Acute appendicitis
Recommendations
Urgent
Seek immediate surgical input and consider involving critical care for any patient with suspected appendicitis and signs of shock or sepsis.
If the patient has signs of shock, give a fluid challenge to correct hypotension and/or tachycardia.[79] See Shock.
In adults, give 250 to 500 mL of either normal saline (0.9% sodium chloride) or Hartmann’s solution (also known as Ringer’s lactate solution), intravenously over 15 minutes.[79]
For fluid resuscitation in children, see Volume depletion in children.
Refer to local guidelines for the recommended approach at your institution for prompt assessment and management of patients with suspected sepsis, or those at risk.[26][80][81][82][83] See Sepsis in adults and Sepsis in children.
Complicated appendicitis occurs in 4% to 6% of adults and less than 19% of children and is defined as appendicitis with any one of:[7][13][19]
Gangrenous appendix with or without perforation
Intra-abdominal abscess
Peri-appendicular phlegmon
Purulent-free fluid.
Involve obstetric support for any pregnant woman with appendicitis as management requires a multidisciplinary approach.[84]
Refer all children with suspected appendicitis to the paediatric surgery team on call, if available. Where no paediatric surgery team is available, joint care should be managed between paediatrics and surgical teams.
Keep the patient nil by mouth if surgery is being considered.
Key Recommendations
Uncomplicated appendicitis
Laparoscopic appendicectomy is the first choice for most adults (including pregnant patients) provided an appropriately skilled surgeon is available.[7][27]
Ensure appendicectomy is not delayed unnecessarily. This is to minimise patient discomfort. Evidence suggests that delaying surgery by up to 24 hours does not increase the risk of perforation.[85]
Consider ambulatory management in patients who are systemically well.
Give a dose of prophylactic antibiotics before surgery[86].
Check local protocols and seek advice from microbiology colleagues.
Consider a conservative (non-operative) approach with intravenous antibiotics only for selected adults who have uncomplicated appendicitis (suspected or confirmed on computed tomographic scan), and do not wish to have, or are unfit for, surgery; ensure the patient is aware of the risk of recurrence of appendicitis.[2][87][88][89][90][91][92][93]
Do not use a conservative approach for pregnant patients.[7]
Do not use a conservative approach in adults if an appendicolith is present, because non-operative management carries a significant failure rate.[2][7][94]
Seek a decision from a specialist paediatric surgeon regarding whether to proceed with non-operative management with antibiotics as an alternative to surgery in children. Non-operative management is only recommended in the absence of an appendicolith.[2][7]
Delaying surgery by up to 24 hours does not increase the risks of perforation for children with uncomplicated acute appendicitis.[7]
Advise that there is a chance of failure and misdiagnosis of complicated appendicitis with non-operative management.[7]
Do not use a conservative approach in children with appendicolith because non-operative management carries a significant failure rate.[2][7][94]
Complicated appendicitis
Request an immediate surgical review for any patient (adults and children) with confirmed or suspected complicated appendicitis.
Patients with a perforated appendix will need urgent appendicectomy.
Give all patients prophylactic antibiotics before surgery and continue these postoperatively if complicated appendicitis is confirmed during surgery.[86] Check local protocols and seek advice from microbiology colleagues.
In children, early appendicectomy within 8 hours should be performed for confirmed or suspected complicated appendicitis.[7]
Involve critical care and seek immediate surgical input for any patient with suspected perforated appendicitis and signs of shock or sepsis.[7][13]
In adults with signs of shock, give a fluid challenge to correct hypotension and/or tachycardia.[79] See Shock.
In adults, give 250 to 500 mL of either normal saline (0.9% sodium chloride) or Hartmann’s solution (also known as Ringer’s lactate solution), intravenously over 15 minutes.[79]
Refer to local guidelines for the recommended approach at your institution for prompt assessment and management of patients with suspected sepsis, or those at risk.[26][80][81][82][83] See Sepsis in adults and Sepsis in children.
For fluid resuscitation in children, see Volume depletion in children.
Give all patients prophylactic antibiotics before surgery to reduce the risk of postoperative complications.[86] Check local protocols and seek advice from microbiology colleagues.
Patients with complicated appendicitis require a postoperative course of antibiotics in addition to this, whereas patients with uncomplicated appendicitis undergoing surgery require only a single preoperative dose.[7][86]
How to insert a peripheral venous cannula into the dorsum of the hand.
Evidence: Antibiotics in acute appendicitis
Evidence generally supports giving preoperative antibiotics for appendicitis.
Involve obstetric support for any pregnant woman with appendicitis as management requires a multidisciplinary approach.[84]
In the community:
Have a low threshold for urgently admitting:
Older patients
Pregnant women
Patients with signs of complications.
Arrange for patients with duration of symptoms <24 hours and who are systemically well to be seen in hospital within 24 hours.[85]
Give adequate analgesia.[27][37]
Paracetamol may be used, or give an opioid (e.g., morphine) if required.
Keep the patient nil by mouth if surgery is being considered.
Run intravenous maintenance fluids for any patient who is being kept nil by mouth.[27]
Appendicectomy is the standard treatment for uncomplicated appendicitis.[13]
Appendicectomy can be either open or laparoscopic.[7]
Laparoscopic appendicectomy is the first choice for most adults (including pregnant patients) provided an appropriately skilled surgeon is available.[7][27][105][106]
Same-day discharge after laparoscopic appendicectomy has been shown to be safe and without increased risk of complications, and may be suitable for certain patients.[7][107]
Do not give postoperative antibiotics in adults with uncomplicated acute appendicitis, because there is no evidence they decrease the rate of surgical infection.[7]
Demonstrates interrupted sutures, vertical mattress sutures, horizontal mattress sutures, continuous subcuticular sutures, and continuous sutures.
Evidence: Laparoscopic versus open appendicectomy in adults
Evidence shows that laparoscopic appendicectomy compares favourably with open appendicectomy and is the first choice for most adults.
[ 
]
[Evidence B]
The advantages of laparoscopic compared with open surgery are:[62][108][109][110]
However, laparoscopic appendicectomy is a slightly longer procedure and more expensive, and there is some evidence that it may be associated with an increased risk of an intra-abdominal abscess.[109][114]
In pregnant women, laparoscopic appendicectomy is now thought to be safe in terms of fetal loss and preterm delivery.[105][106][115]
A systematic review (published 2019, search date unclear) included 22 studies (4694 women; 905 laparoscopic appendicectomies and 3789 open appendicectomies) in a pooled analysis.[116]
While overall fetal loss was more common with laparoscopic appendicectomy (OR 1.72, 95% CI 1.22 to 2.42), this was driven by one large retrospective study (n=3133) which had high rates of complicated appendicitis (30%). Removing this study from the analysis resulted in no significant difference in fetal loss (OR 1.16, 95% CI 0.68 to 1.99).
Laparoscopic appendicectomy was also associated with no difference in preterm delivery (OR 0.76, 95% CI 0.51 to 1.15), and a reduction in both length of hospital stay and surgical site infection.
Patients >65 years have increased perioperative risks due to reduced physiological reserve.
Timing of surgery in uncomplicated appendicitis
Refer any patient with suspected or confirmed appendicitis within 24 hours even if they have uncomplicated appendicitis and are stable.
Ensure appendicectomy is not delayed unnecessarily. This is to minimise patient discomfort. Evidence suggests that delaying surgery by up to 24 hours does not increase the risk of perforation.[85]
Surgery might be delayed while you await investigation results, trial conservative management, or ensure adequate staffing levels.[7]
Minimise surgical delay for patients >65 years old and those with significant comorbidities; these patients may be at increased risk of perforation.[122]
Evidence: Timing of surgery
There is ongoing debate around the timing of appendicectomy in uncomplicated appendicitis.
Immediate surgery may reduce the number of cases of perforated/complicated appendicitis.[123] However, a strategy of delaying surgery while trialling conservative management can reduce the number of unnecessary operations (negative appendicectomies) in patients whose appendicitis will resolve without surgery.[7][124]
A prospective multicentre cohort study of 2510 patients found that:[85]
The risk of developing complicated appendicitis was not related to the timing of appendicectomy for those patients who had surgery delayed by 12-24 hours (odds ratio [OR] 0.98) or even >48 hours (OR 0.82)
Surgery at >48 hours was associated with a higher risk of surgical site infection and 30-day adverse event rate (OR 2.24 and 1.71, respectively) than surgery at <48 hours.
It is now accepted that perforation is a separate pathology rather than a progression of appendicitis.[7][13][125]
In practice, however, it is currently not possible to predict which patients have uncomplicated (non-perforating) appendicitis and which have appendicitis that will progress to perforation.[13]
In certain patient groups (patients >65 years, those with comorbidities, and those with a delay of more than 12 hours before surgery is performed) there is some evidence of increased risk of perforation. Minimise surgical delay in these groups.[122]
Conservative management with antibiotics
Consider conservative (non-operative) management with antibiotics for selected patients, including those who have uncomplicated appendicitis (suspected or confirmed on computed tomographic scan), and do not wish to have surgery, or are unfit to do so; ensure the patient is aware of the risk of recurrence of appendicitis.[2][13][87][90][92][93]
Do not use a conservative approach for pregnant patients.[7]
Do not use a conservative approach if an appendicolith is present, because non-operative management carries a significant failure rate.[2][7][126]
Discuss the risks of conservative management and all other potential treatment options with the patient so that they are able to make an informed decision.[127]
Check local protocols and seek advice from microbiology colleagues when prescribing antibiotics as drug regimens and length of treatment varies. Examples of regimens include ceftriaxone plus metronidazole, cefotaxime plus metronidazole, or amoxicillin/clavulanate.
Evidence: Conservative management
There is insufficient evidence to support conservative non-operative management, using antibiotics only, of uncomplicated acute appendicitis, unless the patient does not want, or is unfit for, surgery.[13][89][91]
More research is needed to establish whether a conservative approach has a role, in particular with respect to patient selection, recurrence rates, and the risk of missing an important underlying diagnosis such as malignancy.[89]
The rationale for a conservative approach is that not every appendicitis will lead to perforation, and there is a well-recognised group of patients with uncomplicated appendicitis that will resolve spontaneously.[88][128] Appendicectomy has been the gold standard treatment for over 100 years.[1] However, surgery comes with risk and potential complications that could be avoided with a conservative non-surgical approach.[90]
Conservative management is not associated with any increase in risk of developing a complication secondary to the appendicitis.[90][129]
A 5-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicentre randomised controlled trial compared appendicectomy with antibiotic therapy. Results showed that 100 of the 256 patients in the antibiotic group (39.1%) ultimately underwent appendicectomy during 5 years of follow-up. Most of these patients (70/100, 70%) had their episode of recurrent appendicitis within 1 year of initial presentation. No patient initially treated with antibiotics who ultimately developed recurrent appendicitis had any complications directly related to the delay in surgery. These findings demonstrate the feasibility of treating appendicitis with antibiotics alone, without surgery. Nearly two-thirds of all patients who initially presented with uncomplicated appendicitis were successfully treated with antibiotics alone; those who ultimately developed recurrent appendicitis did not experience any adverse outcomes related to the delay in appendicectomy.[130]
The APPAC trial compared open appendicectomy with antibiotic-only therapy for appendicitis. It involved 530 patients aged 18 to 60 of whom 273 were randomised to open appendicectomy and 257 to antibiotic therapy.[130]
It showed a 27% recurrence rate at 1 year following antibiotic-only management. At 5-year follow-up, the recurrence rate had risen to 39.1%.[130]
At 5 years, the proportion who had complications (surgical site infection, incisional hernias, abdominal pain, or obstructive symptoms) was much higher in the surgery group than in the antibiotic group (24% compared with 6.5%). This may have been partially related to the use of open rather than laparoscopic surgery.[130]
Seek a decision from a specialist paediatric surgeon regarding whether to proceed with non-operative management with antibiotics as an alternative to surgery in children. Consider conservative (non-operative) management with antibiotics in children, unless an appendicolith is present.[7]
Non-operative management with antibiotics is a safe and effective approach in the absence of appendicolith.[7] The risk of perforation is not increased if surgery is delayed by up to 24 hours.[7]
The family should be advised that non-operative management may not be successful and that misdiagnosis can occur.[7]
Check local protocols and seek advice from microbiology colleagues when prescribing antibiotics as drug regimens and length of treatment vary. Current evidence supports initial intravenous antibiotics with subsequent conversion to oral antibiotics.[7] Examples of regimens include amoxicillin/clavulanate, or ceftriaxone plus metronidazole.
Failure of medical management may be indicated by persistent fever, unremitting symptoms, or rising inflammatory markers.
Refer for surgery if an appendicolith is present, because the failure rate of non-operative management increases in these patients.[2][94]
If surgery is needed:
Ensure appendicectomy is not delayed for children with uncomplicated acute appendicitis beyond 24 hours[7]
Do not give postoperative antibiotics in children with uncomplicated acute appendicitis, because there is no evidence they decrease the rate of surgical infection[7]
Laparoscopic appendicectomy is preferred over open appendicectomy provided an appropriately skilled surgeon is available.[131]
Evidence: Laparoscopic versus open appendicectomy in children
For children with acute appendicitis, if surgery is needed, evidence shows that laparoscopic appendicectomy compares favourably with open appendicectomy as long as resources and an appropriately skilled surgeon are available.
The World Society of Emergency Surgery (WSES) 2020 guideline recommends laparoscopic appendicectomy over open surgery for children with acute appendicitis.[7] This is based on two systematic reviews published in 2017, one in children and the other from indirect evidence in adults.
The first systematic review (search date January 2000 to April 2016) included nine studies (one randomised controlled trial [RCT], one prospective cohort, and seven retrospective cohort studies) comparing laparoscopic and open surgery in children (aged <18 years) with perforated acute appendicitis.[132]
The review authors found that laparoscopic surgery was associated with a lower incidence of surgical site infection (relative risk [RR] 0.88, 95% CI 0.77 to 1.00) and bowel obstruction (RR 0.79, 95% CI 0.64 to 0.98).
However, intra-abdominal abscess was higher with laparoscopic surgery (RR 1.38, 95% CI 1.20 to 1.59).
The second systematic review (search date January 2016) included two RCTs and 14 retrospective cohort studies in adults with complicated acute appendicitis.[133]
Laparoscopic surgery reduced surgical site infection (odds ratio [OR] 0.28, 95% CI 0.25 to 0.31) without increasing the rate of postoperative intra-abdominal abscess (OR 0.79, 95% CI 0.45 to 1.34).
The operating times with laparoscopic surgery were longer than that with open surgery groups (weighted mean difference [WMD] 13.78 minutes, 95% CI 8.99 to 18.57), but the length of hospital stay was significantly shorter with laparoscopic surgery (WMD -2.47 days, 95% CI -3.75 to -1.19), as was the time to oral intake (WMD -0.88 days, 95% CI -1.20 to -0.55).
A subsequent systematic review (published 2019) in children with complicated appendicitis (six RCTS and 33 case-control studies) found similar results to the systematic review in adults included in the WSES guideline.[134]
Laparoscopic surgery reduced surgical site infections (OR 0.37, 95% CI 0.25 to 0.54) without an increase in intra-abdominal abscess formation (OR 1.01, 95% CI 0.71 to 1.43).
Operative time was shorter for open surgery (WMD 12.44 minutes, 95% CI 2.00 to 22.87). However, laparoscopic surgery also had a shorter length of hospital stay (WMD -0.96 days, 95% CI -1.47 to -0.45), lower incidences of postoperative ileus or intestinal obstruction, shorter time to oral intake, and reduced readmission and reoperation rates.
Complicated appendicitis occurs in 4% to 6% of patients and is defined as appendicitis with any one of:[13][19]
Gangrenous appendix with or without perforation
Intra-abdominal abscess
Peri-appendicular phlegmon
Purulent-free fluid.
Be aware that complications are more likely in patients who:[135][136][137]
Have longer duration of symptoms
Are >50 years old
Are female
Have a white blood cell count >16 x 109/L.
Request an immediate surgical review for any patient with confirmed or suspected complicated appendicitis.
Patients with a perforated appendix will need urgent appendicectomy. Laparoscopic appendicectomy is performed in the vast majority of patients in the UK and should be considered as the treatment of choice for most patients if the expertise is available.[95][96]
The optimal management for appendicitis with phlegmon or abscess remains subject to debate. Latest evidence suggests that laparoscopic appendicectomy is associated with fewer readmissions and fewer additional interventions than conservative management, provided advanced laparoscopic expertise is available.[7][138]
However, if the patient has an appendiceal abscess/phlegmon, is stable, and laparoscopic appendicectomy is unavailable, conservative treatment with intravenous antibiotics and percutaneous image-guided drainage is a reasonable alternative.[7]
Check local protocols and seek advice from microbiology colleagues when prescribing antibiotics.
Interval appendicectomy should be considered if the symptoms do not completely resolve and/or if symptoms recur.[7][13]
Ensure any patient aged >40 years who has conservative management without interval appendicectomy also has investigations to rule out colon malignancy; these should include colonoscopy and interval full-dose contrast-enhanced CT scan.[7]
Demonstrates interrupted sutures, vertical mattress sutures, horizontal mattress sutures, continuous subcuticular sutures, and continuous sutures.
Evidence: Laparoscopic versus open appendicectomy in complicated appendicitis
There is ongoing debate about the optimum approach for the management of complicated appendicitis in adults. Current evidence suggests a laparoscopic approach may have advantages compared with open appendicectomy.[96]
Studies have produced conflicting evidence on the best approach to surgery in complicated appendicitis.
A 2017 systematic review of two randomised controlled trials (RCTs) and 14 retrospective cohort studies comparing open versus laparoscopic appendicectomy for perforated appendicitis found the laparoscopic approach reduced the risk of surgical site infection (odds ratio [OR] 0.28) with no increase in risk of intra-abdominal abscess (OR 0.79).[133]
One retrospective cohort study of 150 patients with perforated appendicitis with abscess or peritonitis found a laparoscopic approach reduced the incidence of surgical site infection and repeat surgery and led to a shorter length of stay compared with open surgery.[139] Another study reported a lower rate of small bowel obstruction after laparoscopic compared with open surgery (pooled OR 0.44).[96]
An RCT of 81 patients with complicated appendicitis found no significant difference in outcomes between laparoscopic and open appendicectomy.[140]
However, another study found a higher rate of intra-abdominal abscess after laparoscopic compared with open surgery (6.7 vs. 3.7%).[141]
The World Society of Emergency Surgery guideline concludes that a laparoscopic approach may have benefits over open surgery provided the surgeon is experienced in the procedure.[7]
A 2017 systematic review (3 RCTs and 23 case-control studies) found that laparoscopic appendicectomy reduced morbidity compared with open appendicectomy in people with complicated acute appendicitis (surgical site infections: OR 0.30 [95% CI 0.22 to 0.40]; time to oral intake: weighted mean difference -0.98 days [95% CI -1.09 to -0.86 days]; length of hospital stay: weighted mean difference -3.49 days [95% CI -3.70 to -3.29 days]; no significant difference in intra-abdominal abscess rates).[142]
Operative time was longer with laparoscopic appendicectomy, however this did not reach statistical significance in the RCT subgroup analysis.
Evidence: Conservative versus surgical approach for appendiceal abscess/phlegmon
There is ongoing debate about the best approach for patients with an appendiceal abscess/phlegmon.
In the past, evidence has favoured initial conservative management.
A 2010 meta-analysis included 17 studies and 1572 patients who had complicated appendicitis with abscess or phlegmon. It found that conservative treatment, when compared with immediate surgery, was associated with lower rates of complications (wound infection, abdominal abscess, bowel obstruction, or need for repeat surgery).[143]
Similarly, a 2007 systematic review of 61 mainly retrospective studies found immediate surgery was associated with higher rates of morbidity compared with conservative management (OR 3.3, 95% CI 1.9 to 5.6).[144]
More recent evidence has suggested that early surgery may be preferable, where laparoscopic expertise is available.
Data from the US National Inpatient Sample found that of 2209 adults with appendiceal abscess managed conservatively with drainage, 25.4% required surgery.[145]
A 2019 systematic review identified 21 studies (17 retrospective, 1 prospective and 3 randomised controlled trials [RCTs]; n=1864) comparing surgical (laparoscopic or open appendicectomy) versus conservative treatment for complicated appendicitis.[146]
Overall complications, abdominal/pelvic abscesses, wound infections, and unplanned procedures were significantly lower in the conservative treatment cohort in the general analysis.
However, subgroup analysis of the 3 RCTs (n=140) found no significant difference in abdominal/pelvic abscesses (OR 0.46, 95% CI 0.17 to 1.29).
Analysis from the 2 RCTs rated as high quality (assessed using the Newcastle-Ottawa scale) showed a shorter hospital stay with laparoscopic appendicectomy compared with conservative treatment (mean difference -0.99 days, 95% CI -1.31 to -0.67 days).
All the RCTs were published since 2010 and the systematic review authors used a cumulative meta-analysis to show that, with respect to the outcome of abdominal or pelvic abscesses, there was a shift towards favouring laparoscopic appendicectomy as it has become more widespread.
The most recent of the high-quality RCTs (published 2015) compared 30 patients who had immediate laparoscopic surgery with 30 who had conservative treatment. It found that the conservatively managed group required more additional interventions. These additional interventions were surgery in the conservatively managed group and percutaneous drainage in the immediate laparoscopic surgery group.[147]
Evidence: Role of interval appendicectomy
The role of routine interval appendicectomy remains controversial. The risk of perioperative morbidity needs to be weighed against the risk of recurrence of appendicitis and the age-related incidence of underlying malignancy.[7]
Debate continues as to whether patients with abscess/phlegmon who are initially managed conservatively need routine 'interval appendicectomy' at a later date (typically at 6 weeks).
Some experts advocate routine interval appendicectomy to avoid:
Any risk of recurrence of appendicitis, which has been reported to vary from 7.3% in one systematic review to as high as 27% at 2 months in one randomised controlled trial (RCT)[144][147]
Missing an underlying malignancy (incidence 6%)[13]
The incidence of an underlying malignancy increased to 29% in patients over 40 years of age who had a peri-appendicular abscess in one study.[148] However, interval appendicectomy has been found to carry a morbidity risk of 12.4%.[144]
In a retrospective study of people who underwent appendicectomy for acute appendicitis, 3% of those aged ≥60 years had unexpected malignancy compared with 1.5% of those aged <60 years.[149]
A 2019 RCT comparing interval appendicectomy versus follow up with MRI was stopped early when the interim analysis showed a high rate of malignancy (10/60 [17%], all in people aged >40 years).[148]
The risk of appendiceal neoplasm in patients treated initially with non-operative management of complicated appendicitis is 11%, increasing to 16% in patients aged 50 years and older and 43% in patients aged over 80 years.[150][151][152]
The World Society of Emergency Surgery’s 2020 Jerusalem guideline recommends:[7]
Interval appendicectomy for patients with recurrent symptoms
Colonoscopy and interval full-dose contrast-enhanced CT scan for any patient >40 years of age who is conservatively managed, to reduce the risk of missing a malignancy.[151]
The European Association for Endoscopic Surgery 2015 consensus statement concluded that although there is a rationale for routine interval appendicectomy, data on its benefits are lacking.[13]
The 2019 US Eastern Association for the Surgery of Trauma guideline made a conditional recommendation against routine interval appendicectomy in adults who are otherwise asymptomatic.[153]
They identified 3 observational studies, which showed an increased risk of recurrence without interval appendicectomy (RR 14.16, 95% CI 2.74 to 73.11, quality of evidence assessed as low using GRADE). This represented an increased risk from 15.8% overall with non-operative management to 24.3% in those patients who did not have routine interval appendicectomy.
Therefore the guideline panel felt surgery was only required for people with symptoms of recurrence due to the risk of perioperative complications. They also noted that the decision should also take into consideration the patient's age (due to the progressive increased incidence of malignancy in those >40 years), although they felt that in general the risk of appendiceal malignancy was very low, noting an overall incidence of 0.97 per 100,000 population.
Give postoperative antibiotics to any patient with complicated appendicitis.[7]
Seek advice from microbiology colleagues on the choice of antibiotic as this will be guided by local resistance patterns. Examples of regimens include amoxicillin plus metronidazole, piperacillin/tazobactam, or amoxicillin/clavulanate.
Continue antibiotics typically for 3 to 5 days; start with intravenous and then switch to oral administration.
Discontinue antibiotics based on resolving clinical signs (e.g., fever) and laboratory criteria (e.g., leukocytosis).
Complicated appendicitis is strongly associated with an increased risk of surgical site infection; the postoperative complication rate is up to 4 times higher in complicated compared with uncomplicated appendicitis.[13]
Complicated appendicitis occurs in less than 19% of children.[7] It is defined as appendicitis with any one of:[13][19]
Gangrenous appendix with or without perforation
Intra-abdominal abscess
Peri-appendicular phlegmon
Purulent-free fluid.
Have a low threshold of suspicion for considering complicated appendicitis in children, especially in those of preschool age. This group is less able to articulate their symptoms. They often present with atypical features, more rapid progression, and higher incidence of complications.[154][155][156]
Request an immediate surgical review for any patient with confirmed or suspected complicated appendicitis.
Early appendicectomy should be performed within 8 hours.[7]
Laparoscopic appendicectomy is preferred over open appendicectomy where laparoscopic equipment and expertise are available.[7][157] Laparoscopic appendicectomy decreases the incidence of overall postoperative complications, including wound infection and duration of total hospital stay.[132][133]
The optimal management for appendicitis with phlegmon or abscess remains subject to debate. Laparoscopic appendicectomy is associated with fewer readmissions and fewer additional interventions than conservative management, provided advanced laparoscopic expertise is available.[7][138]
However, if the patient with phlegmon or abscess is stable and laparoscopic appendicectomy is unavailable, conservative treatment with intravenous antibiotics and percutaneous image-guided drainage is a reasonable alternative.[7]
Meta-analyses in children with phlegmon or abscess have found that non-operative management is associated with lower complication and readmission rates and reduced length of hospital stay.[158][159]
Check local protocols and seek advice from microbiology colleagues when prescribing antibiotics.
Interval appendicectomy should be considered if the patient has had conservative management and symptoms persist or recur.[7]
Evidence: Laparoscopic versus open appendicectomy in children
For children with acute appendicitis, if surgery is needed, evidence shows that laparoscopic appendicectomy compares favourably with open appendicectomy as long as resources and an appropriately skilled surgeon are available.
The World Society of Emergency Surgery (WSES) 2020 guideline recommends laparoscopic appendicectomy over open surgery for children with acute appendicitis.[7] This is based on two systematic reviews published in 2017, one in children and the other from indirect evidence in adults.
The first systematic review (search date January 2000 to April 2016) included nine studies (one randomised controlled trial [RCT], one prospective cohort, and seven retrospective cohort studies) comparing laparoscopic and open surgery in children (aged <18 years) with perforated acute appendicitis.[132]
The review authors found that laparoscopic surgery was associated with a lower incidence of surgical site infection (relative risk [RR] 0.88, 95% CI 0.77 to 1.00) and bowel obstruction (RR 0.79, 95% CI 0.64 to 0.98).
However, intra-abdominal abscess was higher with laparoscopic surgery (RR 1.38, 95% CI 1.20 to 1.59).
The second systematic review (search date January 2016) included two RCTs and 14 retrospective cohort studies in adults with complicated acute appendicitis.[133]
Laparoscopic surgery reduced surgical site infection (odds ratio [OR] 0.28, 95% CI 0.25 to 0.31) without increasing the rate of postoperative intra-abdominal abscess (OR 0.79, 95% CI 0.45 to 1.34).
The operating times with laparoscopic surgery were longer than that with open surgery groups (weighted mean difference [WMD] 13.78 minutes, 95% CI 8.99 to 18.57), but the length of hospital stay was significantly shorter with laparoscopic surgery (WMD −2.47 days, 95% CI −3.75 to −1.19), as was the time to oral intake (WMD −0.88 days, 95% CI −1.20 to −0.55).
A subsequent systematic review (published 2019) in children with complicated appendicitis (six RCTS and 33 case-control studies) found similar results to the systematic review in adults included in the WSES guideline.[134]
Laparoscopic surgery reduced surgical site infections (OR 0.37, 95% CI 0.25 to 0.54) without an increase in intra-abdominal abscess formation (OR 1.01, 95% CI 0.71 to 1.43).
Operative time was shorter for open surgery (WMD 12.44 minutes, 95% CI 2.00 to 22.87). However, laparoscopic surgery also had a shorter length of hospital stay (WMD -0.96 days, 95% CI -1.47 to -0.45), lower incidences of postoperative ileus or intestinal obstruction, shorter time to oral intake, and reduced readmission and reoperation rates.
Give postoperative antibiotics to any child with complicated appendicitis.[7]
Seek advice from microbiology colleagues on the choice of antibiotic as this will be guided by local resistance patterns. Examples of regimens include piperacillin/tazobactam and amoxicillin/clavulanate.
Continue postoperative antibiotics for less than 7 days; start with intravenous and then switch to oral administration after 48 hours.
Discontinue antibiotics based on resolving clinical signs (e.g., fever) and laboratory criteria (e.g., leukocytosis).
Complicated appendicitis is strongly associated with an increased risk of surgical site infection; the postoperative complication rate is up to 4 times higher in complicated compared with uncomplicated appendicitis.[13]
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