Management of Appendicular Lump

Information about Management of Appendicular Lump by Dr Dhaval Mangukiya.

Details of Appendicular Lump, Basic to Above the Basics, Incidence, Safe Approach Interval Laparoscopy, Early Surgery etc.

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1. Management of Appendicular lump Dr Dhaval Mangukiya SIDS Hospital & Rearch Center

2. Appendicular Lump Inflammatory tumor consisting of the inflamed appendix, its adjacent viscera, and the greater omentum

3. Basics to Above the Basics

4. Incidence 2-7 % Immediate appendectomy may be technically demanding because of the distorted anatomy and difficulties in closing the appendiceal stump due to the inflamed tissues. Failure of Non surgical treatment 2-4 %

5. Safe Approach Interval Laparoscopy Am Surg. 1994 Oct;60(10):753-8. Appendiceal Mass: Conservative Therapy Followed by Interval Laparoscopic Appendectomy

6. 233 patients Dig. Surg. 2002;19(3 ):216-20; discussion 221 The Need for Interval Appendectomy After Resolution of an Appendiceal Mass Questioned Paul J Willemsen et al When causes for the appendiceal mass other than appendicitis are excluded, interval appendectomy seems unnecessary in patients who respond well to initial conservative treatment.

7. Ann Surg. 2007 Nov;246(5):741-8. doi: 10.1097/SLA.0b013e31811f3f9f. Nonsurgical Treatment of Appendiceal Abscess or Phlegmon: A Systematic Review and Meta-Analysis Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment

8. J Emerg Trauma Shock . 2012 Jan-Mar; 5(1): 33–35. Evaluating conservative treatment for acute appendicitis with lump formation Ajaz Ahmad Malik , Mohd Lateef Wani , Shadab Nabi Wani , Fazl Qadir Parray , Nayeem-Ul-Hassan , and Ifat Irshad Conservative treatment of appendicitis with lump formation is efficient and the recurrence rate is low. Routine interval appendectomy after initial conservative treatment for lump formation is not a cost-effective intervention and not recommended.

9. Am Surg. 2016 Jan;82(1):11-5. A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See? Ghaleb Darwazeh, Steven C Cunningham, Gopal C Kowdley 21 studies with non operative and 5 studies with with interval surgery 1943 patients, of which 1400 patients were managed nonsurgically and 543 patients underwent interval appendectomy Nonoperative treatment had a mean recurrence of 12.4 per cent, a morbidity of 13.3 per cent, and the length of hospital stay was 9.6 days. Interval appendectomy morbidity was 10.4 per cent and 5.0 days, respectively

10. Early Surgery Turkish Journal of Trauma & Emergency Surgery 2010;16 (1): 43-4 Does Ochsner-Sherren regimen still hold true in the management of appendicular mass? Narayanan Dhanasekharan et al Retrospective study Total 506 patients Appendicular lump 114 patients Low morbidity, reduced hospital stay, low cost, and patient compliance favor early operative management for appendicular mass, and it also avoids the possibility of missing entities like intestinal/peritoneal tuberculosis, which have similar presentations and are especially common in a country like India.

11. International Surgery Journal Patel BJ et al. Int Surg J. 2015 May;2(2): 235-238 A comparative study of appendicular lump management Retrospective study 598 patients with Acute appendicitis 64 with appendicular lump taken in study Early exploration is safe, confirms the diagnosis, removes need for readmission, curative, time saving, reduces cost of management and shorten hospital stay with early return to work. Early Surgery

12. Options of treatment Emergency surgery (may need ileocolonic resection) Conservative management followed by interval surgery Totally conservative management without interval surgery

13. Conservative treatment Associated with a risk of missing or delayed hidden pathologies such as cecal cancer or Crohn's disease in about 2 to 3% of the patients In INDIA - Tuberculosis Colonoscopy and / or CT Scan is must (should be after 4 to 6 weeks)

14. Emergency surgery High frequency of complication Conducting colonic resection sometimes necessary

15. Interval Surgery Symptomatic during waiting time Chances of appendicular abscess or perforation May need pigtail or interim exploration

16. How to choose Randomised controlled trial Clinical Trial Indian J Gastroenterol. Sep-Oct 2004;23(5):165-7. Treatment of Appendiceal Mass: Prospective, Randomized Clinical Trial Of the three treatment modalities compared, conservative treatment without subsequent appendectomy appears to be the best.

17. Int Surg . 2015 Jun; 100(6): 1021–1025. Management of Appendiceal Mass and Abscess. An 11-Year Experience Zaza Demetrashvili , Giorgi Kenchadze , Irakli Pipia , Eka Ekaladze , and George Kamkamidze

18. No Definite Conclusion

19. Factors to consider Age / Preop fitness Imaging Clinical Signs

20. Intraoperative decision Dissection

21. Intraoperative decision Thickened appendicular base Inflammed Caecum

22. Intraoperative decision Appendicula stump

23. SIDS Data Tertiary care referral Surgery for Acute Appendicitis by 14 surgeons of Surat – 282 Perforated / Abscess / Peritonitis / Lump – 128 (15 cases open) Right Colectomy – 16 (2 Open / 14 Laparoscopic) SIDS – Emergency surgery, conservative only in unfit or non willing patients

24. Interesting Appendix Case 1 Two episodes of admission for recurrent acute appendicitis Appendicular lump managed conservatively Presented with Appendicular abscess Case Video

25. Interesting Appendix Case 2 Large mucocele forming appendicular lump Case Video

26. Thank you very much for attention