World J. Surg. 27, 800–803, 2003 DOI: 10.1007/s00268-003-6891-1

WORLD Journal of

SURGERY © 2003 by the Socie´te´ Internationale de Chirurgie

Surgical Globetrotting Management of Appendiceal Masses in a Peripheral Hospital in Nigeria: Review of Thirty Cases Pius I.S. Okafor, M.D.,1,2 Jideofor C. Orakwe, M.B.B.Ch.,1,2 Gabriel U. Chianakwana, M.B.B.Ch.1,2 1

St. Victoria Specialist Hospital, Ekwulobia, Anambra State, Nigeria Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, P.M.B. 5025, Nnewi, Anambra State, Nigeria

2

Published Online: June 3, 2003 Abstract. The objective of this work was to conduct a truly rural-based study to evaluate, from our own rural data devoid of influence from urbanbased studies, the management of appendiceal masses in a typical peripheral hospital in Nigeria. The study aimed to highlight the results of neglected appendicitis in our community and the occasional difficulty of making a correct preoperative diagnosis. It also sought to draw the attention of the health care practitioner in our community to the importance of continued enlightenment of the people regarding the need to seek medical treatment early. This was a retrospective study, with the setting at St. Victoria Specialist Hospital, Ekwulobia, Anambra State, Nigeria, a rural hospital serving its community. A series of 30 patients who were managed for an appendiceal mass between January 1, 1992 and December 31, 2001, a 10-year period, were included in the study. We identified the cases by reviewing the surgical register. The relevant case notes were retrieved from the Records Department. The following data were extracted for each patient: age and sex; how early the patient presented; the history and presentation of the patient; whether the diagnosis was made before or during surgery; the treatment modality; length of hospital stay; and outcome. The results showed that 13 patients (43.3%) presented more than 1 week after the onset of symptoms. The age range was 15 to 60 years (average 27 years); 13 patients (43.3%) were in the age range of 40–49 years. Twenty men and ten women were treated, giving a male/female ratio of 2:1. The main clinical features were fever, anorexia, pain, tenderness, and a palpable mass in the right iliac fossa. The problem was diagnosed before surgery in 23 patients (76.7%) and during surgery in 7 (23.3%). Treatment modalities were conservative + interval appendectomy in 18 patients (60%); open and close + conservative + interval appendectomy in 3 patients (10%); immediate appendectomy without burying the stump in 2 cases (6.7%); right hemicolectomy (in one 40-year-old woman and one 55-year-old man); and incision and drainage of an appendiceal abscess in 5 patients (16.7%). No deaths were recorded. The study showed that appendical masses are most prevalent during the fifth decade of life and are rare before age 10 and after age 60. More men are affected than women, and most cases can be diagnosed before surgery, although some patients must await more sophisticated diagnostic tools or surgical exploration for diagnosis.

An appendiceal mass is an inflammatory tangle of the cecum and coils of the terminal ileum intimately wrapped up by the greater omentum, with the aim of walling off an inflamed vermiform ap-

Correspondence to: Pius I.S. Okafor, M.D., e-mail: nauth@infoweb. abs.net

pendix, which now lies in the middle of the tangle. The natural history is either gradual, complete resolution of the mass or steady progress toward appendiceal abscess formation. Between the two extremes, when the greater omentum is well formed and quite competent, appendiceal masses are more prevalent. Early presentation by the patient and prompt institution of the Ochsner-Sherren regimen by the surgeon promote resolution of the mass and reduce the rate of abscess formation. Materials and Methods The surgical register was reviewed with the aim of selecting patients who were treated for appendicitis between January 1, 1992 and December 31, 2001, a 10-year period. A total of 1047 patients were treated, among whom 30 presented with an appendiceal mass, representing 2.9% of the total. These 30 cases were included in our study. The relevant case notes were subsequently retrieved from the Records Department, and the following data were obtained for each patient: age and sex; how soon the patient presented to hospital after the onset of symptoms; the history and presentation of the patient; whether the problem was diagnosed before or during surgery; the treatment modality; length of hospital stay; and the outcome. Results The ages of the patients ranged from 15 to 60 years (average 27 years) (Table 1). The highest prevalence was among those 40 to 49 years of age, with 13 patients (43.3%) being involved. No patient under age 10 years was seen, and only one patient (3.3%) ⱖ 60 years presented. Twenty men and ten women were treated during the period in question, giving a male/female ratio of 2:1. Of the 30 patients, 13 (43.3%) presented when it was more than 1 week after the onset of symptoms (Table 2). Only one patient (3.3%), the earliest, presented on the fourth day of symptoms. None presented before 4 days. The major presenting symptoms were pain in the right iliac fossa in 27 (90.0%) patients, intermittent fever in 18 (60.0%), continuous fever in 3 (10.0%), anorexia in 23 (76.7%), and loss of weight in 4

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Table 3. Major symptoms.

Table 1. Age range of patients 15–60 years (mean 27 years). Age

No. of patients

%

< 10 10–15 16–20 21–30 31–39 40–49 50–59 ⱖ 60 Total

0 2 2 2 7 13 3 1 30

6.7 6.7 6.7 23.3 43.3 10.0 3.3 100

Table 2. Interval between onset of symptoms and presentation to doctor. Interval (hours)

No. of patients

< 24 (1 day) 25–48 (2 days) 49–72 (3 days) 73–96 (4 days) 97–120 (5 days) 121–144 (6 days) 145–168 (7 days) > 1 week Total

0 0 0 1 2 4 10 13 30

%

3.3 6.7 13.3 33.3 43.3 100.0

(13.3%) (Table 3). The three patients who did not present with pain had anorexia and weight loss as their major symptoms. On examination, the signs at presentation were low-grade fever (ⱕ 38.3°C) in 11 (36.7%) patients, high-grade fever (up to 39.0°C) in 3 (10.0%), and tenderness in the right iliac fossa in 25 (83.3%), with rebound in 2 of them. There was a firm, palpable mass in the right iliac fossa in all 30 patients, including 5 with an appendiceal abscess (Table 4). High-grade fever was present in three of the five patients with an appendiceal abscess. Preoperatively, 18 (60.0%) patients were diagnosed accurately as having an appendiceal mass and 5 (16.7%) others as having an appendiceal abscess. Seven cases (23.3%) were diagnosed at surgery (Table 5). The preoperative diagnosis of these seven patients consisted of carcinoma of the cecum in four patients aged 40 to 49 years and a lymphogranulomatous lesion of the cecum and ascending colon in three patients aged 30 to 39 years. None of these seven patients had an appendiceal abscess, but they did have an appendiceal mass. Abdominopelvic ultrasonography was indispensable for serial assessment of the mass during conservative management. As shown in Table 6, the treatment modalities used were as follows: conservative + interval appendectomy in 18 patients (60%); open and close + conservative + interval appendectomy in 3 patients (10%). Two patients (6.7%) underwent immediate appendectomy during which the appendix stump was not buried. These two patients belonged to the seven patients in whom an appendiceal mass was diagnosed at surgery. However, in these two cases the appendix was easy to locate and removal did not pose any difficulty for the surgeon or undue risk to the patient. Two others (a 40-yearold woman and a 55-year-old man) underwent right hemicolectomy because of the difficulty in each case of immediately ruling out a malignant condition. Early incision and drainage of the appendiceal abscess was done as an emergency procedure in five patients (16.7%) in whom this diagnosis was made clinically before surgery and confirmed at surgery. This was followed 6 weeks later by interval appendectomy.

Symptom

No. of patients

%

Pain in the right iliac fossa Intermittent fever Continuous fever Anorexia Loss of weight

27 18 3 23 4

90.0 60.0 10.0 76.7 13.3

Table 4. Signs at presentation. Sign

No. of patients

%

Low-grade fever (ⱕ 38.3°C) High-grade fever (up to 39.0°C) Tenderness in the right iliac fossa (with rebound in two patients) Palpable mass in the right iliac fossa

11 3 25

36.7 10.0 83.3

30

100.0

Table 5. Time of diagnosis. Time of diagnosis

No. of patients

Before surgery Appendiceal mass Appendiceal abscess During surgery Appendiceal mass Total

18 (60.0%) 5 (16.7%) 7 (23.3%) 30 (100%)

Table 6. Treatment modalities. Treatment modality

No. of patients

Conservative + interval appendectomy Open and close + conservative + interval appendectomy Immediate appendectomy without burying stump Right hemicolectomy Emergency incision and drainage of appendiceal abscess Total

18 3

60.0 10.0

2

6.7

2 5a

6.7 16.7

30

%

100

a A 35-year-old man; 45-year-old man; 53-year-old man; 58-year-old woman; and a 60-year-old man.

These five patients included a 35-year-old man, a 45-year-old man, a 53-year-old man, a 58-year-old woman, and a 60-year-old man. The average hospital stay was 1 week during the initial period of conservative management for each of the patients with an appendiceal abscess and those with an appendiceal mass. The patient was discharged home and readmitted after 6 weeks for interval appendectomy during which admission the patient stayed an average of another week in hospital. The two patients who had immediate appendectomy spent only a total of 1 week in hospital and paid half the cost incurred by those who underwent initial conservative management followed by interval appendectomy. No deaths were recorded among the 30 patients. Discussion In this study, the appendiceal mass occurred most commonly during the fifth decade of life (40–49 years of age). This is likely to be

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due to the fact that the greater omentum, competent in this age group, effectively walls off the cecum and loops of the terminal ileum, burying the inflamed vermiform appendix within the mass, thereby preventing spread of the inflammation. Only 1 of our 30 patients (3.3%) was in the age range of ⱖ 60 years, implying that this condition is rare in older people. None of our patients was less than 10 years of age, also implying that the appendiceal mass is rare during the first decade of life. This may have to do with the fact that the greater omentum is not yet well developed in the young and is attenuated in the elderly, although in 1999 Kafetz [1] reported an appendiceal abscess in a woman 102 years of age. Our male/female ratio of 2:1 and average age of 27 years relate closely to the male/female ratio of 1.8:1.0 and the median age of 29 years reported by Willmore and Hill [2] for acute appendicitis in Kenya in 2001. Based on our experience in this community, it was not surprising that only one patient presented as early as 4 days after the onset of symptoms. Delayed presentation to the hospital is common here. It stems from a number of factors, the most common of which are widespread self-medication and initial consultation with quacks. Poverty, illiteracy, and the absence of health insurance are mainly responsible for the community indulging in self-medication and visits to charlatans and quacks. The poor masses therefore find it less expensive to try a few things on their own first and come to hospital only when they can no longer cope. This delay in presentation to hospital by rural dwellers appears to be a common problem in most rural communities in Africa. Harouna et al. [3], in a study of the current prognosis of appendicitis in the Niger Republic in 2000 reiterated this point and emphasized the deterioration of services offered by state health structures as one of the banes of health care services in Africa (both rural and urban). The absence of pain in 3 of our patients and the lack of fever in 16 others was probably due to self-medication with anti-pyretics and analgesics, a common practice in the community under study. The five patients with appendiceal abscess were accurately diagnosed by ultrasonography and were offered early incision and drainage as an emergency procedure in line with the management of abscesses. The need to readmit a patient after 6 weeks for interval appendectomy after the initial 1-week hospital stay for conservative management obviously meant that the patient would pay for two admissions. Such patients incur more expenses than those who undergo immediate appendectomy. Although the appendiceal mass is a benign condition, a number of other conditions, some of them sinister, can mimic this disease and pose a dilemma for the surgeon. Such conditions include cecal diverticulitis, cecal carcinoma, ileocecal tuberculosis [4], and abdominal actinomycosis in which the appendix is the most common intra-abdominal organ involved [5]. Appendiceal mucocele is also an important item in the differential diagnosis. In our study, the most important diagnostic tool was abdomino-pelvic ultrasonography. Where available, computed tomography (CT) scanning and magnetic resonance imaging (MRI) are invaluable as well. The Creactive protein (CRP) level increases markedly after appendiceal abscess formation [6]. Preoperative diagnosis of appendiceal mucocele, a rare disease of the vermiform appendix and an important item in the differential diagnosis of the appendiceal mass, is essential [7] to avoid the risk of rupture at surgery, with subsequent development of pseudomyxoma peritonei [8]. The treatment modalities we adopted depended on the circum-

World J. Surg. Vol. 27, No. 7, July 2003

stances. Eriksson and Styrud [9] were opposed to interval appendectomy and did not recommend it, arguing that the complication rate is the same as for acute appendectomy. In contrast, AlaminosMingorance et al. [10] upheld the practice of interval appendectomy. In our series, the outcome of management was good. No deaths were recorded, and follow-up showed satisfactory results. However, the occurrence of 30 appendiceal masses among 1047 cases of appendicitis (2.9%) is worrisome. It is a reflection of neglected appendicitis. The occasional difficulty experienced before arriving at a correct preoperative diagnosis can be improved upon by the acquisition of modern diagnostic tools (some rural hospitals in our community do not have even ultrasonographic facilities). Public enlightenment by government agencies and health care providers that encourages rural people to present early to hospital would be desirable. In addition, government should shelve rhetoric and initiate an effective, functional health care scheme directed mainly at the rural poor masses. Conclusions We recommend that appendiceal masses be managed by experienced surgeons who may resort to right hemicolectomy when carcinoma cannot be ruled out. Because of the high incidence of appendiceal masses in our rural community, there is a need for all concerned to make sincere efforts to lower these figures. Re´sume´. L’objectif de ce travail a ´ete´ d’e´valuer, par une ´etude unique a ` notre situation rurale, la prise en charge des formes pseudo-tumorales d’appendicite dans un hoˆpital pe´riphe´rique typique en Nigeria; cette forme particulie`re caracte´rise l’e´volution de l’appendicite ne´glige´e dans notre communaute´, souligne les difficulte´s rencontre´es parfois pour faire le diagnostic pre´ope´ratoire correct et attire l’attention sur l’importance de continuer a ` enseigner notre population sur le besoin de chercher un avis me´dical to ˆt. Cette ´etude re´trospective, mene´e a ` l’ho ˆpital rural St. Victoria Specialist Hospital, a ` Ekwulobia, Anambra State, Nigeria, inte´resse 30 patients soigne´s pour appendicite a ` forme pseudotumorale pendant 10 ans, entre le 1 jan 1992 et le 31 de´cembre 2001, identifie´s gra ˆce a ` leurs comptes rendus ope´ratoires et leurs dossiers me´dicaux. Pour chaque patient, on a obtenu l’a ˆge et le sexe, les signes et l’e´tat du patient au moment de sa pre´sentation, son histoire, si le diagnostic a ´ete´ fait avant ou pendant l’acte chirurgical, la modalite´ the´rapeutique employe´e, la dure´e de l’hospitalisation et l’e´volution de la prise en charge. Les re´sultats obtenus concernaient 20 hommes et 10 femmes pour un sexe ratio de 2:1 : l’a ˆge allait de 15-60 ans, la moyenne ´etant de 27 ans et 13 patients (43.3%) avaient entre 40-49 ans. Les donne´es cliniques comprenaient la fie`vre, l’anorexie et la douleur, combine´es a ` une de´fense et une masse palpable dans la fosse iliaque droite. Treize patients (43.3%) se sont pre´sente´s plus d’une semaine apre`s le de´but de leur maladie. Le diagnostic a ´ete´ re´alise´ avant la chirurgie chez 23 patients (76.7%) et pendant l’acte chirurgical chez sept patients (23.3%). Les modalite´s the´rapeutiques comprenaient un traitement conservateur suivi d’appendicectomie a ` distance chez 18 patients (60%); une laparotomie exploratrice suivie de traitement conservateur et ensuite appendicectomie a ` distance chez trois patients (10%); une appendicectomie sans enfouissement chez deux patients (6.7%); une he´micolectomie droite (chez une femme de 40 ans et chez un homme de 55 ans); et enfin une incision et drainage d’un abce`s appendiculaire chez cinq patients (16.7%). Aucun de´ce`s n’est survenu. En conclusion, cette ´etude montre que l’appendicite a ` forme pseudotumorale ou de masse appendiculaire se voient surtout au cours de la cinquie`me de´cennie, rarement avant l’a ˆge de dix ans ou apre`s 60, plus souvent chez l’homme que chez la femme. La plupart peuvent ˆetre diagnostique´s avant l’acte chirurgical, mais pour ce faire, parfois des examens comple´mentaires sont ne´cessaires. Resumen. Se evalu ´a el tratamiento del plastro´n apendicular en los hospitales rurales de Nigeria. Se intenta averiguar las consecuencias del retraso en el diagno´stico y tratamiento de la apendicitis aguda y a las

Okafor et al.: Appendiceal Masses in Nigeria

causas que dificultan un correcto diagno ´stico preoperatorio. Tambie´n se enfatiza sobre la necesidad de que el personal sanitario remita a los enfermos lo ma ´s pronto posible al Hospital para su correcto tratamiento. Estudio retrospectivo en el Hospital Victoria de Ekwulobia, Estado de Anambra Nigeria, que atiende a una comunidad rural. Entre enero de 1992 y diciembre de 2001 se trataron 30 pacientes con plastron apendicular. Los casos se identificaron mediante el libro de operaciones y los datos ma ´s relevantes se obtuvieron de las historias clı´nicas del Departamento. De cada paciente se obtuvieron los siguientes datos: edad, sexo, tiempo transcurrido desde el comienzo de la sintomatologı´a y primera consulta, la historia clı´nica del paciente, si el diagno ´stico se realizo´ antes o durante la intervencio ´n quiru ´rgica, tipo de tratamiento, estancia hospitalaria y resultados. Resultados: 13 pacientes (43.3%) se presentaron en la consulta tras una semana o ma ´s de haberse iniciado la sintomatologı´a. La edad oscilo ´ entre 15-60 an ˜ os con un promedio de 27 an ˜ os, 13 pacientes (43.3%) presentaban edades comprendidas entre los 40-49 an ˜ os. 20 eran varones y 10 hembras (cociente 2:1). Los hallazgos clı´nicos ma ´s importantes fueron: fiebre, anorexia, dolor, contractura y masa palpable en fosa iliaca derecha. En 23 pacientes (76.7%) el diagno´stico se realizo´ preoperatoriamente y en 7 casos (23.3%) durante la operacio´n. Los tratamientos utilizados fueron los siguientes: tratamiento conservador + apendicectomı´a diferida en 18 casos (60%); apertura y cierre + tratamiento conservador + apendicectomı´a diferida en 3 pacientes (10%); apendicectomı´a urgente sin enterramiento del mun ˜o ´n apendicular en 2 (6.7%); hemicolectomı´a derecha (en 1 mujer de 40 y en un hombre de 55 an ˜ os); incisio´n y drenaje del absceso apendicular en 5 pacientes (16.7%). No hubo mortalidad alguna. El plastro ´n apendicular es ma ´s frecuente en la 5ª de´cada de la vida y raro antes de los 10 an ˜ os y despue´s de los 60. Es ma ´s frecuente en hombres que

803

en mujeres. Se diagnostican frecuentemente antes de la operacio´n, pero se precisan ma ´s herramientas diagno ´sticas o ma ´s exploraciones quiru ´rgicas.

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