Interval appendectomy as a safe and feasible treatment approach after conservative treatment for appendicitis with abscess: a retrospective, single-center cohort study

Emergency appendectomy (EA) is the gold standard management for acute appendicitis (AA). However, whether EA or interval appendectomy (IA) after conservative treatment is the optimal approach in AA with abscess remains controversial. This study compared IA and EA in patients presenting with AA accompanied by abscess. This was a retrospective single-center study including 446 consecutive patients undergoing appendectomy between April 2009 and March 2023. AA with abscess was defined as a pericecal abscess observed by computed tomography or abdominal ultrasonography, and patients with signs of peritoneal irritation were excluded. Perioperative outcomes were compared between the patients who directly underwent EA and those who underwent IA after conservative treatment. Among 42 patients (9.4%) with AA and abscess, 34 and 8 patients underwent IA and EA, respectively. The rates of ileocecal resection and postoperative complications were lower in the IA group than in the EA group (3% vs. 50%, P < 0.001 and 9% vs. 75%, P < 0.001, respectively). Colonoscopy before IA was performed in 16 of the 17 patients aged ≥ 40 years in the IA group, and one patient underwent ileocecal resection because of suspicious neoplasm in the root of the appendix. IA after conservative treatment might be considered as the useful therapeutic option for AA with abscess. Colonoscopy during the waiting period between the initial diagnosis and IA should be considered in patients aged ≥ 40 years who may have malignant changes. Implementing IA as a first-line treatment will be beneficial to both patients and healthcare providers.

Emergency appendectomy versus elective appendectomy following conservative treatment for acute appendicitis: a multicenter retrospective clinical study by the Japanese Society for Abdominal Emergency Medicine

PURPOSE

To establish the best treatment strategy for acute appendicitis.

METHODS

We collected data on 2142 appendectomies performed in 2017 and compared the backgrounds and surgical outcomes of patients who underwent early surgery (ES) (< 48 h) with those managed with non-ES (> 48 h). We performed a risk factor analysis to predict postoperative complications and subgroup analysis to propose a standard treatment strategy.

RESULTS

The incidence of postoperative complications was significantly higher in the ES group than in the non-ES group, and significantly lower in the laparoscopic surgery group than in the laparotomy group. Surgical outcomes, including the incidence of postoperative complications, were comparable after acute surgery (< 12 h) and subacute surgery (12-48 h), following antibiotic treatment. The risk factors for postoperative complications in the ES group were a higher age, history of abdominal surgery, perforation, high C-reactive protein level, histological evidence of gangrenous or perforated appendicitis, a long operation time, and intraoperative complications. The risk factors for postoperative complications in the non-ES group were perforation and unsuccessful conservative treatment.

CONCLUSIONS

Non-early appendectomy is feasible for acute appendicitis but should be applied with care in patients with risk factors for postoperative complications or failure of pretreatment, including diabetes mellitus, abscess formation, and perforation.

Is a pediatrician performed gray scale ultrasonography with power Doppler study safe and effective for triaging acute non-perforated appendicitis for conservative management?

PURPOSE

The purpose of this study was to examine whether acute non-perforated appendicitis (ANPA) can be safely triaged by a pediatrician for conservative management (CM) using gray-scale ultrasonography with power Doppler (GSPD).

METHOD

Seventy five cases of ANPA assessed by a pediatrician with GSPD (2013-2015) were reviewed. GSPD grading for ANPA was: I: slightly irregular wall/normal blood flow; II: irregular wall/increased blood flow; III: irregular wall/decreased blood flow; and IV: absence of wall/blood flow. Grades I/II were managed conservatively with intravenous antibiotics then encouraged to book for interval appendectomy (IA). Grades III/IV were reviewed for emergency appendectomy (EA) by a pediatric surgeon.

RESULTS

GSPD grading was I (n=26), II (n=36), III (n=9), and IV (n=4). EA was required for 5 cases, one grade III, and four grade IV cases. One grade IV case was treated conservatively after surgical review but EA was unavoidable. Of the remaining 70 cases discharged well after a mean of 5.7days hospitalization, 25/70 had IA with chronic inflammation on histology, 6/70 had recurrence of ANPA treated successfully by EA, and 39/70 remain asymptomatic at least 10months after declining IA. Overall, GSPD triaging with CM was cheaper than surgery.

CONCLUSIONS

GSPD performed by pediatricians appears to be safe/effective for triaging ANPA.

LEVEL OF EVIDENCE

Level III.