Appendicitis along with its complications is a major health burden for the developing world. Appendicular mass comprises a spectrum of conditions. The appendix may be surrounded by the omentum, edematous caecal wall, sigmoid colon, terminal ileum, or coils of the intestine in the vicinity of appendix which may wall off the inflamed appendix. The mass can be complicated with abscess formation usually when the appendix perforates. If the barrier cannot wall off the inflammation, generalized peritonitis may develop. Although management of appendicular mass is primarily conservative in adult population, there is a general trend among a group of pediatric surgeons for early exploration of appendicular mass [1, 8]. The reasons behind are as follows: earlier perforation of appendix and abscess formation, less capability of omentum to confine the infection, and consequently easier separation of appendix from the mass in children than in adult. Blakely et al. reported that the duration of operation was not significantly longer with early than interval appendectomy [9]. However, many centers also practice conservative approach for appendicular mass [10]. Evidences to suggest the best option are conflicting, and both groups have some evidences to support their approaches.
This study has some observations that are pertinent to developing countries. Firstly, delay in presentation is common. The mean duration of abdominal pain in this study was 4.35 ± 4.23 days, and about 46% patients presented after 3 days of symptoms. However, there was no significant association of duration of pain with the peri-operative condition of appendix (P = 0.118). In most other studies with appendix mass, perforated appendix or appendicular abscess, the mean duration of presentation was between 3 and 4 days [3, 7, 9, 10]. There were 18 patients in this study who had abdominal pain for more than a week, and they had a higher complication rate. Secondly, many patients with appendix mass who underwent conservative treatment in studies from developed world did not meet the criteria of systemic sepsis. On the contrary, most patients in this study had features of systemic sepsis (raised temperature in 64%, tachycardia in 74%, vomiting in 72%). Thirdly, CBC was done in only 87 (39.55%) patients due to the fact that there would be more chance of delay in surgical procedure because of delay in getting the results which usually takes a day. Moreover, operating theaters are shared by different units and are not always available when needed. For these reasons, we cannot always perform standard preoperative investigations for all patients. The reason behind more patients having USG than CBC was that many patients were admitted with an USG performed in remote areas by unqualified sonologists. This is why the findings of USG were very diverse; it could comment about complicated appendicitis in only 40% of patients. The repetition of an USG needs out-of-pocket money, and most of the parents are reluctant to do this. No patients underwent a CT scan. On the other hand, USG is usually used in clinically suspicious cases and CT scans are occasionally performed for equivocal cases in developed world. Due to poor laboratory support, clinical judgement is usually given more emphasis in decision making in the developing world. Fourthly, laparoscopic appendectomy was done in only 14% of the patients. In most developed countries, almost all cases of appendicular mass are now performed laparoscopically. However, it takes more time for the people in developing country to enjoy the benefits of advanced technology. Consistent with other studies, patients who underwent laparoscopic appendectomy had less complications than open surgery (5/31 vs 38/189, P = 0.000) [8, 10].
It has long been established that appendectomy can be performed during the index admission in most patients with an appendicular mass [1]. The reasons behind our choice of early appendectomy over conservative treatment are many-fold. About 10 to 50% of patients, who receive conservative treatment, fail and ultimately needs potentially more difficult appendectomies, extended length of stay, and more complications [1]. Moreover, among the patients who had been discharged after conservative treatment, about 23% have a risk of recurrent appendicitis and 30% need urgent readmissions [6, 11]. Another problem of non-operative management for the developing countries is that these patients need frequent imaging which is costly and may need referral to other centers. Peter et al. reported that patients treated in their series of conservative approach underwent a mean of 3.5 CT scans per patient which is a major cost burden and also major exposure to radiation [12]. Several studies have reported that cost of care is relatively less in early appendectomy versus conservative treatment [4]. Another disadvantage of non-operative management of appendicular masses is misdiagnosis. Early surgery can avoid consequences of misdiagnosis which is not rare [1]. It has also been reported that patients and families suffer from more stress if their appendix had not been removed after an attack of appendicitis [13]. Moreover, many of the patients who present late had already tried some oral or parenteral antibiotics prescribed by a rural doctor or a physician. Another regimen of standard conservative approach would require 7–14 days of antibiotic therapies with uncertain results which is often difficult for parents to accept.
Many centers prefer to do image-guided drainage of appendicular abscess. The set-up for image-guided procedure is not well established in developing countries, and it will surely increase the cost. It has some limitations such as failure or inadequate drainage, non-target puncture or injury to adjacent viscera, bleeding, and infection [14]. However, a prospective randomized trial done in Kansas, USA, did not find any significant difference between image-guided drainage versus early laparoscopic appendectomy with regard to total hospitalization, recurrent abscess rate, or total charges [12].
Several studies have shown that younger patients develop complications early, and they should undergo early surgery [6, 9]. In this study also, patients aged 5 years or less (23 patients) developed pus more frequently (P = 0.45). They also had significantly higher rate of complications (39.13% vs 17.26%, P = .000) and hospital stays (mean 15.61 days vs 9.87 days, P = 0.014). Complications developed in 21.36% patients, mostly related to wound in open appendectomies, which is consistent with reported complication rates of 15 to 50% and more in younger age group. This finding reemphasizes the need for early referral of young children with suspected acute appendicitis to surgical facilities and performing early appendectomy in them.
In many studies that compared early appendectomy with conservative approach, the comparative groups were unequal and there was allocation bias, because patients who underwent surgery were actually the more toxic ones and thus had more complications, delayed hospital stays, and more cost. From the findings of many contradicting studies, it may be assumed that either conservative or early appendectomy is feasible in cases of complicated appendicitis. However, developing countries have some problems, such as delayed presentation, lack of patient compliance and reluctance to repeated hospital admissions, cost of care, and inadequate logistic support, and for them, treatment needs to be definitive and earlier.
