INTRODUCTION

Acute appendicitis is a typical medical emergency worldwide; Peru is no exception since between 2 and 6% present appendicular plastron. An appendicular plastron is a progressive form of acute appendicitis that requires surgical management¹. This is associated with postoperative infectious complications such as intestinal fistula, small bowel obstruction, and recurrence of appendicitis after initially successful non-surgical management^2-5.

Different studies have been developed to determine appendicular plastron characteristics and expected results. According to Laguzzi et al.⁶, of the 30% of patients with edematous appendicitis, 37 cases presented appendicular plastron, a risk of occurrence in the population studied. Cano⁷, identified that 25% of the total population presented complications after diagnosis and treatment due to appendicular plastron, whereas 15% presented high temperature as the primary clinical manifestation; this caused patients to stay at the hospital for an average of 10 days. In the case of Saar et al.⁸, one of the clinical characteristics that was evidenced in patients with appendicular plastron was that 58.8% had hyperleukocytosis. The most common finding method in said population was the abdominal ultrasound (78.8%). Likewise, in Morocco, the epidemiological characteristics found in patients with appendicular plastron were the following: the most common gender was males (20 cases), and the average age was 29 years⁹.

In Peru, the frequency of appendicular plastron varies between 2 to 10%; in addition, among the main characteristics identified, it has been shown that it generally occurs in males (53.25%) and in people with an average age of 35 years and usually the time of illness is 8 days¹⁰.

The handling remains controversial; the conservative approach is highlighted by the assumption that the inflammatory process is already localized and that inadvertent surgery may be challenging and unsafe^11,12. Also, it could be difficult to identify the appendix, and sometimes due to unintentional injury, a fecal fistula may develop³. However, the information available on the subject is scarce. For this reason, identifying the epidemiological and clinical characteristics associated with the results of conservative management is essential and of interest.

Much of the previous research on this topic has focused on whether non-surgical management is safe or feasible. Generally, it focuses on uncomplicated appendicitis and provides little information on the outcomes of patients whose treatment has failed. In this context, the execution of a study was proposed to determine the epidemiological-clinical characteristics associated with the results of conservative management of the appendicular plastron in adult patients from a reference hospital in Peru.

METHODS

RESULTS

DISCUSSION

In the present investigation, 100 patients with a diagnosis of appendicular plastron were studied. It was observed that 81% of the patients obtained an unfavorable result regarding the conservative management of the appendicular plastron. In contrast to these results, the study by Haithem²found that conservative management in patients with appendicular plastron was successful in 84.5% of patients. Debnath et al.¹⁴reported that conservative management was successful in most patients with appendicular plastron (69%).

At the same time, Elsaady¹⁵, reported a success rate of 88% and infrequent postoperative complications (9.5%). Olsen et al.¹⁶, identified a 23% failure rate in adult patients with appendicular plastron. The treatment strategy for appendicular plastron is controversial and ranges from image-guided surgery or drainage to conservative management; the latter can prolong the hospital stay; however, the surgical treatment carries the risk of intestinal resection and major complications⁶. Contrary to the study results, the available evidence seems to support a conservative approach. The difference between results can likely be explained by the impact of COVID-19 at the time of hospital admission, as well as the decision to prioritize conservative management without any formalized stratification criteria or pathway to guide the choice of this management.

Regarding the epidemiological-clinical characteristics associated with the results of conservative management of the appendicular plastron, it was found that, at the level of epidemiological characteristics, alcohol consumption(p<0.05; RPa=1.115; IC95%=1.01-1.23) was associated with unsuccessful conservative management results. No studies were found linking alcohol consumption and unsuccessful conservative management; however, it has been suggested that behavioral factors also stand out among the factors related to the outcome of management^17,18. On the other hand, the clinical characteristics associated with the results of the management of the appendicular plastron were identified as the following: symptoms on admission such as nausea and vomiting (p<0.05, RPa=1.48; IC95%=1.32 - 1.67) as well as diarrhea (p<0.05; RPa=1.08; IC95%=1.01 - 1.17) were associated with an unsuccessful conservative management outcome. The duration of symptoms between 3 and 5 days before hospital admission was considered a clinical characteristic associated with results of unsuccessful conservative management (p<0.05; RPa=1.09; IC95%=1.02 - 1.17). Similar findings were presented by Parmentier et al. ¹⁹, who determined that a factor for failure of conservative management where first-line antibiotics were included was a shorter duration of symptoms before admission (5 vs. 4 days p:0.02). Haithem², reported that conservative management was ineffective in patients who presented between days 3 and 5 (16.3%) after the onset of symptoms; however, this association was not significant. The presence of an appendicular mass as an imaging finding (p<0.05, RPa=1.18; IC95%=1.05 - 1.32) and bandemia (p<0.05, RPa=1.12; IC95%=1.00 - 1.26) were clinical characteristics associated with the results.

Similar results were identified in a study by Talishinskiy et al.²⁰, who mentioned that among the variables that predicted the failure of conservative management was the presence of bandemia ≥ 15% (p<0.01). Likewise, Ayele¹⁸, reported that the study subjects who had a mass in the lower right quadrant before surgical treatment were approximately six times more likely to have unfavorable results.

The present study has limitations inherent to the type of design since it is a single-center study, which implies that it was only carried out in patients from a single hospital, which could affect when extrapolating the data to the population of metropolitan Lima and even more so the national level. However, it has strengths, such as providing evidence in a particular situation such as COVID-19(21) and that may have consequences in the management of these patients^22-24

Among the recommendations, the following should be taken into account. First, to share the study findings among the health personnel of this reference Hospital, to increase the level of knowledge about the management of the appendicular plastron, and to provide information on the patients most vulnerable to non-conservative management. Doing this would prevent complications, prolonging the hospital stay and out-of-pocket expenses. Second, to promote education in patients through educational talks where prevention and the epidemiological characteristics associated with unfavorable results are emphasized. Third, promote adequate care by health personnel. Finally, develop more studies on this subject, including clinical and epidemiological variables associated with conservative management of the appendicular plastron-this way, contrasting study results and contributing to the protocol treatment of this complication.

CONCLUSION

Alcohol consumption, symptoms and signs on admission such as diarrhea, nausea, and vomiting, duration of symptoms between 3 and 5 days, the presence of a palpable mass, and bandemia as laboratory findings on admission were characteristics associated with unsuccessful results on conservative management of the appendicular plastron in adult patients.