ArticlePDF Available

Early laparoscopic management of appendicular mass in children: Still a taboo, or time for a change in surgical philosophy?

Authors:

Abstract and Figures

Introduction: Early appendicectomy has been found to be a safe and better alternative for management of appendicular mass in various studies in adults, while very few studies report such advantages in the paediatric population. We conducted this study to assess the safety, efficacy and need of early laparoscopic appendicectomy (ELA) in child patients with appendicular mass. Materials and methods: All patients with appendicular mass who underwent ELA at our institute between September 2011 and August 2014 were retrospectively reviewed. Appendicular mass was defined as a right iliac fossa mass in a case of acute appendicitis, diagnosed by clinical, laboratory and radiological evaluation, and palpation under anaesthesia, the patient being subjected to laparoscopic treatment. Results: Forty-eight (48) patients were confirmed to have appendicular mass intraoperatively and were included in the analysis. There were 30 males and 18 females, with ages ranging 7-13 years (mean 9 years). In the present study, appendicular complications included appendicular abscess (62.5%), gangrenous appendicitis (25%), sloughed-out appendix (8.33%) and appendicular perforation (4.16%). The average operative time was 72 min (range 45-93 min). One case (1.92%) required conversion to open procedure due to failure of identification of the appendicular base of a sloughed-out appendix. Post-operative complications were found in 4 (7.69%) patients, of whom 3 (5.76%) had minor wound infection at the umbilical port site and 1 (1.92%) had post-operative pelvic abscess, which was managed with percutaneous aspiration. Discussion: ELA avoids misdiagnosis, treats complicated appendicitis at its outset, and avoids complications and/or failure of non-operative treatment of a potentially lethal, diseased appendix. This approach is associated with minimal complications in experienced hands and is a safe and feasible option in children with appendicular mass.
Content may be subject to copyright.
ISSN 0972-9941
Vol 12 / Issue 2 / April-June 2016
Journal of Minimal Access Surgery
Official Publication of
The Indian Association of Gastrointestinal Endo Surgeons
www.journalofmas.com
Included
Included
Journal of Minimal Access Surgery • Volume 166 11 • Issue 3July-August 2015 • Pages 113-
JMAS
© 2016 Journal of Minimal Access Surgery Published by Wolters Kluwer - Medknow
98
Early laparoscopic management of appendicular
mass in children: Still a taboo, or time for a change
in surgical philosophy?
Vikesh Agrawal, Himanshu Acharya, Roshan Chanchlani, Dhananjaya Sharma1
Departments of Pediatric Surgery and 1Surgery, Netaji Subhash Chandra Bose (NSCB) Medical College, Jabalpur,
Madhya Pradesh, India
Address for Correspondence: Dr. Vikesh Agrawal, 11, Paras Colony, Cherytal, Jabalpur - 482 002, Madhya Pradesh, India.
E-mail: drvikeshagrawal@gmail.com
Abstract
INTRODUCTION: Early appendicectomy has been
found to be a safe and better alternative for management
of appendicular mass in various studies in adults,
while very few studies report such advantages in the
paediatric population. We conducted this study to assess
the safety, efficacy and need of early laparoscopic
appendicectomy (ELA) in child patients with appendicular
mass. MATERIALS AND METHODS: All patients
with appendicular mass who underwent ELA at our
institute between September 2011 and August 2014
were retrospectively reviewed. Appendicular mass was
de ned as a right iliac fossa mass in a case of acute
appendicitis, diagnosed by clinical, laboratory and
radiological evaluation, and palpation under anaesthesia,
the patient being subjected to laparoscopic treatment.
RESULTS: Forty-eight (48) patients were con rmed
to have appendicular mass intraoperatively and were
included in the analysis. There were 30 males and
18 females, with ages ranging 7-13 years (mean 9
years). In the present study, appendicular complications
included appendicular abscess (62.5%), gangrenous
appendicitis (25%), sloughed-out appendix (8.33%) and
appendicular perforation (4.16%). The average operative
time was 72 min (range 45-93 min). One case (1.92%)
required conversion to open procedure due to failure of
identi cation of the appendicular base of a sloughed-out
INTRODUCTION
Initial non-operative regimen with selective interval
appendicectomy is the standard management of appendiceal
mass in children. This approach has recently been
questioned due to its failure in 10-20% cases, leading to
complications such as abscess and perforation peritonitis,
which are more difficult to manage and have higher
morbidity.[1] It is also associated with the need for longer
hospitalisation, increased cost of treatment and loss of
school days in children.[2] These patients may need second
Access this article online
Quick Response Code: Website:
www.journalofmas.com
DOI:
10.4103/0972-9941.178518
Original Article
Cite this article as: Agrawal V, Acharya H, Chanchlani R, Sharma D. Early
laparoscopic management of appendicular mass in children: Still a taboo, or
time for a change in surgical philosophy?. J Min Access Surg 2016;12:98-101.
Date of submission: 07/03/2015, Date of acceptance: 26/07/2015
This is an open access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
appendix. Post-operative complications were found in 4 (7.69%)
patients, of whom 3 (5.76%) had minor wound infection at the
umbilical port site and 1 (1.92%) had post-operative pelvic
abscess, which was managed with percutaneous aspiration.
DISCUSSION: ELA avoids misdiagnosis, treats complicated
appendicitis at its outset, and avoids complications and/
or failure of non-operative treatment of a potentially lethal,
diseased appendix. This approach is associated with minimal
complications in experienced hands and is a safe and feasible
option in children with appendicular mass.
Key words: Appendicular mass, children, laparoscopy
Journal of Minimal Access Surgery | April-June 2016 | Volume 12 | Issue 2 99
Agrawal,
et al
.: Early laparoscopic management of appendicular mass in children
admission for interval appendicectomy, and often tend
to delay their surgery and need readmission for another
acute episode. Another disadvantage of non-operative
management is the increased chance of misdiagnosis,
such as intussusceptions, typhoid perforation or Meckel’s
diverticulum, which may be inappropriately treated, adding
considerable morbidity.[3]
Early surgical intervention has been known to be an effective
alternative to conservative therapy for a long time, as it
considerably reduces the morbidity and total hospital stay,
and obviates the need for a second admission.[4]
Thus early surgery has an advantage of being curative in
the index admission and ensuring early return to school,
providing higher compliance at a lower expense. Early
appendicectomy has been found to be a safe and better
alternative for management of appendicular mass in
various studies in adults, while very few studies report such
advantages in the paediatric population.[5] This controversy
is not only confined to the management approach, but also
extends to the technique, that is, laparoscopy versus open,
with regard to their feasibility and safety. While laparoscopy
has become the standard mode of intervention for simple
appendicitis in children, its role in complicated appendicitis
is still controversial.[6] We conducted this study to assess the
safety, efficacy and need of early laparoscopic appendicectomy
(ELA) in child patients with appendicular mass.
MATERIALS AND METHODS
All the patients with appendicular mass who underwent ELA at
our institute between September 2011 and August 2014 were
retrospectively reviewed. Appendicular mass was defined
as a right iliac fossa mass in a case of acute appendicitis,
diagnosed by clinical, laboratory and radiological evaluation,
and palpation under anaesthesia. All the cases of appendicular
mass were initially treated with hydration, nasogastric
aspiration, intravenous antibiotics and analgesic before
ELA. Laboratory evaluation included complete hemogram,
erythrocyte sedimentation rate (ESR) and C-reactive protein
(CRP) level. Routine radiological evaluation included a scout
film of the abdomen and ultrasound examination with a
10 MHz transducer in all the patients. All the operations were
performed using the three-trocar technique. An optical port
(5 mm, 30°) was placed at the umbilicus by open technique,
along with two 5- or 3-mm working ports according to the
size of the patient, in the suprapubic and right paraumbilical
regions. The appendiceal stump was left unburied after
transfixation by intracorporeal endosuturing with 3-0
polyglactin 910 suture. In patients who were found to have
evidence of pus, the areas of intra-abdominal collection were
sucked out and rinsed with normal saline along with tube
drainage. Data pertaining to sex, age, duration of symptoms,
operative time, operative findings, gross appendiceal finding,
difficulties encountered during surgery, complications, length
of hospital stay, and pathological results were reviewed.
Appendicular complication was defined as laparoscopic gross
identification of gangrenous, perforated or sloughed-out
appendix, and appendicular abscess.
RESULTS
During the study period, 52 patients were diagnosed with
appendicular mass, of whom 4 had had misdiagnosis. These
included singular cases of ileal perforation, tubercular
lymphadenitis, ileocolic intussusception, and gangrenous
Meckel’s diverticulum, which were managed with laparoscopic
repair, laparoscopic biopsy, open reduction with resection,
and open resection anastomosis, respectively. The remaining
48 patients were confirmed to have appendicular mass
intraoperatively and were included in the analysis. There
were 30 males and 18 females, with ages ranging 7-13 years
(mean 9 years). The duration of treatment received elsewhere,
before admission to our institute, ranged 3-7 days (mean
4 days). Forty-seven patients (97.91%) had leukocytosis of
greater than 11,000 per mm3, while 42 (87.5%) had raised
ESR (mean 60) and CRP (>3 mg/L). Clinically palpable mass in
right iliac fossa was identified preoperatively in 41 (85.41%)
patients and confirmed on ultrasound, while the rest were
diagnosed under anaesthesia.
The average operative time was 72 min (range 45-93 min).
The post-operative analgesia requirement was not more than
three doses per day of rectal acetaminophen for the initial
2 days. The average time to ambulation, time to resumption
of diet and length of hospital stay were 10 (range 6-11) h;
2 (range 1-3) days and 3 (range 1-6) days, respectively. There
were no major intraoperative complications [Table 1]. The
findings at surgery are listed in Table 1. In the present
study, gross appendicular findings included appendicular
abscess (62.5%), gangrenous appendicitis (25%), sloughed-out
appendix (8.33%) and appendicular perforation (4.16%),
as depicted in Table 1. Forty-eight (48) patients (92.30%)
underwent ELA and 1 (1.92%) required conversion to open
procedure due to failure in identification of appendicular base
of a sloughed-out appendix. In 3 (5.76%) patients, there was
difficulty in localisation of the appendix due to retro-cecal
gangrenous appendix in 1 and sloughed-out appendix in
2 patients. Four (4) patients (7.69%) had dense adhesions
and all had history of more than two attacks of acute
appendicitis (AA) in the past. Post-operative complications
Journal of Minimal Access Surgery | April-June 2016 | Volume 12 | Issue 2
100
Agrawal,
et al
.: Early laparoscopic management of appendicular mass in children
were found in 4 (7.69%) patients, of whom 3 (5.76%) had
minor wound infection at the umbilical port site and 1 (1.92%)
had post-operative pelvic abscess, which was managed with
percutaneous aspiration. This latter patient had appendicular
perforation as a complication and went on to develop
adhesive intestinal obstruction, which was successfully
managed non-operatively. All patients are healthy, at the time
of writing, on the minimum 6-month follow-up.
DISCUSSION
The management of an appendiceal mass in children
is surrounded by controversy amongst two schools of
thoughts: That advocating early surgical intervention
versus that advocating non-operative management with
or without interval appendicectomy.[7] Advocates of
operative initial appendicectomy report the advantages
of immediately excluding other masquerading conditions,
as well as providing a definitive treatment at the initial
admission. More traditional surgeons propose initial
conservative management, reporting that the majority of
a patient’s symptoms will resolve spontaneously, thereby
avoiding an operation during the initial admission which
is considered hazardous. Of those initially managing
appendiceal mass conservatively, some propose elective
interval appendicectomy once the mass has resolved. This
is supposed to have the advantages of a less hazardous
appendicectomy, prevention of any future recurrence
of appendicitis and ruling out other conditions. Others
manage appendiceal mass conservatively and do not
perform interval appendicectomy, following up patients
at the outpatient clinic to exclude other conditions and
the recurrence of symptoms.[8] The need for interval
appendicectomy after successful conservative treatment
is still under debate. Indications for early surgery in
appendiceal mass have been failure of conservative
management or features of generalised peritonitis or
obstruction.[9] A recent questionnaire study of 67 surgeons
in the Mid-Trent region of England showed no agreed
consensus on the management of appendiceal mass.[10]
In the past, ELA in all cases of appendicular mass was
considered an overenthusiastic approach by critics.
There are limitations of non-operative management, such as
leading to failure in up to 10% of cases, frequent misdiagnosis,
need for prolonged index admission along with additional
hospitalisation for interval surgery, dropout, and delays in
surgery by the parents. This leads to increased morbidity
and cost of treatment along with loss of school days for
children.[2] The literature mentions that recurrent attacks
after non-operative treatment of AA usually have a milder
course.[11] In the present study, 18 patients (37.5%) had
evidence of more than two attacks of AA in the past, which
was managed non-operatively and later on presented with
appendicular mass. This reflects the reluctance of Indian
parents to opt for interval surgery; it is also our unit policy,
once the acute attack has been resolved with medical
treatment. Misdiagnosis in 4 out of 48 patients preoperatively,
which included singular cases of ileal perforation, tubercular
lymphadenitis, ileocolic intussusception and gangrenous
Meckel’s diverticulum, also supports the necessity of early
intervention on the index admission. In the present study,
patients developed appendicular complications along with
appendicular mass, which included appendicular abscess
(62.5%), gangrenous appendicitis (25%), sloughed-out
appendix (8.33%) and appendicular perforation (4.16%), as
depicted in Table 1. These hidden complications are promptly
detected and appropriately managed if ELA is opted for as
the preferred treatment of appendicular mass, which would
otherwise predispose patients to treatment failure and
higher morbidity if managed non-operatively. Hence, the
role of laparoscopic appendicectomy (LA) as an emergency
intervention procedure for appendiceal mass is further
substantiated by this study.
The percentage of infectious complications secondary to
laparoscopic appendicectomy in complicated appendicitis
varies widely in the literature: 19-28%, and doubts therefore
remain about the safety of this procedure. In both open
and laparoscopic types of appendicectomy, it is accepted
that the greater the degree of evolution of AA, the worse
the short-term results and the higher the rate of infectious
complications.[12] Initially there were conflicting reports of
increased complications such as pyoperitoneum and faecal
fistula by using this approach, but most of them have been
Table 1: Table showing laparoscopy ndings, operative dif culties and complications
Gross appendiceal
nding (n = 48)
nProcedure Operative dif culties Complications
Dif culty in localisation
of appendix
Dense
adhesions
Umbilical wound
infection
Pelvic
abscess
Adhesive intestinal
obstruction
Appendicular abscess 30 ELA 0 2 1 0 0
Gangrenous appendix 12 ELA 1 0 2 0 0
Appendicular perforation 2 ELA 0 0 0 1 1
Sloughed-out appendix 4 1 ELA, 1 Open 2 2 0 0 0
ELA: Early laparoscopic appendicectomy
Journal of Minimal Access Surgery | April-June 2016 | Volume 12 | Issue 2 101
Agrawal,
et al
.: Early laparoscopic management of appendicular mass in children
recently dismissed.[13] The recent comparative studies have tried
to solve these controversies and have identified comparable
results for laparoscopy in complicated appendicitis.[14] In the
present study, post-operative complications were found in
4 (8.33%) patients; among these, major complication was
observed in only 1 patient (2.08%) in the form of pelvic abscess
and adhesive obstruction, which was managed non-operatively.
The rate of conversion to open procedure, increased duration
of procedure, and prolonged duration of stay were the initial
concerns in ELA for complicated appendicitis, which in the
present study was 2.08% (1/48), 72 min, and 3 days respectively.
These data are comparable to the results of LA performed for
non-mass-forming appendicitis.[15] This supports the statement
that ELA is a safe option for management of appendicular
mass in children.
The question of “golden hours” for emergency LA for “hot”
appendix masses, similar to that identified for emergency
laparoscopic cholecystectomy for acute cholecystitis,
needs to be answered. Nevertheless, the proper timing
for emergency surgery needs further substantiation. At
our institute, we follow the policy of ELA for all children
presenting with appendicular mass on an emergency basis.
But at the same time, one has to be experienced enough to
manage complicated appendicitis laparoscopically and if not,
it is always safer to follow the traditional regimen.
Due to the lack of sufficient Level I evidence for this common
problem, no clear guidelines have been made so far. With the
advancements in minimal access surgery, as seen with other
surgical diseases, the management of appendicular mass
needs change. More multicentre randomised controlled trials
and systematic reviews are required to reach a consensus on
management.
CONCLUSION
ELA avoids misdiagnosis, treats complicated appendicitis at
its outset, and avoids complications and/or failure of non-
operative treatment of a potentially lethal, diseased appendix.
This approach is associated with minimal complications in
experienced hands and is a safe and feasible option in
children with appendicular mass.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
REFERENCES
1. Kaya B, Sana B, Eriş C, Kutaniş R. Immediate appendectomy for appendiceal
mass. Ulus Travma Acil Cerrahi Derg 2012;18:71-4.
2. Blakely ML, Williams R, Dassinger MS, Eubanks JW 3rd, Fischer P, Huang EY,
et al. Early vs interval appendectomy for children with perforated
appendicitis. Arch Surg 2011;146:660-5.
3. Garg P, Dass BK, Bansal AR, Chitkara N. Comparative evaluation of
conservative management versus early surgical intervention in appendiceal
mass — a clinical study. J Indian Med Assoc 1997;95:179-80, 196.
4. Shindholimath VV, Thinakaran K, Rao TN, Veerappa YV. Laparoscopic
management of appendicular mass. J Minim Access Surg 2011;7:136-40.
5. Goh BK, Chui CH, Yap TL, Low Y, Lama TK, Alkouder G, et al. Is early
laparoscopic appendectomy feasible in children with acute appendicitis
presenting with an appendiceal mass? A prospective study. J Pediatr Surg
2005;40:1134-7.
6. Wang X, Zhang W, Yang X, Shao J, Zhou X, Yuan J. Complicated appendicitis
in children: Is laparoscopic appendectomy appropriate? A comparative
study with the open appendectomy--our experience. J Pediatr Surg 2009;44:
1924-7.
7. Meshikhes AW. Appendiceal mass: Is interval appendicectomy “something
of the past”? World J Gastroenterol 2011;17:2977-80.
8. Meshikhes AW. Management of appendiceal mass: Controversial issues
revisited. J Gastrointest Surg 2008;12:767-75.
9. Owen A, Moore O, Marven S, Roberts J. Interval laparoscopic appendectomy
in children. J Laparoendosc Adv Surg Tech A 2006;16:308-11.
10. Ahmed I, Deakin D, Parsons SL. Appendix mass: Do we know how to treat
it? Ann R Coll Surg Engl 2005;87:191-5.
11. Kaminski A, Liu IL, Applebaum H, Lee SL, Haigh PI. Routine interval
appendectomy is not justified after initial nonoperative treatment of acute
appendicitis. Arch Surg 2005;140:897-901.
12. Piskun G, Kozik D, Rajpal S, Shaftan G, Fogler R. Comparison of laparoscopic,
open, and converted appendectomy for perforated appendicitis. Surg
Endosc 2001;15:660-2.
13. Lintula H, Kokki H, Vanamo K, Antila P, Eskelinen M. Laparoscopy in children
with complicated appendicitis. J Pediatr Surg 2002;37:1317-20.
14. Malagon AM, Arteaga-Gonzalez I, Rodriguez-Ballester L. Outcomes after
laparoscopic treatment of complicated versus uncomplicated acute
appendicitis: A prospective, comparative trial. J Laparoendosc Adv Surg
Tech A 2009;19:721-5.
15. Senapathi PS, Bhattacharya D, Ammori BJ. Early laparoscopic appendectomy
for appendicular mass. Surg Endosc 2002;16:1783-5.
... 7 Agarwal et al advocate operative initial appendicectomy and report the advantages of immediately excluding other masquerading conditions, as well as providing a definitive treatment at the initial admission. 8 Patients of all ages were included in the study. The age at presentation ranged from 6-50 years. ...
... 6 In Agrawal et al study, 52 patients were diagnosed with appendicular mass, of whom 4 had had misdiagnosis. 8 The remaining 48 patients were confirmed to have appendicular mass intraoperatively and were included in the analysis. There were 30 males and 18 females, with ages ranging 7-13 years (mean age was 9 years). ...
... Agarwal et al reported duration of procedure 72 min. 8 The average operative time was 95 minutes (range 45-140 minutes) in Vishwanath et al study. 4 The average operative time 1 hr 40 min in Sathykrishna et al study. ...
Article
Full-text available
Background: Appendicular mass consists of matted loops of bowel and omentum adherent to the adjacent inflamed appendix. Laparoscopic approach adds diagnostic value and allows visualization of entire abdominal viscera facilitating better and safer dissection.Methods: This is an observational prospective study done in patients presenting to Gandhi Hospital’s surgical department with incidentally detected appendicular mass on laparoscopy from August 2016 to August 2018.Results: Maximum cases belong to adolescent age group (13 out of 30). Majority of cases are male patients (24 out of 30). Each surgery took around 1 hour. No intraoperative complications occurred in 23 patients. Difficult adhesiolysis experienced in 5 patients. Serosal bowel injury occurred in 1 patient. Orals were delayed where intraoperative dissection was prolonged or difficult. Majority of patients were discharged after 3 days.Conclusions: With immediate operative management of appendicular mass presenting in early stages of inflammation, dissection can be safely proceeded with and appendicectomy can be safely performed eliminating the need for second hospitalization and risk of recurrence. The incidence of intra-operative and post-operative complications is low making laparoscopic appendicectomy in early appendicular mass a safe and feasible treatment option.
... If the barrier cannot wall off the inflammation, generalized peritonitis may develop. Although management of appendicular mass is primarily conservative in adult population, there is a general trend among a group of pediatric surgeons for early exploration of appendicular mass [1,8]. The reasons behind are as follows: earlier perforation of appendix and abscess formation, less capability of omentum to confine the infection, and consequently easier separation of appendix from the mass in children than in adult. ...
... However, it takes more time for the people in developing country to enjoy the benefits of advanced technology. Consistent with other studies, patients who underwent laparoscopic appendectomy had less complications than open surgery (5/31 vs 38/189, P = 0.000) [8,10]. It has long been established that appendectomy can be performed during the index admission in most patients with an appendicular mass [1]. ...
Article
Full-text available
Background Lump or mass formation due to delayed presentation after appendicitis is common, and it is frequently complicated by perforation, gangrene, pus, or abscess formation. Care of patients and management vary between developed world and developing country. The aim of the study is to analyze outcome of early surgery for appendicular mass from a developing country perspective. 220 patients of appendicular mass who underwent early appendectomy over a period of 5 years in the Department of Pediatric Surgery, at author’s institute were retrospectively reviewed. Early appendectomy was defined as appendectomy done within 24 h of admission. Presentation, examination findings, investigations, type of surgery, operative findings, post-operative complications, and hospital stay were analyzed. Results Age of patients ranged from 2 to 12 years (mean 9.04 ± 2.54 years) and male to female ratio was 2:1. Abdominal pain was the most common presentation followed by vomiting and fever. Mean pain duration was 4.35 ± 4.23 days. There was raised temperature in 140 (63.64%) patients, 154 (74.04%) had tachycardia, and 75.86% had raised WBC count. Laparoscopic appendectomy was done in 31 (14.09%) patients, and the rest 189 (85.91%) patients underwent open surgery. Perforated appendix was the most common (171 patients, 77.73%) peri-operative finding followed by formation of pus (135 patients, 61%). Pus was found more in patients less than 5 years old (18 patients out of 23) than patients more than 5 years old (114 patients out of 197) ( P = 0.045). Younger patients also had significantly more complications (39.13% vs 17.26%, P = .000) and hospital stays (mean 15.61 days vs 9.87 days, P = 0.014) than older boys. Complications developed in 42 (19.09%) patients, and wound dehiscence (26 patients, 11.82%) was the most common complication. Conclusion Early appendectomy for appendicular mass is a feasible option in the developing world, and laparoscopic appendectomy has good prospect.
... Our results seem comparable with series of laparoscopic appendectomy in simple appendicitis and also the study done by Argwal and colleagues in 2016 about early laparoscopic management of appendicular masses in children [11,12] . The limitations of this study are the smaller sample size and complexity of these cases that requires a more experienced laparoscopic surgeon to avoid the abovementioned complications. ...
Article
Full-text available
Background: There are numerous reports and studies to date advocating early laparoscopic intervention for complicated acute appendicitis with recommendation for laparoscopy even in cases complicated by gangrene or peritonitis. However, there are few studies concerned with laparoscopic management of appendicular mass formation. This study was conducted to examine the safety and efficacy of early laparoscopic intervention in pediatric patients with appendicular masses. Methods: We retrospectively studied appendicular masses treated laparoscopically at the pediatric surgical department of Cairo University Specialized Pediatric Hospital, in 2 years interval. Intraoperative course and postoperative outcomes were evaluated. Results: Twenty-three patients underwent laparoscopic appendectomy (3 ports). The mean operative time was 52 minutes with no intraoperative complications encountered. Hospital stay ranged from 5 to 7 days (mean 5.5 days). Three patients had minor complications, one suffered from suprapubic port site infection and the other two patients suffered from postoperative collection. Conclusion: Our results suggest that laparoscopic appendectomy is a valid and safe option in children with appendicular masses.
... Vikesh et al., [18], did their study on 48 cases. They did early surgical intervention of these cases with appendicular mass. ...
... Moreover, after successful conservative management, some surgeons proceed with elective IA, whereas others do not. 11 Currently, although no consensus exists among surgeons regarding the optimal treatment for pediatric patients with AM, trend has mostly been in favor of EA globally, in contrast to a primary conservative line followed by IA, as in adult patients. The benefits of either approach or conclusions are however contentious, and continues to be debatable among surgeons worldwide. ...
Article
Full-text available
Background: Early appendectomy (EA) for appendicular mass (AM) has been found to be a safer alternative in various studies in adults, while very few studies report such advantages in pediatric population. The purpose of this study was to assess the safety, efficacy and practical implications of EA in pediatric patients with AM.Methods: All patients with acute appendicitis or its complications that underwent EA between January 2016 and December 2018 were retrospectively reviewed. AM was defined if any or combination of the following criteria were satisfied with other signs of appendicitis: palpable mass in right iliac fossa (RIF), sonologically identified mass in RIF, per-operatively confirmed as a mass by surgeon.Results: 37 patients (among a total of 642 patients) were determined to have AM per-operatively and were included in the analysis. 29.7% (n=11) had a contained appendicular abscess. Age group ranged from 4-12 years (mean 7.8 years). The key per-operative findings were fecolith (21.6%), gangrenous appendix (56.8%), difficult adhesiolysis (48.6%), and full thickness bowel injury (2.7%). Postoperatively, wound infection in 9 (24.3%), intra-abdominal abscess in 1 (2.7%), prolonged ileus in 2 (5.4%) and sepsis in 2 (5.4%) were managed medically.Conclusions: EA approach in AM is a safe option in children as it avoids misdiagnosis, treats complicated appendicitis early, avoids second admission, and has shorter hospital stay with better compliance. Failures of non-operative management and potentially lethal complications of complicated appendicitis are also eliminated.
... Some institutions treat perforated appendicitis nonoperatively if the patient presents with more than 3 d of pain, whereas others use 5-7 d as a threshold for NO management. 3,14,15 To date, two randomized controlled trials (RCTs) have been performed to address the best management for perforated appendicitis, but they show conflicting results. One study involved a small number of patients with unclear superiority of either treatment modality, whereas the other study did not evaluate the costs of the two management strategies. ...
Article
Background: Management of perforated appendicitis in children remains controversial. Nonoperative (NO) and immediate operative (IO) strategies are used with varying outcomes. We hypothesized that IO intervention for patients with perforated appendicitis would be more cost-effective than NO management. Methods: A retrospective chart review of all patients with appendicitis from 2012 to 2015 was performed. Patients with perforated appendicitis were defined by evidence of perforation on imaging. We excluded patients who presented with sepsis, organ failure, and ventriculoperitoneal shunts. NO management was determined by surgeon preference. Univariate and multivariate analyses were performed. Results: IO was performed on 145 patients with perforated appendicitis, whereas 83 were treated with NO management. Compared to IO patients, NO patients incurred higher overall costs, greater length of stay, more readmissions, complications, peripherally inserted central venous catheter lines, interventional radiology drains, and unplanned clinic and emergency department visits (P < 0.0001 for all). Multivariate analysis adjusting for age, days of symptoms, admission C-reactive protein and white blood cell count revealed that NO management was independently associated with increased costs (OR 1.35, 1.12-1.62, 95% CI). Cost curves demonstrated that total cost for IO surpasses that of NO management when patients present with greater than 6.3 d of symptoms (P = 0.01). Conclusions: Our data suggest that IO is more cost-effective than NO management for patients with perforated appendicitis who present with less than 6.3 d of symptoms, after which point, NO management is more cost-effective. Level of evidence: IV.
... patient developed recollection that required second-look laparoscopy for drainage. Similarly, Agrawal et al. [17], in their series of laparoscopic management of cases of appendicular mass, reported PO complications in 7.69% of patients, of whom 5.76% had a minor wound infection at the umbilical port site and 1.92% had PO pelvic abscess, which was managed with percutaneous aspiration. ...
Article
Objective: To find out the feasibility and safety of early surgery in pediatric patients who presented with appendicular mass. Study design: Analytical observational study. Place and Duration of Study: Department of Paediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University, Karachi, from September 2019 to April 2020. Methodology: This study was conducted on 60 children, who were diagnosed with appendicular mass. Patients were operated after initial stabilisation and investigations. Variables analysed included demographic characteristics, clinical presentation, intraoperative surgical difficulties and postoperative complications. Data were entered into SPSS version 22. Chi-square test and Fisher Exact test were used for finding statistical significance among variables. A p-value of <0.05 was considered as significant. Results: There were 41 (68.4%) male and 19 (31.6%) female patients with the mean age of 8.3 + 2.9 year. Mean duration of pain was 3.8 + 1.8 days. In 41 (68.4%) patients, mass was composed of appendix with adherent ileal loops and omentum, while in 19 (31.6%) patients frank pus was also found within the mass. Thirty-four (56.6%) patients had suppurative appendix without gross perforation, while in 26 (43.4%) patients partially sloughed / gangrenous perforated appendix found. Intraoperative difficulties were more in patients with complex mass (p=0.004). Postoperative complications were observed in 14 (23.3%) patients. These were more frequent in female patients (p=0.001), with sloughed, gangrenous perforated appendix (p=0.034) and complex mass (p=0.008). Superficial wound infection was the most common complication noted in 9 (15%) patients. In 5 (8.3%) children, deep seated intra-abdominal collections were found. The mean hospital stay was 3.4 + 1.5 days. Conclusion: Early surgery in pediatric patients with appendicular mass was found feasible with minimal complications. This obviated the need of prolonged follow-up and interval appendectomy with its inherent risks. Key Words: Appendicular mass, Appendicular lump, Appendectomy, Child.
Article
Full-text available
Background In the pediatric population, appendectomy is one of the most common emergency operations. Laparoscopic appendectomy (LA) is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in appendicular lump is more controversial and remains undefined and is not well practiced in low-middle income countries. The aim of this study was to determine a better surgical treatment plan for early appendicular lump in children. Methods This prospective observational study was performed in Pediatric Surgery Department of Chittagong Medical College and Hospital for a period of 1 year from April 2018 to March 2019. Sixty children with appendicular lump selected consecutively as per eligibility criteria underwent either LA or open appendectomy (OA), that is, 30 children per group. They were followed up until hospital discharge to observe outcomes. Results There were no differences in terms of patient’s age, sex, clinical presentation and laboratory findings between the two groups. Postoperative pain severity was significantly less in the LA group than that in the OA group (p<0.01). The incidence of wound infection was significantly lower in the LA group than that in the OA group (6.7% in LA and 46.7% in OA; p<0.01). Children in the LA group had a shorter duration of hospital stay in comparison to the OA group [median (IQR) was 8 (5.75–11.25) days and 12 (7.75–18.00) days, respectively, in LA and OA groups; p=0.01]. Conclusion The study findings suggest that LA is feasible and should replace OA in cases of early appendicular lump in children.
Article
Full-text available
The need for interval appendicectomy (I.A) after successful conservative management of appendiceal mass has recently been questioned. Furthermore, emergency appendicectomy for appendiceal mass is increasingly performed with equal success and safety to that performed in non-mass forming acute appendicitis. There is an increasing volume of evidence -although mostly retrospective- that if traditional conservative management is adopted, there is no need for routine I.A except for a small number of patients who continue to develop recurrent symptoms. On the other hand, the routine adoption of emergency laparoscopic appendicectomy (LA) in patients presenting with appendiceal mass obviates the need for a second admission and an operation for I.A with a considerable complication rate. It also abolishes misdiagnoses and deals promptly with any unexpected ileo-cecal pathology. Moreover, it may prove to be more cost-effective than conservative treatment even without I.A due to a much shorter hospital stay and a shorter period of intravenous antibiotic administration. If emergency LA is to become the standard of care for appendiceal mass, I.A will certainly become 'something' of the past.
Article
Full-text available
Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, its role in the treatment of complicated appendicitis is controversial. This study was undertaken to assess the feasibility of laparoscopic appendectomy for appendicular mass. A retrospective review was performed of all the patients who were treated laparoscopically for appendicular mass from March 2007 to October 2009. Tertiary care hospital. A total of 120 patients were treated for appendicitis. A retrospective review of the patients' records demonstrated that 19 patients (15.8%) had appendicular mass at the time of admission. The average operative time was 95 minutes (range 45-140 minutes). Pathological evidence of appendicitis was present in all the patients. The average length of hospital stay was six days (rang 6-9 days). Three patients (15.7%) had post- operative complications. Two patients developed wound infections and one patient was re-admitted with pain and a lump below the umbilical port. The findings suggest that laparoscopic appendectomy is feasible in patients with appendicular mass. The authors propose a prospective, randomized trial to verify this finding.
Article
Full-text available
To compare the effectiveness and adverse event rates of early vs interval appendectomy in children with perforated appendicitis. Nonblinded randomized trial. A tertiary-referral urban children's hospital. A total of 131 patients younger than 18 years with a preoperative diagnosis of perforated appendicitis. Early appendectomy (within 24 hours of admission) vs interval appendectomy (6-8 weeks after diagnosis). Time away from normal activities (days). Secondary outcomes included the overall adverse event rates and the rate of predefined specific adverse events (eg, intra-abdominal abscess, surgical site infection, unplanned readmission). Early appendectomy, compared with interval appendectomy, significantly reduced the time away from normal activities (mean, 13.8 vs 19.4 days; P < .001). The overall adverse event rate was 30% for early appendectomy vs 55% for interval appendectomy (relative risk with interval appendectomy, 1.86; 95% confidence interval, 1.21-2.87; P = .003). Of the patients randomized to interval appendectomy, 23 (34%) had an appendectomy earlier than planned owing to failure to improve (n = 17), recurrent appendicitis (n = 5), or other reasons (n = 1). Early appendectomy significantly reduced the time away from normal activities. The overall adverse event rate after early appendectomy was significantly lower compared with interval appendectomy. clinicaltrials.gov Identifier: NCT00435032.
Article
The aim of this retrospective study was to evaluate the safety and effectiveness of immediate appendectomy in patients presenting with appendicular mass. Forty-seven patients with appendicular mass were operated within 24 hours after admission to Vakif Gureba Training and Research Hospital, General Surgery Department, from January 2004 to April 2010. The appendiceal mass was diagnosed with physical examination, abdominal ultrasonography, and computed tomography, or during surgical exploration. Age and sex, duration of symptoms, physical examination findings at admission, operation details, intraoperative and postoperative complications, and length of hospital stay were analyzed for each patient. There were 25 males (53.2%) and 22 females (46.8%), with a mean age of 37.23±15.60 (range: 14-75) years. The mean time from the onset of the symptoms to operation was 4.06±2.50 (range: 1-15) days. A simple appendectomy was performed in 38 (80.9%) patients. Twenty-nine (61.8%) patients were discharged and followed up without any complication after surgery. Wound infection was detected in 13 (27.7%) patients. Immediate appendectomy in appendicular mass is a safe and effective alternative to conservative management.
Article
Laparoscopic treatment of simple acute appendicitis (AA) is a safe procedure; however, there are doubts about its safety in cases of complicated AA. The aim of this study was to determine the differences in results of laparoscopic treatment between cases of complicated versus simple AA. We prospectively included all patients treated for suspected AA by two surgeons of our service between May 2002 and May 2007. Of 221 patients, 20 were excluded from the study because the laparoscopic approach was not possible; 116 of 201 had uncomplicated AA, 57 complicated AA, 12 gynecologic ethiology, 11 negative appendectomy, and 5 other causes; patients without acute appendicitis were also excluded from the study. In all cases, laparoscopy was the first treatment option. The following variables were considered: mean surgical time, reconversions, emergency readmissions, emergency reinterventions or invasive procedures, mean postoperative hospital stay, and postoperative complications (i.e., infectious or noninfectious). Our results showed statistically significantly worse results, in terms of surgical time, postoperative stay, reconversions, and infectious complications, for patients with complicated versus uncomplicated AA; however, no differences were observed regarding noninfectious complications, emergency readmissions, and emergency reinterventions or invasive procedures. We consider that laparoscopic treatment of complicated AA may be safely used, despite worse results than in cases of simple AA, since the differences in numbers of severe postoperative complications requiring emergency readmission, reintervention, or invasive procedures were not statistically significant.
Article
Good outcomes have been reported with laparoscopic appendectomy (LA) for uncomplicated appendicitis in children, but the use of laparoscopy for complicated appendicitis in children is more controversial. This is related to a higher incidence of postoperative abdominal and wound infections. The purpose of this trial was to retrospectively compare LA and open appendectomy (OA) for complicated appendicitis and evaluate the efficacy of LA in children with complicated appendicitis. The outcome of 128 patients with complicated appendicitis in children was retrospectively analyzed. There were 80 children in the LA group and 48 in the OA group. The appendectomies were performed by a single senior surgeon and his surgical trainees. There was no selection of cases for LA. Data collection included demographics, operative time, resumption of diet, infectious complications (wound infection and intraabdominal abscess), length of hospitalization, and duration of antibiotic use. There were no cases of LA that required conversion to OA. The operative time for LA (88.5 +/- 28.8 minutes for LA vs 71.8 +/- 30.6 minutes for OA; t = 3.10; P = .002) was longer. Patients in the LA group returned to oral intake earlier (1.8 +/- 0.6 days for LA vs 2.8 +/- 0.8 days for OA; t = -8.04; P < .01) and had a shorter length of hospital stay (6.5 +/- 2.2 days for LA vs 7.8 +/- 2.9 days for OA; t = -2.87; P = .005). The incidence of wound infection (1/80 [1.3%] for LA vs 6/48 [12.5%] for OA; P < .05) and postoperative intraabdominal abscess (2/80 [2.5%] for LA vs 7/48 [14.6%] for OA; P < .05) in LA group was lower. No significant difference was found in the duration of antibiotic administration between the 2 groups (5.8 +/- 1.8 days for LA vs 6.3 +/- 2.3 days for OA; t = -1.37; P = .174). No mortality was observed in either group. The minimally invasive laparoscopic technique is feasible, safe, and efficacious for children with complicated appendicitis. Laparoscopic appendectomy should be the initial procedure of choice for most cases of complicated appendicitis in children.
Article
The management of appendicular mass seems to be taking turn with the availability of better antibiotics, care and anaesthesia. Quite a few workers turned to the other extreme of traditional conservative approach and reported acceptable results with immediate intervention during phlegmonous stage. But practically, surgeons still continue to adopt the same old regime. To alleviate this fear and circumvent the disadvantages of immediate intervention a midpath regime called early appendicectomy has been clinically evaluated. With this new approach in the present study preventing misdiagnosis (15%), no chance of recurrence as also of missing in the follow-up and shorter overall hospital stay with economy are some strong reasons to adopt this regime.
Article
Perforated appendicitis is associated with a significant risk of postoperative abdominal and wound infection. Only a few controversial studies evaluate the role of laparoscopy in perforated appendicitis. The significance of conversion from laparoscopy to open appendectomy for perforated appendicitis is not well defined. Statistical analysis was performed using Student's t-test. Data on 52 patients with perforated appendicitis were prospectively collected and retrospectively reviewed. Among these patients, 18 had laparoscopic appendectomies (LA); 24 had open appendectomies (OA); and 10 had converted appendectomies (CA). The indications for either method were based on the attending surgeons's philosophy. Laparoscopic appendectomy was performed using a retrograde stapler technique. Operative time, hospital stay, ability to tolerate a liquid diet, and postoperative infectious complications were documented. No statistically significant difference in the operative time in minutes was found between the LA (114 +/- 29.3), CA (120.0 +/- 32.2), and OA (105.8 +/- 64.1) groups (p = NS). There was no statistically significance difference in length of stay (days) between the LA (9.2 +/- 4.1), OA (10.5 +/- 3.3), and CA (10.0 +/- 1.8) groups. The wound infection rate was less frequent in the LA group (0%) than in 0A (14%) and CA (10%) groups. The rate of intra-abdominal abscess infections (IAAs) and ileus were 22% and 28%, respectively, in LA group, 38% and 29%, respectively, in OA group, and 60% and 50%, respectively, in CA group. No difference in the rate of postoperative intra-abdominal abscesses exists between laparoscopic and open appendectomy for perforated appendicitis. Wound infections and ileus complicate the postoperative course of patients after laparoscopic appendectomy less frequently than after open appendectomy. The conversion of laparoscopic to open appendectomy for perforated appendicitis is associated with increased postoperative morbidity.
Article
The surgical management of acute appendicitis presenting with appendicular mass remains controversial. The aim of this study was to evaluate the role of early laparoscopy and laparoscopic appendectomy (LA) in the management of appendicular mass. During a 1-year period, 62 patients underwent LA for suspected appendicitis (n = 50), generalized peritonitis (n = 2), and an appendicular mass (n = 10). Another patient who presented with an appendicular mass was found at laparoscopy to have an ileo-ileal intussusception. All appendectomies were attempted and completed laparoscopically. Postoperative complications occurred in two patients; there were no deaths. None of the patients treated for an appendicular mass developed complications. There was no difference between the patients who underwent LA during the index admission for an appendicular mass and those who had surgery for non-mass-forming appendices with regard to the operative time (median [interquartile range]: 45 [36-60] vs 40 [25-50] min, p = 0.085) and postoperative hospital stay (median [interquartile range]: 2 [1-2] vs [1-2] days, p = 0.1). Early LA during the index admission of patients with an appendicular mass is feasible and safe, obviates the need for a second hospital admission, and avoids misdiagnoses.
Article
Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in complicated acute appendicitis is more controversial. The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis. A total of 102 children with suspected acute appendicitis were selected randomly to undergo either a laparoscopic or an open appendectomy. The outcomes of 25 children with complicated appendicitis, 13 in the laparoscopic group and 12 in the open appendectomy group, were analyzed. Children, their parents, and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation. All 25 children completed a 30-day follow-up. There were no differences in terms of patients' age, sex, weight, height, and appendiceal histology between the 2 groups. All laparoscopic procedures were completed without conversion. The mean (+/-SD) operating time was 63 (+/-31) minutes in the laparoscopic group and 37 (+/-18) minutes in the open appendectomy group (mean difference 26 minutes, 95% CI 5 to 47 minutes, P =.02). There were 2 major complications in the laparoscopic group in children with appendiceal masses. One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation. Another child had a pelvic abscess that resolved with antibiotic treatment. Superficial wound infections were encountered in 2 patients in the open appendectomy group. Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis. Good surgical judgement is necessary in patients with an established appendiceal abscess.