Acute appendicitis (AA) is a common acute surgical condition.1,2 Its natural evolution includes parietal perforation with either diffuse peritonitis or omental-visceral block and a localized inflammatory/infectious process.3 These evolved forms are called inflammatory appendiceal masses (IAM),3–5 which also includes appendiceal abscess and phlegmon. At our medical center, 456 adult patients with acute appendicitis (AA) were treated from 2019 to 2021, 12 of whom (3%) presented IAM (see Table 1). The majority were obese (n = 8) women (n = 9), with difficult semiology for both the clinician and surgeon in terms of surgical management. Three presented psychiatric pathology, which made the anamnesis difficult and partially explains the delayed diagnosis. The most frequent presentation was pain in the right iliac fossa, fever and a palpable mass. The median time of evolution was 11.5 days. Seven patients had had previous consultations, and 3 had been prescribed antibiotics.
Clinical characteristics and therapeutic management.
Sex | Age | BMI >30 | Symptoms | Evolution | Treatment | Approach/Procedure |
---|---|---|---|---|---|---|
M | 19 | Yes | Pain in RIF + Fever + Mass | 8 | ATB | – |
M | 45 | No | Pain in RIF + Fever + Mass | 15 | Percutaneous | – |
F | 65 | Yes | Pain in RIF + Fever + Mass | 30 | ATB | – |
F | 35 | Yes | Pain in RIF + Fever + Mass | 5 | Surgery | LaparoscopicSurgical drainage |
F | 40 | Yes | Pain in RIF + Fever | 30 | ATB | – |
M | 55 | No | Pain in RIF + Fever | 5 | Surgery | ConversionRight colectomy |
F | 44 | Yes | Pain in RIF + Fever + Mass | 15 | Percutaneous | – |
F | 45 | Yes | Pain in RIF + Fever | 5 | Surgery | Conversion Right colectomy |
F | 75 | Yes | Pain in RIF | 15 | Surgery | ConversionSurgical drainage |
F | 45 | Yes | Pain in RIF + Fever | 15 | Surgery | ConversionAppendectomy |
F | 42 | No | Pain in RIF | 7 | Surgery | LaparoscopicAppendectomy |
F | 34 | No | Pain in RIF + Fever + Mass | 5 | Surgery | LaparoscopicAppendectomy |
BMI, body mass index; F, female; M, male; RIF, right iliac fossa; ATB, antibiotics.
The diagnosis was confirmed by computed tomography (CT). The ability to identify the appendix is an element to consider in the therapeutic decision-making process. Pneumoperitoneum or free fluid suggestive of macroperforation rule out conservative management. CT is highly valuable for diagnosing elderly patients given the increased prevalence of neoplastic pathology.6 Even with CT, there will always be a group of patients in whom the diagnosis will not be clear. Tekin et al., in their study of 98 patients with a clinical and CT diagnosis of IAM, later excluded 4 after video-assisted colonoscopy provided the diagnoses of colon cancer, diverticulitis and Crohn’s disease. In these cases, the common denominator was the lack of response to therapeutic measures.5
Therapeutic management is controversial,1,3,4 and publications in the literature provide context while also sparking debate. Therapeutic management options range from antibiotic therapy alone to image-guided percutaneous drainage and/or surgical drainage, either with or without appendectomy. Initial treatment may include systematic surgery or conservative management.
In the 7 patients treated surgically, the results were discouraging.
Appendectomy was performed in 3 patients: 2 laparoscopic, and one with subsequent conversion. Patient 4 required conversion, but the appendix still could not be identified. The evolution of all 4 patients was torpid, with residual collections and hospitalization for more than 7 days.
In the 5th patient, it was impossible to identify the cecal appendix, so we opted for drain placement. The patient’s progress was poor, requiring reoperation for drainage of an intra-abdominal collection. She was discharged 15 days after surgery.
Patients 6 and 7 required conversion and extended visceral resection (right colectomy) due to intraoperative suspicion of a cecal tumor. In one case, the suspicion was confirmed by pathology, while in the other the specimen was negative for malignancy.
Conservative management was described by Ochsner4,7 and consisted of antibiotic therapy, either alone or associated with percutaneous drainage, and elective appendectomy (EA) in certain cases. It is indicated in patients in whom surgery must be deferred for reasons of situational context (war, high seas, absence of a surgeon). Currently, the strategy is also used an alternative to undertaking a demanding surgery in a hostile inflammatory locoregional environment, which may be further complicated by the risk of not being able to identify the appendix and the need for conversion or extended resections. The advent of conservative management has been closely linked to the development of percutaneous needle aspiration techniques.3,4 This therapeutic strategy was chosen in 5 patients and providing good evolution; in 2, percutaneous drainage was also performed (Fig. 1).
The choice of therapeutic strategy is decided by the surgeon based on the clinical presentation and CT findings. The days of evolution would seem to play a fundamental role.4,6 In the Deelder et al. study, the evolution time was identified as the only statistically significant difference between the initial surgical treatment group versus the conservative treatment group (5.4 days vs. 8.3, respectively).4 Another element is the surgeon's judgment, which is as significant as it is intangible. Some authors suggest that, in patients in whom the pathological appendix is identified on CT, the approach tends to be surgical at the outset.6 Most authors agree that conservative treatment requires a longer and more patient follow-up for the surgeon. Nevertheless, surgery may present the same prolonged hospitalization due to its morbidity.4
After successful conservative treatment, the diagnostic assessment should be completed with VCC in patients over the age of 40 years of age, and a CT scan should be ordered for follow-up of the evolution.1–3 Ochsner’s treatment regimen culminates with elective appendectomy (EA),8 which is indicated in patients with uncertain diagnoses or recurring symptoms. Recurrence ranges from 6% to 20% with differentials from 3% to 17% associated with a higher age group.1,2,5,9 In the reported experience, EA was indicated in a patient due to recurrence and persistence of a pathological CT scan after the pathology study had ruled out malignant disease. The guidelines do not recommend systematic EA in patients under 40 years of age (Level of evidence 1B).1