Digestive Surgery
Original Paper
The Need for Interval Appendectomy after Resolution of an Appendiceal Mass QuestionedWillemsen P.J.a · Hoorntje L.E.b · Eddes E.-H.H.b · Ploeg R.J.aaDepartment of Surgery, University Hospital Groningen, and bDepartment of Surgery, Deventer Ziekenhuis, Deventer, The Netherlands
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Article / Publication Details
Published online: July 04, 2002
Issue release date: 2002
Number of Print Pages: 7
Number of Figures: 0
Number of Tables: 3
ISSN: 0253-4886 (Print)
eISSN: 1421-9883 (Online)
For additional information: https://www.karger.com/DSU
Abstract
Background: Our current treatment of an appendiceal mass is initially conservative, followed by an interval appendectomy. The necessity of this routine interval appendectomy is debatable. A study was conducted to evaluate whether surgical factors and pathological features of the excised appendices support interval appendectomy. Methods: We performed a retrospective study at the University Hospital Groningen and the Deventer Ziekenhuis. All patients diagnosed with an appendiceal mass in the period January 1991 to January 1997 were identified using the hospital database. The medical records of all these patients (n = 233, 108 M, 125 F) were reviewed. The clinical course of the appendiceal mass patients was split up into three distinct episodes: initial diagnosis and treatment of the appendiceal mass, the interval period and the interval appendectomy. Presenting symptoms, findings at clinical examination and additional imaging (ultrasound) were registered, as well as the course of the primary hospitalisation, the interval period, and the interval appendectomy. Results of histological examination of all resected specimens were reviewed. Results: It was found that clinical findings alone were not specific enough to diagnose an appendiceal mass; 47% had a palpable abdominal mass and the median temperature was 38.2°C ranging from 36 to 40.5°C. Ultrasound examination was done in 69% of patients and showed an appendiceal mass in 72%. During the interval period, 4 patients presented with an appendiceal mass needing drainage, and 3 with acute appendicitis requiring emergency appendectomy. At interval appendectomy, histological examination of resection specimen showed a normal appendix without signs of previous inflammation in 30% of cases. In addition, complications due to interval appendectomy were seen in 18% of patients, including sepsis, bowel perforation, small bowel ileus, and various wound abscesses. Conclusions: We conclude that when causes for the appendiceal mass other than appendicitis are excluded, interval appendectomy seems unnecessary in patients who respond well to initial conservative treatment.
© 2002 S. Karger AG, Basel
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References
-
Silen W: Appendicitis and the differential diagnosis of appendicitis; in Cope’s Early Diagnosis of the Acute Abdomen, ed 19. New York, Oxford University Press. 1996, pp 70–110.
-
Ellis H, Nathanson LK: Appendix and appendectomy; in Maingot’s Abdominal Operations, ed 10. London, Prentice Hall International, 1997, pp 1191–1227.
- Nitecki S, Assalia A, Schein M: Contemporary management of the appendiceal mass. Br J Surg 1993;80:18–20.
- Bagi P, Dueholm S: Nonoperative management of the ultrasonically evaluated appendiceal mass. Surgery 1987;101:602–605.
-
Puylaert JBCM: The use of ultrasound in patients with clinical signs of appendicitis; PhD thesis, Rijksuniversiteit Leiden, the Netherlands, 1988.
- Price MR, Haase GM, Sartorelli KH, Meagher DP: Recurrent appendicitis after initial conservative treatment of appendiceal abscess. J Pediatr Surg 1996;31:291–294.
- Paul DL, Bloom GP: Appendiceal abscess. Arch Surg 1982;117:1017–1019.
- Elmore JR, Dibbins AW, Curci MR: The treatment of complicated appendicitis in children. What is the gold standard? Arch Surg 1987;122:424–427.
- Mazziotti MV, Marley EF, Winthrop AL, Fitzgerald PG, Walton M, Langer JC: Histopathologic analysis of interval appendectomy specimens: Support for the role of interval appendectomy. J Pediatr Surg 1997;32:806–809.
- Janik JS, Ein SH, Shandling B, Simpson JS, Stephens CA: Nonsurgical management of appendiceal mass in late presenting children. J Pediatr Surg 1980;15:574–576.
- Thomas DR: Conservative management of the appendix mass. Surgery 1973;73:677–680.
- Wilcox RT, Traverso LW: Have the evaluation and treatment of acute appendicitis changed with new technology? Surg Clin N Am 1997;77:1355–1370.
- Hoffma J, Lindhard A, Jensen H-E: Appendix mass: Management without interval appendectomy. Am J Surg 1984;148:379–382.
- Mosegaard A, Nielsen OS: Interval appendectomy: A retrospective study. Acta Chir Scand 1979;145:109–111.
- Skoubo-Kristensen E, Hvid I: The appendiceal mass: Results of conservative management. Ann Surg 1982;196:584–587.
- Engkvist O: Appendectomy a froid: A superfluous routine operation? Acta Chir Scand 1971;137:797–800.
- Eriksson S, Styrud J: Interval appendicectomy: A retrospective study. Eur J Surg 1998;164:771–774.
- Ein SH, Shandling B: Is interval appendectomy necessary after rupture of an appendiceal mass? J Pediatr Surg 1996;31:849–850.
- Jordan JS, Kovalcik PJ, Schwab CW: Appendicitis with a palpable mass. Ann Surg 1981;193:227–229.
- Foran B, Berne TV, Rosoff L: Management of the appendiceal mass. Arch Surg 1978;113:1144–1145.
- Decadt B, Sussman L, Lewis MP, Secker A, Cohen L, Rogers C, Patel A, Rhodes M: Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain. Br J Surg 1999;86:1383–1386.
-
Christopher’s Textbook of Surgery, ed 7. London, Saunders, 1960.
-
Greenfield et al: Surgery, Scientific Principles and Practice. Philadelphia, Lippincott, 1993.
- Oliak D, Yamini D, Udani V, Lewis R, Arnell T, Vargas H, Stamos M: Initial nonoperative management for periappendiceal abscess. Dis Colon Rectum 2001;44:936–941.
Article / Publication Details
Published online: July 04, 2002
Issue release date: 2002
Number of Print Pages: 7
Number of Figures: 0
Number of Tables: 3
ISSN: 0253-4886 (Print)
eISSN: 1421-9883 (Online)
For additional information: https://www.karger.com/DSU
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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
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PubMed IDD.J. Leaper
North Tees General Hospital, Stockton-on-Tees, UK
This paper attempts to answer a general surgical enigma. To show that interval appendicectomy is necessary after resolution of an appendiceal mass really needs a randomised controlled trial. This is probably not possible to conduct for logistic reasons, so does this retrospective cohort study give adequate data to allow an evidence based approach?
Their definitions of an ‘appendiceal mass’ are acceptable, as is their histological definition of prior appendicitis (interestingly 30% showed no signs of previous inflammation). The number of patients presenting with an appendiceal mass over the 8 years of study is remarkable (n = 233) and should allow inferences to be made with confidence. Two thirds of the patients had an ultrasound examination which confirmed an appendiceal mass in over 70% which is not widespread practice; certainly not in the UK. During the period of study their accepted management was to undertake an interval appendicectomy approximately 12 weeks later. Their concerns surround an 18% major complication rate after appendicectomy, a 5-day admission period, and a seemingly high negative appendicectomy rate. However, 7 of their patients needed surgical intervention, appendicectomy or drainage of an abscess, and there were 10 other patients who had a readmission in the interval period.
There are other causes of ‘appendiceal mass’, cecal carcinoma being the principle concern. The paper is slightly unclear about how these exclusions were made but barium enema, colonoscopy, CT and small bowel X-rays were undertaken. It appears that no other diseases were missed in the cohort of 233 patients. They have recommended which patients should be further investigated or those over 40 years old. Perhaps they should have a midline laparotomy rather than appendicectomy through a McBurney/Lanz incision or be investigated by barium enema or colonoscopy. They do emphasise the value of expert ultrasonography.
This paper adds to a personal conviction that interval appendicectomy is unnecessary after resolution of an appendiceal mass, provided other confounding diseases are excluded (malignancy in particular). Proof from an RCT is not likely to be forthcoming; nor is it likely that early laparoscopy for the diagnosis and management of appendiceal mass will be either, as the authors suggest.
The Need for Interval Appendectomy: How Many Times Do We Need to Kill the Gimmick?
Moshe Schein
Department of Surgery, Bronx Lebanon Hospital Center, Bronx, New York, N.Y., USA
‘It is less important to invent new operations and new techniques of operating than to find ways and means to avoid surgery ...’
[Bernhard von Langenbeck, 1810–1887]
An appendiceal mass is an entity which lies within the wide spectrum of acute appendicitis. As such it represents a spectrum of its own: ranging from an inflammatory mass – a phlegmon – to an appendiceal abscess [1]. The latter has again a spectrum of its own: from a few drops of pus to a complex multi-loculated process [2]. The development of an appendiceal mass signifies that the patient’s local and systemic defense mechanisms succeeded in walling-off the contaminating-infective appendicular process, allowing it to resolve spontaneously with or without the help of our non-operative management.
This study by Willemsen and colleagues from the Netherlands is retrospective and rather confused. ‘CT scans were not done on a regular basis’; ‘Antibiotics were not routinely administered; ‘15 patients ... were treated on an outpatient basis’. At interval appendectomy ‘a normal appendix or other non-appendicitis-linked pathology was seen in 30.2% of the patients’. In fact, I am not convinced that all patients in this series indeed suffered from an ‘appendiceal mass’. Nevertheless, the substantial size of this series serves to re-iterate what we already know.
Typically, patients with an appendiceal mass present late in the course of the disease, with symptoms of an ‘abdominal condition’ lasting a week or more (median of 5 days in Willemsen’s series). Occasionally, they report a spontaneous improvement in their symptoms, reflecting the localization of the inflammatory process. On clinical examination, one finds a right iliac fossa mass. Overlying tenderness or obesity may obscure the presence of the mass.
Therefore, one has to suspect an appendiceal mass in the ‘late presenters’ or those with an atypical ‘smoldering’ picture. When palpation is not rewarding, a CT scan is the best diagnostic modality in our hands [3]. As we know since more than 100 years, the appendiceal mass (and small abscess) can be managed nonoperatively. People did – and do – operate but the removal of the appendix involved in an inflammatory mass may be more hazardous than usual, occasionally necessitating as ‘much’ as a right hemicolectomy. On the other hand, conservative treatment with antibiotics leads to the resolution of the mass in the vast majority of cases. Failure of the mass to respond to antibiotics signifies an abscess. As is true with small peri-diverticular abscesses – appendiceal masses with a small amount of pus respond to antibiotic treatment. Larger and well-localized abscesses usually respond to percutaneous drainage while the very rare, extensive-complex abscesses (type III according to Jeffrey [
As no more – and perhaps less – than 1 of 5 patients will suffer a recurrence of appendicitis (usually within 1 year and not a severe attack), the dogma of routine ‘interval appendectomy’ within 8 weeks has become obsolete. As demonstrated also in this study such an unnecessary operation is not free from complications. I agree, however, that in patients over the age of 40 years an elective colonoscopy and CT scan (after 3 months) are necessary to exclude the rare situation in which cecal carcinoma was the cause of the mass.
I find the statement by the authors ‘role of laparoscopy in the management of appendiceal mass needs further investigation’ rather ridiculous. Why employ invasive technology in patients who can be managed conservatively? And if an appendiceal mass is identified at laparoscopy – should we convert to open, continue laparoscopically, or abort? Typically, the resource to unnecessary procedures creates more new dilemmas than solutions.
It is clear that currently interval appendectomy represents a gimmick. As such it follows the natural history of any surgical gimmick. It is introduced by necessity – real or false – then it is entrenched into surgical psyche and dogma – being practiced indefinitely even though it is no longer indicated. Typically, people want you to prove again and again that the value of the unproven gimmick is indeed unproven. Interval appendectomy made some sense in the ‘older days’ when acute appendicitis was a life-threatening condition, but today, with modern anesthesia, surgery and antimicrobials, it is safer to wait for a recurrent appendicitis, which may develop in few of those patients, rather than punish all of them with an unnecessary appendectomy. The fact that an interval appendectomy can be performed laparoscopically is not an excuse to perform one! The gimmick of interval appendectomy is dead – we are grateful to Willemsen et al. for killing it again. But how many times should a gimmick be killed before it is buried?
Finally, what to do with a patient with a clinically suspected acute appendicitis who is anesthetized, and when his abdominal wall is relaxed one feels a mass? Should we proceed with the operation or should we wake him up? I do not know.
References
01 Nitecki S, Assalia A, Schein M: Contemporary management of the appendiceal mass. Br J Surg 1993;80:18–20.
02 Jeffrey RB: Management of periappendiceal inflammatory mass. Semin Ultrasound CT MR 1989;10:341–347.
03 Schein’s Common Sense Emergency Abdominal Surgery. Heidelberg, Springer, 2000, chap 22.
