Routine Interval Appendectomy Research Articles

Comparison of treatment methods in plastron appendicitis: a tertiary center experience.

It is controversial which treatment method is superior in plastron appendicitis and the research is still going on. The aim of this study is to compare treatment methods for plastron appendicitis in the adult population with our experience. The data of 92 patients who were diagnosed with plastron appendicitis in university hospital between 2015 and 2021 were analyzed retrospectively. Data were taken from the hospital database. The patients were divided into three groups: those treated with primary surgery, with interval appendectomy and only with conservative method. Interval appendectomy resulted in a lower rate of conversion to open surgery compared to primary surgery, shorter operative time, and lower complication rates. Surgical procedures were found to be superior in detecting neoplasms compared to conservative treatment. After conservative treatment, one of three patients was retreated with the diagnosis of acute appendicitis. In plastron appendicitis, routine interval appendectomy can be performed due to its advantages over other treatments such as the frequency of attacks after conservative treatment, the risk of the tumor being overlooked in conservative treatment, and the high rate of complications and conversion to open surgery in the primary surgery group.

Risk of appendiceal malignancy in conservatively treated acute appendicitis.

Appendectomy has historically been the standard treatment of acute appendicitis, but lately, conservative treatment of uncomplicated acute appendicitis with antibiotics has successfully been used in selected patients. Complicated acute appendicitis is often treated conservatively initially, but may benefit from interval appendectomy due to the higher risk of appendiceal malignancy and recurrence. Recommendations for follow-up after conservatively treated appendicitis vary. Furthermore, the risk of underlying malignancy and the necessity of routine interval appendectomy are unclear. This study aims to evaluate follow-up status, recurrence, and underlying appendiceal malignancy in conservatively treated uncomplicated and complicated acute appendicitis. This study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and data on follow-up, recurrence, number of appendectomies after initial conservative treatment, and underlying malignancy were retrieved from medical charts. The study cohort included 391 patients, 152 with uncomplicated and 239 with complicated acute appendicitis. Median time of study follow-up was 52 months. The recurrence risk was 23 (15.1%) after uncomplicated and 58 (24.3%) after complicated acute appendicitis (p = 0.030). During follow-up, 55 (23%) patients with complicated acute appendicitis underwent appendectomy. Appendiceal malignancies were found in 12 (5%) patients with previous complicated acute appendicitis versus no appendiceal malignancies after uncomplicated acute appendicitis (p = 0.002). The risk of appendiceal malignancy and recurrent appendicitis was significantly higher in patients with complicated acute appendicitis compared with uncomplicated acute appendicitis.

Interval appendectomy-do we need to do it in current era?

Background: Our current treatment of an appendiceal mass is initially conservative, followed by an interval appendectomy. The necessity of this routine interval appendectomy is debatable. Aim was to evaluate whether surgical factors and pathological features of the excised appendices support interval appendectomy. Methods: It was a retrospective study conducted for a period of 5 years (2017-2022). To assess the number of patients with appendicitis and a peri-appendiceal mass, all patients in both hospitals encoded for appendicitis were listed. Over this period of 5 years a total of 2,090 patients were diagnosed with acute appendicitis. Of these, 230 patients were operated through Interval appendectomy. All medical records of these patients were then reviewed and relevant variables were registered. Results: It was found that clinical findings alone were not specific enough to diagnose an appendiceal mass; 47% had a palpable abdominal mass and the median temperature was 38.2°C ranging from 36 to 40.5°C. Ultrasound examination was done in 70% of patients and showed an appendiceal mass in 72%. During the interval period, 4 patients presented with an appendiceal mass needing drainage, and 3 with acute appendicitis requiring emergency appendectomy. Conclusions: We conclude that when causes for the appendiceal mass other than appendicitis are excluded, interval appendectomy seems unnecessary in patients who respond well to initial conservative treatment.

AB162. Routine interval appendectomy is the past

AB162. Routine interval appendectomy is the past

Increased Risk of Neoplasms in Adult Patients Undergoing Interval Appendectomy.

PurposeThe low rate of recurrent appendicitis after initial nonsurgical management of complicated appendicitis supports the recently implemented strategy of omitting routine interval appendectomy. However, several reports have suggested an increased incidence rate of neoplasms in these patients. We aimed to identify the risk of neoplasms in the population undergoing interval appendectomy.MethodsThis study retrospectively analyzed consecutive cases of appendicitis that were treated surgically between January 2014 and December 2018 at a single tertiary referral center. Patients were divided into 2 groups depending on whether they underwent immediate or interval appendectomy. Demographics and perioperative clinical and pathologic parameters were analyzed.ResultsAll 2,013 adults included in the study underwent surgical treatment because of an initial diagnosis of acute appendicitis. Of these, 5.5% (111 of 2,013) underwent interval appendectomy. Appendiceal neoplasm was identified on pathologic analysis in 36 cases (1.8%). The incidence of neoplasm in the interval group was 12.6% (14 of 111), which was significantly higher than that of the immediate group (1.2% [22 of 1,902], P < 0.001).ConclusionThe incidence rate of neoplasms was significantly higher in patients undergoing interval appendectomy.These findings should be considered when choosing treatment options after successful nonsurgical management of complicated appendicitis.

Management of acute appendicitis in adults: A practice management guideline from the Eastern Association for the Surgery of Trauma

Acute appendicitis (AA) has been considered one of the most common acute surgical conditions in the world. Recent studies, however, have suggested that nonoperative management (NOM) with a course of antibiotics (ABX) may be as effective as surgery in treating appendicitis. As there are evolving perspectives regarding the optimal therapy for appendicitis, we sought to provide recommendations regarding the role of NOM with the administration of antibiotics (antibiotics-first approach) in uncomplicated AA as well as the need for routine interval appendectomy (RIA) in those presenting with appendiceal abscess or phlegmon (AAP) initially managed without appendectomy. A writing group from the Guidelines Committee of the Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analysis of the current literature regarding appendicitis in adult populations. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied and meta-analyses and evidence profiles generated. When comparing antibiotics-first therapy to surgery for uncomplicated AA in adult populations, we found that perforation and recurrence of disease were the only outcomes consistently represented in the literature. For perforation, we were unable to make a definitive conclusion based on the degree of heterogeneity among the six randomized controlled trials reviewed. The risk of recurrence at 1 year with antibiotics-first treatment was 15.8% (95% confidence interval, 12.05-118.63). Critical outcomes could not be evaluated with the current literature. In NOM patients for AAP, the risk of recurrence was 24.3% if RIA was not performed (95% confidence interval, 2.74-73.11). Based on the completed meta-analysis and Grading of Recommendations Assessment, Development and Evaluation profiles, we were unable to make a recommendation for or against the antibiotics-first approach as primary treatment for uncomplicated AA. For NOM with AAP, we conditionally recommend against RIA in an otherwise asymptomatic patient. This review reveals multiple limitations of the published literature, leaving ample opportunities for additional research on this topic. Systematic review, level II.

Risk of Appendiceal Neoplasm in Periappendicular Abscess in Patients Treated With Interval Appendectomy vs Follow-up With Magnetic Resonance Imaging

The step after conservative treatment of periappendicular abscess arouses controversy, ranging from recommendations to abandon interval appendectomy based on low recurrence rates of the precipitating diagnosis to performing routine interval appendectomy owing to novel findings of increased neoplasm risk at interval appendectomy. To our knowledge, there are no randomized clinical trials with sufficient patient numbers comparing these treatments. To compare interval appendectomy and follow-up with magnetic resonance imaging after initial successful nonoperative treatment of periappendicular abscess. The Peri-Appendicitis Acuta randomized clinical trial was a multicenter, noninferiority trial conducted in 5 hospitals in Finland. All patients between age 18 and 60 years with periappendicular abscess diagnosed by computed tomography and successful initial nonoperative treatment from January 2013 to April 2016 were included. Data analysis occurred from April 2016 to September 2017. Patients were randomized either to interval appendectomy or follow-up with magnetic resonance imaging; all patients underwent colonoscopy. The primary end point was treatment success, defined as an absence of postoperative morbidity in the appendectomy group and appendicitis recurrence in the follow-up group. Secondary predefined end points included neoplasm incidence, inflammatory bowel disease, length of hospital stay, and days of sick leave. A total of 60 patients were included (36 men [60%]; median [interquartile range] age: interval appendectomy group, 49 [18-60] years; follow-up group, 47 [22-61] years). An interim analysis in April 2016 showed a high rate of neoplasm (10 of 60 [17%]), with all neoplasms in patients older than 40 years. The trial was prematurely terminated owing to ethical concerns. Two more neoplasms were diagnosed after study termination, resulting in an overall neoplasm incidence of 20% (12 of 60). On study termination, the overall morbidity rate of interval appendectomy was 10% (3 of 30), and 10 of the patients in the follow-up group (33%) had undergone appendectomy. The neoplasm rate after periappendicular abscess in this small study population was high, especially in patients older than 40 years. If this considerable rate of neoplasms after periappendicular abscess is validated by future studies, it would argue for routine interval appendectomy in this setting. ClinicalTrials.gov identifier: NCT03013686.

A survey of management of appendiceal mass among surgeons: what is best practice?

Background: An appendix mass is the result of a walled-off perforation of the appendix which localizes, resulting in a mass and it is encountered in up to 7% of patients presenting with acute appendicitis. The management of such problem is controversial. Immediate appendectomy may be technically demanding. Traditionally, management of these patients is conservative followed by interval appendectomy to prevent recurrence. However, the need for interval appendectomy has recently been questioned due to relatively small risk of recurrence. Also, there is still debate on adopting conservative management regarding the recurrence rate, the complication rate of interval appendectomy, and the potential for underlying malignancy. Our aim was to assess the preferred approach and current practice for management of acute appendix mass among surgeons in Al Taif Saudi Arabia.Methods: A questionnaire for the practice of surgeons in dealing with appendicular mass was designed and distributed to 21 consultants and 45 specialists.Results: 14.3% of consultant and 53.3% of specialist practiced the conservative management without routine interval appendectomy. Also, 14.3% and 26.7% of them respectively preferred immediate appendectomy while 71.4% of consultants and 20.0% of specialists did routine interval appendectomy. Most of the surgeons prefer to adopt the open method in immediate appendectomy while laparoscopic approach is the main adopting procedure for interval appendectomy. 57% of consultants stated risk of recurrence as the reason for performing interval appendectomy while, 53.4% of specialists would perform it to out-ruling neoplasm.Conclusions: Surgeons prefer to carry conservative approach with an interval appendectomy in management of appendix mass and laparoscopic approach for interval appendectomy. However immediate appendectomy and conservative management without interval appendectomy was preferred in other studies, which increase the necessity for national guidelines to be considered for management of this clinical condition.

Editorial

There are no clear guidelines in the treatment of a perforated appendicitis associated with periappendiceal abscess without generalized peritonitis.We retrospectively studied six examples of treated children in order to discuss the reasons of our team’s therapeutic approach. Some children were treated with a conservative antibiotic therapy to solve acute abdomen pain, planning a routine interval appendectomy after some months. Others, instead, underwent an immediate appendectomy.By examining these examples we wanted to highlight how the first approach may be associated with shorter surgery time, fewer overall hospital days, faster refeeding and minor complications.Our team’s therapeutic choice, in the case of a perforated appendicitis with an abscess and coprolith is an initial conservative case management followed by a routine interval appendectomy performed not later than 4 months after discharge.

Tu1575 Conservative Treatment and Interval Appendectomy for Acute Appendicitis

BACKGROUND Conservative treatment for acute appendicitis (AA) is gradually being adopted as valuable therapeutic choice. Interval appendectomy (IA) after conservative treatment is controversial. OBJECTIVE To clarify the success and recurrence rate of conservative treatment for acute appendicitis, and necessity of IA Patients and Methods We reviewed 503 patients with AA between 2006 and 2013. RESULTS In 503 patients, of which 122 patient undergone emergency appendectomy within 3 days after admission, remaining 381 patients underwent conservative treatment. In 381 patients taken conservative treatment, the success rate of conservative treatment was 98%. Nine patients (2%) were required appendectomy because of progressive disease despite of conservative treatment. After conservative treatment 95 patients (27%) were diagnosed as a recurrent AA at median follow-up 18 months. The predictor for recurrence after conservative treatment was the only following multiple episodes of AA (p=0.002, HR 2.1, 95%CI [1.56-41.1]). The abscess formation and appendicolith did not predict the disease recurrence. At the recurrent AA, 37 of 95 (39%) patients underwent appendectomy including IA. The morbidity of appendectomy for recurrent disease was 5%. Especially the morbidity of IA for recurrent disease was 0%. CONCLUSIONS The success rate of conservative treatment was very high and the risk of recurrence after conservative treatment was 27%. The morbidity of appendectomy for recurrent disease was low (5%). The conservative treatment may be an effective alternative to emergency appendectomy. The routine IA is probably not warranted following successful management of AA, but IA should be required to patients with multiple episodes of AA. Morbidity rate of appendectomy by timing of operation

Interval Appendectomy after resolution of an appendiceal massis it really necessary?

The necessity of routine interval appendectomy after resolution of appendicular mass is debatable. A study was conducted to evaluate whether surgical factors and pathological features of excised appendices support interval appendectomy. (Key words: Appendiceal mass. Diagnosis, Conservative treatment, interval appendectomy).

Evaluating conservative treatment for acute appendicitis with lump formation

Background:Interval appendectomy after acute appendicitis with lump formation (phlegmon) remains controversial. We conducted this study to determine the risk of recurrent appendicitis following initial non-operative treatment for appendicitis, and evaluate factors associated with recurrence. Secondarily, we evaluate the efficacy of interval appendectomy versus no appendectomy.Materials and Methods:Patients who received conservative treatment for appendicitis with lump formation were prospectively studied from June 2006 to June 2008. These patients were followed for recurrence of appendicitis.Results:Of 763 patients with acute appendicitis some 220 patients had lump formation (28.8%). Median age was 28 years. Conservative treatment was successful in 213 (96.8%) patients. The rate of recurrence was 13.1%, all occurring within six months after the index admission. Mean follow-up was 26±18 months.Conclusion:Conservative treatment of appendicitis with lump formation is efficient and the recurrence rate is low. Routine interval appendectomy after initial conservative treatment for lump formation is not a cost-effective intervention and not recommended.

Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed

Conservative management of acute appendicitis (AA) is gradually being adopted as a valuable therapeutic choice in the treatment of selected patients with AA. This approach is based on the results of many recent studies indicating that it is a valuable and effective alternative to routine emergency appendectomy. Existing data do not support routine interval appendectomy following successful conservative management of AA; indeed, the risk of recurrence is low. Moreover, recurrences usually exhibit a milder clinical course compared to the first episode of AA. The role of routine interval appendectomy is also questioned recently, even in patients with AA complicated by plastron or localized abscess formation. Surgical judgment is required to avoid misdiagnosis when selecting a conservative approach in patients with a presumed "appendiceal" mass.

Dollars and sense of interval appendectomy in children: a cost analysis

Purpose Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy. Methods Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates. Results Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios. Conclusion Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.

Routine or Selective Interval Appendectomy for Non-Surgically Treated Appendiceal Mass

The purpose of this study was to evaluate the need for interval appendectomy after a successful conservative treatment of an appendiceal mass. This retrospective study was conducted on patients admitted with appendiceal mass at King Saud Medical City during between July-2004 to July-2009. Only patients who were successfully treated conservatively (non-surgical) were included in the study. Data on patient demography, clinical presentations, investigations, follow up, relapse of symptoms and/ or recurrent acute appendicitis were collected and analyzed. Seventy-three patients were successfully treated conservatively for appendiceal mass. After discharge from the hospital, all were followed up in an OPD clinic. Seven patients (9.6%) developed recurrent symptoms/ appendicitis and underwent appendectomy. Sixty six patients (90.4%) were discharged from the outpatient clinic as they remained asymptomatic. All were seen in OPD at least twice before discharge. At the time of data collection for this study, all of them were contacted and recalled for assessment in the outpatient department. Five patients (6.8 %) had emergency appendectomy elsewhere after discharge from the OPD clinic. Overall, 12 patients (16.4 %) needed appendectomy after a successful conservative treatment for appendiceal mass. Sixty one patients (83.6 %) have remained asymptomatic since their discharge from the clinic. Routine interval appendectomy is unnecessary after a successful conservative treatment of an appendiceal mass. It should be recommended selectively to those who develop recurrent symptom or recurrent acute appendicitis.

The Necessity of a Routine Interval Appendectomy Necessary in Adults?: Initial Experience

Purpose: The traditional management of a periappendiceal abscess or a perforated appendicitis has been initial conservative treatment, followed by an interval appendectomy (IA). However, the necessity of the interval appendectomy has been questioned by an increasing number of studies recently. The purpose of this study was to clarify the role of conservative treatment, instead of IA, in managing a perforated appendicitis or a periappendiceal abscess after successful initial conservative treatment. Methods: We prospectively studied 26 out of 80 patients who had been admitted for a perforated appendicitis or a periappendiceal abscess to Chonbuk National University Hospital from March 2005 to December 2007. These 26 patients were initially treated by using conservative treatment instead of surgery. We analyzed these 26 patients’ progression and prognosis after treatment. The IAs were conducted at intervals of 6 to 12 wk after colonoscopy when the patient wanted an operation. Results: Twenty-three out of 26 (88.5%, 23/26) patients were improved after initial conservative treatment. Only 3 patients who were not improved were managed surgically. Four out of 23 patients who were relieved by conservative treatment underwent an IA voluntarily at intervals of 6 to 12 wk. Of the remaining 19 patients without IA, 1 patient (5%, 1/19) suffered a recurrence after 6 mo, and an appendectomy was performed. Eighteen (78%, 18/23) patients without an IA have shown no recurrence for 15 mo, and they are still being followed up. Conclusion: We conclude that a routine IA after successful initial conservative treatment for a perforated appendicitis or a periappendiceal abscess seems unnecessary. Those patients should undergo colonoscopy to detect any underlying diseases and to rule out coexistent colorectal cancer.

Routine or Selective Interval Appendectomy for Non-Surgically Treated Appendiceal Mass “Arabic abstracts”

Routine or Selective Interval Appendectomy for Non-Surgically Treated Appendiceal Mass “Arabic abstracts”

Routine interval appendectomy is unnecessary after conservative treatment of appendiceal mass

The traditional management of appendiceal mass is initial conservative treatment followed by interval appendicectomy. Recently interval appendicectomy has been questioned by a growing amount of evidence. The purpose of this study was to clarify the role of interval appendicectomy after successful initial conservative treatment. The study included 98 patients with a mass in the right iliac fossa. Four (4%) patients were excluded wing to another diagnosis of appendiceal mass including caecal cancer (two), diverticulitis (one), and Crohn's disease (one). The remaining 94 patients were treated conservatively. Routine interval appendicectomy was not performed after successful conservative treatment. Ultrasound (US)-guided drainage was performed in seven (7.4%) patients. Two were drained surgically because of a persistent abscess despite a previous US-guided drainage. In five (5.3%) patients, a delayed operation was necessary because of complications. One patient developed small bowel obstruction, and in three patients, conservative treatment was unsuccessful with the abscess remaining unresolved. Within 3 months, seven out of the 89 patients were readmitted to hospital with a recurrent mass in two patients and acute appendicitis without a mass in five patients. Six (6.7%) patients were readmitted with recurrent appendicitis after 3 months. The recurrence rate after successful conservative treatment was 14.6%. The majority (nine patients; 10.1%) of the recurrences occurred within the first 6 months, and after 1 year the recurrence rate was very low (two patients; 2.2%). Routine interval appendicectomy after initial successful conservative treatment is not justified and should be abandoned. At present, there is no consensus for the management of appendiceal mass. There is, therefore, a need to develop a protocol for the management of this common problem.

Routine interval appendectomy in children is not indicated

Background This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis. Methods A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay. Results The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis. Conclusion Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.

Interval Appendectomy after Conservative Treatment of an Appendiceal Mass

The purpose of this study was to clarify the role of interval appendectomy after conservative treatment of an appendiceal mass. From January 1998 to December 2003, patients with an appendiceal mass who received conservative treatment at the Taipei Veterans General Hospital were studied retrospectively. Data on demographics, rate of appendicitis recurrence, duration of hospital stay, and complication rate were collected and analyzed. A total of 165 patients were included (89 males, 76 females). The mean age was 53.6 years (range 7-89 years). The rate of appendicitis recurrence after conservative treatment was 25.5%; most recurred within 6 months after discharge (83.3%). The benefit of preventing recurrence is less than 16% if interval appendectomy is performed 6 weeks after discharge and less than 10% if it is done 12 weeks later. The complication rate of appendectomy performed before or after recurrence was 10% in both groups. The duration of the second hospital stay for patients who underwent interval appendectomy before or after recurrence was 4.43 +/- 3.32 vs. 6.75 +/- 5.73 days (P = 0.023). Of the 165 patients, 17 (10.3%) had their diagnosis changed after survey or surgery, and 5 (3.03%) were found to have colon cancer upon follow-up. Patients who recovered from conservative treatment of an appendiceal mass should undergo colonoscopy or barium enema to detect any underlying diseases and to rule out coexistent colorectal cancer. Routine interval appendectomy benefits less than 20% of patients.