Appendicolith delays resolution of appendicitis following nonoperative management

SAGES guideline for the diagnosis and treatment of appendicitis

BACKGROUND

Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis.

METHODS

A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts.

RESULTS

Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty.

CONCLUSIONS

These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Paradigm Shifts in the Treatment of Appendicitis

Acute appendicitis is the most common cause of emergent surgery in children. Historically, surgical dogma dictated emergent appendectomy due to concern for impending perforation. Recently, however, there has been a paradigm shift in both the understanding of its pathophysiology as well as its treatment to more nonoperative management. No longer is it considered a spectrum from uncomplicated appendicitis inevitably progressing to complicated appendicitis over time. Rather, uncomplicated and complicated appendicitis are now considered two distinct pathophysiologic entities. This change requires not only educating the patients and their families but also the general practitioners who will be managing treatment expectations and caring for patients long term. In this article, we review the pathophysiology of appendicitis, including the differentiation between uncomplicated and complicated appendicitis, as well as the new treatment paradigms. [Pediatr Ann. 2016;45(7):e235-e240.].

Recurrence of acute appendicitis after non-operative treatment of appendiceal abscess in children: a single-centre experience

BACKGROUND/PURPOSE

The aim of this study was to evaluate the incidence of recurrence of acute appendicitis after initial successful non-operative treatment of appendiceal abscess in children.

METHODS

This study was an observational cohort study of children treated non-operatively for appendiceal abscess at a large tertiary referral centre from 2006 to 2010. The primary outcome was recurrence of acute appendicitis. Secondary outcome variables were re-admission and interval appendectomy.

RESULTS

Eighty-nine patients were discharged after successful non-operative treatment of appendiceal abscess. The median age was 10.1 (1.3-16.3) years. Nine patients underwent surgery during the follow-up period. Five patients were re-admitted with ongoing symptoms leading to an appendectomy. They all returned shortly after discharge and are considered failures of initial treatment. Two of 82 patients returned with a new episode of acute appendicitis during the trial period. Hence, the recurrence rate was 2.4 % during 5.1 years of follow-up.

CONCLUSION

Our data support the strategy of not performing an interval appendectomy after successful non-operative treatment with antibiotics of an appendiceal abscess in children.

Delayed appendectomy versus early appendectomy in the treatment of acute appendicitis: a retrospective study

Background

The controversy still exists about the timing of operation for appendicitis. The aim of this study was to compare the outcomes between early appendectomy and delayed appendectomy and assess the feasibility of delayed operation.

Methods

The medical records of patients with acute appendicitis who received operation between January 1, 2011 and December 31, 2011, were retrospectively reviewed. Outcome measures were white blood cell (WBC) count at postoperative first day, time to soft diet, complication rate, surgical site infection (SSI) rate, length of hospital stay, and readmission within 30 days.

Results

During the study period, a total of 478 patients underwent appendectomies, and 145 patients were excluded, leaving 333 who met inclusion criteria. Based on the time from arrival at hospital to incision, they were divided into two groups: 177 (53.2%) in group A and 156 (46.8%) in group B. There were no significant differences in preoperative demographics and clinical data between two groups. The mean WBC count at postoperative first day of group B were lower than that of group A (p = 0.0039). There were no significant differences in time to soft diet, length of postoperative hospital stay, complication rate, and readmission rate between two groups. SSI including intra-abdominal abscess was also shown no significant difference (Group A, 1.7% and Group B, 3.9%; p = 0.3143).

Conclusions

This study revealed that delayed appendectomy was safe and feasible for adult patient although the clinical outcomes of delayed appendectomy were not superior to those of early appendectomy. We suggest that surgeons would decide the appropriate timing of appendectomy with consideration other situations such as available hospital resources.