The Appendiceal Mass

Results of Conservative Management

ERIK SKOUBO-KRISTENSEN, M.D., IVAN HVID, M.D.

During a ten-year period 193 patients with an appendicealmass-and subsequently proved postinflammatory changes ofthe appendix-were treated conservatively. The course wasuneventful in 88%. Twelve per cent underwent delayed surgicalintervention caused by complications with one death. Electiveappendectomy was performed after three months with a com-plication rate of 3.4%. In comparison with series with earlyoperation the conservative management seems to carry a lowermorbidity. The value of elective appendectomy is discussed.

r HE PRIMARY TREATMENT of an appendiceal massor abscess may be either nonoperative or consist

of surgical drainage plus appendectomy if possible.Whatever method is preferred, the question of intervalappendectomy becomes pertinent in most cases. Recentreports on operative management suggest a high rate ofcomplications." 2 This has prompted the authors to re-view the results of appendiceal abscess treated duringthe last decade in this department, where the treatmentfor many years has been nonoperative followed by ascheduled appendectomy.

Methods and Patients

Appendiceal abscess was diagnosed in patients witha history of fever and right lower quadrant pain whena mass could be felt in the right lower quadrant or byrectal examination. Mature female patients had a gyne-cologic examination on admission, and repeatedly ifnecessary, to rule out inflammatory or neoplastic diseaseof the internal genital organs. Bed rest was obligatoryuntil subsidence of fever, significant reduction of ESR,and reduction of the size of the palpable mass. Naso-gastric suction and intravenous fluids were used whenthe patient was nauseated or showed other signs of in-testinal paralysis. Opium for constipation was widelyused in the first years of the period. The attitude toward

Reprint requests: E. Skoubo-Kristensen, M.D., Department of Sur-gery, Aarhus Amtssygehus, DK-8000 Aarhus C, Denmark.

Submitted for publication: January 12, 1982.

From the Department of Surgery, County Hospital,University of Aarhus, Aarhus, Denmark.

antibiotic treatment changed through the period. Peni-cillin and streptomycin were given to most patients dur-ing the first years; later on only patients with high tem-perature or fever spikes received antibiotics. In lateryears ampicillin and metronidazole were the preferredfirst-choice antibiotics. The patients stayed in hospitaluntil the mass was reduced to a small nontender lumpor had disappeared. As a rule interval appendectomywas contemplated to take place three months after theend of primary hospitalization.

All patients files from the period 1970 to 1979 car-rying a diagnosis of appendiceal abscess were reviewed.As the authors were interested in the outcome of con-servative treatment, not in diagnostic problems, onlypatients with confirmed sequelae of appendicular in-flammation are reported in this study, criteria for en-tering being clear macroscopic or microscopic pathologyor both in addition to the above mentioned clinical find-ings. Two hundred and two patients were identified forreview. The institution serves a predominantly urbanarea with approximately 150,000 inhabitants. The meanincidence of appendiceal mass with verified sequelae ofappendicitis was thus 13 per year per 100,000 inhabit-ants.

Results

Age and sex distribution ofthe 202 patients (92 malesand 110 females) is shown in Figure 1. The youngestpatient was three years and the eldest 86 years old.Maximum incidence was in the second decade. Sixty-five patients (32.2%) had symptoms prior to admissionfor three days or less, and 82 (40.6%) had a history ofone week or more (Fig. 2).

All but nine patients presented with an abdominal orpelvic mass identified at the admission or during the

0003-4932/82/1100/0584 $01.00 © J. B. Lippincott Company

584

APPENDICEAL MASS

first days in hospital. The nine patients are included inthe study because an abscess was found at a primaryoperation in seven cases and at interval appendectomyin two cases.

Most patients (93%) had elevated ESR. WBC was notroutinely taken. Temperature did not exceed 38 C in13% of the patients, while 55% experienced febrile ep-isodes with temperature above 39 C.

Antibiotics in various combinations were adminis-tered to 138 patients (68.3%) as part ofthe primary treat-ment.The treatment is summarized in Table 1. Nine pa-

tients were primarily operated on in suspicion ofanotherdiagnosis. Three patients had nothing further done afterrecognition of the appendiceal mass, leaving the masses

to spontaneous resolution, and two patients were treatedby appendectomy without drainage. Four patients hada right hemicolectomy performed because of difficultyin differentiating the mass from a malignant lesion. Sub-sequent histologic examination gave evidence of inflam-mation in every case, but confirmed a neoplastic disease,a benign carcinoid, in one case only.

Nonoperative treatment was started in 193 patientsof which 170 patients (88%) experienced an uneventfulcourse and were discharged after median 13 days ofhospitalization (interquartile range: 10-17 days, range:3-52 days).

In 23 patients (1 1.9%) a delayed operation was nec-

essary because of complications during conservativetreatment, as listed in Table 2. An 86-year-old womandied a few days after surgical drainage, as a result of a

large retroperitoneal and abdominal abscess-in fact theonly death in the series-a mortality rate of 0.5%. An-other patient developed a fecal fistula that persisted forseven months until surgical closure. A third patient hada reoperation the day after the tubulation because of

ca)

0

E

;z

45

40

35

30

25

15

10

5

El 6' N= 92

9 N= 110

1K

Li

0 10 20 30 40 50 60 70 80 90 Age in years

FIG. 1. Age and sex distribution.

ta

0

-o

E

-z

1 2 3 4 5 6 7 or more DaysFIG. 2. Duration of symptoms before admission to hospital.

perforation of the abscess to the peritoneal cavity. Thiscomplication is very serious and often fatal; the devel-opment in this case was long and difficult.

Recurrences

Before the scheduled appendectomy, 12 out of the170 patients discharged after conservative treatmentwere readmitted to hospital with a recurrent mass ineight cases and acute appendicitis without a mass in fourcases, a recurrence rate of 7.1% within three months.One patient with the appendix mass during pregnancy

did not come to appendectomy after delivery as rec-

ommended, but returned with a recurrent mass after 15months. Eight patients were again treated nonopera-

tively with resolution of the mass. Five patients under-went an uncomplicated appendectomy.

Interval Appendectomy

A total of 179 patients underwent an interval appen-

dectomy, out of which six patients experienced com-

plications, a rate of 3.4%. Four patients had wound in-fections, one had recurrent abscess and fistula, and one

had small bowel obstruction. Median time in hospital

TABLE 1. Treatment of Patients with an Appendiceal Mass

No. ofTreatment Patients

Primarily operated 9Completed nonoperative treatment 170Delayed operated 23Total 202

VOl. 196 * NO. 5 585

TABLE 2. Delayed Surgical Intervention in 23 Unsuccessful Conservatively Treated Cases

No. ofPatients Indication Treatment Secondary Complications

6 Small bowel obstruction All lysis + appendectomy 1 Douglas abscess + pleuropneumonia(+ drainage 2, - drainage 4) 1 bleeding gastric ulceration

- gastrectomy - subphrenic abscess

8 Sepsis + unresolved abscess All drainage + elective appendectomy 1 diffuse peritonitis after drainage operation1 fecal fistula

6 Unresolved abscess All drainage + 5 elective appendectomy 1 death

3 Suspicion of perforation of abscess 1 appendectomy 1 subphrenic abscess(1 verified) I drainage + app.

1 drainage + elective app.

for this procedure was five days (interquartile range: 5-7 days, range: 3-40 days).

Microscopic examination of the removed appendicesrevealed seven with mucocele and two with benign car-cinoid tumors. Simple inflammatory changes werefound in 154 specimens. The microscopy was normalin three cases and was not done in 13 cases, but in thesecases macroscopic changes consistent with previous peri-appendiceal inflammation was recorded at the opera-tion.

Discussion

Reports on conservative vs. early operative treatmentofappendiceal mass and abscess are difficult to compareand, certainly, no single prospective and randomizedtrial has been carried out to clarify the possible superi-ority ofany ofthese treatment plans. One main problemin comparing existing retrospective results is the lack ofconsistency in using the terms appendiceal mass andappendiceal abscess. As emphasized by McPherson andKinmonth,3 the two terms are not synonymous, appen-diceal mass thus signifying a palpable lump around aninflamed appendix, that at operation might turn out tobe either a phlegmon with adherent adjacent organs ora definite abscess. Studies of conservative managementdeal with both conditions, while most studies of earlyoperation deal with the stage of abscess formation. Clin-ically it is not possible in most cases to distinguish withcertainty between the two conditions, but in two recentreports about half ofthe patients presenting with a massproved to have phlegmons at surgery.24 In this way itbecomes uncertain to what extent definite abscesses re-solve spontaneously or need incision. It remains to -beshown ifultrasonography might clarify this point as pro-posed.2

Eighty-eight per cent of the patients in this study didwell on conservative treatment, which is in accordancewith other investigators.3'5'6 A similar success rate has

been reported in children.7'8 In the old-age group, all didwell in Thomas' study,5 but in the present study five outof seven patients past 70 years of age underwent a de-layed operation because of failure of the conservativemanagement.The mortality has been decreasing through this cen-

tury. In this series there was one death (0.5%), and nofatalities connected to interval appendectomy. Mortal-ity in recent studies on operative treatment isequally low.",2'4The authors consider resorting to operation after start-

ing conservative treatment to be a complication, whichamounted to 12% in this series. In a recent paper byJordan et al.2 on surgical treatment, the overall com-plication rate was 36%, but about 50% in the abscessgroup, and 21% in the group with phlegmons. This studyis comparable to the authors', the criterion for enteringthe study being appendicitis with a palpable mass. Inanother study ofsurgical drainage, the complication ratewas 28%.' These figures may suggest that conservativetreatment carries a lower morbidity, yet Foran et al.showed no significant complications and good resultswith either form of therapy,9One advantage generally accepted with operative

treatment is a somewhat shorter stay in hospital. Themedian total stay (including exacerbations and admit-tance for interval appendectomy) in the 193 conserva-tively treated cases was 21 days. With early operationBradley and Isaacs found an average hospital stay of 17days for primary operative treatment, and five days forinterval appendectomy, while Jordan et al. found anaverage hospital stay of 16 days.The benefit of interval appendectomy has been ques-

tioned in several recent studies.10-2 The argument isthat therapeutic gain (avoidance of recurrences, identi-fication of malignant, and potentially malignant lesions)is minimal (about 10% of patients) and contrasting toan unduly high rate of complications to the appendec-tomy (13-19%). However, there is a wide variation in

Ann. Surg. 9 November 198f586 SKOUBO-KRISTENSEN AND HVID

Vol. 196 * No. 5 APPENDICEAL MASS 587

the rate of recurrent appendicitis after an attack of ap-pendiceal abscess. Bauer reviewed the earlier literaturein 1933, and found the frequency to vary between 10%and 46%, but only 9.7% in his own study with a longfollow-up.'3 In a contemporary study Engkvist reporteda recurrence rate of 7% with a follow-up period fromthree to 15 years. Generally quite many recurrences takeplace within the first months of the convalescence, andcannot be prevented unless the interval before electiveappendectomy is a few weeks. On the other hand theinflammatory changes may not have subsided at thattime, and more complications to this procedure mightbe anticipated. In this series the rate of complicationswas low, 3.4%, and it seems that some of the compli-cations noted by others are so harmless that intervalappendectomy should not be rejected on that account.The following conclusions were made: (1) conserva-

tive management of appendiceal mass is successful inmost cases and the complication rate seems lower thanwith early operative treatment; and (2) complicationsto elective appendectomy can be kept to a minimum,but the therapeutic gain of this procedure remains ques-tionable.

References

1. Bradley EL, Isaacs J. Appendiceal abscess revisited. Arch Surg1978; 113:130-132.

2. Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpablemass. Ann Surg 1981; 193:227-229.

3. McPherson AG, Kinmonth JB. Acute appendicitis and the ap-pendix mass. Br J Surg 1945; 32:365-370.

4. Vakili C. Operative treatment of appendix mass. Am J Surg 1976;131:312-314.

5. Thomas DR. Conservative management of the appendix mass.Surgery 1973; 73:677-680.

6. Lehman EP, Parker WH. The treatment of intraperitoneal abscessarising from appendicitis. Ann Surg 1938; 108:833-856.

7. Gierup J, Karpe B. Aspects on appendiceal abscess in childrenwith special reference to delayed appendectomy. Acta ChirScand 1975; 141:801-803.

8. Janik JS, Ein SH, Shandling B, Simpson JS, Stephens CA. Non-surgical management of appendiceal mass in late presentingchildren. J Pediat Surg 1980; 15:574-576.

9. Foran B, Berne TV, Rosoff L. Management of the appendicealmass. Arch Surg 1978; 113:130-132.

10. Engkvist 0. Appendectomy a froid a superfluous routine opera-tion? Acta Chir Scand 1971; 137:797-800.

11. Bulow S, Christoffersen I, Olsen JH. Appendectomi a froid.Ugeskr Lag 1977; 139:1120-1122.

12. Mosegaard A, Nielsen OS. Interval appendectomy, a retrospectivestudy. Acta Chir Scand 1979; 145:109-111.

13. Bauer G. Zur Behandlung der Appendicitis-Peritonitis. ActaChir Scand 1933; Suppl 24:486-495.