Approach

The usual standard of care for the management of uncomplicated appendicitis in adults continues to be operative.

There is emerging evidence to suggest that a nonoperative, antibiotic-only approach may be feasible in select patient populations. The evidence supporting nonoperative management of appendicitis continues to be conflicting, and further research is warranted. There is more evidence to support a nonoperative approach in children than in adults.[10][66][67][68][69][70][71][72][73]

Uncomplicated presentation

Once the diagnosis of acute appendicitis is made, patients should be given nothing by mouth.

Intravenous fluids, such as lactated Ringer solution, should be started.

Adults

Prompt appendectomy remains the treatment of choice in international guidelines and should be recommended in most cases. A single preoperative dose of broad-spectrum antibiotic such as cefoxitin should be given to patients with uncomplicated appendicitis undergoing appendectomy. Postoperative antibiotics are not indicated.[10]

An antibiotic-only approach may be reasonable for select groups with uncomplicated appendicitis (suspected or confirmed on computed tomographic scan), where patients understand the risk of recurrent appendicitis.[10][73][71]

An antibiotic-only approach is not recommended if an appendicolith is present since nonoperative management carries a significant failure rate.[10][74] A conservative approach should be avoided in pregnant patients.[10]

Children

Guidance from the World Society of Emergency Surgery supports nonoperative management as feasible, safe, and effective as initial treatment unless an appendicolith is present.[10] However, in the US the usual standard of care for the management of uncomplicated appendicitis in children continues to be operative. Postoperative antibiotics are not indicated in children with uncomplicated acute appendicitis since there is no evidence they decrease the rate of surgical infection.[10]

Appendicectomy should not be delayed for children with uncomplicated acute appendicitis needing surgery beyond 24 hours from admission. Surgery performed within this time is not associated with increased risk of adverse outcomes such as perforation, complications, or operating time in children who receive timely administration of antibiotics and undergo appendectomy less than 24 hours after diagnosis.[10]

As for adults, surgery is not recommended in children with appendicoliths since the failure rate of nonoperative management increases in these cases.[10]

Complicated presentation

Adults

Complications of acute appendicitis occur in 4% to 6% of patients and include gangrene with subsequent perforation or intra-abdominal abscess.[16]

Initial management includes keeping the patient nothing by mouth and starting intravenous fluids. Patients who are in shock should be given a bolus of intravenous fluid, such as lactated Ringer solution, in order to maintain a stable pulse rate and BP.[75][76]

Intravenous antibiotics (e.g., cefoxitin or piperacillin/tazobactam) should be started immediately and continued until the patient becomes afebrile and the leukocytosis is corrected. For more severe infections, a carbapenem antibiotic may be used as a single agent. Combination antibiotic regimens may also be used based on local sensitivities and protocols.[16]

In patients with acute peritonitis, appendectomy should be performed without delay. Patients presenting with right lower quadrant abscess should be managed with intravenous antibiotics and drainage either by interventional radiology (computed tomography-guided drainage) or by operative drainage. If there is clinical improvement and the signs and symptoms are completely resolved, interval appendectomy may be unnecessary.[10][77][78][79][80]

Interval appendectomy is associated with a non-negligible rate of morbidity.[79]

Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved.[10][11] Adoption of a wait-and-see approach, reserving appendectomy for patients with recurrent symptoms, is the most cost-effective strategy compared with routine interval appendectomy.[10]

The incidence of appendicular neoplasms is high (3% to 17%) in patients ≥40 years old with complicated appendicitis. Any patient ages ≥40 years who has conservative management without interval appendicectomy should also undergo screening with colonoscopy and interval full-dose contrast-enhanced CT scan.[10]

The optimal management for appendicitis with phlegmon or abscess remains subject to debate.[10] Latest evidence suggests that laparoscopic appendectomy is associated with fewer readmissions and fewer additional interventions than conservative management, provided advanced laparoscopic expertize is available.[10] However, nonoperative management with antibiotics and, if available, percutaneous image-guided drainage is a reasonable alternative if the patient is stable and laparoscopic appendectomy is unavailable, although there is a lack of evidence for its use on a routine basis.[10]

Children

As with adults, initial management includes keeping the patient nothing by mouth and starting intravenous fluids and intravenous antibiotics. Early appendectomy within 8 hours should be performed in case of complicated appendicitis.[10] Laparoscopic appendectomy is preferred over open appendectomy in children where laparoscopic equipment and expertize are available.[10] Postoperative antibiotics for less than seven days seems to be safe and is not associated with an increased risk of complications. These can be switched from intravenous to oral form after 48 hours in children with complicated appendicitis with an overall length of therapy shorter than seven days.[10]

As per management of adults with phlegmon or abscess, nonoperative management (antibiotics and, if available, percutaneous image-guided drainage) is a reasonable alternative if the patient is stable and laparoscopic appendectomy is unavailable. Nonoperative management has been associated with better results in terms of complication rate and readmission rate in children but evidence does not support its routine use.[81]

Surgical options

There are 2 operative options for appendectomy: open and laparoscopic. Most procedures are now undertaken laparoscopically.

In adults, the choice of appendectomy generally depends upon the experience of the surgeon. Studies have shown laparoscopic appendectomy to have better cosmetic results, shorter length of hospital stay, reduced postoperative pain, and reduced risk of wound infection, compared with open appendectomy.[82] [ Cochrane Clinical Answers logo ] [Evidence B] Laparoscopic appendectomy is recommended for uncomplicated appendicitis, as well as complicated and perforated appendicitis.[83][84] It is also considered the safest approach in obese patients.[10][85] 

In children, laparoscopic appendectomy decreases the incidence of overall postoperative complications, including wound infection and duration of total hospital stay.[86][87][82][88][89]


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In pregnant patients, laparoscopic appendectomy should be preferred to open appendectomy when surgery is indicated and where expertize of laparoscopy is available. It is safe in terms of risk of fetal loss and preterm delivery. Compared to open surgery during pregnancy, laparoscopic appendectomy is associated with shorter length of hospital stay and lower incidence of surgical site infection. Laparoscopy is technically safe and feasible during pregnancy.[10][91]

Antibiotic-only therapy

Antibiotics alone for the treatment of uncomplicated appendicitis can be successful in selected patients who wish to avoid surgery, and who accept the risk of up to 39% recurrence. In such cases, it is recommended that the diagnosis of uncomplicated appendicitis is confirmed by imaging, and that patient expectations are managed via a shared decision-making process.[10][92][71][73] An antibiotic-only approach is not recommended in pregnant patients or if an appendicolith is present.[10][74]

Outpatient laparoscopic appendectomy

Some patients may be discharged safely after laparoscopic appendectomy without hospitalization. This outpatient approach is suitable for patients with uncomplicated appendicitis, provided that an ambulatory pathway with well-defined ERAS (Enhanced Recovery After Surgery) protocols and patient information/consent are locally established.[10] ERAS implementation after laparoscopic appendectomy carries similar rates of morbidity and readmissions compared with conventional care.[93] Its potential benefits include earlier recovery after surgery and lower hospital and social costs.[10]

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