INTRODUCTION

Appendiceal mass, infrequent pathology that appears as an acute appendicitis complication: it consist of an inflammatory myo fibroblastic tumor constituted by the swollen appendix, which is generally already punctured, adjacent viscera and greater omentum. It may or may not contain pus (abscess/phlegmon). It occurs when the organism can partially control this process, hence avoiding a peritonitis. Additionally, the infectious process increments morbidity, as well as prolonging the treatment, hospitalization or resting time, tests, etc(¹,²).

There are advantages and disadvantages between the choice of medical (conservative) or surgical (whether immediate or de ferred) treatment. Deferred surgical treatment consists of initial conservative treatment followed by a scheduled appendectomy: it entails minimal complications, given that it’s performed in a stable patient, with solved inflammatory symptoms. Further- more, it prevents recurring appendiceal episodes, which are present more frequently between the 6 to 24 following months, also preventing diseases such as Meckel diverticulum, Crohn’s disease or appendiceal neoplasms, and if some of these are al- ready in progress, early detection allows better prognosis hence avoiding the use of more aggressive therapies(²,³).

On immediate surgical treatment a simple drainage (if the appendix is digested), appendectomy, or even a right hemi- colectomy can be performed. A Colombian research of 2,175 acute appendicitis cases reported that a right hemicolectomy was necessary in 1.7% of cases (half of them due to an unspecific inflammatory mass or plastron), with primary anastomosis and a morbidity of 69%. (⁴) Another surgical option is ileocolic resection, a procedure associated with low morbi-mortality, compared to the right hemicolectomy. (⁵) Malignant tumors of the appendix, cecum and ascending colon are the main cause of concern when a surgeon finds these inflammatory masses; in these cases a right hemicolectomy with lymph node dissection and primary anastomosis is recommended. (⁴) The advantages of immediate surgery, although high mass recurrency chance (71%), and high malignant tumor incidence, show a lessened hospitality stay and, therefore lower use of resources, however it presents multiple complications such as other viscera’s injuries, surgical wound’s infection, pelvic abscess and the need of surgical reintervention. Henceforth, this option is not of the first considerations of professionals, choosing the conservative approach to avoid the aforementioned adverse situations. (⁶,⁷)

Those who propose the conservative approach only predicate based on the number of patients that develop a subsequent appendicitis and/or appendiceal cancer to be minimum (0.2- 0.5% of the total of gastrointestinal tumors), considering it’s an intervention that increases hospitalizations and unnecessary use of resources. However, it also presents complications as failure, uncomplete drainage or the need of additional drain- ages, infections, fistula, laparotomy for abscess drainage and recurrent appendicitis. (⁶) Nowadays the use of minimally invasive therapy with percutaneous drainage for the resolution of abdominal build-up and abscessed appendiceal mass is also recommended. Its use will depend on the personnel’s experience and the existence of this resource in the institution, how- ever it also presents limitations as to not being able to achieve an anatomopathological study, therefore being unable to discard malignant pathology(⁸).

The relevance of this work rests on the lack of national publications about the subject and above all else the fact that nowadays there are many diverse stances on a pathology’s treatment that could eventually present low morbidity and be fatal in cases in which diagnosis nor proper treatment were achieved. The present retrospective research seeks to determine the appendiceal mass patient’s characteristics and handle, within the Adult General Surgery Services in the Hospital Nacional de Itauguá, during 2011 through 2021.

RESULTS

Regarding the sample total (50 patients), 54% of cases were of the female gender and the prevalent age range were between 16 to 26 years old (Graphic 1). 88% of patients consulted because of pain, while the rest did so because of tumors, with an average formation rate of 9.27 days before consultation.

Graphic 1.  Appendiceal mass patient’s age. n=50. 

Upon performing the physical exam, it was reported that 82% of patients presented tangible tumors on the right iliac fossa and 64% presented Delbet’s sign during abdominal palpation. Between the most frequent ultrasound findings are the over lapped intestinal loops (68%), free fluid (28%) (See Graphic 2).

Graphic 2.  Appendiceal mass patient’s ultrasound findings. n=50. 

Those whom required surgical treatment during hospital stay were 56% of patients, in whom surgical techniques inform that 16 cases had cavity cleaning and draining, with most of them having a generalized postoperative peritonitis diagnosis by broken-cavity abscessed mass, from which a successful appendectomy was only achieved in 8 cases, right colectomy was performed in one case and only an ileostomy plus drainage was performed in one case, minimally invasive was performed in 2 of the cases (percutaneous drainage) (See Table 1). 80% did not present any complications, among mentioned postoperative complications are surgical site infection as first place (14%), and evisceration, fecal fistula in less cases. There was only one de- ceased, caused by sepsis on a senior patient.

The remaining patients received the conservative handle (antibiotic therapy), being ciproflozacin/metronidazole the combination utilized in 98% of cases.

The general average of hospital stay days was 11.

DISCUSSION

According to the references, a conservative attitude towards appendiceal mass has been extending for the past few years. The presence of a pericecal inflammatory mass of infectious etiology has reached a variable frequency of 2-10% of the appendiceal procedures(⁹,¹⁰).

Nowadays the appendiceal mass treatment options are the deferred surgical alternative, versus the conservative or medical handle, as the most idoneous treatment. On the other hand, the no-less-important immediate surgery option is also presented. There is no consensus regarding which would be the correct option, the resolution is greatly related to the surgeon’s experience, resource availability and the patient’s state. In the last few years a conservative attitude has been extending in non-complicated ways through hydration, broad-spectrum antibiotic therapy and clinical observation, based on the development of imagery techniques with better diagnostic precision, increasing therapeutic efficiency and the concept that a non-complicated appendicitis will not always evolve towards perforation, regardless of showing a near 20% global recurrency of appendicitis symptoms and a small impact on the necessity of a subsequent appendectomy due to therapeutic failure(³,¹¹,¹²,¹³).

According to studies, appendectomy have much simple results when performed in between 3-6 months(¹⁴). In our research, however, immediate surgical treatment was performed in 56% of cases, without considering deferred surgical use, most likely due to lack of proper follow-up of the patients after discharge, which represents a bias. The vast majority of patients were young, who attended the emergency room reporting 9-month evolutive symptoms, and unlike other researches, the most frequently used surgical technique in our casuistry was abdominal cavity cleaning and drainage. Only 20% presented postoperative complications. The consultation reason and performed surgery is most likely due to most patients already arriving with pre- operative acute abdomen diagnosis and whose intraoperative findings were acute generalized peritonitis by broken-cavity abscessed appendiceal mass, which also explains the fact that one of the most frequent postoperative complications was surgical site infection. We will continue to perform follow-ups to dis- charged patients without surgery, and investigate further about the handling to reach an unanimous and effective conclusion regarding therapeutics.

CONCLUSION

In our research immediate surgery was performed in 56% of cases. We did not consider to the use of deferred surgery, most likely due to lack of patient follow-ups. Most of them report with 9-days symptoms, them being broken-cavity abscess in most cases, therefore cavity cleaning and draining was the most utilized surgical technique. This study is of outmost relevance due to the fact that there is practically no recent national publications about the subject, and as we described during the study, this pathology can be of high impact to the working capability and quality of life of the patient, especially due to handling being mostly conservative, reason why it’s very important to avoid subsequent complications.