Article Type : Review Article
Authors : Kumar HR, Soma M, Ganesh R2
Keywords : Complicated appendicitis; Appendicular mass; Interval appendectomy; Laparoscopic appendectomy; Early appendectomy
The
treatment of complicated appendicitis has always been conservative treatment
followed by interval appendectomy, but with time the management has slowly
evolved towards early appendectomy. As there is no consensus on its management,
the treatment of this condition is usually decided by the treating surgeon. The
emergence of laparoscopic appendectomy has seen a shift towards early
appendectomy. We have conducted this review article to investigate the current
management of complicated appendicitis looking into the role of conservative
management, interval appendectomy and early appendectomy.
The definition of complicated appendicitis is also
known to include appendicular mass and appendicular phlegmon, which involves
the perforated appendix, omentum and surrounding bowel that forms a localized
mass. Most General surgeons agree on the definition of complicated appendicitis
that includes perforation of the appendix, intra-abdominal abscess, and
purulent peritonitis. Controversy exists with regards to the management of
complicated appendicitis, which can be divided into conservative treatment with
intravenous antibiotics and fluids followed by interval appendectomy or
immediate appendectomy [1]. The role of interval appendectomy after
conservative treatment of appendicular mass has been questioned with it being
indicated for patients who present with recurrent attacks of pain. Computed
tomography and colonoscopy may be used to investigate older patients who have
completed conservative treatment to not miss any other pathology [2]. The
management of complicated can be divided into 1) Conservative treatment
followed by interval appendectomy after 8 to 12 weeks.2) Conservative treatment
without interval appendectomy.3) Immediate appendectomy. Conservative treatment
involves the use of intravenous antibiotics and fluids [3]. As the management
of complicated appendicitis is still controversial and hence, we have conducted
this review article to investigate this. A literature review was performed on
PubMed, the Cochrane database of systemic reviews and Google Scholar looking
for original articles, observational studies, clinical trials, cohort studies,
systemic reviews, meta-analysis, and clinical reviews from 1990 to 2023.The
following keywords were used “complicated appendicitis”,” Appendicular mass”,”
Appendicular Phlegmon”,” Appendicular abscess “and “interval appendectomy”. All
articles were in the English language only and case reports, case studies,
commentaries and tutorials were excluded (Figure 1).
Conservative
treatment of complicated appendicitis
Conservative treatment as described by Ochsner and Sheeren involves keeping the patient fasted, starting intravenous antibiotics, and analgesics. This is usually followed by an interval appendectomy in 8 to 12 weeks’ time. This has been the traditional management of appendicular mass [4]. The use of conservative treatment in the management of complicated appendicitis is safe and effective and it avoids injury to the intestines and surrounding structures. The need for interval appendectomy is often indicated to prevent recurrence [5].
Figure
1: Flowchart
of the management of complicated appendicitis.
The application of conservative treatment in the
management of complicated appendicitis was associated with lower complication
rate and a systemic review by Olsen et al, showed that the treatment failure
rate was 8-15% when compared with immediate surgery. The drawback of this
systemic review was that most of the studies were retrospective in nature [6].
A meta-analysis by simillis et al comparing conservative treatment versus
appendectomy for complicated appendicitis showed that conservative treatment
was associated with reduced complication and reoperation rates [7]. The
duration of hospitalization, duration of antibiotic therapy, the overall
complication rate and reoperation rates were important factors to decide the
effectiveness of conservative treatment of complicated appendicitis
[8].Conservative treatment may be a safer option in patients who present late
to the hospital due to financial problems or ignorance on the part of the
patient to self-medicate with analgesics. In these patients’ immediate
appendectomy may be associated with higher post-operative complication and risk
of bower resection due to bowel injury [9]. Among the factors that may affect
conservative treatment of complicated appendicitis is the size of the mass in
the right iliac fossa and the duration of symptoms. Treatment failure is often
seen in larger masses and prolonged duration of symptoms. In the pediatric
patients below the age of 5 years, treatment failure is often due to the
underdeveloped omentum and the earlier progression to appendicular abscess and
generalized peritonitis [10]. Additional unfavorable outcomes for treatment of
complicated appendicitis are presence of a mass in the right iliac fossa and
the female gender. Patients living in rural areas as these may delay the
presentation to the hospital for management [11]. A meta-analysis by andersson
et al on the role of conservative management of complicated appendicitis showed
that after successful treatment, the recurrence rate was 7.4% and they
concluded that interval appendectomy was not indicated after conservative
treatment [12]. For patients above the age of 40 may need follow up with
computerized tomography or colonoscopy. Conservative management of complicated
appendicitis in children is a safe and effective when compared to immediate
appendectomy as increased blood loss and risk of injury to the neighboring
bowel is higher [13]. A meta-analysis by fugazzola et al on early appendectomy
vs conservative management in complicated appendicitis in children showed that
children who underwent conservative treatment were found to have better
complication rates and reduced readmission rates. Hence in children
conservative treatment should be the treatment of choice in complicated
appendicitis [14]. Pediatric patients with complicated appendicitis who are
present with appendicular abscess may benefit from percutaneous drainage
followed by conservative therapy. This therapy is associated with lower
incidence of complications and faster recovery although patients may need to be
followed up [15].
Table
1:
Studies that support conservative treatment of complicated appendicitis.
Studies |
Efficacy |
Study type |
N-numbers |
Elaasdy et al |
88% |
Prospective study |
169 |
Olsen et al |
85% |
Systemic review |
3,772 |
Anderson et al |
93% |
Meta-analysis |
59,488 |
Gillick et al |
84.2% |
Retrospective study |
427 |
Fugazolla et al |
90% |
Meta-analysia |
1,288 |
The use of
percutaneous drainage followed by intravenous antibiotics in the management of
complicated appendicitis with appendicular abscess is associated with a smaller
need for interval appendectomy and a lower risk of recurrent attacks of right
iliac fossa pain [16]. The common predictors of recurrent appendicitis after
conservative management of complicated appendicitis include persist symptoms
after completion of conservative treatment and resolution of symptoms that are
longer than 6 days. The presence of appendicolith on ultrasonography is also an
independent factor for recurrent attacks of appendicitis [17]. The presence of
an appendicolith and not the location of the appendicolith affects the success
rate of conservative management in the pediatric patient who presents with
complicated appendicitis. This may predict those patients who may need an
emergency appendectomy if there is failure of conservative management
[18]. These studies concluded that there
is a role for conservative treatment in the management of complicated
appendicitis, especially in the pediatric group. The wound infection rates and
recurrence rates were low but as most of the studies were retrospective in
nature, further prospective studies may be required to evaluate this (Table 1).
Interval appendectomy in complicated appendicitis
Upon completion of conservative treatment in
complicated appendicitis, interval appendectomy is always performed in 8 to 12
weeks’ time to prevent recurrence and to establish a diagnosis. Its indication
has been questioned as the reported recurrence rates and morbidity are low and
with interval appendectomy [19]. A study done in the mid-Trent region of the
United Kingdom showed that 75% of general surgeons were likely to offer
interval appendectomy after completion of conservative treatment where else
specialist registrars were less likely to offer interval appendectomy to
patients. This study showed the indication for interval appendectomy varies
among various levels of surgeons and specialist trainees [20]. The South Coast
appendicular mass management survey also confirmed the diverse nature of
management of complicated appendicitis and a significant number of surgeons who
do not perform interval appendectomy after conservative treatment [21]. The reason for performing an interval
appendectomy after completion of conservative treatment for complicated
appendicitis was to prevent recurrence and not to miss any other pathologies
like malignancy. As these patients can be followed up with computerized tomography
and colonoscopy, the indication of interval appendectomy is being questioned
now [22]. As routine interval appendectomy is not required after completion of
conservative treatment for complicated appendicitis, it is still being
performed by surgeons as there is no clear recommendations on its indication
and the judgement falls on the surgeon who is managing the patient [23]. A
systemic review by Darwazeh et al looked at the indication of interval
appendectomy after completion of conservative treatment. With the reported
recurrence rate ranging from 6 to 20 %, performing an interval appendectomy
does not offer any additional benefit and is associated with increased cost and
morbidity. Most patients can be followed up with imaging like computerized
tomography and colonoscopy [24]. Interval appendectomy is now offered to
selected patients who present with recurrent symptoms of abdominal pain after
completion of conservative treatment. It should not be a routine practice in
the management of complicated appendicitis [25]. In the pediatric patients who
present with complicated appendicitis, the risk of perforation is about 20% and
interval appendectomy may be indicated in these patients to prevent recurrence
and subsequent readmission [26]. The pathological examination of the specimen
following interval appendectomy was done by fouad et al, who conducted a
retrospective study. 51% of the specimens showed chronically inflamed appendix,
34.9% showed acute on chronic inflammation, 12.8% acutely inflamed appendix, 16.8%
fecolith and 1.3% acute fibromuscular tissue. This study showed the importance
of interval appendectomy in children [27]. Also examined the histopathology of
the appendix specimen of patients who underwent interval appendectomy and the
results showed that all specimens had various grades of inflammation and there
were no neoplasms [28]. These studies concluded that interval appendectomy need
not be routinely done after completion of conservative treatment. As patients
can be followed up with computerized tomography and colonoscopy, Interval
appendectomy is only indicated for patients who present with recurrent symptoms
(Table 2).
Table
2: Studies
that support interval appendectomy following conservative treatment.
Studies |
year |
N-numbers |
Study type |
Complication rate |
Gillick et al |
2001 |
427 |
Systemic review |
2.3% |
Gonzales et al |
2003 |
41 |
Case-control study |
N/A |
Darwazeh et al |
2016 |
543 |
Systemic review |
10.4% |
Weiner et al |
1989 |
104 |
Retrospective study |
5.9% |
Fouad et al |
2017 |
149 |
Observational study |
6% |
Early
appendectomy and Laparoscopic appendectomy
Early appendectomy has been advocated in the
management of complicated appendicitis as it reduces the need of a second
admission and misdiagnosis of other conditions like carcinoma of the caecum.
Early appendectomy is also associated with reduced wound infection rate and
better recovery. It is also safe due to significant improvements in surgical
techniques and better post-operative care [29-32]. A meta-analysis by
Gavrillidis et al showed the shift in management of complicated appendicitis
from conservative treatment to early appendectomy due to better diagnostic
tools and significantly better surgical expertise and experience with a trend
towards laparoscopic surgery [33]. The trend of early appendectomy has been slowly
shifting from open appendectomy towards laparoscopic appendectomy. The
advantage of laparoscopic surgery is better visualization of the abdomen and
easier mobilization of the organs and better access for peritoneal lavage. As
the skin incision is smaller, it is associated with decreased post-operative
pain and faster mobilization. It is also associated with reduced hospital stay
and a faster discharge [34-37]. Early appendectomy is also advocated in the
management of complicated appendicitis in children as it is associated with
better recovery, reduced wound infection rates, and reduced readmission rates
when compared to conservative treatment. Laparoscopic appendectomy has also
been advocated in the management of complicated appendicitis in the pediatric
age group. The advantages are reduced wound infection rates, earlier recovery
and reduced hospital stay [38-40]. Laparoscopic appendectomy was found to be
feasible in the management of complicated appendicitis in childrenas it
associated with reduced wound infection rate and intra-abdominal abscess
formation when compared to open appendectomy [41]. An advantage of laparoscopic
appendectomy in the management of complicated appendicitis is the reduced rate
of wound infection when compared to open appendectomy.
Table
3: Studies
that favor early laparoscopic appendectomy for complicated appendicitis.
Studies |
Study type |
N-numbers |
Wound infection rate |
Year of study |
Ali et al |
Randomized control trial |
150 |
8% |
2014 |
Prasad et al |
Retrospective study |
100 |
0% |
2017 |
Garg et al |
Comparative study |
49 |
8.2% |
2008 |
YM lin et al |
Retrospective study |
94 |
1.1% |
2009 |
Gavrillidis et al |
Systemic review |
810 |
4.6% |
2018 |
This can lead to
reduced hospital stay and a faster discharge of the patient [42]. As we enter
the laparoscopic era, the role of laparoscopic appendectomy in the management
of complicated appendicitis is becoming popular due to better access to the
abdomen and reduced post-operative complications, better analgesia and reduced
hospital stay. The mean blood loss was also reduced in patients who underwent
laparoscopic appendectomy for complicated appendicitis. The drawback of these
studies was that they were retrospective in nature and sample size were small
[43-45]. Performed a systemic review and meta-analysis on the feasibility of
laparoscopic appendectomy for complicated appendicitis.16 studies were
identified which included 2 randomized control trials and 14 retrospective
cohort studies. The results showed that laparoscopic appendectomy was
associated with reduced wound infection rate, shorter hospital stay and faster
oral intake, but the operative time was longer. This showed that laparoscopic
appendectomy was feasible in the management of complicated appendicitis. The
limitations of this study were that most of the studies were retrospective in
nature [46].These studies show that laparoscopic appendectomy is associated
with fewer complications, decreased wound infection rates, and reduced hospital
stay. With more training in laparoscopic surgery, more surgeons will be able to
perform this procedure. The limitations of the studies were that the majority
were retrospective studies, and the sample size was small. Further randomized
control trials may be needed to evaluate this (Table 3).
This review article concludes that the
management of complicated appendicitis is moving towards early appendectomy and
laparoscopic appendectomy being the operation of choice. The World Society of
Emergency Surgeons in their guidelines have suggested early appendectomy via
laparoscopic method. But in countries where laparoscopic services are not
available, conservative treatment is an accepted treatment option. The role of
interval appendectomy is only reserved for patients who present with recurrent
symptoms. The absence of proper guidelines makes management of complicated
appendicitis decided by the treating surgeon. The management of complicated
should be early or immediate appendectomy with conservative treatment being
reserved for patients with comorbidities or if the expertise is not available.
Conservative treatment of complicated appendicitis may still be relevant as
performing early appendectomy may require training and as appendectomy is
usually performed by surgical registrars and junior surgeons and the risk of
complications are slightly higher. Laparoscopic appendectomy was performed by
experienced surgeons in all the studies that were reviewed. Hence proper
training is required for surgeons who want to perform early appendectomy for
patients with complicated appendicitis.