RGUHS Nat. J. Pub. Heal. Sci Vol: 14 Issue: 4 eISSN: pISSN
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Sam Joy* , Ravindra Devani, Nandkishor Shinde
Department of Surgery, Faculty of Medical Sciences, Khaja Banda Nawaz University, Kalaburagi - 585104, Karnataka, India.
*Corresponding author:
Dr. Sam Joy, Junior Resident, Department of Surgery, Faculty of Medical Sciences, Khaja Banda Nawaz University, Kalaburagi-585104, Karnataka, India. E-mail: samwaits.joy7@ gmail.com
Abstract
Background and Aims: Type of management of appendicular mass may influence surgical outcomes. We decided to study the outcomes of different modalities of intervention in patients with appendicular mass.
Methods: A retrospective study was conducted in our tertiary care center, over a period of three years. Retrospectively records of all the patients diagnosed with appendicular lump were analysed. A total of 32 patients diagnosed with appendicular lump were included. Patients with appendicular abscess and septicaemia were excluded. Demographic data, clinical presentation, investigations (USG and CT scan reports), intraoperative findings, complications, hospital stay were recorded. After the diagnosis, patients were divided into two groups based on the type of management. Group I included patients who were managed conservatively with OchsnerSherren regimen, followed by interval appendicectomy after six weeks which composed of twenty patients (12 males and 8 females) and Group II included patients managed with immediate surgical intervention which composed of 12 patients, (8 males and 4 females).
Results: In group I, conservative treatment was successful in 18 patients (90%), while in two patients there was failure of conservative treatment and they underwent immediate exploration (6.25%). Rest of the patients underwent interval appendicectomy after six weeks. Eleven patients in group II were discharged within six days (96.87%). Most of them (68.75%) were discharged within three days of admission to hospital, whereas eight patients in group I were discharged within six days (25%).
Conclusion: Early exploration of lump is safe, curative, time saving, reduces cost of management and shortens hospital stay facilitating early return to work.
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Article
Introduction
Acute appendicitis is the commonest cause of “acute surgical abdomen”. The best treatment of acute appendicitis is emergency appendicectomy. If the treatment is delayed, then complications like appendicular lump can result.1 Delayed diagnosis changes the uncomplicated simple acute appendicitis into complicated appendicitis.2 Appendicular lump is formed in 2-6% cases of acute appendicitis, if appendicectomy is not done.3 The appendicular mass is more commonly seen amongst elderly males.4
Lump forms after 48-72 hours of first symptoms of acute appendicitis. Lump develops when appendicitis is caused by obstruction of the lumen and there is danger of perforation of appendix following ischemic necrosis and gangrene of the appendicular wall.5
Conventional treatment according to Ochsner-Sherren regime, popularized by Oschner has been practiced over many years as the standard treatment for the appendicular lump.6,7 Conservative management had 88-95% success rate.8 Interval appendicectomy is recommended after conservative treatment due to high rate of recurrence of appendicitis and lump formation.9
In modern era, where facilities and expertise for laparoscopic surgery and anaesthesia facilities are available, early exploration of appendicular mass is preferred to eliminate the need for second hospital admission with no added morbidity and mortality, shortening the hospital stay,10-14
Methods
A retrospective study was conducted in our tertiary care center, over the period of three years from 2018 to 2021. Retrospectively records of all the patients diagnosed with appendicular lump were analysed from MRD case sheets. A total of 32 patients diagnosed with appendicular lump were included.
Inclusion criteria
Patients who were diagnosed with and who underwent treatment for appendicular lump
Exclusion criteria
Patients with appendicular abscess and septicaemia Patient whose diagnosis changed afterwards Patients who were lost to follow up Demographic data, clinical presentation, investigations (USG and CT scan reports), intraoperative findings, complications, hospital stay were recorded. All the data was analysed using SPSS, Version 24.0
Patients were randomly divided in to two groups - Group I included patients who were managed conservatively with Ochsner-Sherren regimen, followed by interval appendicectomy after six weeks and Group II included patients who were managed with immediate surgical intervention.
Results
The results of our study are depicted in tables 1-6. In group I, conservative treatment was successful in 18 patients (90%), while in two patients there was failure of conservative treatment and they underwent immediate exploration (6.25%). Rest of the patients underwent interval appendicectomy after six weeks. Two patients from group II developed faecal fistula after surgery, which was successfully managed conservatively. Eleven patients in group II were discharged within six days (96.87%). Most of them (68.75%) were discharged within three days of admission to hospital, whereas eight patients in group I were discharged within six days (25%).
Discussion
Appendicular lump is more commonly seen in extremes of ages (children and old age). It may complicate to cause appendicular perforation, gangrene of appendix or caecum wall, abscess. The conservative treatment followed by interval appendicectomy is an established method and still is popular. But in recent years, early exploration of the appendicular lump is preferred because of less overall hospital stay, the low economic burden with no added major complication.5,6
The main cause of lump formation was delayed presentation of the patient. In our study, 40% patients belonged to younger age group (21-30 years). The male to female ratio was 1.5:1.
In group II, hospital stay was shorter up to three days in 68.75%, 4-6 days in 28.13% cases, while only two patients (3.12%) developed faecal fistula requiring more than two weeks stay and were successfully managed conservatively. Early exploration reduces readmission, is safe, time saving, facilitating an early return to work.11-14
Failure of conservative regimen occurs in 2-4% cases (up to 10% cases), where urgent exploration is essential.12 Conventional treatment is favoured sometimes because it can avoid potential complications like damage to caecum and the development of faecal fistula.7 Failure rate of conservative treatment in our patients which later converted to immediate exploration was found to be similar to other reported studies.13,14
Caecal malignancy and ileocaecal tuberculosis can sometimes be confused with acute appendicitis.10,11 We had not encountered such a finding in any of the cases in our 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.13,14
Conclusion
Early exploration of lump is safe, curative, time saving and reduces the cost of management and shortens hospital stay facilitating early return to work.
Conflicts of Interest
None.
Supporting File
References
1. Farquharson M, Moran B. Operations on appendix. In: Margaret Farquharson, eds. Farquharson’s Textbook of Operative General Surgery. 9th ed. UK: A Hodder Arnold Publication; 2005.
2. Chan L, Shin LK, Pai RK, Jeffery RB. Pathologic continuum of acute appendicitis: sonographic findings and clinical management implications. Ultrasound Q 2011;27(2):71-9.
3. Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpable mass. Ann Surg 1981;193(2):227-9.
4. Okafor PL, Orakwe JC, Chianakawana GU. Management of appendiceal mass in a peripheral hospital in Nigeria: review of thirty cases. World J Surg 2003;27(7):800-3.
5. William NS, Bulstrode CJK, Ronan O’Connel P. In: Norman S. William, Christopher JK. Bulstrode, P. Ronan O’Connel, eds. Vermiform Appendix in Short Practice of Surgery. 25th ed. London: Edward Arnold Publisher Ltd; 2008. p. 1205-1217.
6. Oscner AJ. The cause of diffuse peritonitis complicating appendicitis and its prevention. JAMA 1901;26:1747-54.
7. Nitecki S, Assalia A, Schein M. Contemporary management of appendiceal mass. Br J Surg 1993; 80:18-20.
8. Ullah S, Khan M, Ahmad S, Mumtaz N. Conservative treatment of appendicular mass without interval appendectomy. J Postgrad Med Inst (JPMI) 2007;21(1):55-9.
9. Friedell ML, Izquierdo PM. Is there a role for interval appendectomy in the management of acute appendicitis? Am Surg 2000;68:1158-62.
10. Garg P, Das BK, Bansal AR, Chitkara N. Comparative evaluation of conservative management versus early surgical intervention in appendicular mass: a clinical study. J Indian Med Assoc 1997;95(6):179- 80.
11. Garba ES, Ahmed A. Management of appendiceal mass. Ann Afr Med 2008;7(4):200-4.
12. Olika D, Yamini D, Udani VM, Lewis RJ, Vargas H, Arnell T, et al. Non-operative management of perforated appendicitis without peri-appendiceal mass. Am J Surg 2000;179:177-81.
13. Pandey CP, Kesharwani RC, Chauhan CG, Pandey MK, Mittra P, Kumar P, et al. Management of appendicular lump: early exploration vs. conservative management. Int J Med Sci Public Health 2013;2:1067-70.
14. Ali S, Rafique HM. Appendicular mass: early exploration vs. conservative management. Professional Med J 2010;17(2):180-4.