This document discusses the management of appendicular lumps. It notes that appendicular lumps are inflammatory tumors consisting of the inflamed appendix and surrounding tissues. Treatment options include emergency surgery, conservative management followed by interval surgery, or totally conservative management without interval surgery. Conservative treatment is associated with a risk of missing hidden pathologies. Emergency surgery carries a high risk of complications while interval surgery risks appendicular abscess or perforation during the waiting period. Randomized controlled trials have found that conservative treatment without interval surgery appears to be the best approach for appendicular masses and abscesses. The document examines factors to consider in decision making and presents cases studies from a tertiary care center.

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 Willemsenet 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