META-ANALYSIS

Nonsurgical Treatment of Appendiceal Abscess or

Phlegmon
A Systematic Review and Meta-analysis
Roland E. Andersson, PhD, MD,*† and Max G. Petzold, PhD‡

Objective: A systematic review of the nonsurgical treatment of

patients with appendiceal abscess or phlegmon, with emphasis on
T he inflammation in acute appendicitis may sometimes be
enclosed by the patients own defense mechanisms, by the
formation of an inflammatory phlegmon or a circumscribed
the success rate, need for drainage of abscesses, risk of undetected
serious disease, and need for interval appendectomy to prevent
abscess, often presenting some days after the onset of symp-
recurrence.
toms as a palpable mass.
Summary Background Data: Patients with appendiceal abscess or
The management of these patients is controversial.1
phlegmon are traditionally managed by nonsurgical treatment and
Immediate appendectomy may be technically demanding
interval appendectomy. This practice is controversial with propo-
because of the distorted anatomy and the difficulties to close
nents of immediate surgery and others questioning the need for
the appendiceal stump because of the inflamed tissues. The
interval appendectomy.
exploration often ends up in an ileocaecal resection or a
Methods: A Medline search identified 61 studies published between
right-sided hemicolectomy due to the technical problems or a
January 1964 and December 2005 reporting on the results of
suspicion of malignancy because of the distorted tissues.
nonsurgical treatment of appendiceal abscess or phlegmon. The
The traditional management of these patients is non-
results were pooled taking the potential clustering on the study-level
surgical treatment followed by interval appendectomy to
into account. A meta-analysis of the morbidity after immediate
prevent recurrence. The need for interval appendectomy after
surgery compared with that after nonsurgical treatment was per-
a successful nonsurgical treatment has recently been ques-
formed.
tioned as the risk of recurrence is relatively small.2–7
Results: Appendiceal abscess or phlegmon is found in 3.8% (95%
After successful nonsurgical treatment of an appen-
confidence interval (CI), 2.6 – 4.9) of patients with appendicitis.
diceal mass, the true diagnosis is uncertain and an underlying
Nonsurgical treatment fails in 7.2% (CI: 4.0 –10.5). The need for
diagnosis of cancer or Crohn’s disease may be delayed. Some
drainage of an abscess is 19.7% (CI: 11.0 –28.3). Immediate surgery
authors therefore advocate immediate surgery with a right-
is associated with a higher morbidity compared with nonsurgical
sided hemicolectomy if needed, as the definitive treatment
treatment (odds ratio, 3.3; CI: 1.9 –5.6; P ⬍ 0.001). After successful
with acceptable morbidity.8 –12
nonsurgical treatment, a malignant disease is detected in 1.2% (CI:
Recently, the conditions for conservative management
0.6 –1.7) and an important benign disease in 0.7% (CI: 0.2–11.9)
of these patients has changed due to the development of
during follow-up. The risk of recurrence is 7.4% (CI: 3.7–11.1).
computerized tomography (CT) and ultrasound (US), which
Conclusions: The results of this review of mainly retrospective
has improved the diagnosis of enclosed inflammation and
studies support the practice of nonsurgical treatment without interval
made drainage of intra-abdominal abscesses easier. New
appendectomy in patients with appendiceal abscess or phlegmon.
efficient antibiotics have also given new opportunities for
nonsurgical treatment of appendicitis.
(Ann Surg 2007;246: 741–748) This report aims at reviewing the results of nonsurgical
treatment of patients with enclosed appendiceal inflamma-
tion, with emphasis on the success rate, the need for drainage
of abscesses, the risk of undetected serious disease, and the
need for interval appendectomy to prevent recurrence.

From the *Department of Surgery, University Hospital, Linköping, Sweden;
†Department of Surgery, County Hospital Ryhov, Jönköping, Sweden;
and ‡Nordic School of Public Health, Göteborg, Sweden.
Correspondence: Roland Andersson, PhD, MD, Department of Surgery,
County Hospital Ryhov, SE 551 85 Jönköping, Sweden. E-mail: roland.
andersson@lj.se.
Reprints will not be available from the author.
Copyright © 2007 by Lippincott Williams & Wilkins
ISSN: 0003-4932/07/24605-0741
DOI: 10.1097/SLA.0b013e31811f3f9f
MATERIALS AND METHODS
A Medline search with the profile “appendicitis AND
(expectant OR expectantly OR nonsurgical OR nonsurgically
OR conservative OR conservatively OR interval appendec-
tomy OR froid OR mass OR resolving OR phlegmon)”
identified 546 references, written in English, German, French,
Spanish, Italian, Swedish, Norwegian, or Danish, between
January 1964 and December 2005. Based on the title and the

Annals of Surgery • Volume 246, Number 5, November 2007 741

Andersson and Petzold Annals of Surgery • Volume 246, Number 5, November 2007

TABLE 1. Studies Reporting the Proportion of Patients With Appendicitis Who Developed Enclosed Inflammation
No. With No. With Enclosed
Study Definition of Diagnosis Age Appendicitis Inflammation
Jordan et al, 198125 Palpable mass All 806 45 (5.6)
Thomas, 197326 Palpable mass All 501 37 (7.4)
Willemsen et al, 20027 Palpable mass All 2325 233 (10.0)
Gahukamble et al, 199327 Palpable mass Children 1853 66 (3.6)
Gästrin et al, 196928 Palpable mass Children 3191 59 (1.8)
Janik et al, 198029 Palpable mass Children 2589 37 (1.4)
Puri et al, 198130 Palpable mass Children 3677 158 (4.3)
Samuel et al, 200231 Palpable mass Children 740 82 (11.1)
Shipsey and O’Donnell, 198532 Palpable mass Children 834 77 (9.2)
Arnbjörnsson E, 198433 Palpable mass Adults 2214 48 (2.2)
Bradley and Isaacs, 197834 Palpable mass or abscess found at All 2621 68 (2.6)
exploration
Gibeily et al, 200335 Palpable mass or abscess/phlegmon shown All 313 32 (10.2)
by CT and ⬎2 d duration of symptoms
Hsia et al, 199536 Palpable mass and abscess shown by CT/US All 263 18 (6.8)
and ⬎3 d duration of symptoms
Karp et al, 198637 Palpable mass with no signs of peritonitis Children 485 12 (2.5)
and ⬎5 d duration of symptoms
Erdogan et al, 200538 Palpable mass or abscess/phlegmon shown Children 939 40 (4.2)
by US or at exploration
Elmore et al, 198721 Abscess found at exploration Children 233 10 (4.3)
Befeler, 196439 Abscess found at exploration Adults 586 49 (8.4)
Bufo et al, 199840 Abscess/phlegmon shown by CT or US or at Children 190 87 (45.8)
operation
Oliak et al, 200141 Abscess shown by CT Adults 2150 88 (4.1)
Kaminski et al, 200542 Patients with a discharge diagnosis of All 32.938 1.012 (3.1)
appendicitis without appendectomy
Pooled results Clinical diagnosis — 55.593 5.1 (3.5–6.8)
Diagnosis made with CT or US — 3.855 14.2 (⫺1.4 to 29.8)
Overall — 59.448 3.8 (2.6–4.9)
Values inside parentheses indicate percentages.

abstracts, potential reports were selected and the full text was
analyzed to identify original studies that reported results after
nonsurgical treatment for appendiceal phlegmon or abscess.
A total of 74 such original reports were identified. Seven of
these were excluded because of double publishing.4,13–18
Another 5 studies were excluded because they reported re-
sults from less than 10 patients.19 –23 One study from rural
Nigeria was judged not applicable to the western society.24
After these exclusions, there remain 61 studies for analysis.
Definitions
The analysis of the studies is hampered by incom-
plete definitions and lack of information regarding the
diagnosis and treatment, how the patients were selected for
nonsurgical treatment, and the definition of failure of this
treatment. The term “perforated appendicitis” is often used
to describe a palpable appendiceal mass, an appendiceal
phlegmon, or a localized abscess without distinction. In
this review, all these conditions are brought together as
appendicitis with enclosed inflammation. In the studies, the
diagnosis of enclosed inflammation is made by the findings of
a palpable mass at clinical examination before or after anes-
thesia has been given, or by the findings of an inflammatory
mass or a circumscribed abscess by CT, US, or at surgical
exploration of the abdomen. The analyses of the studies are
where possible grouped according to how the diagnosis is done.
Failure of nonsurgical treatment is defined as the pa-
tients who are operated with appendectomy during the same
hospital stay after an initial period of nonsurgical treatment.
The proportion of patients treated with drainage is the pa-
tients who had drainage of an abscess without appendectomy,
either percutaneously or by surgical exploration. The mor-
bidity includes postoperative infectious complications, intes-
tinal fistula, small bowel obstruction, and recurrence after
initially successful nonsurgical management. The length of
hospital stay on the primary hospital admission, at recurrence,
and at elective appendectomy is analyzed separately, if pos-
sible. The risk of recurrence is analyzed from studies that did
not apply interval appendectomy.
Statistical Methods
For all analyses, potential clustering on the study-level
is taken into account via random coefficient (normal distri-
bution) modeling. For confidence intervals (CIs) and statisti-
cal tests of differences, a logistic link is used for binary
outcomes and an identity link is used for continuous out-

742 © 2007 Lippincott Williams & Wilkins

Annals of Surgery • Volume 246, Number 5, November 2007 Nonsurgical Treatment of Appendix Mass

TABLE 2. Results of Nonsurgical Management of Patients With an Enclosed Appendiceal Inflammation and the Numbers
With a Different Definite Diagnosis at Follow-Up, According to How the Diagnosis Was Made
Other Diagnoses at Follow Up
Study Age No. Pts. Drainage of Abscess Treatment Failure Malignant Benign
Palpable mass
Arnbjornsson, 198433 Adults 27 0 (0.0) 6 (22.2) 1 1
Foran et al, 197846 Adults 30 1 (3.3) 3 (10.0) 2 1
Hurme and Nylamo, 19953 Adults 69 0 (0.0) 5 (7.2) 1 3
Lewin et al, 198847 Adults 115 14 (12.2) 3 (2.6) 0 0
Thomas, 197326 Adults 37 2 (5.4) 1 (2.7) 0 0
Bülow et al, 197748 All 148 0 (0.0) 0 (0.0) 5 0
Engkvist, 197149 All 47 15 (31.9) 0 (0.0) 1 2
Gomez-Lorenzo et al, 198750 All 106 4 (3.8) 5 (4.7) 0 0
Hoffmann et al, 198451 All 59 10 (16.9) 2 (3.4) 2 1
Hoffmann et al, 199152 All 28 0 (0.0) 0 (0.0) 1 0
Marya et al, 199353 All 61 0 (0.0) 2 (3.2) 0 0
Mosegaard and Nielsen, 19792 All 79 3 (3.8) 0 (0.0) 4 4
Ein and Shandling, 20054 Children 96 63 (66.0) 5 (0.0) 0 0
Gahukamble et al, 199327 Children 59 2 (3.4) 0 (0.0) 0 0
Gahukamble and Gahukamble, 200054 Children 59 0 (0.0) 5 (8.5) 0 0
Gästrin and Josephson, 196928 Children 29 3 (10.3) 6 (20.7) 0 0
Gierup and Karpe, 197555 Children 52 13 (25.0) 0 (0.0) 1 1
Gillick et al, 200156 Children 411 27 (6.6) 18 (4.4) 0 0
Janik et al, 198029 Children 37 6 (16.2) 1 (2.7) 0 0
Karp et al, 198637 Children 12 0 (0.0) 0 (0.0) 0 0
Powers et al, 198157 Children 48 0 (0.0) 16 (33.3) 0 0
Puri et al, 198130 Children 31 2 (6.5) 0 (0.0) 0 0
Shipsey and O’Donnell, 198532 Children 77 4 (5.2) 4 (5.2) 0 0
Pooled results — — 9.5 (3.3–15.8) 5.8 (2.5–9.2) — —
Drained periappendiceal abscess
vanSonnenberg et al, 198758 All 17 17 (100) 0 (0.0) 0 0
Lasson et al, 200259 All 24 24 (100) 0 (0.0) 1 0
Pooled results — — 100% 0% — —
Abscess or phlegmon diagnosed by imaging
Bagi and Dueholm, 198760 Adults 40 17 (42.5) 3 (7.5) 0 0
Dixon et al, 200361 Adults 237 63 (26.6) 7 (2.9) 3 of 66 2 of 66
Brown et al, 200362 All 68 59 (86.8) 3 (4.4) 0 0
Gibeily et al, 200335 All 17 3 (17.6) 0 (0.0) 0 0
Hsia et al, 199536 All 18 0 (0.0) 10 (55.6) 0 0
Jeffrey et al, 198863 All 61 28 (45.9) 6 (9.8) 1 0
Paull and Bloom, 198264 All 42 32 (76.2) 0 (0.0) 2 0
Tingstedt et al, 20026 All 50 9 (18) 1 (2.0) 3 1
Bufo et al, 199840 Children 41 0 (0.0) 7 (17.1) 0 0
Erdogan et al, 200538 Children 21 0 (0.0) 0 (0.0) 0 0
*Kogut et al, 200144 Children 101 0 (0.0) 22 (21.8) 0 0
Samuel et al, 200231 Children 57 10 (17.5) 9 (15.8) 1 0
Weber et al, 200365 Children 25 6 (24.0) 9 (36.0) 0 0
Pooled results — — 27.6 (12.0–43.2) 13.0 (4.5–21.5)
Flegmone
*Garg et al, 199743 All 40 0 (0.0) 0 (0.0) 0 0
Karaca et al, 20015 Children 17 0 (0.0) 0 (0.0) 0 0
*Kumar and Jain, 200445 All 60 0 (0.0) 0 (0.0) 0 0
Adalla, 199666 All 30 0 (0.0) 3 (10.0) 0 1
Pooled results — — 0% 2.5 (⫺2.4 to 7.3) — —
Palpable mass or preoperatively found abscess
Bradley and Isaacs, 197834 All 55 48 (87.3) 0 (0.0) 0 0
Skoubo-Kristensen and Hvid, 198267 All 193 15 (7.8) 8 (4.1) 2 0
Pooled results — — 47.5 (⫺30.5 to 125.4)% 2.6 (⫺1.4 to 6.5) — —
Pooled results Table 2 — — 19.7 (11.0–28.3) 7.2 (4.0–10.5) 1.2 (0.6–1.7)% 0.7 (0.2–11.9)%
Values inside parentheses indicate percentages.
*Prospective studies.

© 2007 Lippincott Williams & Wilkins 743

Andersson and Petzold Annals of Surgery • Volume 246, Number 5, November 2007

5.1% (CI: 3.5– 6.8)兴, P ⫽ 0.048. It is also more common in

FIGURE 1. Meta-analysis of the morbidity of nonsurgical
compared with that of immediate surgical treatment of con-
tained appendiceal inflammation.
comes. In the analyses, percentages also were considered as
continuous in a few cases ending up with CIs outside 0% to
100%. For the meta-analysis, random-coefficient models
based on the DerSimonian and Laird method are used with
the estimate of heterogeneity being taken from the inverse
variance fixed effect model.
All analyses were done using Stata version 9.2. Given
CIs are on the 95% level and a significant difference is stated
on the 5% level.
RESULTS
Proportion of Patients With Appendicitis Who
Develop Enclosed Appendiceal Inflammation
The proportion of all patients with appendicitis treated
for enclosed inflammation is reported in 20 studies with a
total of 59.448 patients (Table 1). According to these studies,
the proportion of enclosed inflammation is 3.8% (CI: 2.6 –
4.9). Enclosed inflammation is more common in studies
where the diagnosis is based on CT or US than in studies
based on clinical diagnosis 关14.2% (CI: ⫺1.4 to 29.8) vs.
children than in adults as shown by the trend of 8.8% (CI:
0.6 –17.0) in children, 6.5% (CI: 4.2– 8.7) in patients of all
ages, and 4.8% (CI: 1.3– 8.4) in adults (P ⬍ 0.001).
Failure Rate of Nonsurgical Treatment and
Need for Drainage of Abscess
The results of primary nonsurgical treatment for en-
closed appendiceal inflammation are reported in 44 studies,
of which 3 are prospective (Table 2).43– 45 All studies report
a low-failure rate for nonsurgical treatment without appen-
dectomy, 4 of them even without giving antibiotics treatment.
The failure rate for all the studies in Table 2 is 7.2% (CI:
4.0 –10.5). No difference is seen in the failure rate depending
on the definition of the diagnosis, the age of the patients, or
between the prospective and the retrospective studies.
The proportion of patients in need for drainage of an
abscess is strongly related to how the diagnosis is made, with
100% in studies of patients selected because of a drained
abscess, 47.5% (CI: ⫺30.5 to 125.4) in patients with a
“palpable mass or preoperatively found abscess,” 27.6% (CI:
12.0 – 43.2) in patients with an “abscess or phlegmon diag-
nosed by CT or US,” 9.5% (CI: 3.3–15.8) in patients with a
palpable mass and no need for drainage in studies of patients
with a phlegmon diagnosed by CT or US (P ⬍ 0.001). There
is no association between the need for drainage and the
patients’ age.
Immediate Surgical Treatment Compared With
Nonsurgical Treatment
The results of immediate surgical compared with those
of nonsurgical treatment, eventually followed by interval
appendectomy, have been reported in 19 retrospective studies
(Table 4 and Fig. 1). No details are presented about how the
selection between the 2 treatments was done.
In these studies, nonsurgical treatment fails in 7.6%
(CI: 3.2–12.0), which is close to the result of 7.2% (CI:
4.0 –10.5) in the larger analysis in Table 2. The risk of
recurrence is 7.2% (CI: 3.2–11.0), which is slightly lower
than the result of 7.4% (CI: 3.7–11.0) in the analysis of
studies that did not practice interval appendectomy (Table
3). The mean length of stay after immediate surgery
compared with that after nonsurgical treatment was more
than 1 day longer in 7 and more than 1 day shorter in 6

TABLE 3. Recurrence After Nonsurgically Treated Appendicitis in Studies That Did Not Practice Interval Appendectomy
Study Age Diagnosis No. Pts. Follow-Up (y) Recurrences
66
Adalla, 1996 All Phlegmon 30 Mean 1.3 (range 0.5–3) 2 (7.5)
Bagi and Dueholm, 198760 Adults Palpable resistance 40 Median 3.8 (range 0.4–9.3) 3 (7.5)
Ein Shandling, 19964 Children Palpable resistance 10 (range 0.5–13) 1 (10)
Engkvist, 197149 All Palpable resistance 41 (range 3–15) 3 (7.3)
Hoffmann et al, 198451 All Palpable resistance 59 (range 0.5–22) 9 (18.4)
Kaminski Liu, 200542 All Discharge diagnosis of appendicitis 864 Median 4 (range 0.5–12) 39 (5)
without appendectomy
Karaca et al, 20015 All Phlegmon 17 (range 1–7) 0 (0.0)
Pooled results — — 1.061 7.4 (3.7–11.0)
Values inside parentheses indicate percentages, unless specified otherwise.

744 © 2007 Lippincott Williams & Wilkins

 TABLE 4. Results of Immediate Appendectomy and Primary Nonsurgical Treatment
Immediate Appendectomy Conservative Treatment
Authors
No. Hospital Stay Delayed Hospital Recommended
Study Age Pts. Hemicolectomy Morbidity (d) Nos. Failure Recurrence Diagnoses Morbidity Stay (d) Management
Palpable mass
Gomez-Lorenzo All 89 3 infl 48% 12.0 106 9 (8%) 14 (15%) — 13% 9.5 Cons
et al, 198750
Hoffmann et al, All 19 1 infl 53% 8 28 0 (0%) 2 (7%) — 7% 10 Cons
199152
Foran et al, 197846 Adults 13 1 infl, 1 CD 0% 7.5 30 4 (13%) 4 (15%) 2ca,1CD 23% 11 —

© 2007 Lippincott Williams & Wilkins

Arnbjornsson, Adult 21 1 ca, 1 CD 57% 6.5 27 6 (22%) 5 (24%) 1ca,1CD 30% 11 Immediate
198433
Lewin et al, 198847 Adults 95 5 infl, 1 ca 34% 12 98 3 (3%) 1 (1%) — 1 (⫹18)% 11 (⫹9) Cons
Hurme and Nylamo Adults 78 1 infl, 1 CD 28% 69 6 (9%) 0 (0%) 1ca,3CD 0% Cons
et al, 19953
Gästrin and Children 30 — 47% 15 29 6 (21%) 0 (0%) — 0% 11 (⫹6) Cons
Josephson,
196928
Powers et al, Children 100 — 22% 12.3 48 0 (0%) 0 (0%) — 8% 12.3* Cons
198157
Annals of Surgery • Volume 246, Number 5, November 2007

Puri et al, 198130 Children 16 — 69% 32.3 38 0 (0%) 1 (3%) — 24% 19.1 (⫹8.7) Cons
Karp et al, 198637 Children 88 — 6.8% 11.3 12 0 (0%) 1 (8%) — 8 (⫹8)% 12.5 (⫹4.8) Cons
Abscess or phlegmon
Paull et al, 198264 All 17 24% 14.9 42 0 (0%) 2 (5%) 1 ca 17 (⫹10)% 14.7 Cons
Tingstedt et al, All 43 5 infl 63% 7 (⫹2) 50 1 (2%) 4 (8%) 14% 5 (⫹1.5) Cons
20026
Gibeily et al, All 15 — 30% 7.8 17 0 (0%) 1 (6%) — 24% 6.1 (⫹2.5) Cons
200335
Oliak et al, 200141 Adults 67 — 38% 9.0 88 5 (6%) 7 (8%) — 22 (⫹9)% 9.0 Cons
Brown et al, Adults 36 — 67% 14.8 (⫹0.5) 68 3 (4%) 2 (3%) — 19% 9 (⫹1.7) Cons
200362
Bufo et al, 199840 Children 46 — 21% 6.2 41 7 (17%) 0 (0%) — 0 (⫹5)% 4.2 (⫹1.4) Cons
Samuel et al, Children 24 — 17% 4.8 57 9 (16%) 19 (40%) — 33% 10.7 (⫹2.6) Immediate
200231
Weber et al, Children 71 — 28% ⬃7 25 9 (36%) 0 (0%) — 12% ⬃10 Cons
200365
Erdogan et al, Children 18 — 22% 8.7 22 0 (0%) 2 (9%) — 9% 8.9 (⫹2.9) Cons
200538
Pooled results — — — 35.6 (26.9–44.2)% — — 7.6 (3.2–12.0)% 7.2 (3.2–11.0)% — 13.5 (8.8–18.1)% — —
⫹11.0
(5.5–15.4)

The causes for hemicoelctomy and delayed diagnosis are: infl indicates inflammation; CD, Crohn’s disease; and ca, cancer. Morbidity from the interval appendectomy is given within parentheses. Length of hospital stay relates
to the first admittance. Hospital stay for complications or interval appendectomy is given within parentheses.
*Hospital stay including all admittances.

745
Nonsurgical Treatment of Appendix Mass
Andersson and Petzold Annals of Surgery • Volume 246, Number 5, November 2007

studies. The reported data were too sparse for a formal
statistical analysis of the length of stay. Right-sided hemi-
colectomy for suspicion of a malignant disease or for
technical reasons, but where only inflammatory changes
could be found at histopathologic examination, was re-
ported in 17 of a total 493 adult patients. In all but 3 of the
studies, the authors conclude that nonsurgical treatment is
to be recommended.
Immediate surgery is associated with morbidity in
35.6% (CI: 26.9 – 44.2) compared with that in 13.5% (CI:
8.8 –18.1) with nonsurgical treatment and an additional
11.0% (CI: 5.5–15.4) after interval appendectomy (Table 4).
The risk of morbidity after immediate surgery compared with
that after nonsurgical treatment for the individual studies and
a meta-analysis are given in Figure 1. Because of the heter-
ogeneous results between the studies (heterogeneity test, P ⬍
0.001), the meta-analysis is made according to a random
effects model. Surgical treatment is associated with a higher
morbidity with an odds ratio of 3.31 (CI: 1.95–5.61, P ⬍
0.001) according to the meta-analysis. A funnel plot did not
show any signs of publication bias.
Only 3 of 19 studies show a (nonsignificant) lower
morbidity after immediate surgery. In the study by Foran et
al, this is due to the combination of an unusual low morbidity
in the group of patients that had immediate surgery (0%) and
a relatively high proportion of missed diagnoses in the group
that received nonsurgical treatment (10%).46 In the small
study by Karp et al, the slightly higher morbidity after
nonsurgical treatment is caused by only 1 patient who had a
recurrence.37 In the study by Samuel et al, this is due to an
unusual high frequency of recurrence, described as intermit-
tent abdominal pain or signs of a persistent appendiceal
abscess at the planned interval appendectomy.31
The majority of the studies practiced elective interval
appendectomy after successful nonsurgical treatment. The
morbidity of interval appendectomy was reported in 5 studies
with a pooled value of 11.0% (CI: 5.5–15.4; Table 4). The
age of the included patients had no influence on the results.
Primary Nonsurgical Treatment Followed by
Delayed or Interval Appendectomy or Without
Appendectomy
The results of primary nonsurgical treatment followed
by delayed appendectomy during the same hospital stay
compared with those of interval appendectomy are reported
in 2 prospective, randomized trials and 1 retrospective study
(Table 5).43– 45,53 Delayed appendectomy is associated with
morbidity in 18.2% (CI: 7.7–28.7) compared with that in
12.4% (CI: 0.3–24.5) after interval appendectomy. The return
to work took longer time for patients treated with interval
appendectomy, mainly because the patients wanted to have
the planned interval appendectomy done before they were
willing to return to work.
One prospective study randomized patients to primary
nonsurgical treatment followed by delayed or interval or no
appendectomy.45 The group with nonsurgical treatment with-
out appendectomy had the lowest morbidity and the shortest
length of stay. The authors’ conclusion was a recommenda-
tion for nonsurgical treatment with delayed appendectomy in
the 2 former studies, mainly because of the longer time to
return to work with interval appendectomy, and nonsurgical
treatment without appendectomy in the latter study.
The Risk of Missing Other Diagnoses
A total of 31 malignant and 17 benign diseases were
identified during follow-up in 2771 patients (Table 2). Four
of these patients were under the age of 40 years—2 children
had a carcinoid in the appendix, one 26-year-old woman had
ovarian carcinoid, and one 25-year-old patient had gastric
cancer. The remaining patients were all older than 40 years.
A malignant disease was detected during follow-up in
1.2% (CI: 0.6 –1.7). This risk was related to age at diagnosis
with 0.2% (CI: 0.0 – 0.5) in children, 1.8% (CI: 0.9 –2.8) in
studies of all ages, and 1.4% (CI: 0.1– 0 2.7) in adults (P ⬍
0.001). There was no difference in relation to how the
diagnosis was done.

TABLE 5. Comparison of Results of Nonsurgical Treatment With Delayed Versus Interval or No Appendectomy
Authors Conclusion
Study Treatment No. Pts. Morbidity Hospital Stay (d) About Best Treatment
Kumar and Jain, 200445 Nonsurgical ⫹ delayed op 20 30% 21.4 (8.5) Nonsurgical only
Prospective study Patients with No nonsurgical ⫹ interval op 20 0% 14.7 (2.9)*
phlegmon
All ages Nonsurgical only 20 0% 4.9 (1.5)
Garg et al, 199743 Prospective Nonsurgical ⫹ delayed op 20 10% 18.3 Nonsurgical ⫹ delayed op
study patients with palpable
mass
All ages Nonsurgical ⫹ interval op 20 15% 19.3
53
Marya et al, 1993 Retrospective Nonsurgical ⫹ delayed op 32 17% 15 Nonsurgical ⫹ delayed op,
study patients with palpable because of earlier return
mass to work
All ages Nonsurgical ⫹ interval op 29 21% 19.1*
Pooled results Nonsurgical ⫹ delayed op 72 18.2 (7.7–28.7) — —
Nonsurgical ⫹ interval op 69 12.4 (0.3–24.5)
*Length of hospital stay including all admittances.

746 © 2007 Lippincott Williams & Wilkins

Annals of Surgery • Volume 246, Number 5, November 2007
An important benign disease, mainly Crohn’s disease,
was detected in 0.7% (CI: 0.2–11.9) during follow-up after
nonsurgical treatment (Table 2). This risk was related to age
with 0.1% (CI: ⫺0.1 to 0.3) in children, 0.8% (CI: 0.0 –1.6)
in all ages, and 1.5% (CI: 0.1–2.9) in adults (P ⬍ 0.001;
Table 2). There was no difference in relation to how the
diagnosis was done.
The Risk of Recurrence
The risk of recurrence was estimated from 7 studies that
did not apply interval appendectomy. During follow-up, there
were 58 recurrences in a total of 1061 patients (Table 3). The
pooled estimate of the risk of recurrence was 8.9% (CI:
4.4 –13.3). The majority of recurrences occurred within 6
months after the initial hospital stay.
DISCUSSION
Circumscribed appendiceal inflammation is common
and often undiagnosed preoperatively. The diagnosis can be
suspected in patients with a palpable mass or with duration of
symptoms of more than 3 days and is more common in
children, especially in children younger than 5 years.32,41 The
diagnosis is made on clinical grounds in about 5% of patients
with suspected appendicitis, and in about 14% of the patients
if diagnostic imaging is used. This suggests that diagnostic
imaging should be used more frequently in children, in
patients with a long duration of symptoms, and in patients
with a palpable mass.
Immediate surgical treatment of enclosed appendiceal
inflammation is associated with a more than 3-fold increase in
morbidity compared with conservative management, and may
result in an unnecessary ileocecal resection or right-sided
hemicolectomy for technical reasons or suspicion of malig-
nancy in about 3% of the patients.
Nonsurgical treatment is successful in about 93% of the
patients, but may need percutaneous drainage of abscesses in
about 20% of the patients. Nonsurgical treatment is associ-
ated with a lower morbidity and shorter hospital stay com-
pared with immediate appendectomy.
The risk of recurrence after successful nonsurgical
treatment is less than 10% and is often associated with an
appendicolith.4 The recurrence is characterized by a milder
course than the primary attack in most cases.61 Elective
interval appendectomy is associated with morbidity in about
11%. These results do not motivate routine elective interval
appendectomy after successful nonsurgical treatment.
Nonsurgical treatment is associated with a risk of miss-
ing or delaying an underlying cancer diagnosis or Crohn’s
disease in about 2% of the patients. Most of the cancer cases
occur in patients over age 40 years. The risk of missing an
important alternative diagnosis is probably lower if imaging
is used for the diagnosis of enclosed appendiceal inflamma-
tion, but this assumption could not be verified in this review.
This underlines the need of follow-up after nonsurgical treat-
ment, especially in patients over age 40 years. By tradition,
this follow-up consists of colonoscopy or a barium study of
the colon, but a virtual colonoscopy, CT scan, or US is
probably more accurate to detect malignant conditions out-
side the colon or Crohn’s disease.
© 2007 Lippincott Williams & Wilkins
Nonsurgical Treatment of Appendix Mass
The results must be interpreted with caution as they are
mainly based on retrospective case series and only 3 small
prospective randomized studies.
CONCLUSIONS
In patients with suspicion of contained appendiceal
inflammation, based on a palpable mass or long duration of
symptoms, the diagnosis should be confirmed by imaging
techniques. The patient should receive primary nonsurgical
treatment with antibiotics and drainage of abscesses as
needed. After successful nonsurgical treatment, no interval
appendectomy is indicated, but the patient should be in-
formed about the risk of recurrence. The risk of missing
another underlying condition is low, but motivates a fol-
low-up with a colon examination and/or a CT scan or US,
especially in patients above the age of 40 years. However, the
results should be interpreted with caution as it is mainly based
on retrospective studies and only 3 small randomized trials.
REFERENCES
1. Ahmed I, Deakin D, Parsons SL. Appendix mass: do we know how to
treat it? Ann R Coll Surg Engl. 2005;87:191–195.
2. Mosegaard A, Nielsen OS. Interval appendectomy. A retrospective
study. Acta Chir Scand. 1979;145:109 –111.
3. Hurme T, Nylamo E. Conservative versus operative treatment of appen-
dicular abscess. Experience of 147 consecutive patients. Ann Chir
Gynaecol. 1995;84:33–36.
4. Ein SH, Shandling B. Is interval appendectomy necessary after rupture
of an appendiceal mass? J Pediatr Surg. 1996;31:849 – 850.
5. Karaca I, Altintoprak Z, Karkiner A, et al. The management of appen-
diceal mass in children: is interval appendectomy necessary? Surg
Today. 2001;31:675– 677.
6. Tingstedt B, Bexe-Lindskog E, Ekelund M, et al. Management of
appendiceal masses. Eur J Surg. 2002;168:579 –582.
7. Willemsen PJ, Hoorntje LE, Eddes EH, et al. The need for interval
appendectomy after resolution of an appendiceal mass questioned. Dig
Surg. 2002;19:216 –220.
8. Thompson JE, Bennion RS, Schmit PJ, et al. Cecectomy for complicated
appendicitis. J Am Coll Surg. 1994;179:135–138.
9. Vakili C. Operative treatment of appendix mass. Am J Surg. 1976;131:
312–314.
10. Sarkar R, Bennion RS, Schmit PJ, et al. Emergent ileocecectomy for
infection and inflammation. Am Surg. 1997;63:874 – 877.
11. Kovalicik PJ, Simstein NL, Cross GH. Ileocecal masses discovered
unexpectedly at surgery for appendicitis. Am Surg. 1978;44:279 –281.
12. Lane JS, Schmit PJ, Chandler CF, et al. Ileocecectomy is definitive
treatment for advanced appendicitis. Am Surg. 2001;67:1117–1122.
13. Puri P, O’Donnell B. Appendicitis in infancy. J Pediatr Surg. 1978;13:
173–174.
14. Barakos JA, Jeffrey RB, Federle MP, et al. CT in the management of
periappendiceal abscess. Am J Roentgenol. 1986;146:1161–1164.
15. Jeffrey RB, Tolentino CS, Federle MP, et al. Percutaneous drainage of
periappendiceal abscesses: review of 20 patients. Am J Roentgenol.
1987;149:59 – 62.
16. Vargas HI, Averbook A, Stamos MJ. Appendiceal mass: conservative
therapy followed by interval laparoscopic appendectomy. Am Surg.
1994;60:753–758.
17. Yamini D, Vargas H, Bongard F, et al. Perforated appendicitis: is it truly
a surgical urgency? Am Surg. 1998;64:970 –975.
18. Oliak D, Yamini D, Udani VM, et al. Nonoperative management of
perforated appendicitis without periappendiceal mass. Am J Surg. 2000;
179:177–181.
19. Handa N, Muramori K, Taguchi S. Early appendectomy versus an
interval appendectomy for appendiceal abscess in children. Fukuoka
Igaku Zasshi. 1997;88:389 –394.
20. Nunez D, Huber JS, Yrizarry JM, et al. Nonsurgical drainage of
appendiceal abscesses. Am J Roentgenol. 1986;146:587–589.
747
Andersson and Petzold
21. Elmore JR, Dibbins AW, Curci MR. The treatment of complicated
appendicitis in children. What is the gold standard? Arch Surg. 1987;
122:424 – 427.
22. Friedell ML, Perez-Izquierdo M. Is there a role for interval appendec-
tomy in the management of acute appendicitis? Am Surg. 2000;66:
1158 –1162.
23. De U, Ghosh S. Acute appendicectomy for appendicular mass: a study
of 87 patients. Ceylon Med J. 2002;47:117–118.
24. Okafor PI, Orakwe JC, Chianakwana GU. Management of appendiceal
masses in a peripheral hospital in Nigeria: review of thirty cases. World
J Surg. 2003;27:800 – 803.
25. Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpable mass.
Ann Surg. 1981;193:227–229.
26. Thomas DR. Conservative management of the appendix mass. Surgery.
1973;73:677– 680.
27. Gahukamble DB, Khamage AS, Gahukamble LD. Management of
appendicular mass in children. Ann Trop Paediatr. 1993;13:365–367.
28. Gästrin U, Josephson S. Appendiceal abscess—acute appendectomy or
conservative treatment? Acta Chir Scand. 1969;135:539 –542.
29. Janik JS, Ein SH, Shandling B, et al. Nonsurgical management of
appendiceal mass in late presenting children. J Pediatr Surg. 1980;15:
574 –576.
30. Puri P, Boyd E, Guiney EJ, et al. Appendix mass in the very young child.
J Pediatr Surg. 1981;16:55–57.
31. Samuel M, Hosie G, Holmes K. Prospective evaluation of nonsurgical
versus surgical management of appendiceal mass. J Pediatr Surg.
2002;37:882– 886.
32. Shipsey MR, O’Donnell B. Conservative management of appendix mass
in children. Ann R Coll Surg Engl. 1985;67:23–24.
33. Arnbjörnsson E. Management of appendiceal abscess. Curr Surg. 1984;
41:4 –9.
34. Bradley EL, Isaacs J. Appendiceal abscess revisited. Arch Surg. 1978;
113:130 –132.
35. Gibeily GJ, Ross MN, Manning DB, et al. Late-presenting appendicitis:
a laparoscopic approach to a complicated problem. Surg Endosc. 2003;
17:725–729.
36. Hsia CY, Chiu JH, Lui WY. Elective interval laparoscopic management
for periappendiceal abscess. Zhonghua Yi Xue Za Zhi (Taipei). 1995;56:
52–57.
37. Karp MP, Caldarola VA, Cooney DR, et al. The avoidable excesses in
the management of perforated appendicitis in children. J Pediatr Surg.
1986;21:506 –510.
38. Erdogan D, Karaman I, Narci A, et al. Comparison of two methods for
the management of appendicular mass in children. Pediatr Surg Int.
2005;21:81– 83.
39. Befeler D. Interval appendectomy in the laparoscopic era. J Gastrointest
Surg. 2000;4:223.
40. Bufo AJ, Shah RS, Li MH, et al. Interval appendectomy for perforated
appendicitis in children. J Laparoendosc Adv Surg Tech A. 1998;8:209 –
214.
41. Oliak D, Yamini D, Udani VM, et al. Initial nonoperative management
for periappendiceal abscess. Dis Colon Rectum. 2001;44:936 –941.
42. Kaminski A, Liu IL, Applebaum H, et al. Routine interval appendec-
tomy is not justified after initial nonoperative treatment of acute appen-
dicitis. Arch Surg. 2005;140:897–901.
43. Garg P, Dass BK, Bansal AR, et al. Comparative evaluation of conser-
vative management versus early surgical intervention in appendicular
mass—a clinical study. J Indian Med Assoc. 1997;95:179 –180.
44. Kogut KA, Blakely ML, Schropp KP, et al. The association of elevated
748
Annals of Surgery • Volume 246, Number 5, November 2007
percent bands on admission with failure and complications of interval
appendectomy. J Pediatr Surg. 2001;36:165–168.
45. Kumar S, Jain S. Treatment of appendiceal mass: prospective, random-
ized clinical trial. Indian J Gastroenterol. 2004;23:165–167.
46. Foran B, Berne TV, Rosoff L. Management of the appendiceal mass.
Arch Surg. 1978;113:1144 –1145.
47. Lewin J, Fenyö G, Engström L. Treatment of appendiceal abscess. Acta
Chir Scand. 1988;154:123–125.
48. Bülow S, Christoffersen I, Olsen JH. Appendektomi á froid. Ugeskr
Laeger. 1977;139:1120 –1122.
49. Engkvist O. Appendectomy a froid—a superfluous routine operation?
Acta Chir Scand. 1971;137:797– 800.
50. Gomez-Lorenzo E, Dominguez Sanchez J, Octavio de Toledo JM, et al.
Plastron apendicular: estudio comparativo de la apendicectomia de
urgencia con el tratamiento conservador (195 casos). Rev Esp Enferm
Apar Dig. 1987;71:151–155.
51. Hoffmann J, Lindhard A, Jensen HE. Appendix mass: conservative
management without interval appendectomy. Am J Surg. 1984;148:379 –
382.
52. Hoffmann J, Rolff M, Lomborg V, et al. Ultraconservative management
of appendiceal abscess. J R Coll Surg Edinb. 1991;36:18 –20.
53. Marya SK, Garg P, Singh M, et al. Is a long delay necessary before
appendectomy after appendiceal mass formation? A preliminary report.
Can J Surg. 1993;36:268 –270.
54. Gahukamble DB, Gahukamble LD. Surgical and pathological basis for
interval appendicectomy after resolution of appendicular mass in chil-
dren. J Pediatr Surg. 2000;35:424 – 427.
55. Gierup J, Karpe B. Aspects on appendiceal abscess in children with
special reference to delayed appendectomy. Acta Chir Scand. 1975;141:
801– 803.
56. Gillick J, Velayudham M, Puri P. Conservative management of appendix
mass in children. Br J Surg. 2001;88:1539 –1542.
57. Powers RJ, Andrassy RJ, Brennan LP, et al. Alternate approach to the
management of acute perforating appendicitis in children. Surg Gynecol
Obstet. 1981;152:473– 475.
58. vanSonnenberg E, Wittich GR, Casola G, et al. Periappendiceal ab-
scesses: percutaneous drainage. Radiology. 1987;163:23–26.
59. Lasson A, Lundagards J, Loren I, et al. Appendiceal abscesses: primary
percutaneous drainage and selective interval appendicectomy. Eur
J Surg. 2002;168:264 –269.
60. Bagi P, Dueholm S. Nonoperative management of the ultrasonically
evaluated appendiceal mass. Surgery. 1987;101:602– 605.
61. Dixon MR, Haukoos JS, Park IU, et al. An assessment of the severity of
recurrent appendicitis. Am J Surg. 2003;186:718 –722.
62. Brown CV, Abrishami M, Muller M, et al. Appendiceal abscess: imme-
diate operation or percutaneous drainage? Am Surg. 2003;69:829 – 832.
63. Jeffrey RB, Federle MP, Tolentino CS. Periappendiceal inflammatory
masses: CT-directed management and clinical outcome in 70 patients.
Radiology. 1988;167:13–16.
64. Paull DL, Bloom GP. Appendiceal abscess. Arch Surg. 1982;117:1017–
1019.
65. Weber TR, Keller MA, Bower RJ, et al. Is delayed operative treatment
worth the trouble with perforated appendicitis is children? Am J Surg.
2003;186:685– 688.
66. Adalla SA. Appendiceal mass: interval appendicectomy should not be
the rule. Br J Clin Pract. 1996;50:168 –169.
67. Skoubo-Kristensen E, Hvid I. The appendiceal mass: results of conser-
vative management. Ann Surg. 1982;196:584 –587.
© 2007 Lippincott Williams & Wilkins