49
Total                62             100

Table-3: Duration of Symptoms at Presentation

Duration of Symptoms (Days)    Frequency (n=62)       %

[less than or equal to] 2             9             14.52
3-4                                   28            45.17
5-6                                   11            17.75
>6                                    14            22.59

Table-4: Symptomatology of Patients

Symptoms                                          No.      %

                          Periumbilical           34     54.84
Site of Onset of    Generalized abdominal pain     8     12.90
Abdominal Pain              Epigastric            03     04.84
                       Right lower abdomen        17     27.42

Shifting of Pain             Shifted              57     91.94
                           Not shifted            05     08.07

GI Upset *                   Present              58     93.55
                              Absent              04     06.46

Temperature                   Raised              36     58.07
(Fever)                       Normal              26     41.94

* GI Upset: nausea/ vomiting, anorexia, loose stool and constipation

Table-5: Operative Findings & Procedure (n=34)

Operative finding                Procedure          No.       %

Supurative appendix            appendectomy         25      73.53

Gangrenous appendix            Appendectomy         05      14.70

Perforated appendix and    Drainage of abscess      04      11.77
  appendicular abscess       and appendectomy

Normal appendix                     Nil             Nil      Nil

Table-6: Post-Operative Complications

Complications                         Group I         Group II
                                       (n=31)          (n=31)

Wound infection                      3 (9.67%)        2 (6.45%)
Residual abscess                       0 (0%)         2 (6.45%)
Faecal fistula                       1 (3.22%)         0 (0%)
Adhesive intestinal obstruction        0 (0%)         3 (9.67%)
Chest complication                   1 (3.22%)       5 (16.12%)
Haematoma                            1 (3.22%)         0 (0%)
Incisional hernia                      0 (0%)          0 (0%)
Failure of treatment                   0 (0%)         3 (9.67%)
Lost in follow up                      0 (0%)         2 (6.45%)
Misdiagnosis                           0 (0%)         1 (3.22%)
Readmission                            0 (0%)        8 (25.80%)

Table-7: Hospital Stay

Hospital Stay         Group I       Group II          Total

Less than 3 days    26 (83.87%)       0 (0%)       26 (83.87%)
4-6 days            5 (16.12%)      8 (25.80%)     13 (20.69%)
More than a weak      0 (0%)       23 (74.19%)     23 (37.09%)
Total                   31              31             62
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Article Details
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Title Annotation:RESEARCH ARTICLE
Author:Pandey, Chandra; Kesharwani, Ram; Chauhan, Chandra; Pandey, Manmohan; Mittra, Purnima; Kumar, Pramod
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Date:Oct 1, 2013
Words:1714
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