- Email: [email protected]
The optimal management of adult patients presenting with appendiceal abscess: “Conservative” vs immediate operative management
cles on common bile duct stones published from 1993 to 2003, and 50 deal specifically with the management of CBD stones encountered during laparoscopic cholecystectomy. Forty-two of these articles favor laparoscopic common bile duct exploration. It is our opinion that the surgeon must individualize the care for each patient based on his/her experience and the experience and expertise available at the institution. doi:10.1016/j.cursur.2004.05.025
REFERENCES 1. Ritchie WP, Rhodes RS, Blester TW. Work loads and prac-
tice patterns of general surgeons in the United States ,19921997: a report from the American Board of Surgery. Ann Surg. 1999;230:533-543. 2. Hamy A, Hennekinne S, Pessaux P, et al. Endoscopic sph-
icterotomy prior to laparoscopic cholecystectomy for the treatment of cholelithiasis. Surg Endosc. 2003;17:872-875. 3. Sarli L, Iusco DR, Roncoroni L. Preoperative endoscopic
sphincterotomy and laparoscopic cholecystectomy for the management of cholecystocholedocholithiasis: 10-year experience. World J Surg. 2003;27:180-186. 4. Boraschi P, Gigoni R, Braccini G, et al. Detection of com-
mon bile duct stones before laparoscopic cholecystectomy evaluation with MR cholangiography. Acta Radiol. 2002; 43:593-598.
QUESTIONS AND ANSWERS Questions 1. It is predicted that __% of a common duct stones discovered at laparoscopic cholecystectomy will spontaneously pass.
a. b. c. d. e.
10% 20% 30% 50% 80%
2. During laparoscopic cholecystectomy, 6 common duct stones are identified on cholangiography in a 20-mm duct.. Transcystic duct extraction of the stones is successful. The character of the stones is soft and mud like. The best next step is: a. Choledochotomy and t-tube insertion b. Transcystic duct biliary drainage c. Ligation of the cystic duct and life long stone dissolution medication d. Choledochoduodenostomy 3. Which of the following is true regarding laparoscopic common bile duct exploration. a. Transcystic duct exploration is better than choledochotomy b. It is unsafe in the elderly c. Requires t-tube drainage in all cases d. Primary closure with out t-tube drainage is safe Answers 1. c. Up to 30 % of stones will pass spontaneously. This is unrelated to age of the patient, size or number of stones and the diameter of the bile duct. 2. d. The character of the stones suggests that they are primary stones and are likely to recur if the common duct is not drained. Other options would have included endoscopic or surgical sphincterotomy. 3. d. Primary closure is safe with an expected morbidity of 6%. If the technique is used, the suture line should be tested and observed with cholangiography.
Abdomen and Its Contents The Optimal Management of Adult Patients Presenting with Appendiceal Abscess: “Conservative” vs Immediate Operative Management Guest Reviewers: Denise Gee, MD, and Timothy J. Babineau, MD, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts APPENDICEAL ABSCESS: IMMEDIATE OPERATION OR PERCUTANEOUS DRAINAGE? Brown CVR, Abrishami M, Muller M, Velmahos GC. Am Surg. 2003;69:829-832. 524
Objective: To compare immediate appendectomy versus ex-
pectant management, including percutaneous drainage with or without interval appendectomy to treat periappendiceal abscess. CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
Design: Retrospective review of medical records of patients with acute appendicitis from 1992 until 2001. Setting: Los Angeles County and University of Southern Cal-
ifornia Medical Center. Participants: A total of 104 patients with acute appendicitis
complicated by periappendiceal abscess were divided into 2 groups: immediate appendectomy (IMM APP, 36 patients) and expectant management (EXP MAN, 68 patients). Results: Outcome measures included morbidity and length of
hospital stay. Immediate appendectomy patients had a higher
rate of complications than EXP MAN patients at initial hospitalization (58% vs 15%, p ⬍ 0.001) and for all hospitalizations (67% vs 24%, p ⬍ 0.001). The IMM APP group also had a longer initial (14.8 ⫾ 16.1 vs 9.0 ⫾ 4.8 days, p ⫽ 0.01) and overall hospital stay (15.3 ⫾ 16.2 vs 10.7 ⫾ 5.4 days, p ⫽ 0.04). Conclusions: Percutaneous drainage and interval appendec-
tomy is preferable to immediate appendectomy for treatment of appendiceal abscess because it leads to a lower complication rate and a shorter hospital stay.
REVIEWER COMMENTS
This recent paper demonstrates a shorter hospital stay in those patients who present with appendiceal abscess and are treated “expectantly” (eg, broad-spectrum antibiotics, percutaneous drainage of abscess if feasible, and interval appendectomy) versus immediate laparotomy. This difference was noted both in the initial length of stay as well as in the subsequent hospitalizations. Similar to other studies, the paper also concludes that patients who are managed expectantly have lower overall complication rates. Although well designed and one of the largest series to date, the study is nonetheless retrospective. Furthermore, the 2 groups of patients (IMM APP and EXP MAN) were not per-
fectly matched, with a higher pulse rate found in those patients undergoing immediate appendectomy. It is difficult to determine whether the tachycardia was an incidental finding or a marker for increased severity of disease. Over the past decade, Brown et al. from the University of Southern California have reported other successes with the expectant management of patients with appendiceal abscess through the use of close monitoring, antibiotics, and percutaneous drainage. They provide strong evidence for the efficacy and safety of an initial nonoperative approach in the management of patients presenting with appendiceal abscess.
MANAGEMENT OF APPENDICEAL MASSES
complications, recurrence of appendicitis, and incidence of interval appendicectomy during follow-up.
Tingstedt B, Bexe-Lindskog E, Ekelund M, Andersson R. Eur J Surg. 2002;168:579-582. Objective: To evaluate the outcome of patients treated for
appendiceal abscess, and managed either conservatively or surgically, and to describe the short- and long-term outcome as well as incidence of interval appendicectomy in those treated conservatively. Design: Retrospective study of 93 patients with the diagnosis
of appendiceal abscess. Setting: Lund University Hospital in Sweden. Participants: Ninety-three patients with the diagnosis of ap-
pendiceal abscess, 50 treated conservatively and 43 who were operated on, with a mean age of 46 (14 to 93) years. Mean (range) follow-up for patients operated on was 65 (11 to 135) and for those treated conservatively 66 (6 to 136) months. Main outcome measures included course of acute disease, recorded
Results: The duration of pain before admission was 4 (0.5 to 82) days for those operated on and 7 (2 to 60) days for those treated conservatively. A palpable mass was more common in the conservatively managed group. Complications were common among patients who were operated on. No interval appendicectomies were done during the second half of the study period. Four of the patients treated conservatively (8%) had an underlying tumor diagnosed at follow-up. Conclusions: Operative management of patients with appendiceal masses seems to be associated with a high risk of postoperative complications and the risk of a more extensive surgical procedure. If possible, a conservative approach should be advocated. Because of inaccurate radiological imaging during the acute phase and the risk of an underlying malignancy, routine follow-up is necessary. Routine interval appendicectomy cannot be recommended.
REVIEWER COMMENTS
Through the retrospective review of 93 patients, this Swedish study from Lund University Hospital examines which management approach (conservative versus surgical) is most optimal
for patients with appendiceal abscesses. In addition, it examines the short- and long-term outcomes of patients who are treated nonoperatively, paying particular attention to their follow-up
CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
525
and the necessity of interval appendectomy. The authors found that early operative intervention leads to higher postoperative complications, longer hospital stays, and often, a more extensive operation given the acute inflammation present during the initial operation. Given the risk of other pathologies masquerading as appendicitis, the authors feel that routine follow-up is necessary, although interval appendectomy may not be warranted for all
patients. The study design is somewhat problematic because patients treated from 1990 to 1995 were more likely to have an interval appendectomy compared with those treated from 1996 to 2000 because of a major change in treatment protocol during this time period (ie, from 1996 to 2000, only 2 patients underwent interval appendectomy). As such, broad extrapolation of their data to the current setting is difficult and the role of interval appendectomy was not conclusively studied.
INITIAL NONOPERATIVE MANAGEMENT FOR PERIAPPENDICEAL ABSCESS
(CT) scan results. Five patients were excluded because of incomplete or unavailable medical records.
Oliak D, Yamini D, Udani V, et al. Dis Colon Rectum. 2001;
Results: The patient population consisted of 107 males and 48
44:936-941.
females, with an average age of 33 (range, 16 to 75) years. Age, gender, comorbidity, white blood cell count, temperature, and heart rate did not differ significantly between groups. For the initial nonoperative management group, the failure rate was 5.8% and the appendicitis recurrence rate was 8% after a mean follow-up of 36 weeks. The response to treatment of the initial nonoperative group and the initial operative group was compared by length of stay (9 ⫾ 5 days vs 9 ⫾ 3 days; p ⫽ NS), days until white blood cell count normalized (3.8 ⫾ 4 days vs 3.1 ⫾ 3 days; p ⫽ NS), days until temperature normalized (3.2 ⫾ 3 days vs 3.1 ⫾ 2 days; p ⫽ NS), and days until a regular diet was tolerated (4.7 ⫾ 4 days vs 4.6 ⫾ 3 days; p ⫽ NS). Complication rate was significantly lower in the nonoperative group (17% vs 36%; p ⫽ 0.008).
Objective: To compare initial operative and nonoperative management for periappendiceal abscess complicating appendicitis. Design: Retrospective review of 155 consecutive patients with
appendicitis complicated by periappendiceal abscess treated between 1992 and 1998. Setting: Harbor-UCLA Medical Center, Torrance, Califor-
nia. Participants: Out of 2150 adult patients with a clinical diagnosis of appendicitis between 1992 and 1998, 160 patients were treated for periappendiceal abscess without peritonitis. Ninety patients underwent initial nonoperative therapy, and 70 underwent initial operative therapy. Periappendiceal abscesses were documented by operative reports and computed tomography
Conclusions: Initial nonoperative management of appendicitis complicated by periappendiceal abscess is safe and effective. Patients undergoing initial nonoperative management have a lower rate of complications, but they are at risk for recurrent appendicitis.
REVIEWER COMMENTS
Oliak et al. at Harbor-UCLA have published a number of papers on the conservative management of patients with appendiceal abscesses. This paper examines the safety and efficacy of nonoperative management (parenteral antibiotics, nothing by mouth (NPO), selective percutaneous drainage, and interval appendectomy) in patients with complicated appendicitis. Although it failed to demonstrate a significant decrease in each of the outcome parameters (length of stay, days until normalization of white blood cell count, days until temperature normalization, and days until resumption of normal diet), it does show a significantly lower complication rate among those patients initially managed nonoperatively.
Patients presenting with peritonitis were excluded from this study, which may lead to a lower reporting of complications and recurrent disease. In addition, the 2 groups differed with respect to days of pain and percentage of patients with a palpable mass with significantly increased numbers in the nonoperative group (7 days vs 4 days and 33% vs 6%, respectively). This paper, although retrospective, documents that nonoperative management is acceptable and does not compromise patient outcomes. In fact, the lower complication rate indicates that conservative management should be considered as the optimal initial plan.
APPENDICEAL ABSCESSES: PRIMARY PERCUTANEOUS DRAINAGE AND SELECTIVE INTERVAL APPENDICECTOMY
Objective: To present the results of nonsurgical primary man-
Lasson A, Lundagards J, Loren I, Nilsson PE. Eur J Surg. 2002;168:264-269. 526
agement of appendiceal abscesses using ultrasonic percutaneous drainage under local anaesthesia and selective interval appendicectomy. Design: Retrospective study. CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
Setting: Malmo University Hospital, University of Lund,
Sweden. Participants: Twenty-four patients with appendiceal abscesses 3 to 12 cm in size who underwent primary ultrasonic percutaneous drainage under local anaesthesia, antibiotic treatment, and selective surgical treatment. Main outcome measure was long-term follow-up. Results: All patients had their abscesses drained successfully
without complications. One patient continued to have fever, but eventually responded to conservative treatement, and in one, the bowel was perforated by the drain, but again, this was
treated conservatively. Four abscesses were also operated on one for caecal adenocarcinoma and two for persisting symptoms and enterocutaneous fistulas. Conclusions: Appendiceal abscesses can be effectively drained percutaneously using ultrasound-guided drainage under local anaesthesia, without complications. Recurrent appendicitis is common, and malignancy is a substantial risk in elderly patients. Modern laparoscopic appendicectomy and early postoperative discharge makes interval appendicectomy a valid treatment option after primary nonsurgical management of appendiceal abscesses.
REVIEWER COMMENTS
Although retrospective, this Swedish study is unique in that it represents a combined radiological and surgical effort to examine the “conservative” management of appendiceal abscess. A group of 24 patients’ conditions were diagnosed with appendiceal abscess and treated with ultrasonic percutaneous drainage, antibiotics, and in some patients, an interval appendectomy. All abscesses were successfully drained, and the clinical course remained primarily uneventful in 22 of the 24 patients. Four of these patients did have recurrent abscesses, but they were managed with further percutaneous drainage. Interval appendectomy was only planned in 7 of 24 patients, although 3 additional patients were operated on for adenocarcinoma (1), continued symptoms (1), and an enterocuta-
neous fistula (1). The remaining 14 patients were followed up for 43 months and had not developed any malignancy. Seven of these patients underwent barium enema, and 4 of 7 patients needed further examinations. This paper demonstrates the effectiveness of a nonoperative approach in patients who present with appendiceal abscess. Regarding interval appendectomy, if a “selective” approach is followed, strict guidelines should be adopted so that malignancies are not missed. However, the authors note that interval appendectomy is associated with low complication rates and short hospital stays (both open and laparoscopic), and as such, interval appendectomy is a valid treatment option for all patients.
REVIEWER SUMMARY
Even in 2004, the treatment of appendicitis can, at times, be controversial. Historically, the cornerstone of management has been surgical removal of the offending organ, given the natural progression of appendicitis to perforation, peritonitis, and possible abscess formation. The controversy, however, develops in the management of those patients who present late in their disease course. Such patients represent about 1% to 13% of all cases of appendicitis, often presenting with an appendiceal abscess or phlegmon.1 Surgical intervention in such patients is often associated with a high perioperative complication rate. Therefore, some surgeons began using a “conservative” approach based on bowel rest and intravenous antibiotics. With clinical improvement, patients would be discharged home and scheduled for interval appendectomy in 6 to 12 weeks after the acute infectious process has subsided. If no improvement occurred, an operation would then be performed. More recently, the diagnosis of appendicitis has been enhanced with improved radiological techniques. With the increased use of abdominal ultrasound and CT scans, appendiceal abscesses have been diagnosed more frequently. Further, improved imaging has also facilitated the percutaneous placement of radiologically guided drains and catheters. A number of studies have demonstrated the high success rate of CT or ultrasound-guided percutaneous drainage of appendiceal abscesses (see the reviewed article by Lasson et
al.).2 As such, this technique was quickly added to the conservative management of patients with appendicitis. Although conservative management has proven to be a viable alternative to immediate appendectomy in patients with appendiceal abscess or phlegmon, there have been no prospective randomized trials examining the specific risks and benefits of such treatment. Proponents of immediate operation advocate the prompt removal of infection. However, disadvantages to immediate appendectomy include possible dissemination of infection as well as difficulty in operative dissection, resulting in risk of damage to surrounding viscera and later complications such as fistulae formation. In general, it has been found that the complication rate as well as the length of hospital stay has been the same or less in patients treated conservatively versus those treated with immediate operation. This includes the hospital stay even if an interval appendectomy is performed (see the reviewed articles by Brown et al. Tingstedt et al. and Oliak et al.).1 In addition to the issue of immediate versus conservative management of appendiceal abscess, the need for interval appendectomy has also been a source of controversy. The concern is that nonoperative patients are exposed to the risk of recurrent appendicitis. Various studies have reported rates of 10% to0 20% after conservative management, with the majority occurring early on, within the first 3 to 9 months (see the reviewed
CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
527
article by Oliak et al.). An interval appendectomy would prevent recurrences and allow for the diagnosis of conditions that may otherwise be mistaken for appendicitis (eg, malignancy). The incidence of such other pathologies is 0% to 12%.3 Opponents of interval appendectomy argue that recurrences are usually not associated with serious morbidity. In fact, these patients can, many times, be treated nonoperatively. Many of these surgeons feel that older patients should undergo barium enema or colonoscopy after resolution of symptoms to rule out other diagnoses (see the reviewed article by Tingstedt et al.). Furthermore, it is important to note that although conservatively managed patients are asked to return for interval appendectomy, a portion of them do not. Generally, patients are asked to return approximately 6 to 12 weeks after discharge. However, they may be reluctant to undergo a surgery without manifestation of symptoms. Given the above data, we believe that patients who present with an acute episode of appendicitis not complicated by abscess formation should be treated with an immediate appendectomy via either an open or laparoscopic approach. However, in those patients who present later in their disease, a more “conservative” approach should be considered. These patients often have a higher degree of inflammation associated with an appendiceal abscess or phlegmon. The appropriate management, under these circumstances, should include NPO and antibiotics. If there is no improvement within the first 24 to 48 hours, then the patient should undergo percutaneous drainage of any drainable collections, and if this is not possible, surgery should be performed with open drainage. Finally, in those patients who are managed conservatively, the surgeon must decide whether an interval appendectomy should be performed. We believe that these patients are still at risk for recurrent disease; thus, an interval procedure should be planned 6 to 12 weeks after the acute disease process subsides. This will prevent future recurrences as well as exclude and/or treat any other diagnoses such as malignancy. It should be noted that our recommendations pertain to adult patients and do not necessarily apply to the pediatric population. As a result of the varied clinical presentations of children with appendicitis, there has been no consensus on the
optimal management of late presentations and the current literature outlines several treatment options. doi:10.1016/j.cursur.2004.07.004
REFERENCES 1. Yamini D, Vargas H, et al. Perforated appendicitis: is it
truly a surgical urgency? Am Surg. 1998;64:970-975. 2. Shapiro MP, Gale E, Gerzof SG. CT of appendicitis: diag-
nosis and treatment. Radiol Clin N Am. 1989;27:753-762. 3. Nitecki S, Assalia A, Schein M. Contemporary manage-
ment of the appendiceal mass. Br J Surg. 1993;80:18-20.
QUESTIONS AND ANSWERS Questions 1. T or F: Patients presenting late in the course of appendecitis with abscess formation are best treated with immediate surgical management, wide debridement and right hemi-colectomy. 2. The optimal management of patients with appendecial abscess include all of the following except: a. b. c. d. e.
antibiotics IV Fluids Initial NPO Diet order Percutaneous drainage Barium Enema
3. T or F: Patients with appendiceal abscess treated ⬙conservatively⬙ initially, should ultimately undergo an interval appendectomy. Answers 1. F 2. e 3. T
Breast Nipple Discharge: Its Significance and Evaluation Guest Reviewers: Michael Self, MD, and Ernest Dunn, MD, Department of Surgery, Methodist Hospitals of Dallas, Dallas, Texas SURGICAL DECISION MAKING AND FACTORS DETERMINING A DIAGNOSIS OF BREAST CARCINOMA IN WOMEN PRESENTING WITH NIPPLE DISCHARGE.
Objective: Identify patient and nipple discharge characteris-
Cabioglu N, Hunt KK, Singletary SF, et al. J Am Coll Surg.
Design: Retrospective chart review of patients with nipple
2003;196:354-364.
discharge at a single institution.
528
tics associated with the diagnosis of breast cancer and determine the utility of mammography, sonography, ductography, and cytology in pathologic nipple discharge.
CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
REFERENCES 1. Ritchie WP, Rhodes RS, Blester TW. Work loads and prac-
tice patterns of general surgeons in the United States ,19921997: a report from the American Board of Surgery. Ann Surg. 1999;230:533-543. 2. Hamy A, Hennekinne S, Pessaux P, et al. Endoscopic sph-
icterotomy prior to laparoscopic cholecystectomy for the treatment of cholelithiasis. Surg Endosc. 2003;17:872-875. 3. Sarli L, Iusco DR, Roncoroni L. Preoperative endoscopic
sphincterotomy and laparoscopic cholecystectomy for the management of cholecystocholedocholithiasis: 10-year experience. World J Surg. 2003;27:180-186. 4. Boraschi P, Gigoni R, Braccini G, et al. Detection of com-
mon bile duct stones before laparoscopic cholecystectomy evaluation with MR cholangiography. Acta Radiol. 2002; 43:593-598.
QUESTIONS AND ANSWERS Questions 1. It is predicted that __% of a common duct stones discovered at laparoscopic cholecystectomy will spontaneously pass.
a. b. c. d. e.
10% 20% 30% 50% 80%
2. During laparoscopic cholecystectomy, 6 common duct stones are identified on cholangiography in a 20-mm duct.. Transcystic duct extraction of the stones is successful. The character of the stones is soft and mud like. The best next step is: a. Choledochotomy and t-tube insertion b. Transcystic duct biliary drainage c. Ligation of the cystic duct and life long stone dissolution medication d. Choledochoduodenostomy 3. Which of the following is true regarding laparoscopic common bile duct exploration. a. Transcystic duct exploration is better than choledochotomy b. It is unsafe in the elderly c. Requires t-tube drainage in all cases d. Primary closure with out t-tube drainage is safe Answers 1. c. Up to 30 % of stones will pass spontaneously. This is unrelated to age of the patient, size or number of stones and the diameter of the bile duct. 2. d. The character of the stones suggests that they are primary stones and are likely to recur if the common duct is not drained. Other options would have included endoscopic or surgical sphincterotomy. 3. d. Primary closure is safe with an expected morbidity of 6%. If the technique is used, the suture line should be tested and observed with cholangiography.
Abdomen and Its Contents The Optimal Management of Adult Patients Presenting with Appendiceal Abscess: “Conservative” vs Immediate Operative Management Guest Reviewers: Denise Gee, MD, and Timothy J. Babineau, MD, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts APPENDICEAL ABSCESS: IMMEDIATE OPERATION OR PERCUTANEOUS DRAINAGE? Brown CVR, Abrishami M, Muller M, Velmahos GC. Am Surg. 2003;69:829-832. 524
Objective: To compare immediate appendectomy versus ex-
pectant management, including percutaneous drainage with or without interval appendectomy to treat periappendiceal abscess. CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
Design: Retrospective review of medical records of patients with acute appendicitis from 1992 until 2001. Setting: Los Angeles County and University of Southern Cal-
ifornia Medical Center. Participants: A total of 104 patients with acute appendicitis
complicated by periappendiceal abscess were divided into 2 groups: immediate appendectomy (IMM APP, 36 patients) and expectant management (EXP MAN, 68 patients). Results: Outcome measures included morbidity and length of
hospital stay. Immediate appendectomy patients had a higher
rate of complications than EXP MAN patients at initial hospitalization (58% vs 15%, p ⬍ 0.001) and for all hospitalizations (67% vs 24%, p ⬍ 0.001). The IMM APP group also had a longer initial (14.8 ⫾ 16.1 vs 9.0 ⫾ 4.8 days, p ⫽ 0.01) and overall hospital stay (15.3 ⫾ 16.2 vs 10.7 ⫾ 5.4 days, p ⫽ 0.04). Conclusions: Percutaneous drainage and interval appendec-
tomy is preferable to immediate appendectomy for treatment of appendiceal abscess because it leads to a lower complication rate and a shorter hospital stay.
REVIEWER COMMENTS
This recent paper demonstrates a shorter hospital stay in those patients who present with appendiceal abscess and are treated “expectantly” (eg, broad-spectrum antibiotics, percutaneous drainage of abscess if feasible, and interval appendectomy) versus immediate laparotomy. This difference was noted both in the initial length of stay as well as in the subsequent hospitalizations. Similar to other studies, the paper also concludes that patients who are managed expectantly have lower overall complication rates. Although well designed and one of the largest series to date, the study is nonetheless retrospective. Furthermore, the 2 groups of patients (IMM APP and EXP MAN) were not per-
fectly matched, with a higher pulse rate found in those patients undergoing immediate appendectomy. It is difficult to determine whether the tachycardia was an incidental finding or a marker for increased severity of disease. Over the past decade, Brown et al. from the University of Southern California have reported other successes with the expectant management of patients with appendiceal abscess through the use of close monitoring, antibiotics, and percutaneous drainage. They provide strong evidence for the efficacy and safety of an initial nonoperative approach in the management of patients presenting with appendiceal abscess.
MANAGEMENT OF APPENDICEAL MASSES
complications, recurrence of appendicitis, and incidence of interval appendicectomy during follow-up.
Tingstedt B, Bexe-Lindskog E, Ekelund M, Andersson R. Eur J Surg. 2002;168:579-582. Objective: To evaluate the outcome of patients treated for
appendiceal abscess, and managed either conservatively or surgically, and to describe the short- and long-term outcome as well as incidence of interval appendicectomy in those treated conservatively. Design: Retrospective study of 93 patients with the diagnosis
of appendiceal abscess. Setting: Lund University Hospital in Sweden. Participants: Ninety-three patients with the diagnosis of ap-
pendiceal abscess, 50 treated conservatively and 43 who were operated on, with a mean age of 46 (14 to 93) years. Mean (range) follow-up for patients operated on was 65 (11 to 135) and for those treated conservatively 66 (6 to 136) months. Main outcome measures included course of acute disease, recorded
Results: The duration of pain before admission was 4 (0.5 to 82) days for those operated on and 7 (2 to 60) days for those treated conservatively. A palpable mass was more common in the conservatively managed group. Complications were common among patients who were operated on. No interval appendicectomies were done during the second half of the study period. Four of the patients treated conservatively (8%) had an underlying tumor diagnosed at follow-up. Conclusions: Operative management of patients with appendiceal masses seems to be associated with a high risk of postoperative complications and the risk of a more extensive surgical procedure. If possible, a conservative approach should be advocated. Because of inaccurate radiological imaging during the acute phase and the risk of an underlying malignancy, routine follow-up is necessary. Routine interval appendicectomy cannot be recommended.
REVIEWER COMMENTS
Through the retrospective review of 93 patients, this Swedish study from Lund University Hospital examines which management approach (conservative versus surgical) is most optimal
for patients with appendiceal abscesses. In addition, it examines the short- and long-term outcomes of patients who are treated nonoperatively, paying particular attention to their follow-up
CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
525
and the necessity of interval appendectomy. The authors found that early operative intervention leads to higher postoperative complications, longer hospital stays, and often, a more extensive operation given the acute inflammation present during the initial operation. Given the risk of other pathologies masquerading as appendicitis, the authors feel that routine follow-up is necessary, although interval appendectomy may not be warranted for all
patients. The study design is somewhat problematic because patients treated from 1990 to 1995 were more likely to have an interval appendectomy compared with those treated from 1996 to 2000 because of a major change in treatment protocol during this time period (ie, from 1996 to 2000, only 2 patients underwent interval appendectomy). As such, broad extrapolation of their data to the current setting is difficult and the role of interval appendectomy was not conclusively studied.
INITIAL NONOPERATIVE MANAGEMENT FOR PERIAPPENDICEAL ABSCESS
(CT) scan results. Five patients were excluded because of incomplete or unavailable medical records.
Oliak D, Yamini D, Udani V, et al. Dis Colon Rectum. 2001;
Results: The patient population consisted of 107 males and 48
44:936-941.
females, with an average age of 33 (range, 16 to 75) years. Age, gender, comorbidity, white blood cell count, temperature, and heart rate did not differ significantly between groups. For the initial nonoperative management group, the failure rate was 5.8% and the appendicitis recurrence rate was 8% after a mean follow-up of 36 weeks. The response to treatment of the initial nonoperative group and the initial operative group was compared by length of stay (9 ⫾ 5 days vs 9 ⫾ 3 days; p ⫽ NS), days until white blood cell count normalized (3.8 ⫾ 4 days vs 3.1 ⫾ 3 days; p ⫽ NS), days until temperature normalized (3.2 ⫾ 3 days vs 3.1 ⫾ 2 days; p ⫽ NS), and days until a regular diet was tolerated (4.7 ⫾ 4 days vs 4.6 ⫾ 3 days; p ⫽ NS). Complication rate was significantly lower in the nonoperative group (17% vs 36%; p ⫽ 0.008).
Objective: To compare initial operative and nonoperative management for periappendiceal abscess complicating appendicitis. Design: Retrospective review of 155 consecutive patients with
appendicitis complicated by periappendiceal abscess treated between 1992 and 1998. Setting: Harbor-UCLA Medical Center, Torrance, Califor-
nia. Participants: Out of 2150 adult patients with a clinical diagnosis of appendicitis between 1992 and 1998, 160 patients were treated for periappendiceal abscess without peritonitis. Ninety patients underwent initial nonoperative therapy, and 70 underwent initial operative therapy. Periappendiceal abscesses were documented by operative reports and computed tomography
Conclusions: Initial nonoperative management of appendicitis complicated by periappendiceal abscess is safe and effective. Patients undergoing initial nonoperative management have a lower rate of complications, but they are at risk for recurrent appendicitis.
REVIEWER COMMENTS
Oliak et al. at Harbor-UCLA have published a number of papers on the conservative management of patients with appendiceal abscesses. This paper examines the safety and efficacy of nonoperative management (parenteral antibiotics, nothing by mouth (NPO), selective percutaneous drainage, and interval appendectomy) in patients with complicated appendicitis. Although it failed to demonstrate a significant decrease in each of the outcome parameters (length of stay, days until normalization of white blood cell count, days until temperature normalization, and days until resumption of normal diet), it does show a significantly lower complication rate among those patients initially managed nonoperatively.
Patients presenting with peritonitis were excluded from this study, which may lead to a lower reporting of complications and recurrent disease. In addition, the 2 groups differed with respect to days of pain and percentage of patients with a palpable mass with significantly increased numbers in the nonoperative group (7 days vs 4 days and 33% vs 6%, respectively). This paper, although retrospective, documents that nonoperative management is acceptable and does not compromise patient outcomes. In fact, the lower complication rate indicates that conservative management should be considered as the optimal initial plan.
APPENDICEAL ABSCESSES: PRIMARY PERCUTANEOUS DRAINAGE AND SELECTIVE INTERVAL APPENDICECTOMY
Objective: To present the results of nonsurgical primary man-
Lasson A, Lundagards J, Loren I, Nilsson PE. Eur J Surg. 2002;168:264-269. 526
agement of appendiceal abscesses using ultrasonic percutaneous drainage under local anaesthesia and selective interval appendicectomy. Design: Retrospective study. CURRENT SURGERY • Volume 61/Number 6 • November/December 2004
Setting: Malmo University Hospital, University of Lund,
Sweden. Participants: Twenty-four patients with appendiceal abscesses 3 to 12 cm in size who underwent primary ultrasonic percutaneous drainage under local anaesthesia, antibiotic treatment, and selective surgical treatment. Main outcome measure was long-term follow-up. Results: All patients had their abscesses drained successfully
without complications. One patient continued to have fever, but eventually responded to conservative treatement, and in one, the bowel was perforated by the drain, but again, this was
treated conservatively. Four abscesses were also operated on one for caecal adenocarcinoma and two for persisting symptoms and enterocutaneous fistulas. Conclusions: Appendiceal abscesses can be effectively drained percutaneously using ultrasound-guided drainage under local anaesthesia, without complications. Recurrent appendicitis is common, and malignancy is a substantial risk in elderly patients. Modern laparoscopic appendicectomy and early postoperative discharge makes interval appendicectomy a valid treatment option after primary nonsurgical management of appendiceal abscesses.
REVIEWER COMMENTS
Although retrospective, this Swedish study is unique in that it represents a combined radiological and surgical effort to examine the “conservative” management of appendiceal abscess. A group of 24 patients’ conditions were diagnosed with appendiceal abscess and treated with ultrasonic percutaneous drainage, antibiotics, and in some patients, an interval appendectomy. All abscesses were successfully drained, and the clinical course remained primarily uneventful in 22 of the 24 patients. Four of these patients did have recurrent abscesses, but they were managed with further percutaneous drainage. Interval appendectomy was only planned in 7 of 24 patients, although 3 additional patients were operated on for adenocarcinoma (1), continued symptoms (1), and an enterocuta-
neous fistula (1). The remaining 14 patients were followed up for 43 months and had not developed any malignancy. Seven of these patients underwent barium enema, and 4 of 7 patients needed further examinations. This paper demonstrates the effectiveness of a nonoperative approach in patients who present with appendiceal abscess. Regarding interval appendectomy, if a “selective” approach is followed, strict guidelines should be adopted so that malignancies are not missed. However, the authors note that interval appendectomy is associated with low complication rates and short hospital stays (both open and laparoscopic), and as such, interval appendectomy is a valid treatment option for all patients.
REVIEWER SUMMARY
Even in 2004, the treatment of appendicitis can, at times, be controversial. Historically, the cornerstone of management has been surgical removal of the offending organ, given the natural progression of appendicitis to perforation, peritonitis, and possible abscess formation. The controversy, however, develops in the management of those patients who present late in their disease course. Such patients represent about 1% to 13% of all cases of appendicitis, often presenting with an appendiceal abscess or phlegmon.1 Surgical intervention in such patients is often associated with a high perioperative complication rate. Therefore, some surgeons began using a “conservative” approach based on bowel rest and intravenous antibiotics. With clinical improvement, patients would be discharged home and scheduled for interval appendectomy in 6 to 12 weeks after the acute infectious process has subsided. If no improvement occurred, an operation would then be performed. More recently, the diagnosis of appendicitis has been enhanced with improved radiological techniques. With the increased use of abdominal ultrasound and CT scans, appendiceal abscesses have been diagnosed more frequently. Further, improved imaging has also facilitated the percutaneous placement of radiologically guided drains and catheters. A number of studies have demonstrated the high success rate of CT or ultrasound-guided percutaneous drainage of appendiceal abscesses (see the reviewed article by Lasson et
al.).2 As such, this technique was quickly added to the conservative management of patients with appendicitis. Although conservative management has proven to be a viable alternative to immediate appendectomy in patients with appendiceal abscess or phlegmon, there have been no prospective randomized trials examining the specific risks and benefits of such treatment. Proponents of immediate operation advocate the prompt removal of infection. However, disadvantages to immediate appendectomy include possible dissemination of infection as well as difficulty in operative dissection, resulting in risk of damage to surrounding viscera and later complications such as fistulae formation. In general, it has been found that the complication rate as well as the length of hospital stay has been the same or less in patients treated conservatively versus those treated with immediate operation. This includes the hospital stay even if an interval appendectomy is performed (see the reviewed articles by Brown et al. Tingstedt et al. and Oliak et al.).1 In addition to the issue of immediate versus conservative management of appendiceal abscess, the need for interval appendectomy has also been a source of controversy. The concern is that nonoperative patients are exposed to the risk of recurrent appendicitis. Various studies have reported rates of 10% to0 20% after conservative management, with the majority occurring early on, within the first 3 to 9 months (see the reviewed
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article by Oliak et al.). An interval appendectomy would prevent recurrences and allow for the diagnosis of conditions that may otherwise be mistaken for appendicitis (eg, malignancy). The incidence of such other pathologies is 0% to 12%.3 Opponents of interval appendectomy argue that recurrences are usually not associated with serious morbidity. In fact, these patients can, many times, be treated nonoperatively. Many of these surgeons feel that older patients should undergo barium enema or colonoscopy after resolution of symptoms to rule out other diagnoses (see the reviewed article by Tingstedt et al.). Furthermore, it is important to note that although conservatively managed patients are asked to return for interval appendectomy, a portion of them do not. Generally, patients are asked to return approximately 6 to 12 weeks after discharge. However, they may be reluctant to undergo a surgery without manifestation of symptoms. Given the above data, we believe that patients who present with an acute episode of appendicitis not complicated by abscess formation should be treated with an immediate appendectomy via either an open or laparoscopic approach. However, in those patients who present later in their disease, a more “conservative” approach should be considered. These patients often have a higher degree of inflammation associated with an appendiceal abscess or phlegmon. The appropriate management, under these circumstances, should include NPO and antibiotics. If there is no improvement within the first 24 to 48 hours, then the patient should undergo percutaneous drainage of any drainable collections, and if this is not possible, surgery should be performed with open drainage. Finally, in those patients who are managed conservatively, the surgeon must decide whether an interval appendectomy should be performed. We believe that these patients are still at risk for recurrent disease; thus, an interval procedure should be planned 6 to 12 weeks after the acute disease process subsides. This will prevent future recurrences as well as exclude and/or treat any other diagnoses such as malignancy. It should be noted that our recommendations pertain to adult patients and do not necessarily apply to the pediatric population. As a result of the varied clinical presentations of children with appendicitis, there has been no consensus on the
optimal management of late presentations and the current literature outlines several treatment options. doi:10.1016/j.cursur.2004.07.004
REFERENCES 1. Yamini D, Vargas H, et al. Perforated appendicitis: is it
truly a surgical urgency? Am Surg. 1998;64:970-975. 2. Shapiro MP, Gale E, Gerzof SG. CT of appendicitis: diag-
nosis and treatment. Radiol Clin N Am. 1989;27:753-762. 3. Nitecki S, Assalia A, Schein M. Contemporary manage-
ment of the appendiceal mass. Br J Surg. 1993;80:18-20.
QUESTIONS AND ANSWERS Questions 1. T or F: Patients presenting late in the course of appendecitis with abscess formation are best treated with immediate surgical management, wide debridement and right hemi-colectomy. 2. The optimal management of patients with appendecial abscess include all of the following except: a. b. c. d. e.
antibiotics IV Fluids Initial NPO Diet order Percutaneous drainage Barium Enema
3. T or F: Patients with appendiceal abscess treated ⬙conservatively⬙ initially, should ultimately undergo an interval appendectomy. Answers 1. F 2. e 3. T
Breast Nipple Discharge: Its Significance and Evaluation Guest Reviewers: Michael Self, MD, and Ernest Dunn, MD, Department of Surgery, Methodist Hospitals of Dallas, Dallas, Texas SURGICAL DECISION MAKING AND FACTORS DETERMINING A DIAGNOSIS OF BREAST CARCINOMA IN WOMEN PRESENTING WITH NIPPLE DISCHARGE.
Objective: Identify patient and nipple discharge characteris-
Cabioglu N, Hunt KK, Singletary SF, et al. J Am Coll Surg.
Design: Retrospective chart review of patients with nipple
2003;196:354-364.
discharge at a single institution.
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tics associated with the diagnosis of breast cancer and determine the utility of mammography, sonography, ductography, and cytology in pathologic nipple discharge.
CURRENT SURGERY • Volume 61/Number 6 • November/December 2004