Treatment options of inflammatory appendiceal masses in adults

Abstract

At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn’s disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Keywords: Appendicitis; Phlegmon; Abscess; Computed tomography; Antibiotics; Percutaneous drainage; Surgery

Core tip: The management of adult patients with inflammatory appendiceal masses is controversial. This report aims at reviewing the treatment options of these patients, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence. The debate arises over the importance of the complication rate of interval appendicectomy. Moreover, if appendicectomy is not performed, consideration needs to be given to what investigations should be undertaken and in which patients. It is also worth recalling that the appendix is used in reconstructive surgery.