What is the standard treatment approach for a patient with acute appendicitis, considering the DAMA (Diagnostic And Management Algorithm) protocol?

Standard Treatment Approach for Acute Appendicitis

Laparoscopic appendectomy performed within 24 hours of admission is the gold standard treatment for acute appendicitis, offering superior outcomes including less pain, lower infection rates, shorter hospital stays, and faster return to work compared to open surgery. 1, 2

Preoperative Management

Diagnosis and Risk Stratification

• Use clinical scoring systems (AIR score or Adult Appendicitis Score) to stratify patients into low, intermediate, or high-risk categories, as these tools accurately exclude appendicitis and identify which patients need imaging 3
• Obtain CT imaging for intermediate-risk patients to confirm diagnosis and identify complications such as perforation, abscess, or appendicolith 4
• Document disease severity using a standardized intra-operative grading system (WSES 2015 or AAST EGS grading score) based on clinical, imaging, and operative findings 3, 2

Antibiotic Administration

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision for all patients undergoing appendectomy 3, 2
• For complicated appendicitis, use piperacillin-tazobactam or combination therapy with metronidazole plus vancomycin 5, 6

Surgical Approach

Timing of Surgery

• Perform appendectomy within 24 hours of admission for uncomplicated appendicitis to minimize complications 1, 2
• For complicated appendicitis with perforation or abscess, perform surgery within 8 hours when possible 1, 5

Laparoscopic Technique

• Use conventional three-port laparoscopic appendectomy rather than single-incision technique, as it results in shorter operative times, less postoperative pain, and lower wound infection rates 1, 2
• This approach is particularly beneficial for obese patients, elderly patients, those with comorbidities, and pregnant patients 1, 2
• Use monopolar or bipolar electrocoagulation for mesoappendix dissection 1
• Close the appendiceal stump with endoloops/suture ligation or polymeric clips using simple ligation rather than stump inversion 1, 5

Intraoperative Decisions

• Remove the appendix even if it appears "normal" during surgery when no other pathology is found in symptomatic patients, as surgeon's macroscopic judgment of early appendicitis is highly inaccurate 3, 1, 2
• In complicated appendicitis with intra-abdominal collections, perform suction alone rather than irrigation 1, 2

Management of Complicated Appendicitis

Appendiceal Abscess or Phlegmon

• When advanced laparoscopic expertise is available, proceed directly with laparoscopic appendectomy, as this approach results in fewer readmissions and additional interventions compared to conservative management 3, 2
• If laparoscopic expertise is unavailable, use non-operative management with antibiotics and percutaneous drainage (if accessible) 3, 2

Interval Appendectomy

• Do not perform routine interval appendectomy after successful non-operative management in young adults (<40 years old) and children, as recurrence rates only justify surgery in one of eight patients 3
• Reserve interval appendectomy only for patients with recurrent symptoms 3
• For patients ≥40 years old treated non-operatively, perform colonoscopy and interval contrast-enhanced CT scan to exclude appendiceal neoplasms, which occur in 3-17% of this population 3

Postoperative Care

Antibiotic Management

• For uncomplicated appendicitis, discontinue antibiotics after the single preoperative dose 3, 2
• For complicated appendicitis, continue postoperative antibiotics with metronidazole 500 mg every 6 hours plus vancomycin 25-30 mg/kg loading dose, then 15-20 mg/kg every 8 hours 5
• Typical treatment duration is 7-10 days for uncomplicated cases and 7-14 days for complicated cases 2, 6

Drain Placement

• Do not place abdominal drains following appendectomy for complicated appendicitis in adults or children, as they do not improve outcomes 1, 2

Discharge Planning

• Consider outpatient laparoscopic appendectomy for uncomplicated appendicitis when an ambulatory setting with well-defined ERAS protocols is available 1, 2
• Send all appendix specimens for routine histopathological examination to identify unexpected findings including neoplasms 1, 2

Alternative Non-Operative Management

Patient Selection

• Antibiotic therapy alone may be considered for selected patients with uncomplicated appendicitis who lack high-risk CT findings (no appendicolith, no mass effect, appendiceal diameter <13 mm) 4, 7
• Approximately 70% of appropriately selected patients respond successfully to antibiotics, but 30% require appendectomy within one year 4, 8

When to Avoid Non-Operative Management

• Patients with appendicolith on CT have approximately 40% failure rate with antibiotics and should undergo surgery if fit for operation 4
• Pregnant patients and immunosuppressed patients should undergo timely surgical intervention rather than antibiotics-first approach 7

Common Pitfalls

• Delaying surgery beyond 24 hours increases complication rates including perforation and sepsis, which occur in 17-32% of delayed cases 1, 9
• Relying on surgeon's visual assessment of a "normal-appearing" appendix leads to missed early appendicitis, as macroscopic judgment is highly variable and inaccurate 3, 1
• Performing routine interval appendectomy after successful non-operative management wastes resources, as only 12-24% of patients experience recurrence 3