What is the treatment for a ruptured base of the appendix (vermiform appendix)?

From the Guidelines

The treatment for a ruptured base of the appendix involves immediate surgical intervention with appendectomy, followed by postoperative broad-spectrum antibiotics for 3-5 days, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. The surgical approach may be either open or laparoscopic, depending on the patient's condition and surgeon preference.

• Broad-spectrum intravenous antibiotics should be started immediately and continued postoperatively,
• The optimal course of antibiotics remains to be identified, but current evidence suggests that longer postoperative courses do not prevent surgical site infections (SSI) compared with 2 days of antibiotics 1.
• A recent RCT comparing the outcomes of short (24 h) and the extended (> 24 h) postoperative antibiotic therapy in complicated acute appendicitis found that 24 h of antibiotic therapy following appendectomy does not result in worse primary outcomes, but results in a significant reduction in length of hospitalization 1.
• Fluid resuscitation with crystalloids is essential to maintain hemodynamic stability,
• Pain management with opioid analgesics should be provided,
• Close monitoring for complications like abscess formation, sepsis, or wound infection is crucial. The ruptured appendix base presents higher surgical challenges than standard appendicitis due to friable tissue and potential for stump closure difficulties, sometimes necessitating partial cecectomy or ileocecectomy in severe cases to ensure complete removal of infected tissue and secure closure.
• The 2020 WSES Jerusalem guidelines recommend against prolonging antibiotics longer than 3–5 days postoperatively in case of complicated appendicitis with adequate source control, with a high quality of evidence and strong strength of recommendation [QoE: High; Strength of recommendation: Strong; 1A] 1.

From the Research

Treatment for Ruptured Base of the Appendix

The treatment for a ruptured base of the appendix, also known as acute appendicitis, can vary depending on the severity of the condition and the patient's overall health.

• The standard treatment for acute appendicitis is appendectomy, which is the surgical removal of the appendix 2, 3.
• However, in some cases, antibiotic therapy may be used as an alternative to immediate appendectomy, especially in patients with uncomplicated appendicitis 2, 4.
• The use of broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluoroquinolones with metronidazole, has been shown to be effective in treating uncomplicated acute appendicitis in approximately 70% of patients 2.
• In patients with perforated appendicitis, a dual antibiotic regimen consisting of ceftriaxone and metronidazole has been shown to be a cost-effective and efficient mode of therapy compared to triple antibiotic therapy 5, 6.
• The choice of treatment ultimately depends on the individual patient's condition and the surgeon's professional judgment 2, 3.

Considerations for Treatment

When considering treatment for a ruptured base of the appendix, the following factors should be taken into account:

• The severity of the condition, including the presence of perforation or abscess 2, 3.
• The patient's overall health and medical history 2, 4.
• The risk of complications, such as wound infections or antibiotic resistance 5, 6.
• The patient's preferences and values, including their willingness to undergo surgery or antibiotic therapy 2, 4.