Do you recommend surgical intervention for a patient presenting with phlegmonous appendicitis?

Management of Phlegmonous Appendicitis

For phlegmonous appendicitis, initiate non-operative management with broad-spectrum intravenous antibiotics as first-line treatment, reserving immediate surgery only for centers with advanced laparoscopic expertise readily available. 1, 2

Initial Treatment Strategy

Non-operative management is the preferred approach for phlegmonous appendicitis when advanced laparoscopic expertise is not immediately accessible, with success rates of 70-90%. 1, 2

Antibiotic Regimen

• Start broad-spectrum IV antibiotics immediately covering enteric gram-negative organisms (E. coli) and anaerobes (Bacteroides species). 1, 2
• Recommended single-agent options: ertapenem, meropenem, imipenem-cilastatin, or piperacillin-tazobactam. 2
• Combination therapy alternatives: ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole. 2, 3
• Continue antibiotics for 5-14 days depending on clinical response. 2

Percutaneous Drainage Considerations

• Add percutaneous drainage when an abscess component is present (≥3 cm) and interventional radiology is available. 4, 1, 5
• When percutaneous drainage is unavailable, proceed directly to surgery. 4

Surgical Management Alternative

Laparoscopic appendectomy may be performed as first-line treatment when advanced laparoscopic expertise is immediately available, with potential benefits including shorter hospital stay, reduced readmissions, and fewer additional interventions compared to conservative treatment. 1, 2

Key Surgical Considerations

• Maintain a low threshold for conversion to open surgery given the inflammatory mass. 1
• Be prepared for potential ileocecal resection or right hemicolectomy in approximately 10% of cases when operating acutely. 4
• Avoid routine intraoperative irrigation as it does not prevent abscess formation. 4

Interval Appendectomy Decision

Do NOT perform routine interval appendectomy after successful non-operative management in patients <40 years old. 1, 2

Rationale

• Recurrence rate after non-operative management is only 12-24%. 1, 2
• Interval appendectomy prevents recurrence in only 1 in 8 patients, making routine performance unjustified from cost-benefit perspective. 1
• Reserve interval appendectomy only for patients with recurrent symptoms. 4

Age-Specific Follow-Up Protocol

For patients ≥40 years old treated non-operatively, mandatory follow-up includes:

• Colonoscopy to exclude underlying neoplasm (3-17% incidence in this age group). 1, 2
• Interval full-dose contrast-enhanced CT scan. 1, 2

Special Population Exceptions

Proceed directly to surgery in:

• Pregnant patients to minimize complication risk. 6
• Immunosuppressed patients to prevent progression. 6

Common Pitfalls to Avoid

• Do not operate immediately unless advanced laparoscopic expertise is present or percutaneous drainage fails—non-operative management has fewer complications and shorter overall hospitalization. 1
• Do not continue antibiotics beyond 3-5 days postoperatively if adequate source control achieved. 1, 2
• Do not skip age-appropriate cancer screening in patients ≥40 years after non-operative treatment. 1, 2
• Do not perform routine interval appendectomy in young patients—only 12-24% will have recurrence. 1, 2