From the Guidelines
The management of acute appendicitis in New Zealand primarily involves surgical intervention through laparoscopic appendectomy, which is the gold standard treatment, as recommended by the 2020 update of the WSES Jerusalem guidelines 1.
Key Considerations
- The standard approach includes initial stabilization with intravenous fluids and analgesia, followed by antibiotic prophylaxis, typically with cefuroxime and metronidazole, as supported by the guidelines 1.
- For uncomplicated appendicitis, a single preoperative dose of antibiotics is sufficient, while complicated cases require continued antibiotics for 3-5 days, as outlined in the guidelines 1.
- Non-operative management with antibiotics alone may be considered in select uncomplicated cases, particularly when surgical resources are limited or in patients with significant comorbidities, but this approach carries a 30% risk of recurrence within one year, as noted in the guidelines 1.
Surgical Approach
- Laparoscopic appendectomy is preferred over open appendectomy due to its association with less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, and better quality of life scores, as recommended by the guidelines 1.
- The surgical approach allows for definitive removal of the inflamed appendix, preventing recurrence and enabling histological examination to rule out malignancy, which occurs in approximately 1% of appendectomy specimens, as supported by the guidelines 1.
Post-Operative Care
- Post-operative care includes early mobilization, oral intake as tolerated, and discharge typically within 24-48 hours for uncomplicated cases, as outlined in the guidelines 1.
- The management of acute appendicitis in New Zealand should prioritize laparoscopic appendectomy as the primary treatment option, with non-operative management considered only in select cases, due to the benefits of surgical intervention in reducing morbidity, mortality, and improving quality of life, as recommended by the guidelines 1.
From the Research
Management of Acute Appendicitis in New Zealand
- The management of acute appendicitis in New Zealand is based on the presentation of the patient and dividing it into uncomplicated and complicated disease 2.
- Uncomplicated appendicitis can be managed with antibiotics alone, while complicated appendicitis requires timely surgical intervention 2.
- A study conducted in South Auckland, New Zealand, found that appendicitis does not vary in incidence across the major ethnic groups of New Zealand European, Maori, and Pacific people 3.
- However, the study found that Maori and Pacific people had a trend towards a greater proportion of perforated appendicitis, which was not related to delayed presentation to hospital 3.
- The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging, with classic symptoms including vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever 4.
- Laparoscopic appendectomy remains the most common treatment, but increasing evidence suggests that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 4.
Treatment Approaches
- Non-operative management (NOM) with antibiotics and aggressive intravenous hydration is a valid treatment option for healthy adults and poor surgical candidates 5.
- Surgical appendectomy is recommended for patients with high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix greater than 13 mm 4.
- Interval appendectomy (IA) can be considered for patients with a contained appendiceal perforation on initial presentation, and can help distinguish malignant and non-malignant causes of acute appendicitis 5.
- The timing of surgery and the role of IA should be based on patient characteristics and the severity of appendicitis 5.
Patient Considerations
- Pregnant patients and immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications 2.
- Patients with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management 2.
- The decision to delay appendectomy for a few hours on index admission should be made based on the patient's baseline health status and severity of appendicitis 5.