Treatment of Secondary Appendicitis
The treatment of secondary appendicitis involves surgical management with laparoscopic appendectomy as the preferred approach, combined with appropriate antibiotic therapy based on the severity of the condition. 1
Surgical Management
- Laparoscopic appendectomy is the treatment of choice for secondary appendicitis due to less postoperative pain, lower incidence of surgical site infections, decreased length of hospital stay, and earlier return to work compared to open appendectomy 1
- Surgery should be performed within 24 hours of admission to reduce the risk of complications 1
- In cases where laparoscopic expertise is not available, open appendectomy remains a viable alternative 2
- If the appendix appears "normal" during surgery but the patient was symptomatic, appendix removal is still recommended 2
Antibiotic Therapy
Preoperative Antibiotics
- A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 1, 2
- For uncomplicated appendicitis, second or third-generation cephalosporins (such as cefoxitin or cefotetan) are appropriate 2
Postoperative Antibiotics
- For uncomplicated appendicitis with adequate source control, postoperative antibiotics are not recommended 1, 2
- For complicated appendicitis (perforated or with abscess formation), postoperative antibiotics should be continued but not beyond 3-5 days when adequate source control has been achieved 2, 1
- Early transition to oral antibiotics (after 48 hours) is safe and effective in children with complicated appendicitis 2
Antibiotic Selection for Complicated Cases
- For complicated appendicitis, broader-spectrum coverage is recommended 2:
Management of Complicated Appendicitis with Abscess or Phlegmon
- For patients with periappendiceal abscess where laparoscopic expertise is not available: non-operative management with antibiotics and percutaneous drainage (if available) is recommended 1, 2
- Laparoscopic management is associated with fewer readmissions and fewer additional interventions than conservative treatment when performed by experienced surgeons 2, 1
- Routine interval appendectomy after non-operative management is not recommended for young adults (<40 years) and children unless they develop recurrent symptoms 2
- For patients ≥40 years old treated non-operatively, both colonic screening with colonoscopy and interval full-dose contrast-enhanced CT scan are recommended due to higher incidence (3-17%) of appendicular neoplasms 2
Special Considerations
- Drains are not recommended following appendectomy for complicated appendicitis as they provide no benefit in preventing intra-abdominal abscess and lead to longer hospitalization 1
- Routine histopathology after appendectomy is recommended to identify unexpected findings 1
- Non-operative management with antibiotics alone may be considered for selected patients with uncomplicated appendicitis without appendicolith, with success rates of approximately 70% 3
- CT findings of appendicolith, mass effect, or a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (~40%) with an antibiotics-first approach 3
Pitfalls to Avoid
- Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
- Metronidazole is not indicated when broad-spectrum antibiotics such as aminopenicillins with β-lactam inhibitors or carbapenems are used 2
- Extended-spectrum antibiotics offer no advantage over narrower-spectrum agents for children with surgically managed acute appendicitis 2
- Routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation and may be avoided 1