From the Guidelines
Acute appendicitis requires prompt surgical intervention, preferably via laparoscopic appendectomy, to minimize complications and improve quality of life, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. The symptoms of acute appendicitis typically include right lower quadrant pain, often starting periumbilically, with nausea, vomiting, and fever. Diagnosis is based on clinical presentation, laboratory findings, such as an elevated white blood cell count, and imaging, including ultrasound or CT scan.
Treatment Options
- Laparoscopic appendectomy is the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, due to its significant advantages, including less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, overall costs, and better quality of life scores 1.
- Prior to surgery, patients should receive intravenous antibiotics, such as a combination of cefazolin and metronidazole, or piperacillin-tazobactam for more severe cases, as well as pain management, typically including acetaminophen and/or ketorolac 1.
- Conventional three-port laparoscopic appendectomy is recommended over single-incision laparoscopic appendectomy, due to its shorter operative times, less postoperative pain, and lower incidence of wound infection 1.
- In pediatric patients with acute appendicitis and favorable anatomy, single incision/transumbilical extracorporeal laparoscopic-assisted appendectomy or traditional three-port laparoscopic appendectomy may be considered, based on local skills and expertise 1.
- Outpatient laparoscopic appendectomy for uncomplicated acute appendicitis is feasible and safe, without any difference in morbidity, and may be adopted in an ambulatory setting 1.
Timing of Appendectomy
- Short, in-hospital surgical delay up to 24 h is safe in uncomplicated acute appendicitis and does not increase complications and/or perforation rate in adults, and appendectomy should be planned, minimizing the delay wherever possible 1.
- Delaying appendectomy for acute appendicitis needing surgery beyond 24 h from admission is not recommended, as it may increase the risk of adverse outcomes 1.
- In pediatric patients with uncomplicated acute appendicitis needing surgery, early appendectomy within 8 h should be performed in case of complicated appendicitis, and delaying appendectomy beyond 24 h from admission should be avoided 1.
From the Research
Symptoms of Acute Appendicitis
- Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever 2
- Abdominal pain which localizes in the right lower quadrant is a well-recognized clinical presentation of acute appendicitis, more typical in men than in women of childbearing age 3
Treatment Options for Acute Appendicitis
- Laparoscopic appendectomy remains the most common treatment for acute appendicitis 2
- Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluoroquinolones with metronidazole, can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2
- Antibiotic therapy can be used as an alternative to immediate appendectomy in selected patients with uncomplicated appendicitis, with a cure rate of 73.4% within two weeks without major complications (including recurrence) within one year 4
- Endoscopic retrograde appendicitis therapy (ERAT) has emerged as a promising non-invasive treatment modality for acute uncomplicated appendicitis, with a recurrence rate of up to 30% at 1 year for patients treated with antibiotics, compared to 5-7% for ERAT 5
- Patients with complicated acute appendicitis, such as those with a large appendiceal abscess or phlegmon, should undergo timely surgical intervention, while those with high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix, may require surgical management 2, 3
Patient-Specific Treatment Considerations
- Pregnant patients and immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications 3
- Patients who are unfit for surgery may be considered for an antibiotics-first approach, with surgery reserved for those who fail antibiotic treatment 2
- The choice of treatment should be based on individual patient characteristics, including the presence of high-risk CT findings, and patient preferences 2, 6