Management of an appendix mass

If an appendix mass is present and the condition of the patient is satisfactory, the standard treatment is the conservative Ochsner—Sherren regimen. This strategy is based on the premise that the inflammatory process is already localised and that inadvertent surgery is difficult and may be dangerous. It may be impossible to find the appendix and, occasionally, a faecal fistula may form. For these reasons it is wise to observe a nonoperative programme, but to be prepared to operate should clinical deterioration occur (Table 59.7).

Careful record of the patient’s condition and the extent of the mass should be made, and the abdomen regularly re­examined. It is helpful to mark the limits of mass on the abdominal wall using a skin pencil. A nasogastric tube should be passed and intravenous fluid and antibiotic therapy instigated. Temperature and pulse rate should be recorded 4-hourly and a fluid balance record maintained. Clinical deterioration or evidence of peritonitis is indication for early laparotomy. Clinical improvement is usually evident within 24—48 hours at which time the nasogastric tube can be removed and oral fluids introduced. Failure of the mass to resolve should raise suspicion of a carcinoma or Crohn’s disease. Using this regime approximately 90 per cent of cases resolve without incident. It is advisable to remove the appendix usually after an interval of 6—8 weeks.

Postoperative complications

Postoperative complications following appendicectomy are relatively uncommon and reflect the degree of peritonitis that was present at the time of operation and intercurrent diseases that may predispose to complications (Table 59.8).

Wound infection

This is the most common postoperative complication which occurs in 5—10 per cent of all cases. This usually presents with pain and erythema of the wound on the fourth or fifth postoperative day, often soon after hospital discharge. Treatment is by wound drainage and antibiotics when required. The organisms responsible are usually a mixture of Gram-negative bacilli and anaerobic bacteria, predominantly Bacteroides species and anaerobic streptococci.

Intra-abdominal abscess

Intra-abdominal abscess has become a relatively rare complication after appendicectomy with the use of perioperative antibiotics. Postoperative spiking fever, malaise and anorexia, developing 5—7 days after operation, suggest an intraperi­toneal collection. Interloop, paracolic, pelvic and subphrenic sites should be considered. Abdominal ultrasonography and CT scanning greatly facilitate diagnosis and allow percuta­neous drainage. Laparotomy should be considered in patients suspected to have intrabdominal sepsis in whom imaging fails to show a collection, particularly those with continuing ileus.

Ileus

A period of adynamic ileus is to be expected after appen­dicectomy, and may last for a number of days following removal of a gangrenous appendix. Ileus persisting for more than 4—5 days, particularly in the presence of a fever, is indicative of continuing intra-abdominal sepsis and should prompt further investigation (see above).

Respiratory

In the absence of concurrent pulmonary disease, respiratory complications are rare following appendicectomy. Adequate postoperative analgesia and physiotherapy, when appropriate, reduce the incidence.

Venous thrombosis and embolism

These are rare after appendicectomy except in the elderly and women taking the oral contraceptive pill. Appropriate prophylactic measures should be taken in such cases.

Portal pyaemia (Pylephlebitis)

Pylephlebitis is a rare but very serious complication of gangrenous appendicitis associated with high fever, rigors and jaundice. It is due to septicaemia in the portal venous system and may leads to the development of intrahepatic abscesses (often multiple). Treatment is with systemic antibiotics and percutaneous drainage of hepatic abscesses as appropriate.

Faecal fistula

Leakage from the appendicular stump rarely occurs, but may follow if the encircling stitch has been put in too deeply or if the caecal wall was involved by oedema or inflammation. Occasionally, a fistula may result following appendicectomy in Crohn’s disease.

Adhesive intestinal obstruction

Adhesive intestinal obstruction is the most common late complication of appendicectomy. At operation often a single band adhesion is responsible. Occasionally, chronic pain in the right iliac fossa is attributed to adhesion formation after appendicectomy. In such cases laparoscopy is of value in confirming the presence of adhesions and allowing division.

Right inguinal hernia

This is said to be more common following a grid-iron incision for appendicitis due to injury to the iliohypogastric nerve.