Early surgical intervention in appendicular lump

1
Early Surgical intervention in cases of
appendicular lump

• Presented by UNIT III GENERAL SURGERY, MCH,
  KOLKATA

2
APPENDICULAR LUMP !!!

• Appendicular lump is formed in 2-6 cases of
  acute appendicitis if appendicectomy is not done.
• It is basically an inflammatory mass composed of
  inflammed appendix, caecum, omentum, terminal
  ileum, mesoappendix and at times right tubes and
  ovaries in female.
• This has been attributed to a protective
  mechanism of body to prevent the spread of
  infection.
• C/F- Firm tender irregular mass in RIF with
  localized guarding and rigidity.

3
USG FINDING IN A C/O APPENDICULAR LUMP
APPENDICULAR LUMP- EXAMINATION UNDER ANESTHESIA
4
CLINICAL PRESENTATIONS ..
N17, the total number of patients who presented
with appendicular lump in between 1st october16
till 30th april17
5
Age and sex distribution
Age( yrs) No.
11-20 1 5.9
21-40 14 82.3
41-60 2 11.8
gt60 0 0
Sex No.
Male 12 70.6
Female 5 29.4
Middle aged male are more prone to develop
appendicular lump. Male Female ratio is
2.41.0
6
Duration of symptoms at presentation
Duration of symptoms (days) No.
Within 2days 2 11.8
Within 3-4 days 11 64.7
Within 5-6 days 3 17.6
After 6 days 1 5.9
7
Sypmtomatology .
SYMPTOMS SYMPTOMS NO.
Site of onset of abdominal pain Periumbilical 07 41.2
Site of onset of abdominal pain Epigastric 01 05.8
Site of onset of abdominal pain Right lower abdomen 09 53
Shifting of pain Shifted 10 41.2
Shifting of pain Not shifted 07 58.8
GI upset Present 17 100
GI upset Absent - -
Fever Present 12 70.6
Fever Absent 05 29.4
GI upset nausea/vomiting, anorexia, loose
stool, constipation
8
TREATMENT of APPENDICULAR LUMP ..
9
Ochsner- sherren regime the conservative
approach

• NPO
• Iv fluids
• Nasogastric tube insertion
• Iv antibiotics and analgesics
• Mark the limits of the mass on the abdominal wall
  using a skin pencil
• Monitor vital signs, size of the mass,
  input/output chart
• ? Clinical improvement is expected in 24-48hrs of
  starting the therapy.

10
Criteria for stoping ochsner-sherren
regime

• A rising pulse
• Increased vomiting or copious gastric aspirate
• Increasing or spreading of abdominal pain
• Increasing size of the lump
• ? These factors indicates developing of
  appendicular abscess requiring urgent operative
  intervention.

11
Ochsner-sherren regime . The
controversy !!!!

• The conventional conservative treatment followed
  by interval appendicectomy (after 6-8 weeks) in
  patients with appendicular lump is a well
  recommended treatment.
• Majority resolves gradually, but 10-20 fail to
  respond and required urgent surgery.
• Moreover 7-46 patients suffer a recurrence of
  acute appendicitis or appendicular lump after
  successful conservative treatment.

12
Conservative treatment . WHAT
WE OBTAINED !!!!
OUTCOMES NO.
UNDERWENT SUCCESSFUL INTERVAL APPENDICECTOMY 4 57.4
UNDERWENT EMERGENCY OPERATION AFTER ABANDONMENT OF OS REGIME 1 14.2
REQUIRED READMISSION WITH ACUTE APPENCITIS AND UNDERWENT OPERATION 1 14.2
REFUSED INTERVAL APPENDICECTOMY? LOST TO FOLLOW UP 1 14.2
N7
13
OUR TAKE EARLY SURGICAL INTERVENTION IN
CASE OF APPENDICULAR LUMP.
14
Operative findings AND PROCEDURE .
OPERATIVE FINDINGS PROCEDURE No.
SUPPURATIVE APPENDIX APPENDICECTOMY 07 70
GANGRENOUS APPENDIX APPENDICECTOMY 02 20
PERFORATED APPENDIX AND APPENDICULAR ABSCESS DRAINAGE OF ABSCESS AND APPENDICECTOMY 01 10
N 10
15
Gangrenous appendix.
16
Suppurative appendix
17
Perforated appendix with appendicular abscess
18
POST OPERATIVE COMPLICATIONS
COMPLICATIONS TREATED WITH EARLY SURGERY (N10) TREATED CONSERVATIVELY (N7)
WOUND INFECTION 2 (20) 1 (14.3)
RESIDUAL ABSCESS 0 2 (28.6)
CHEST COMPLICATION 1(10) 3 (42.8)
RE-ADMISSION 0 1 (14.3)
LOST IN FOLLOW UP 0 1 (14.3)
19
HOSPITAL STAY .
DURATION OF HOSPITAL STAY IN DAYS TREATED WITH EARLY SURGERY (N10) TREATED CONSERVATIVELY (N7)
3-4 DAYS 7 0
5-7 DAYS 2 3
MORE THAN 1WEEK 1 4
20
Thus

• EARLY SURGICAL INTERVENTION ENSURES
• LESSER POST-OPERATIVE COMPLICATIONS
• LESSER HOSPITAL STAY
• NO CASE IS LOST IN FOLLOW UP
• NO REQUIREMENT OF RE-ADMISSION
• although the study is continuing, but the
  results till now, signifies the importance of
  early surgical intervention in cases of
  appendicular lump.

21
(No Transcript)