Contemporary Management Strategies for Appendicular Abscess: A Narrative Review

Kumar Hari Rajah

Department of Surgery, Taylors University School of medicine and Health Science,47500 Selangor, Malaysia

*Corresponding Author’s Email: kharirajah@yahoo.com.my

Abstract

Introduction: Appendicular abscess is a complication arising from the perforation of the appendix, occurring in approximately 10% of acute appendicitis cases. It is diagnosed through clinical examination, leucocytosis, and imaging techniques such as ultrasound or computed tomography (CT). Management traditionally involves a conservative approach, including intravenous fluids, antibiotics, and percutaneous drainage. However, with advancements in laparoscopic surgery, immediate appendectomy has gained preference, while interval appendectomy is now reserved for patients with recurrent symptoms. Methods: This narrative review explores the various management strategies for appendicular abscess. Relevant literature was reviewed to assess the effectiveness of conservative treatment, percutaneous drainage, and surgical interventions, including laparoscopic and interval appendectomy. Results: Conservative management remains the first-line treatment for appendicular abscess, focusing on infection control and symptom relief. The shift towards laparoscopic appendectomy has been observed, with evidence supporting its safety and feasibility. Interval appendectomy, once routinely performed, is now limited to cases with recurrent symptoms, reflecting a change in clinical practice. Conclusion: The management of appendicular abscess has evolved over time, with a growing preference for early laparoscopic intervention in select cases. While conservative treatment remains a viable approach, interval appendectomy is no longer routine. Further studies are needed to refine treatment protocols and optimize patient outcomes.

Keywords: Appendectomy; Appendicular Abscess; Appendicular Mass; Complicated Appendicitis; Laparoscopic Appendectomy; Percutaneous Drainage

Introduction

An appendicular abscess typically results from the perforation of the appendix and falls under the broader term "appendicular mass". This term describes a clinical spectrum arising from an appendix perforation, leading to the formation of a mass in the right iliac fossa. The components of this mass include the cecum, terminal ileum, omentum, and the perforated appendix. An appendicular mass can present as either a phlegmon or an abscess (Garba & Ahmed, 2008). Diagnosis of an appendicular abscess or mass involves a thorough clinical examination of the abdomen, which may reveal a palpable mass in the right iliac fossa. Additional diagnostic methods include blood investigations, which may indicate leucocytosis or elevated C-reactive protein levels, along with imaging techniques such as ultrasound or computerised tomography. The management of an appendicular abscess is categorised into conservative treatment and surgical intervention. In stable patients, conservative management includes intravenous antibiotic therapy and percutaneous drainage of the abscess. However, in unstable patients, an immediate appendectomy is required, followed by intravenous antibiotic administration. For stable patients, immediate appendectomy is generally discouraged due to the increased risk of complications such as postoperative abscess formation and enterocutaneous fistula development (Ahmed et al., 2005; Becker, Fichtner-Feigl, & Schilling, 2018; Tannoury & Abboud, 2013).

Traditionally, an interval appendectomy was performed eight weeks after conservative treatment. However, it is no longer considered a routine necessity due to the low recurrence rates. For older patients (above the age of 40), performing computerised tomography or colonoscopy is recommended to identify any underlying pathology in the colon and avoid missing lesions such as malignancies (Demetrashvili et al., 2019). Interval appendectomy can be performed using either an open or laparoscopic approach. However, laparoscopic interval appendectomy is associated with better outcomes compared to open interval appendectomy (Rashid et al., 2013).

The World Society of Emergency Surgeons (WSES), in their guidelines for the management and treatment of acute appendicitis, recommends that patients with an appendicular mass or abscess can be managed with an immediate laparoscopic appendectomy. However, when laparoscopic surgical services are unavailable, conservative treatment with intravenous antibiotics and percutaneous drainage of the abscess may be utilised (Di Saverio et al., 2020). Similarly, the European Association of Emergency Surgeons (EAES), in their guidelines for the diagnosis and management of acute appendicitis, advocates for conservative or non-operative treatment for patients presenting with an appendicular mass or abscess (Gorter et al., 2016).

The necessity of performing an interval appendectomy is now being questioned due to the low recurrence rates of right iliac fossa pain. Patients below the age of 40 are not required to undergo elective interval appendectomy. However, for patients above the age of 40, further investigation using imaging modalities such as computerised tomography (CT) and colonoscopy is recommended (Koirala et al., 2016; Panahi et al., 2020).

There is no current consensus in the management of appendicular abscess; therefore, this review article examines its diagnosis and management. The role of percutaneous drainage of appendicular abscess and immediate surgery is evaluated. This study conducted a literature review using PUBMED, the Cochrane database of systemic reviews, Google scholar and semantic scholar looking for randomised control trials, non-randomised trials, observational and cohort studies, clinical reviews, systemic reviews, and meta-analysis from 1980 to 2024.The following keywords were used, “complicated appendicitis”, “appendicular mass”, “appendicular abscess”, “appendectomy“, “laparoscopic appendectomy” and “percutaneous drainage” (Figure 1). All articles were in English, and all articles were assessed by manual cross referencing of the literature. Commentaries, case reports and editorials were excluded from this review. Adult and pediatric patients were included in this study and pregnant patients with acute appendicitis were excluded.

Figure 1: Flowchart Showing the Management of Appendicular Mass and Abscess

Discussion

Conservative Treatment of Appendicular Abscess

Conservative treatment of an appendicular abscess involves initiating intravenous antibiotics, administering analgesics, monitoring vital signs, and keeping the patient fast. This management approach was popularised by Ochsner and Sheeren and was associated with a success rate of 80% to 90%, with a low incidence of complications. Following conservative treatment, an interval appendectomy was traditionally performed after eight weeks to prevent recurrence (Coccolini et al., 2018; Elsaady, 2019; Tingstedt et al., 2002).

A systematic review and meta-analysis on the nonsurgical treatment of appendiceal abscess or phlegmon was conducted by Andersson et al. This study included 20 studies with a total of 59,448 patients. Conservative treatment was found to have a success rate of 92.8% and a recurrence rate of 7.4%. Additionally, percutaneous drainage of the abscess was required in 19.7% of cases that underwent conservative management. Due to the low recurrence rates, interval appendectomy was not routinely performed, and high-risk patients were monitored using computerised tomography and colonoscopy (Andersson & Petzold, 2007).

A meta-analysis comparing conservative treatment and appendectomy for complicated appendicitis was conducted by Simillis et al. This study included 17 studies with a total of 1,572 patients, of whom 847 underwent conservative treatment and 725 underwent appendectomy. The findings indicated that conservative treatment was associated with a lower wound infection rate, reduced intra-abdominal abscess formation, and a lower incidence of intestinal obstruction compared to immediate appendectomy (Simillis et al., 2010). Additionally, another meta-analysis by Fugazzola et al. compared early appendectomy and conservative management in children with complicated acute appendicitis. This study included 1,288 patients and found that conservative treatment had a success rate of 90% and a recurrence rate of 15.4%. However, the length of hospital stay was shorter for patients who underwent immediate appendectomy (Fugazzola et al., 2019).

Percutaneous Drainage of Appendicular Abscess

Percutaneous drainage is a well-established technique for managing patients with complicated appendicitis accompanied by abscess formation. This procedure can be performed using the Seldinger technique under ultrasound or computerised tomography guidance. When combined with conservative treatment, percutaneous drainage is associated with improved outcomes, a lower risk of recurrence, and a reduced hospital stay (Roach et al., 2007; Shinde et al., 2020; Zavras & Vaos, 2020). In children above the age of 13 years, percutaneous drainage of an appendicular abscess is linked to a lower incidence of interval appendectomy and better overall outcomes. Additionally, the use of intravenous antibiotics further reduces the recurrence rate (Luo et al., 2016). A prospective study conducted by Zerem et al. compared the therapeutic effectiveness of percutaneous drainage combined with antibiotics versus antibiotics alone. This study included 50 patients and concluded that percutaneous drainage, when combined with intravenous antibiotics, is a safe and effective approach with low recurrence rates (Zerem et al., 2007).

The size of an appendicular abscess significantly impacts its outcome. Abscesses smaller than 5 cm are associated with better outcomes and fewer complications, whereas larger abscesses (greater than 5 cm) often require continuous drainage for several days (Lasson et al., 2002). Image-guided percutaneous drainage using computerised tomography has shown a higher success rate and improved outcomes. However, ill-defined abscesses are typically linked to poorer prognoses (Marin et al., 2010). Several factors influence the success of percutaneous drainage of an appendicular abscess, including the presence of a low-grade abscess without multiloculation, the use of computerised tomography- guided drainage, and the trans gluteal approach (Fagenholz et al., 2016). A systematic review on the treatment of appendicular mass was conducted by Olsen et al., which included 48 studies with a total of 3,772 patients. The study concluded that percutaneous drainage of an appendicular abscess in both adults and children may reduce the risk of treatment failure. However, it was also associated with a moderate risk of complications (Olsen et al., 2014) (Table 1).

Table 1: The Recurrence Rate After Percutaneous Drainage of Appendicular Abscess

Interval Appendectomy After Percutaneous Drainage of Abscess

Interval appendectomy was traditionally performed following conservative treatment of an appendicular abscess to prevent recurrence. However, given that the recurrence rate for appendicitis ranges from 5% to 25%, with a complication rate of 23% associated with the procedure, the necessity of performing an interval appendectomy has been questioned. Several studies have indicated that, due to the low recurrence rate, there is no clear justification for routinely performing an interval appendectomy (Corfield, 2007; Tekin et al., 2008; Willemsen et al., 2002).

A systematic review conducted by Darwazeh et al. examined whether an interval appendectomy should be performed after conservative management of perforated appendicitis and phlegmon. The review included 21 studies with a total of 1,943 patients, of which 1,400 underwent conservative treatment and 543 underwent an interval appendectomy. The morbidity rate for conservative treatment was 13.3%, with a recurrence rate of 12.4%. The morbidity rate for interval appendectomy was 10.4%. The study concluded that interval appendectomy was associated with minimal benefit and resulted in increased costs and morbidity (Darwazeh et al., 2016).

An open label randomised controlled trial, the CHINA study, compared active observation versus interval appendectomy after successful non-operative treatment of an appendicular mass in children. This study, conducted by Hall et al., included 106 patients, with 52 undergoing interval appendectomy and 54 undergoing conservative treatment. The recurrence rate for patients who received conservative treatment was 12%, while the complication rate for those who underwent interval appendectomy was 6%. The study concluded that interval appendectomy should not be performed routinely and that a wait- and-see approach might be more suitable for treating patients with recurrent symptoms (Hall et al., 2017). Additionally, Hall et al. conducted a systematic review to assess the justification for performing an interval appendectomy after successful conservative treatment for appendicular mass in children. This review included 3 studies with 127 cases, revealing a 20% recurrence rate after conservative treatment and a 3.4% complication rate following interval appendectomy. The study concluded that interval appendectomy may not be necessary after the completion of conservative treatment (Hall et al., 2011).

Early Laparoscopic Appendectomy for Appendicular Abscess

Early or immediate appendectomy was traditionally not favoured in the management of appendicular abscesses due to the increased risk of wound infection, intra-abdominal abscess formation, and intestinal obstruction. However, with the introduction of laparoscopic appendectomy, there has been a shift towards performing immediate appendectomy. This is attributed to the reduced risk of postoperative infections, early ambulation, and decreased postoperative nausea and vomiting (Cueto et al., 2006; Forsyth et al., 2017). Several studies have demonstrated that laparoscopic appendectomy for appendicular abscess is associated with reduced symptoms of pain, vomiting, and a shorter length of hospital stay. While the risk of intra-abdominal abscess formation was initially higher compared to open appendectomy, this risk has been decreasing over the years as laparoscopic appendectomy techniques and surgeon experience have improved (Ball et al., 2004; Khiria et al., 2011; Kirshtein et al., 2007; Yau et al., 2007).

A systematic review and meta-analysis comparing laparoscopic appendectomy versus open appendectomy in adults with complicated appendicitis was conducted by Athanasiou et al. The study patients undergoing open appendectomy. Laparoscopic appendectomy was associated with a reduced wound infection rate, faster recovery, and a shorter length of hospital stay. The intra-abdominal abscess rate was similar between the two groups. This study concluded that laparoscopic appendectomy was associated with better outcomes compared to open appendectomy (Athanasiou et al., 2017). Another systematic review and meta-analysis comparing laparoscopic versus open appendectomy in adults with complicated appendicitis was conducted by Markides et al. (2010). They found that laparoscopic appendectomy was associated with reduced wound infection rates, and the intra-abdominal abscess rate was comparable to that of open appendectomy (Markides et al., 2010).

A meta-analysis was conducted by Low et al., comparing laparoscopic appendectomy with open appendectomy in paediatric patients with complicated appendicitis. Thirty-nine studies included 3,402 patients who underwent laparoscopic appendectomy and 4,522 patients who underwent open appendectomy. Patients who underwent laparoscopic appendectomy had a shorter hospital stay and a lower incidence of surgical site infection. The intra-abdominal abscess rate was similar between both groups; however, the study concluded that laparoscopic appendectomy should be the procedure of choice in paediatric patients with an appendicular abscess (Low et al., 2019).

Conclusion

There is no consensus on the optimal management for a patient presenting with appendicular abscess, the treatment approach is largely determined by the patient's clinical presentation and the experience of the treating surgeon. Conservative treatment is a safe and effective option, particularly when combined with percutaneous drainage of the abscess, which is associated with better outcomes. The size of the appendicular abscess plays a critical role in determining the success of percutaneous drainage. If laparoscopic surgical expertise is available, immediate appendectomy should be performed, as this addresses the underlying issue and reduces the risk of recurrence. Immediate appendectomy is also cost-effective. Routine interval appendectomy is not necessary, as patients can be monitored using imaging techniques such as computerised tomography or colonoscopy for further assessment.

Conflict of Interest

The authors declare no conflict of interest.

Acknowledgement

The author would like to thank all the participants who endeavoured to fill the questionnaire. Also, immensely grateful to Bashair Alhidri, Teaching Assistant, King Saud bin Abdulaziz university for health sciences, College of medicine, Jeddah, Saudi Arabia for her helps on Data collection, although any errors are my own and should not tarnish the reputation of these esteemed professionals.

References

Ahmed, I., Deakin, D., & Parsons, S. L. (2005). Appendix mass: do we know how to treat it?. Annals of the Royal College of Surgeons of England, 87(3), 191. https://doi.org/10.1308/1478708051649

Andersson, R. E., & Petzold, M. G. (2007). Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Annals of Surgery, 246(5), 741-748. https://doi.org/10.1097/SLA.0b013e31811f3f9f

Athanasiou, C., Lockwood, S., & Markides, G. A. (2017). Systematic review and meta‐analysis of laparoscopic versus open appendicectomy in adults with complicated appendicitis: an update of the literature. World Jusnal of Surgery, 41(12), 3083-3099. https://doi.org/10.1007/s00268-017-4123-3

Ball, C. G., Kortbeek, J. B., Kirkpatrick, A. W., & Mitchell, P. (2004). Laparoscopic appendectomy for complicated appendicitis: An evaluation of postoperative factors. Surgical Endoscopy and Other Interventional Techniques, 18(6), 969–973. https://doi.org/10.1007/s00464-003-8262-2

Becker, P., Fichtner-Feigl, S., & Schilling, D. (2018). Clinical management of appendicitis. Visceral Medicine, 34(6), 453–458. https://doi.org/10.1159/000494883

Coccolini, F., Fugazzola, P., Sartelli, M., Cicuttin, E., Sibilla, M. G., Leandro, G., De’angelis, G. L., Gaiani, F., Di Mario, F., Tomasoni, M., Catena, F., & Ansaloni, L. (2018). Conservative treatment of acute appendicitis. In Acta Biomedica, 89(Suppl 9), 119–134. https://doi.org/10.23750/abm.v89i9-S.7905

Corfield, L. (2007). Interval appendicectomy after appendiceal mass or abscess in adults: what is “best practice”?. Surgery Today, 37(1), 1-4. https://doi.org/10.1007/s00595-006-3334-2

Cueto, J., D’Allemagne, B., Vazquez-Frias, J. A., Gomez, S., Delgado, F., Trullenque, L., ... & Franklin, M. E. (2006). Morbidity of laparoscopic surgery for complicated appendicitis: an international study. Surgical Endoscopy and Other Interventional Techniques, 20, 717-720. https://doi.org/10.1007/s00464-005-0402-4

Darwazeh, G., Cunningham, S. C., & Kowdley, G. C. (2016). A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See?. The American Surgeon, 82(1), 11–15. https://doi.org/10.1177/000313481608200107

Demetrashvili, Z., Kenchadze, G., Pipia, I., Khutsishvili, K., Loladze, D., Ekaladze, E., Merabishvili, G., & Kamkamidze, G. (2019). Comparison of treatment methods of appendiceal mass and abscess: A prospective Cohort Study. Annals of Medicine and Surgery, 48, 48–52. https://doi.org/10.1016/j.amsu.2019.10.016

Di Saverio, S., Podda, M., De Simone, B., Ceresoli, M., Augustin, G., Gori, A., ... & Catena, F. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery, 15, 1-42. https://doi.org/10.1186/s13017-020-00306-3

Elsaady, A. (2019). Management of appendicular mass; comparative study between different modalities. Austin J Gastroenterol, 6(1), 1097. https://doi.org/10.26420/austinjgastroenterol.1097.2019

Fagenholz, P. J., Peev, M. P., Thabet, A., Michailidou, M., Chang, Y., Mueller, P. R., Hahn, P. F., & Velmahos, G. C. (2016). Abscess due to perforated appendicitis: factors associated with successful percutaneous drainage. American Journal of Surgery, 212(4), 794–798. https://doi.org/10.1016/j.amjsurg.2015.07.017

Forsyth, J., Lasithiotakis, K., & Peter, M. (2017). The evolving management of the appendix mass in the era of laparoscopy and interventional radiology. The Surgeon, 15(2), 109-115.https://doi.org/10.1016/j.surge.2016.08.002

Fugazzola, P., Coccolini, F., Tomasoni, M., Stella, M., & Ansaloni, L. (2019). Early appendectomy vs. conservative management in complicated acute appendicitis in children: a meta-analysis. Journal of Pediatric Surgery, 54(11), 2234-2241. https://doi.org/10.1016/j.jpedsurg.2019.01.065

Garba, E. S., & Ahmed, A. (2008). Management of appendiceal mass. Annals of African Medicine, 7(4), 200–204. https://doi.org/10.4103/1596-3519.55652

Gorter, R. R., Eker, H. H., Gorter-Stam, M. A. W., Abis, G. S. A., Acharya, A., Ankersmit, M., Antoniou, S. A., Arolfo, S., Babic, B., Boni, L., Bruntink, M., van Dam, D. A., Defoort, B., Deijen, C. L., DeLacy, F. B., Go, P. M., Harmsen, A. M. K., van den Helder, R. S., Iordache, F., … Bonjer, J. (2016). Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surgical Endoscopy, 30(11), 4668–4690. https://doi.org/10.1007/s00464-016-5245-7

Hall, N. J., Eaton, S., Stanton, M. P., Pierro, A., & Burge, D. M. (2017). Active observation versus interval appendicectomy after successful non-operative treatment of an appendix mass in children (CHINA study): an open- label, randomised controlled trial. The Lancet Gastroenterology and Hepatology, 2(4), 253–260.https://doi.org/10.1016/S2468-1253(16)30243-6

Hall, N. J., Jones, C. E., Eaton, S., Stanton, M. P., & Burge, D. M. (2011). Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. Journal of Pediatric Surgery, 46(4), 767-771. https://doi.org/10.1016/j.jpedsurg.2011.01.019

Khiria, L. S., Ardhnari, R., Mohan, N., Kumar, P., & Nambiar, R. (2011). Laparoscopic appendicectomy for complicated appendicitis: is it safe and justified?: A retrospective analysis. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 21(3), 142–145. https://doi.org/10.1097/SLE.0b013e31821ad770

Kirshtein, B., Bayme, M., Domchik, S., Mizrahi, S., & Lantsberg, L. (2007). Complicated appendicitis: Laparoscopic or conventional surgery? World Journal of Surgery, 31(4), 744–749. https://doi.org/10.1007/s00268-006-0467-9

Koirala, A., Thakur, D., Agrawal, S., Pathak, K. R., Bhattarai, M., & Sharma, A. (2016). Appendicular mass: a conservative approach. Journal of Nobel Medical College, 5(2), 47-50. https://doi.org/10.3126/jonmc.v5i2.16317

Lasson, Å., Lundagårds, J., Lorén, I., & Nilsson, P. E. (2002). Appendiceal abscesses: primary percutaneous drainage and selective interval appendicectomy. European Journal of Surgery, 168(5), 264-269. https://doi.org/10.1002/ejs.44

Low, Z. X., Bonney, G. K., So, J. B. Y., Loh, D. L., & Ng, J. J. (2019). Laparoscopic versus open appendectomy in pediatric patients with complicated appendicitis: a meta-analysis. Surgical Endoscopy, 33(12), 4066–4077. https://doi.org/10.1007/s00464-019-06709-x

Luo, C. C., Cheng, K. F., Huang, C. S., Lo, H. C., Wu, S. M., Huang, H. C., Chien, W. K., & Chen, R. J. (2016).Therapeutic effectiveness of percutaneous drainage and factors for performing an interval appendectomy in pediatric appendiceal abscess. BMC Surgery, 16(1). https://doi.org/10.1186/s12893-016-0188-4

Marin, D., Ho, L. M., Barnhart, H., Neville, A. M., White, R. R., & Paulson, E. K. (2010). Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome. American Journal of Roentgenology, 194(2), 422-429. https://doi.org/10.2214/AJR.09.3098

Markides, G., Subar, D., & Riyad, K. (2010). Laparoscopic versus open appendectomy in adults with complicated appendicitis: Systematic review and meta-analysis. World Journal of Surgery, 34(9), 2026–2040. https://doi.org/10.1007/s00268-010-0669-z

Olsen, J., Skovdal, J., Qvist, N., & Bisgaard, T. (2014). Treatment of appendiceal mass--a qualitative systematic review. Danish Medical Journal, 61(8), A4881. Retrieved from: https://content.ugeskriftet.dk/sites/default/files/scientific_article_files/2018-11/a4881.pdf. Accessed on 10th February, 2024.

Panahi, P., Ibrahim, R., Veeralakshmanan, P., Ackah, J., & Coleman, M. (2020). Appendiceal phlegmon in adults: Do we know how to manage it yet?. Annals of Medicine and Surgery, 59, 274-277. https://doi.org/10.1016/j.amsu.2020.08.033

Rajah, K. H. (2024). Appendicular Phlegmon: Current Management. European Journal of Medical and Health Research, 2(1), 118-122. https://doi.org/10.59324/ejmhr.2024.2(1).19

Rashid, A., Nazir, S., Kakroo, S. M., Chalkoo, M. A., Razvi, S. A., & Wani, A. A. (2013). Laparoscopic interval appendectomy versus open interval appendectomy: a prospective randomized controlled trial. Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 23(1), 93-96.https://doi.org/10.1097/SLE.0b013e318277df6a

Roach, J. P., Partrick, D. A., Bruny, J. L., Allshouse, M. J., Karrer, F. M., & Ziegler, M. M. (2007). Complicated appendicitis in children: a clear role for drainage and delayed appendectomy. American Journal of Surgery, 194(6), 769–773. https://doi.org/10.1016/j.amjsurg.2007.08.021

Shinde, N., Devani, R., Baseer, M. A., & Desai, K. (2020). Study of management of appendicular abscess in children. African Journal of Paediatric Surgery, 17(3-4), 64-67. https://doi.org/10.4103/ajps.AJPS_18_18

Simillis, C., Symeonides, P., Shorthouse, A. J., & Tekkis, P. P. (2010). A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery, 147(6), 818- 829. https://doi.org/10.1016/j.surg.2009.11.013

Singh, J. (2024). Ultrasound Guided Percutaneous Drainage In The Management Of Appendicular Abscess. International Journal, 7(5), 65. Retrieved from: https://www.ijmscr.com/asset/images/uploads/17266652368097.pdf. Accessed on 18th March, 2024.

Tannoury, J., & Abboud, B. (2013). Treatment options of inflammatory appendiceal masses in adults. World Journal of Gastroenterology, 19(25), 3942–3950. https://doi.org/10.3748/wjg.v19.i25.3942

Tekin, A. H. M. E. T., Kurtoğlu, H. C., Can, I., & Öztan, S. (2008). Routine interval appendectomy is unnecessary after conservative treatment of appendiceal mass. Colorectal Disease, 10(5), 465-468.https://doi.org/10.1111/j.1463-1318.2007.01377.x

Tingstedt, B., Bexe-Lindskog, E., Ekelund, M., & Andersson, R. (2002). Management of appendiceal masses. The European Journal of Surgery, 168(11), 579-582. https://doi.org/10.1080/11024150201680001

Willemsen, P. J., Hoorntje, L. E., Eddes, E. H., & Ploeg, R. J. (2002). The need for interval appendectomy after resolution of an appendiceal mass questioned. Digestive Surgery, 19(3), 216–221.https://doi.org/10.1159/000064216

Yau, K. K., Siu, W. T., Tang, C. N., Yang, G. P. C., & Li, M. K. W. (2007). Laparoscopic Versus Open Appendectomy for Complicated Appendicitis. Journal of the American College of Surgeons, 205(1), 60–65. https://doi.org/10.1016/j.jamcollsurg.2007.03.017

Zavras, N., & Vaos, G. (2020). Management of complicated acute appendicitis in children: Still an existing controversy. World Journal of Gastrointestinal Surgery, 12(4), 129–137. https://doi.org/10.4240/wjgs.v12.i4.129

Zerem, E., Salkic, N., Imamovic, G., & Terzić, I. (2007). Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess: Is appendectomy always necessary after perforation of appendix? Surgical Endoscopy and Other Interventional Techniques, 21(3), 461–466. https://doi.org/10.1007/s00464-006-9005-y