What is the management of acute appendicitis?

From the Guidelines

The management of acute appendicitis should involve prompt surgical intervention with laparoscopic appendectomy as the preferred approach, due to its significant advantages over open appendectomy in terms of less pain, lower incidence of surgical site infection, and better quality of life scores, as recommended by the 2020 update of the WSES Jerusalem guidelines 1.

Key Considerations

• For uncomplicated acute appendicitis, laparoscopic appendectomy is the recommended treatment, minimizing delay wherever possible, with a short, in-hospital surgical delay of up to 24 hours being safe and not increasing complications or perforation rate in adults 1.
• The use of intravenous antibiotics with subsequent conversion to oral antibiotics is recommended in the case of non-operative management (NOM), based on patient's clinical conditions, with a moderate quality of evidence and strong strength of recommendation 1.
• Delaying appendectomy for uncomplicated acute appendicitis for up to 24 hours after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical site infection, or morbidity, but appendectomies performed after 24 hours from admission are related to an increased risk of adverse outcomes 1.

Surgical Approach

• Laparoscopic appendectomy offers significant advantages over open appendectomy, 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, with a high quality of evidence and strong strength of recommendation 1.
• Conventional three-port laparoscopic appendectomy is preferred over single-incision laparoscopic appendectomy, due to shorter operative times, less postoperative pain, and lower incidence of wound infection, with a high quality of evidence and strong strength of recommendation 1.

Special Considerations

• In pediatric patients with acute appendicitis, laparoscopic appendectomy should be preferred over open appendectomy, where laparoscopic equipment and expertise are available, with a moderate quality of evidence and strong strength of recommendation 1.
• Outpatient laparoscopic appendectomy for uncomplicated acute appendicitis is feasible and safe, without any difference in morbidity, provided that an ambulatory setting is available, with a suggestion for its adoption 1.

From the Research

Diagnosis and Management of Acute Appendicitis

The management of acute appendicitis involves a combination of clinical evaluation, laboratory tests, and imaging studies. The diagnosis is typically made based on history, physical examination, laboratory evaluation, and imaging findings, with approximately 90% of patients presenting with classic symptoms such as vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever 2, 3, 4.

Treatment Options

Treatment options for acute appendicitis include:

• Laparoscopic appendectomy, which remains the most common treatment 2
• Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, which can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2
• Non-operative management with antibiotics, which can be considered as first-line therapy in selected patients with uncomplicated appendicitis 3, 5, 6

Patient Selection for Antibiotics-First Approach

The decision to use an antibiotics-first approach should be based on patient selection, with consideration of factors such as:

• Presence of high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix greater than 13 mm, which are associated with a higher risk of treatment failure 2
• Patient fitness for surgery, with surgical management recommended for patients who are fit for surgery and have high-risk CT findings 2
• Patient preferences, with a shared decision-making approach recommended for patients with uncomplicated appendicitis without risk factors for failure of non-operative management 3

Complicated Appendicitis

Management of complicated appendicitis depends on the clinical state, with options including:

• Immediate surgery 3, 4
• Primarily antibiotic therapy, combined with drainage of abscess, followed by interval appendectomy in some cases 3, 4
• Percutaneous drainage and antibiotic management for patients presenting with a large appendiceal abscess or phlegmon 4

Special Considerations

Certain patient populations, such as pregnant patients and immunosuppressed patients, should be considered for surgical intervention to decrease the risk of complications 4.