Modern Management of the Appendix: So Many Options

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Key points

  • All uncomplicated cases of appendicitis, including those with a fecalith, should undergo operative management.

  • Complicated cases of appendicitis (abscess, mass, phlegmon) should have an interval appendectomy performed.

  • All appendicitis patients older than 40 years should have surveillance endoscopy performed to rule out neoplasm.

Nonoperative Management

To date, numerous studies have examined the nonoperative management (NOM) of uncomplicated appendicitis. The Appendicitis Acute (APPAC) trial was a multicenter, open-label, noninferiority randomized clinical trial. It was conducted from 2009 to 2012 in Finland, randomizing 530 patients to either open appendectomy or NOM with antibiotics. The NOM arm performed well overall, with only 27.3% of patients requiring appendectomy within 12 months of randomization (21% during the index hospitalization

Complicated appendicitis

For patients with complicated appendicitis, including free perforation, periappendiceal mass, phlegmon, or abscess, management is variable. Of the approximately 300,000 appendectomies performed annually in the United States, 25% of them are for complicated appendicitis.26 Patients with generalized peritonitis due to free perforation in the abdominal cavity need to undergo preoperative resuscitation (crystalloid, antibiotics, and vasopressor support) before emergency appendectomy to achieve

Surgical approach

When surgery is to be performed (uncomplicated, complicated, or interval cases of appendicitis), the authors recommend for a laparoscopic approach. Assuming surgeon familiarity and institutional capability, the minimally invasive laparoscopic exposure has been well studied and proved to be superior over doing the case open.42 It has resulted in lower wound infections, less postoperative pain, less postoperative adhesions,43 and a shorter length-of-stay. It also has advantages in the obese,

Summary

Appendicitis is extremely common, and the immediate and long-term management must take into consideration several patient and disease factors. In uncomplicated cases of appendicitis, NOM is safe and cost-effective, but it is associated with high rates of recurrence, and so patients should be appropriately counseled, and appropriate follow-up should be arranged. For those with complicated diverticulitis, most will not receive appendectomy at the index hospitalization. Interval colonoscopy is

Disclosure

The authors have nothing to disclose.

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