Available via license: CC BY 4.0
Content may be subject to copyright.
Page 1/13
Appendiceal Phlegmon as an intraoperative nding:
A retrospective analysis
Danny Conde
Hospital Universitario Mederi
Lina Rodríguez
Universidad de los Andes
David Venegas
Universidad del Rosario
Carlos Rey
Hospital Universitario Mederi
Ricardo E. Núñez-Rocha
Universidad de los Andes
Ricardo Nassar
Universidad de los Andes
Marco Vanegas
Universidad del Rosario
Catalina Monsalve
Universidad del Rosario
Pablo Pinzón
Hospital Universitario Mederi
Felipe Girón ( felipegiron15@gmail.com )
Universidad del Rosario
Research Article
Keywords: Appendicitis, appendiceal phlegmon, expertise, experience, acute abdomen
Posted Date: March 23rd, 2023
DOI: https://doi.org/10.21203/rs.3.rs-2640598/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
Page 2/13
Abstract
Background
Emergency procedures due to acute surgical abdomen correspond to a great part of emergency surgeries.
Appendicitis is the most common abdominal surgical emergency in the world. Intraoperative ndings can
represent a challenging scenario for the surgical team and its decisions. Appendiceal phlegmon/plastron
presents in 3.8-7% of patients with appendicitis and can be considered as a challenging surgical scenario
where expertise may gain a fundamental value in terms of decision-making process. Therefore, we
present clinical courses and outcomes of 40 patients that underwent emergency surgery with these
intraoperative ndings from 2016 to 2018.
Methods
Retrospective study with a prospective database in which we described patients with emergent need for
surgical procedure due to peritoneal signs with surgical ndings of appendiceal phlegmon. Multivariate
analysis was performed to prove the relationship between obesity, diabetes, and surgeon experience with
any complication and colonic resection.
Results
40 patients underwent surgical procedure due to peritoneal signs with intraoperative ndings of
appendiceal phlegmon. Mean age was 51.9 (± 20.4). Procedures were performed based on intraoperative
ndings being appendectomy the most frequent (85%), followed by right hemicolectomy (10%) and
partial cecum resection (5%). Three patients required reintervention. No mortalities were documented.
Surgeries performed by junior surgeons have a higher probability to require colonic resections (P = 0.05,
OR 4.05 ,95% CI), also obesity is associated with complications (P = 0.04, OR 1.44, 95% CI).
Conclusion
Finding of appendiceal phlegmon constitute a challenging surgical scenario in daily practice. Our
patient’s complication rates are similar to those described in literature despite its emergent
circumstances. Surgeons' expertise appears to be associated with outcomes. Further studies are needed
to give clear recommendations.
Background
Acute surgical abdomen corresponds to a great part of emergency surgeries (1). Acute abdominal pain
can represent a challenging scenario to the surgical team and its decisions (2). Acute abdomen
encompasses a great number of pathologies that could require immediate surgical procedures, ranging
Page 3/13
from inammatory diseases to neoplasms, and vascular problems [1, 2]. Given this broad spectrum,
clinical presentation represents a challenge for the surgeon when faced with a patient with peritoneal
signs that could lead to different therapeutic or diagnostic approaches that may delay the appropriate
management. (1–3).
In general terms, acute appendicitis is the most common abdominal surgical emergency with a
prevalence between 14–88% (depending on the patient's age), followed by bowel obstruction (5.5–45%),
and benign biliary tract disease (13–25%) [1]. Appendiceal phlegmon, secondary to an inammatory
process on the appendix, presents in 2–10% of patients with appendicitis (4). Traditionally, patients with
appendiceal phlegmon have been managed with non-surgical treatment followed by interval
appendectomy to prevent recurrence (5). Nevertheless, a challenging surgical scenario takes place once
patients present with peritoneal signs and underwent surgical procedures with an intraoperative nding
of appendiceal phlegmon. Indeed, this happens since there is no consensus on appendiceal phlegmon
management as an incidental intraoperative nding in the context of emergency surgery (6–8).
Among surgical approaches, laparoscopic appendectomy is considered the gold standard management
for appendicitis, regardless of if it presents as an uncomplicated acute appendicitis case or an
appendicular phlegmon with peritoneal signs (9). Superiority has been determined in terms of decrease of
nancial burden rates, readmission rate, ICU stay, overall mortality, and early diagnosis of underlying
pathologies compared with open approaches (9,10). Despite the clear importance of laparoscopy in the
management of emergency appendectomy, the challenge for our patients relies on the fact that diagnosis
was made during surgery as an intraoperative nding. At this time, the surgeon is faced with a
therapeutic challenge and must make decisions in a matter of seconds that may impact directly on
patient outcomes, allowing the surgeon’s expertise as an important tool in the decision-making process.
Throughout surgical practice, different complex and challenging scenarios may be presented to the
surgical team (11). These situations constitute a cornerstone in the continuous growth and expertise
paradigm of the surgeon, contributing tools to enhance and enrich their progress (11). Hence, surgeons
with richer experiences have a wider range of tools to use when making on-the-spot decisions when
facing challenging scenarios, which may lead to better performance and fewer mistakes over time
(11,12). Therefore, herein we present a retrospective analysis of 40 patients who underwent emergency
surgery due to peritoneal signs with an incidental intraoperative nding of appendicular phlegmon.
Likewise, we relate their outcomes to the level of expertise of the surgical team.
Methods
After Institutional Review Board approval (Research Ethics Committee) at Hospital Universitario Mayor
Mederi, all patients undergoing surgical management for acute abdomen who had appendiceal
phlegmon as an incidental intraoperative nding between January 2016 and December 2018, were
included. Only patients over 18 years old were accepted into the study. Exclusion criteria involved patients
with incomplete clinical history, previous conservative management, or patients who were intervened
Page 4/13
extra-institutionally. Preoperative data included patients' demographics and clinical history. The type of
procedure performed, and its approach was included in the intraoperative data. Postoperative data
included early and late complications. According to institutional protocol, all patients received at least 5
days of antibiotic postoperative care.
Descriptive statistics of all study parameters were provided. Data were analyzed using IBM SPSS
Statistics 25 software. Continuous data were summarized by their ni mean, standard deviation, median,
minimum, and maximum. Categorical data were summarized by their frequency and proportion. Bivariate
analysis between qualitative and quantitative variables was performed using the Mann-Whitney test or t-
test for independent samples. For associations between categorical variables, odds ratios with 95%
condence intervals were provided. The surgeon’s expertise cut-off was considered as 5 years of
experience, we accepted a signicant p-value ≤ 0.05.
Results
From January 2016 to December 2018 a total of 48 patients with peritoneal signs underwent surgical
management with intraoperative ndings of appendiceal phlegmon. 8 patients were excluded due to
previous extra-institutional management. The mean age of patients was 51.9 (± 20.4) years old with a
mean BMI of 26.8 (± 4.5) Kg/m² (Table1). 7.5% of all patients had a history of type II diabetes mellitus,
25 patients had a history of abdominal surgery, 20% had BMI > 30 Kg/m² and 5% were active smokers
(Table2). All patients had blood chemistry laboratories as an initial emergency department approach and
24 patients required additional diagnostic imagenological tests (Table 3). All patients underwent surgery,
and the approach was selected by the surgical team. Procedures were performed based on intraoperative
ndings being appendectomy the most frequent (85%), followed by right hemicolectomy (10%) and
partial cecum resection (5%) (Table 4).
Page 5/13
Table 3. Diagnostic Criteria
Diagnostic Criteria n %
Clinical 16 40
CT 21 52,5
MRI 3 7,5
Mean Standard Deviation
Leucocytes 13423,7 5701,8
Neutrophils 10389,6 5257,6
Table 4. Procedure and Surgical Approach
Page 6/13
Variables n %
Surgical Approach Infraumbilical midline laparotomy 24 60
Mc Burney 4 10
Midline laparotomy 7 17,5
Rockey-Davis 2 5
Laparoscopic 2 5
Hockey stick 1 2,5
Procedure performed Appendectomy 34 85
Right Hemicolectomy 4 10
Partial Cecum Resection 2 5
Table. 5 Complications
n %
Superficial/ Deep Incisional SSI* 2 5
Ileus 6 15
Organ space SSI* 2 5
Evisceration 1 2,5
Anastomotic Leak 1 2,5
Organ space SSI* + Evisceration 1 2,5
None 27 67,5
*Surgical Site Infection (SSI)
Page 7/13
Page 8/13
Early complications were reported if they occurred within 30 days. Most patients had an uneventful
follow-up (67.5%). 6 patients presented postoperative ileus that was managed successfully with
hydration, early ambulation, and nasogastric tube placement. Reinterventions were required in 3 cases,
including one anastomotic leak, with no need for additional procedures (Table 5). No mortality cases
were reported. Surgical teams were divided in two according to surgeon experience, considering 5 years
of experience as a cut-off point. 70% of procedures were performed by senior surgeons and four patients
presented ileus as the only postoperative complication in this group. Three patients managed by junior
attendings required reintervention, all with uneventful postoperative follow-up (Table 6). In the bivariate
analysis, diabetes, obesity, and surgeon experience showed p-values < 0.05. ORs were calculated (Table
7).
In the bivariate analysis, diabetes, obesity, and surgeon experience showed p-values < 0.05. Our study
found that postoperative complications are related to past history of diabetes with a signicant statistical
value (P = 0.04, 95% CI, OR 1.44). In addition, if the initial surgery was performed by a junior surgeon, our
analysis reports a four times more chance of requiring colonic resections (P = 0.05, 95% CI, OR 4,05).
Discussion
Acute abdomen represents 5–10% of the visits to the emergency room, with acute appendicitis being the
most common abdominal surgical emergency in the world, with a prevalence that can be up to 90%
among all causes of acute abdominal pain (1). Appendiceal phlegmon presents in up to 10% of patients
with appendicitis (4). Early appendectomy and conservative management with or without interval
appendectomy are both considered feasible options (5,13). Nevertheless, intraoperative incidental nding
of appendiceal phlegmon in patients with peritoneal signs constitutes a challenging scenario that
requires immediate solutions that impact patients’ outcomes and life quality.
Evidence for optimal appendiceal phlegmon management as an intraoperative incidental nding is
scarce, with most of the studies focusing in the management of a before-surgery diagnosed appendiceal
phlegmon (14,15). Even though the ideal approach of these patients is still unclear because of recurrence
rates, conservative management with or without interval appendectomy appears to be more feasible and
secure, considering possible complications as turning points while selecting adequate management (16–
18). Nonetheless, in our study conservative management was not possible due to the nature of its
detection as an intraoperative nding.
In terms of selecting the appropriate surgical approach, laparoscopic surgery has seemingly improved
outcomes making it a feasible and safe surgical approach (9,10). In our study, the surgical management
approach was selected following the rst surgeon's preference, being infraumbilical laparotomy the most
common (60%), only 2 cases were managed laparoscopically due to the nature of the surgical indication
and in alignment to institutional guidelines.
Complication rate observed in our patients was 32,5%, similar to the rate described by Cheng et al (4) in a
Cochrane review where they report an overall complications rate of 30% in the early appendectomy group.
Page 9/13
The majority of them were classied as grade I and II (ileus and supercial surgical site infection)
according to Clavien-Dindo’s classication, as found in our patients (19). Ahmed et al (20) suggest that
there must be a strict following process for patients in order to exclude the presence of hidden
pathologies like colitis and even malignancies, especially in elderly patients (20,21). Nonetheless, in our
population, no appendiceal, colonic neoplasms, or any other hidden pathologies were documented in
pathology reports.
Complex and infrequent scenarios in the surgical room demand a fast-paced decision-making process in
which expertise and experience gain relevance due to their relation to one's ability to adequately manage
unexpected ndings (22–24). Satkunasivam et al (23) in a Canadian retrospective cohort study of
1.159.676 patients undergoing emergent and elective procedures showed lower rates of 30-day mortality,
readmission, and complications in patients treated by older surgeons compared with younger. This is
similar to the results found in our population, where we documented a 32,5% overall rate of complications
with junior surgeons having more severe ones, classied as type IIIb (Clavien-Dindo Classication) than
senior surgeons. Additionally, we found an association between expertise and complications showing
complication rates are 4,05 IC (3,5–6,9) (P 0,04) times more frequent in junior surgeons, similar to those
reported by Mentula et al (8) where immediate laparoscopic surgery outperformed conservative
management because almost all the procedures were performed by a single experienced surgeon with
expertise in acute surgical conditions. Although our conclusions do not necessarily establish a causal
relationship, severe complications are more frequently documented in inexperienced surgeons.
Exposure to challenging situations, such as acute abdomens and surgical practices can vary broadly
among surgeons (25). Outcomes in the management of appendiceal phlegmon in the context of acute
abdomen may be altered by surgeons’ expertise. Cristancho et al (24) proposed a model of intraoperative
decision-making that consists of 3 steps: Assessing the situation and making an ideal plan, a
reconciliation cycle where the ndings are contrasted to what was expected, and implementing the
planned course of action in the previous step (24). In spite of the demanding situation faced by our
surgical teams, complication rates were similar to those reported in other studies in which surgical
management was preferred by surgeons like those presented by Cheng et al (4). Thus, although the
management of appendiceal phlegmon is debated and adequately described, there is no established
consensus in the case of appendiceal phlegmon as an intraoperative incidental nding. Therefore, it will
depend on the surgical criteria and the individual characteristics of each patient to dene the appropriate
approaches.
Among the limitations of this study are the relatively small number of patients, its retrospective nature,
the lack of previous studies to compare our results in terms of expertise and experience of the surgical
team. Further prospective studies are needed to validate our results.
Conclusion
Page 10/13
Surgery in patients with peritoneal signs in the emergency context leads to increased challenges. We
found that in patients who underwent surgery and had an incidental intraoperative nding of appendiceal
phlegmon, emergency laparotomy followed by appendectomy had good outcomes, with no increase of
complications. Our study suggests that surgery performed by junior surgeons has a higher probability to
require colonic resections, and patients with any grade of obesity have an increased risk to present any
complication. Further prospective studies are needed to conrm our results.
Declarations
Ethical approval: All procedures performed involving human participants were in accordance with the
ethical standards of the Institutional Review Board (Research Ethics Committee) at Hospital Universitario
Mayor Mederi approval.
Ethical guidelines: All procedures were in accordance with the 1964 Helsinki Declaration and its later
amendments. Also, in accordance with the current legislation on research Res. 008430-1993 and Res.
2378-2008 (Colombia) and the International Committee of Medical Journal Editors (ICMJE) were ensured
under our Ethics and Research Institutional Committee (IRB) approval. Informed consent was lled out as
required for the execution of this study.
Consent for publication: Consent for publication was obtained in order to publish this manuscript.
Availability of data and materials:The dataset generated is available from the corresponding author
upon reasonable request.
Competing interests:None.
Funding:This research did not receive any specic grant from funding agencies in the public,
commercial, or not-for-prot sectors.
Acknowledgements:None.
CRediT authorship contribution statement:
Danny Conde: Study conception and design, interpretation of data, drafting of manuscript, critical
revision of manuscript.
Lina Rodríguez: Study design, analysis and interpretation of data, drafting of manuscript, critical revision
of manuscript.
David Venegas: Study conception and design, acquisition of data, analysis and interpretation of data,
drafting of manuscript, critical revision of manuscript.
Carlos Rey: Study design, analysis and interpretation of data, drafting of manuscript, critical revision of
manuscript.
Page 11/13
Ricardo Núñez: Acquisition of data, drafting of manuscript, critical revision of manuscript.
Ricardo Nassar: Study conception, critical revision of manuscript.
Marco Venegas: Study design, drafting of manuscript, critical revision of manuscript.
Catalina Monsalve: Acquisition of data, drafting of manuscript, critical revision of manuscript.
Pablo Pinzon: Study conception and design, Analysis and interpretation of data and Critical revision of
manuscript
Felipe Girón Arango: Study conception and design, acquisition of data, analysis and interpretation of
data, drafting of manuscript, critical revision of manuscript.
References
1. Takayama Y, Kaneoka Y, Maeda A, Fukami Y, Takahashi T, Uji M. Etiologies and outcomes of
emergency surgery for acute abdominal pain: an audit of 1456 cases in a single center. Eur J Trauma
Emerg Surg Off Publ Eur Trauma Soc. 2020 Apr;46(2):363–9.
2. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the
emergency department. Int J Gen Med. 2012 Sep 26;5:789–97.
3. Altamimi A, Hassanain M, Nouh T, Ateeq K, Aljiffry M, Nawawi A, et al. Predictors of morbidity and
mortality post emergency abdominal surgery: A national study. Saudi J Gastroenterol Off J Saudi
Gastroenterol Assoc. 2018 Oct;24(5):282–8.
4. Cheng Y, Xiong X, Lu J, Wu S, Zhou R, Cheng N. Early versus delayed appendicectomy for
appendiceal phlegmon or abscess. Cochrane Database Syst Rev. 2017 Jun 2;6:CD011670.
5. Al-Kurd A, Mizrahi I, Siam B, Kupietzky A, Hiller N, Beglaibter N, et al. Outcomes of interval
appendectomy in comparison with appendectomy for acute appendicitis. J Surg Res. 2018
May;225:90–4.
. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative
treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery.
2010 Jun;147(6):818–29.
7. Ahmed I, Deakin D, Parsons SL. Appendix mass: do we know how to treat it? Ann R Coll Surg Engl.
2005 May;87(3):191–5.
. Mentula P, Sammalkorpi H, Leppäniemi A. Laparoscopic Surgery or Conservative Treatment for
Appendiceal Abscess in Adults? A Randomized Controlled Trial. Ann Surg. 2015 Aug;262(2):237–42.
9. Tiwari MM, Reynoso JF, Tsang AW, Oleynikov D. Comparison of outcomes of laparoscopic and open
appendectomy in management of uncomplicated and complicated appendicitis. Ann Surg. 2011
Dec;254(6):927–32.
Page 12/13
10. Towgh S, Chen F, Mason R, Katkhouda N, Chan L, Berne T. Laparoscopic appendectomy
signicantly reduces length of stay for perforated appendicitis. Surg Endosc. 2006 Mar;20(3):495–9.
11. Managing complexity in the operating room: a group interview study | BMC Health Services Research
| Full Text [Internet]. [cited 2022 Sep 4]. Available from:
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05192-8
12. Sachdeva AK. Acquiring and maintaining lifelong expertise in surgery. Surgery. 2020
May;167(5):787–92.
13. Aranda-Narváez JM, González-Sánchez AJ, Marín-Camero N, Montiel-Casado C, López-Ruiz P,
Sánchez-Pérez B, et al. Conservative approach versus urgent appendectomy in surgical management
of acute appendicitis with abscess or phlegmon. Rev Espanola Enfermedades Dig Organo Of Soc
Espanola Patol Dig. 2010 Nov;102(11):648–52.
14. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a
systematic review and meta-analysis. Ann Surg. 2007 Nov;246(5):741–8.
15. Calvert CE, Tracy S, Zhou J, Graham D, Lebowitz M, Dennett KV, et al. Treatment of Perforated
Appendicitis in Children: Focus on Phlegmon. Am Surg. 2014 Mar 1;80(3):314–6.
1. Willemsen PJ, Hoorntje LE, Eddes EHH, Ploeg RJ. The need for interval appendectomy after
resolution of an appendiceal mass questioned. Dig Surg. 2002;19(3):216–20; discussion 221.
17. Hurme T, Nylamo E. Conservative versus operative treatment of appendicular abscess. Experience of
147 consecutive patients. Ann Chir Gynaecol. 1995;84(1):33–6.
1. Mosegaard A, Nielsen OS. Interval appendectomy. A retrospective study. Acta Chir Scand.
1979;145(2):109–11.
19. Kumar S, Jain S. Treatment of appendiceal mass: prospective, randomized clinical trial. Indian J
Gastroenterol Off J Indian Soc Gastroenterol. 2004 Oct;23(5):165–7.
20. Ahmed A, Feroz SH, Dominic JL, Muralidharan A, Thirunavukarasu P. Is Emergency Appendicectomy
Better Than Elective Appendicectomy for the Treatment of Appendiceal Phlegmon?: A Review.
Cureus. 12(12):e12045.
21. Deelder JD, Richir MC, Schoorl T, Schreurs WH. How to treat an appendiceal inammatory mass:
operatively or nonoperatively? J Gastrointest Surg Off J Soc Surg Aliment Tract. 2014
Apr;18(4):641–5.
22. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical
experience and quality of health care. Ann Intern Med. 2005 Feb 15;142(4):260–73.
23. Satkunasivam R, Klaassen Z, Ravi B, Fok KH, Menser T, Kash B, et al. Relation between surgeon age
and postoperative outcomes: a population-based cohort study. CMAJ Can Med Assoc J J Assoc
Medicale Can. 2020 Apr 14;192(15):E385–92.
24. Cristancho SM, Vanstone M, Lingard L, LeBel ME, Ott M. When surgeons face intraoperative
challenges: a naturalistic model of surgical decision making. Am J Surg. 2013 Feb;205(2):156–62.
Page 13/13
25. Apramian T, Cristancho S, Watling C, Ott M, Lingard L. “They Have to Adapt to Learn”: Surgeons’
Perspectives on the Role of Procedural Variation in Surgical Education. J Surg Educ. 2016
Apr;73(2):339–47.
Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.
Highlights.docx
