When to perform a laparoscopic appendectomy on an incidentally encountered normal appendix in a patient with inflammatory bowel disease (IBD) initially suspected to have acute appendicitis?

From the Guidelines

When encountering a normal appendix during laparoscopy for suspected appendicitis but finding inflammatory bowel disease (IBD) instead, the appendix should generally not be removed. The primary focus should shift to addressing the IBD findings through appropriate tissue sampling and consultation. If the appendix appears completely normal and IBD is evident, a biopsy of inflamed bowel segments should be taken for definitive diagnosis, and the appendix should be left intact unless there are specific indications for removal such as future diagnostic confusion or if the patient is immunocompromised 1.

The surgical approach should then focus on documenting the extent and severity of IBD, obtaining biopsies, and arranging prompt gastroenterology consultation for medical management with medications like mesalamine, corticosteroids, or immunomodulators depending on disease classification. Incidental appendectomy in this scenario offers little benefit and may complicate future management, as the appendix can be useful for certain reconstructive procedures in IBD patients. Additionally, removing a normal appendix introduces unnecessary surgical risks and may complicate the postoperative course when the primary issue is IBD rather than appendicitis.

Some studies suggest that the accuracy of the surgeon in defining a “normal” appendix is very poor, with almost apparently normal appendices being inflamed histologically 1. However, the most recent guidelines recommend a laparoscopic approach in hemodynamically stable patients presenting with complications related to IBD, when skills are available, in order to decrease morbidity and length of hospital stay 1.

Key considerations in the management of IBD in the emergency setting include:

• Performing a surgical exploration by laparotomy in a hemodynamically unstable patient presenting with complications related to IBD such as perforation and severe peritonitis, massive intestinal bleeding, obstruction, toxic megacolon, severe colitis non-responder to medical treatment 1
• Considering an (stapled or hand sewn) anastomosis in hemodynamically stable patients with Crohn’s disease who have good pre-existing nutritional status and who are taking no steroids or other immunosuppression and presenting with no bowel vascular compromise and only localized peritonitis 1
• Arranging prompt gastroenterology consultation for medical management with medications like mesalamine, corticosteroids, or immunomodulators depending on disease classification.

Overall, the management of IBD in the emergency setting requires a multidisciplinary approach, and the decision to remove a normal appendix should be made on a case-by-case basis, taking into account the patient's overall condition and the potential risks and benefits of the procedure 1.

From the Research

Laparoscopic Appendectomy for Incidentally Encountered Normal Appendix with Inflammatory Bowel Disease

• The decision to perform a laparoscopic appendectomy on an incidentally encountered normal appendix in a patient with inflammatory bowel disease (IBD) is complex and depends on various factors.
• According to 2, the management of IBD involves optimizing pharmacologic treatment, and surgery may be considered in certain cases, but the study does not provide specific guidance on the management of an incidentally encountered normal appendix.
• Studies on acute appendicitis, such as 3, 4, and 5, suggest that the management of appendicitis depends on the severity of the disease, patient factors, and imaging findings, but do not address the specific scenario of an incidentally encountered normal appendix with IBD.
• In the context of IBD, 6 discusses the use of 5-aminosalicylic acid compounds for ulcerative colitis, but does not provide guidance on the management of an incidentally encountered normal appendix.

Considerations for Laparoscopic Appendectomy

• The presence of IBD may affect the decision to perform a laparoscopic appendectomy, as patients with IBD may be at higher risk for complications.
• The study 2 highlights the importance of personalized therapy plans for IBD patients, which may include consideration of surgical options.
• However, there is limited evidence to support the routine removal of an incidentally encountered normal appendix in patients with IBD, and the decision should be made on a case-by-case basis, considering the individual patient's circumstances and the potential risks and benefits of surgery.