RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate and address (in block letters) / : / DR. Chandrahasa,P.G. IN DEPT OF SURGERY MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA-585 105
Permanent address / : / DR. Chandrahasa
C/O nagesh Basavanahalli
Dist: Chikamagalore
2 / Name of the Institution / : / H.K.E. SOCIETY’S MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA-585 105
3 / Course of Study and Subject / : / M.S. (GENERAL SURGERY)
4 / Date of admission to the course / : / 17 may 2012
5 / Title of the Topic / : / A COMPARATIVE STUDY OF EARLY VERSUS INTERVAL APPENDICECTOMY IN CASES OF APPENDICEAL MASS
6 / Brief Resume of the intended work / :
6.1 / Need for the study
Appendicular mass is a common complication of acute appendicitis. The traditional treatment of this is conservative management followed by interval appendectomy. But now with advancement in all the fields of medicine early surgical exploration of the appendicular mass can be done with satisfactory results. Management of an appendicular mass is therefore controversial with three general approaches usually employed.1
'Classical management' involves initial conservative management with broad spectrum antibiotics and intravenous fluid until the inflammatory mass resolves. Patients are offered interval appendicectomy following resolution of symptoms. The semi-conservative approach involves performing immediate appendicectomy during the initial admission after resolution of the inflammatory mass. Proponents of an entirely conservative approach claim appendicectomy, whether interval (delayed) or immediate (during initial admission), is unnecessary.1
None of these approaches has gained total universal acceptance. This study aims to review the current available literatures describing management of appendiceal mass, compare the advantages of Early versus Interval Appendicectomy and suggest an acceptable approach based on available local resources.
6.2 / Review of Literature
Acute appendicitis i.e. acute inflammation of the appendix from mild inflammation of mucous membrane to gangrene, perforation and peritonitis is the most common acute surgical condition4-6. Regardless of the cause it is associated with definite morbidity and mortality if not managed properly. The definite treatment of acute appendicitis is appendicectomy to avoid complications7. If timely appendicectomy is not done due to any reason 2-6% of patients develop a mass as one of the early complications.
On the third day (rarely sooner) of commencement of acute appendicitis, a tender mass can frequently be felt in right iliac fossa. This mass is composed of omentum, edematous caecal wall and edematous loop of ileum. In its midst is a perforated or inflamed appendix8. In its natural course from 5th to 10th day, the mass either becomes larger and an appendicular abscess results or it becomes smaller and subsides as the inflammation resolves.9
The conventional conservative treatment followed by delayed appendicectomy in patients with appendicular mass is well recommended10 but misdiagnosis is another enigma, conditions such as caecal carcinoma in middle aged or elderly; intussusceptions in children an ileocaecal tuberculosis at any age may mimic appendicular mass.11
With the availability of better operative and anaesthesia facilities and to avoid the uncertain natural course and misdiagnosis, an early exploration of the appendicular mass is recommended11.This cuts short the hospital stay, cures and diagnoses the disease and obviates the need of a second hospital admission with no added morbidity and mortality11.
In June 2010 a study done by Ali S, Rafique HM on appendicular mass; Early exploration vs conservative management concluded that early surgical exploration of appendicular mass is safe and cost effective.
In February 2006, Juan Bass, Steven Rubin, Abdulelah Hummadi published a study on Interval Appendectomy: An Old New Operation in The Journal of Laparoendoscopic & Advanced Surgical Techniques and based on the findings, supported the need for interval appendectomy, and suggested that laparoscopy is a safe alternative to open appendectomy.
In 2004 a study done by Derya Erdog˘ an Æ _Ibrahim Karaman Æ Adnan Narcı Ays- e Karaman Æ Y. Hakan C¸ avus,og˘ lu M. Kemal Aslan Æ O ¨ zden C¸ akmak on Comparison of two methods for the management of appendicular mass in children concluded thatconservative treatment of appendicular mass is safe; and also advocate elective appendectomy because of the probable risk of recurrence.
In 2008 a study done by Malik Arshad, Laghari A. Aziz, Mallah Qasim, K. Altaf Hussain Talpur on Early appendicectomy in Appendicular mass concluded that early appendicectomy is a safe and superior option in patients with Appendicular mass compared to conventional treatment.
6.3 / Objective of the Study
1. A comparison of Early Exploration versus Interval Appendicectomy in management of Appendicular mass.
2. To identify and compare the morbidity associated with early and interval appendicectomy.
7 / Materials and methods
7.1 / Source of data.
Source of data is collected from a pre-tested proforma from the inpatient register of our Hospital During The Study Period (Dec 2012-Nov 2014)
Sample Size
50 Cases of Appendicular Mass
Comparative Study
Total of 50 patients who will undergo either early or interval appendicectomy in diagnosed cases of appendicular mass
Parameters to be measured
1.Duration of hospital stay
2.Incidence of complications
7.2 / Methods of collection of Data (including sampling Procedure, if any)
Methods:-
Collection of data is from the clinical history, physical examination, relevant investigations and imaging modalities.
Statistical Methods
1. Descriptive statistics
2. Chi-square test
3. Cross tabulation (contingency table)
4. Independent samples ‘t’ test.
The statistical operations are done through SPSS (Statistical Presentation System Software) for Windows, version 16.0 (SPSS, 1999. SPSS Inc: New York)
Inclusion Criteria
1. All cases of Appendicular Mass diagnosed clinically and radiologically in the study period between December 2012 to November, 2014
2. Age 14 years and above.
Exclusion Criteria
1. Simple appendicitis with no mass.
2. Signs and symptoms suggestive of appendicular perforation.
3. Patients unfit for surgery.
4. Patients not willing for surgery.
7.3 / Does the study require any investigation or intervention to be conducted on patients or other human or animals? If so please describe briefly.
Yes,
1. Routine hematological investigations.
2. Chest x-ray and ECG for fitness for surgery.
3. Ultrasonography of the abdomen.
4. CT scan if required.
7.4 / Has ethical clearance been obtained from your institution in case of 7.3?
Yes, Ethical clearance has been obtained from research and dissertation committee/ethical committee of the institution for this study.
8 / List of Reference
1. E. S. Garba and A. Ahmed. “Management of Appendiceal Mass”. Annalsof African Medicine Vol. 7, No.4; 2008: 200 – 204
2. Eryilmaz, R., M. Sahin, and M. R. Savas. “Is interval appendectom necessary after conservative treatment of appendiceal masses?”Ulus Travma Derg. 2004.10.3: 185-88.
3. Bagi P, Dueholm S. “Nonoperative management of the ultrasonically evaluated appendiceal mass”.Surgery. 1987;101:602-605.
4. Caterino S. “Acute abdominal pain in emergency surgery”. Ann-Ital-Chir, 1997:68 (6):807-1.
5. Cushieri A. “Small intestine and Vermiform appendix” In:Cushieri A, Gillies GR, Moosa AR. Essential surgical, 3rd edition.Oxford:Butterworth. Heiwemann,1995;1297-1328.
6. Mufti Js, Akhtar, Khan K, et al. “Diagnostic accuracy in acute appendicitis.Comparison between clinical impression and ultrasound findings”. JAMC, 1996;8(1):13-15.
7. Rintoul RF. “Operations on the appendix” In :Rintoul RF Farquharson’s Textbook of operative surgery, 8th edition. Edinburgh; Longman group Ltd, 1995:451-58
8. Bernard M, Jefee and David H. Berger; “The appendix” ; 11(2)526.Schwartzs Principles of Surgery 8th Edition 2005; P-1125.
9. P. Ronan O’Connell; “The Verniform appendix”; Short practice of surgery 25th edition 2008; P1204-18
10. Kevin P. Lally; Charles S. Cox; “Appendix”; Sabistan Textbook of Surgery 17th edition 2004; P1389.
11. Ali S, Rafique HM. “Appendicular mass; Early exploration vs conservative management”. Professional Med J Jun 2010;17(2):180-184.
9. / Signature of Candidate
10. / Remarks of the Guide / GOOD COMPARATIVE STUDY DESERVES CONSIDERATION FOR DISSERTATION STUDY.
11. / Name and Designation of (in block letters)
11.1 / Guide / Dr. RaviNDRA. B. Dhaded
M.S.,
Professor
Department of Surgery
M.R. Medical College, Gulbarga.
11.2 / Signature
11.3 / Co-Guide(if any)
11.4 / Signature
11.5 / Head of the Department / Dr. S.A.HALKAI
M.S.,
Professor & Head of the
Department of Surgery.
M.R. Medical College, Gulbarga.
11.6 / Signature
12 / 12.1 / Remarks of the Dean and Principal
12.2 / Signature