| Abstract|| |
Two hundred and seventy-seven patients were admitted with acute appendicitis to KKUH during a 5 year period. There were 189 males (68%) and 88 females (32%). Of these,51 patients(18.4%) had appendicular mass diagnosed clinically or under anaesthesia. Twenty five were males and twenty six females. All patients with appendicular mass underwent exploration and six were found to have abscess formation.All patients had their appendix removed.
There was no mortality. Three patients developed wound infection, one a pelvic collection and one had sub-acute intestinal obstruction, giving a complication rate of 9.8%. We feel a surgical approach for appendicular mass, in a specialised centre dealing with paediatric surgical patients, is a safe alternative to the classical textbook conservative approach. It also has the benefit of reducing the hospital stay and requires no readmission for interval appendectomy, for which many patients fail to return.
|How to cite this article:|
Al-Samarrai A. Surgery for appendicular mass. Saudi J Gastroenterol 1995;1:43-6
| Clinical material|| |
Of 277 patients admitted with a diagnosis of acute appendicitis, 51 (18.4%) had appendicular mass clinically or discovered under anaesthesia.There were 25 males (49%) and 26 females (51%). About 84% were Saudi and 15% other nationalities. The age range varied between 2 and 12 years, Mean 6.59 , with 31% of the cases between the ages of 4 and 6 years [Figure - 1].
The duration of symptoms varied between 1 and 14 days, with a mean of 2.8 days for males and 3.3 days for females, (P value > 0.05 ). The majority of patients had abdominal pain. vomiting and tenderness in the right iliac fossa (58.8 %) [Figure - 2]. Temperature varied between 37.3 and 40.3 degree centigrade (C) with a mean of 37.9 for males and 38.4 C for females (P value < 0.05).
Total white blood cell count varied from 4.600 to 37.100 with a mean of 17.026 for males and 18.539 for females (P value > 0.05) [Figure - 3]. All patients had the usual investigations (CBC, urea and electrolytes) and were given IV antibiotics prior to surgery, either ampicillin, gentamycin and flagyl or cefoxtine and flagyl. A nasogastric tube was inserted if the child was vomiting, otherwise this was done in theatre.
| Surgical approach|| |
All patients had a standard transverse muscle cutting incision 2-4 cm above and medial to the anterior superior iliac spine and a swab was taken for culture as soon as the peritoneum was opened. A sucker was introduced to suck the pus and reactionary fluid, if any, and the surgeon's index finger was introduced to gently localise the appendix, peel the omentum and the surrounding bowel and deliver the appendix, taking care not to contaminate the skin. In cases where a localised abscess had already formed, this was sucked first and the peritoneal cavity was only washed out with normal saline after appendectomy if there had been pus spillage in the peritoneal cavity. After closing the peritoneum, the wound was cleaned with normal saline and diluted providone iodine. The peritoneal cavity was drained in all patients and the drain was left in for 5-7 days. Another drain was used to drain the wound if there had been wound contamination.
The peritoneum, muscles and subutanous fat were closed in the usual manner using subcutaneous dexson or vicryle for the skin.
The nasogastric tube remained until bowel sounds returned to normal, on average 48-72 hours The child was then allowed fluids, gradually replaced by soft diet and full normal feed prior to discharge. All patients had CBC and urea and electrolytes daily until their nasogastric tube was removed and WBC prior to discharge. An appointment was given at the outpatients clinic 710 days later. Histology confirmed the clinical diagnosis in all patients.
| Results|| |
It is interesting to see that this operative approach has a relatively low rate of morbidity, especially as regards the infection rate, when compared with other series. The commonest organisms found on culture and sensitivity were E.Coli and bacteroides, both of which are sensitive to our antibiotic protocol.The patient who had a pelvic collection had aspiration with ultrasound guidance, and the boy with intestinal obstruction responded to conservative treatment.
Hospital stay ranged from 3 to 23 days [Figure - 4] with a mean of 7.6 days for males and 7.3 days for females. There was no significant difference between males and females in this study apart from the mean temperature value where females seem to run a higher temperture than males (P = 0.0382).
| Discussion|| |
Acute appendicitis is the commonest surgical emergency in childhood. It is uncommon in infancy, the incidence increasing with the age of the child and reaching its maximum incidence in teenagers.  Classically, it presents with abdominal pain, periumbilical, radiating to the right iliac fossa (RIF), with nausea and vomiting usually following the pain. (A point to remember in gastroenteritis, where vomiting preceeds the pain). Anorexia usually occurs in most patients. On physical examination, low grade fever and mild leucocytosis less than 15000 are the usual findings unless the appendix is perforated. Normally, these children have tenderness over the RIF, with muscle guarding, if there is peritoneal irritation due to perforation, mass or abscess formation. Rebound tenderness should not be performed in children when there is tenderness over the right iliac fossa on gentle palpation, nor have we performed rectal examination in our patients. It is important to realise that not all patients present with the classical signs and symptoms as some children can tolerate pain and the appendix can be in an unusual position. Patients may present with pain in the RIF, having had mild peri-umbilical pain for several days which has gone unnoticed. Patients with appendicitis may be apyrexial and have a normal WBC. The child's ability to localise an inflammatory process is well developed and nearly one third of the patients developing appendicitis during the first year of life have an appendix mass at the time of diagnosis.  The diagnosis of appendicular mass in our patients was done on clinical grounds and was confirmed by ultrasound in 12 selected patients.
Management of appendicular mass is controversial, though most would advocate conservative treatment i.e. bed rest, antibiotics and i.v. fluids. Only if the child remains febrile and the tenderness spreads is the abscess drained with possible removal of the appendix if it is easily found. Children treated conservatively are advised to return for interval appendicectomy four weeks later. Some centres undertake immediate surgery in the presence of a mass, though their complication rate is higher than with conservative treatment, varying between 35.7% and 68%. , However, we have found immediate surgical exploration of all appendicular masses has a minimal morbidity of 9.8% with an infection rate of 5.9% This may be attributed to our practice of administering I. V antibiotics to all our patients, soon after admission, together with thorough cleaning of the wound and drainage. Average length of stay with conservative treatment varies from 10 to 18 days , with a further 8 days required for elective appendicectomy. Our patients had an average stay of 6.5 days (3 - 23 days).
An operative approach for appendicular mass was reported by Vakili in 34 patients who underwent surgery within 32 hours of admission.  They reported local wound problems in six patients (17.6%) and drainage of pus from drain site in 4 patients (11.8%). The average hospital stay was nine days, varying between 7 and 19 days. Jordan et al operated immediately on 42 patients with appendicular mass and in most patients, appendectomy was possible. There were no deaths but wound infection was reported in 14% with an overall complication rate of 35.7%.  Another study by Marya et al compared conservative treatment in 26 patients to operative treatment in 30 patients. The latter had an infection rate of 17% with a mean hospital stay of 15 days while in the former the infection rate was 8% and the hospital stay 19.1 days.The author concluded that early appendectomy appeared to be a safe and costeffective treatment for appendicular mass formations. 
| Conclusion|| |
We would recommend managing children with appendicular mass with immediate surgery which is normally carried out by an experienced registrar or senior registrar.
| References|| |
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|3.||Gahkamble DB, Khamage AS, Gahukamble LD. Management of Appendicular mass in children. Ann Trop Paed 1993; 13:365-67. |
|4.||Vakilli C. Operative Treatment of Appendix Mass. Am J Surg 1976; 131:312-4. |
|5.||Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpable mass. Ann Surg 1981; 193:227-9. [PUBMED] [FULLTEXT]|
|6.||Marya SK, Garg P, Singh M, et al Comment Canadian J Surg 1993; 36: 201. |
Asal Y Izzidien Al-Samarrai
Department of Surgery, Division of Paediatric Surgery, Medical College and KKUH, P.O Box 2925, Riyadh 11461
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]