Evidence - Appendectomy, laparoscopic - general and visceral surgery

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  • Literature summary

    Management of acute appendicitis

    Acute appendicitis (AA) is not, as has long been assumed, a linear inflammation of the appendix possibly ending in perforation, peritonitis with subsequent sepsis, and even death, if no medical intervention is undertaken. Rather, AA is a much more heterogeneous and complex disorder.

    There is a distinction between uncomplicated appendicitis (UA; inflammatory thickening of the appendix) and complicated appendicitis (CA), which is present in about 20% of cases and is defined by the occurrence of gangrene or perforation of the appendix or a periappendiceal abscess. In most cases, however, they are no longer understood as two successive stages of the same disease, but rather as two distinct entities of this disease [1]. This finding is based on epidemiological data, according to which the incidence of both entities develops independently  2,3].

    Diagnostic work-up

    In addition to the medical history, a clinical examination including the various signs of appendicitis (McBurney, Lanz, Blumberg, Rovsing, Psoas) and a lab panel are mandatory [4]. A common complaint in patients with a history of AA is pain migrating from the epigastrium to the right lower quadrant [5]. 

    Leukocytosis and elevated CRP levels are nonspecific parameters of inflammation [6]. If two or more parameters are confirmed, the presence of AA is more likely; if all parameters are missing, this diagnosis is unlikely [7]. Procalcitonin has no relevant place in routine diagnostic work-up; however, high procalcitonin levels in combination with high CRP levels correlate with complicated appendicitis [8,9].

    While elevated temperature and fever are nonspecific symptoms, they correlate with advanced AA, and therefore temperature should be measured routinely [6]. According to a meta-analysis, digital rectal examination is not mandatory [10].

    Urinalysis (strip test) and pregnancy testing in young women of childbearing age should be performed regularly [4].

    Appendicitis scores

    Various scores have been developed to better assess the likelihood of AA being present: Alvarado (MANTRELS)-Score, Appendicitis Inflammatory Response (AIR oder Andersson) score, Pediatric Appendicitis Score (PAS), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score, and Adult Appendicitis Score (AAI) [11-14]. These may facilitate decision making [15] but are rarely used in routine clinical practice in Germany.

    Diagnostic imaging

    Ultrasonography (specificity 71-94%, sensitivity 81-98%) can reliably confirm AA with appropriate expertise, but it is not reliable enough to rule it out with certainty [16, 17, 18]. Abdominal computed tomography (CT) (sensitivity 76-100%, specificity 83-100%) is superior to ultrasonography for ruling out or confirming the diagnosis of AA [16]. However, radiation exposure should not be underestimated, especially in children, adolescents, and pregnancy [11]. Here, MRI (sensitivity 97%, specificity 95%) with its lack of radiation exposure offers a safe alternative to CT [16].

    In the United States, imaging in suspected appendicitis is performed in more than 80% of patients (usually CT), whereas imaging is not performed in approximately 1/3 of European patients and in approximately 3/4 of Australian patients [15]. The Dutch guidelines regard imaging as indispensable in the diagnosis of appendicitis [19].

    Surgical treatment of appendicitis

    At present, there is no German guideline for the treatment of appendicitis. There are the „Guidelines for Laparoscopic Appendectomy“ by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). More recent guidelines have been published by the European Association of Endoscopic Surgery in a consensus conference (EAES) and by the World Society of Emergency Surgery (WSES) [11, 16, 20]. There is widespread agreement in the guidelines recommending laparoscopic appendectomy as first-line treatment.

    Laparoscopic appendectomy has been reported to result in an increased rate of intraabdominal abscess, particularly in complicated appendicitis, while the open technique reportedly suffers from higher rates of wound infection and transit disorders [21, 22, 23].

    In AA, perioperative administration of broad-spectrum antibiotics (single-shot) reduces the incidence of wound infection and abscess formation. In UA, postoperative continuation of antibiotics is not advised; in CA they should be continued for 3 to 5 days, considering the clinical situation and lab results [11].

    Timing of surgery in acute appendicitis

    When imaging suspects UA, appendectomy can be deferred for 12-24 hours without increasing morbidity after prompt initiation of antibiotics. Patients ≥ 65 years of age or with comorbidities, should undergo surgery ≤ 12 hours from the time of diagnosis. Appendectomy ≥ 48 hours is associated with a higher rate of surgical infection [11, 24, 25, 25a, 25b].

    In CA with phlegmon or abscess, the current literature does not permit a definite recommendation on the timing of surgery.  The urgency here depends on the severity of the clinical findings and comorbidities. In perforated appendicitis with free air, there is undoubtedly an urgent indication for surgery [26].

    Nonsurgical treatment of uncomplicated appendicitis

    Primary non-surgical management of UA, most often confirmed by CT, with antibiotics is effective in approximately 86% of patients. If conservative treatment fails (14% of cases with persistent or even progressive symptoms), prompt appendectomy should be performed [27]. Patients primarily responding to antibiotics may be spared appendectomy in nearly 80% of cases in the first year, although at least 22.5% experience recurrent appendicitis during the first year [28]. In a study with a 5-year follow-up, the incidence of recurrent appendicitis was 27% in the first year, 34% after 2 years, 35.5% after 4 years, and 39% after 5 years [29]. A 2019 review indicated that as many as 37% of patients initially treated conservatively required appendectomy within one year [29a]. A meta-analysis published in 2019 found no statistically relevant increase in the rate of perforation in imaging-confirmed UA managed non-surgically, although the efficacy of surgical treatment of AA is higher [28, 30].

    Management of complicated appendicitis

    At present, there is no internationally standardized evidence-based protocol for CA management.

    There are some retrospective studies and meta-analyses showing low morbidity for non-surgical or interventional management in CA versus urgent/emergent appendectomy [31,32]. In contrast, other studies have shown the benefit of surgical therapy in CA [33, 34, 35]. A 2019 meta-analysis contrasted two groups of patients: laparoscopic (appendectomy or lavage with drainage) and conservative (antibiotics only or antibiotics with interventional drainage). The laparoscopic group reported higher rates of uncomplicated courses, shorter LOS in hospital, and lower incidence of recurrent or residual abscess. Thus, the meta-analysis clearly favored laparoscopic management in CA [34].

    Laparoscopic interval appendectomy 4 to 6 months after CA should be reserved for selected patients (e.g., with persistent symptoms) because these patients suffer from a higher conversion rate, significantly more intraoperative complications, and intra-abdominal infections compared with urgent/emergent appendectomy [36, 37].

    Even though conservative management is becoming more important, various publications indicate that the current data are inadequate to justify departure from the primary surgical approach in acute appendicitis [38-41]. The main criticism is the lack of randomized placebo-controlled blind trials to resolve long-term outcomes with regard to adverse effects of conservative treatment.

  • Ongoing trials on this topic

  • References on this topic

    1. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. (2015) Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet;386:1278

    2. Livingston EH, Woodward WA, Sarosi GA, Haley RW. (2007) Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg;245:886–92

    3. Andersson RE. (2007) The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg Jan;31(1):86–92

    4. Humes DJ, Simpson J.(2006)  Acute appendicitis. BMJ; 333(7567):530–534

    5. Humes DJ, Speake WJ, Simpson J. (2007) Appendicitis. BMJClinEvid;408

    6. Shogilev DJ et al. (2014) Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. West JEmergMed;15(7):859–871

    7. Andersson RE. (2004) Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg;91(1):28–37

    8. Yu CW et al. (2013) Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein andwhite blood cell count for suspected acute appendicitis. Br J Surg;100(3):322–329

    9. Li, Y., Zhang, Z., Cheang, I. et al. (2020) Procalcitonin as an excellent differential marker between uncomplicated and complicated acute appendicitis in adult patients. Eur J Trauma Emerg Surg; 46, 853–858

    10. Takada T et al. (2015) The role of digital rectal examination for diagnosis of acute appendicitis: a systematic reviewand meta-analysis. PLoS One; 10(9):e136996

    11. Di Saverio S et al. (2016)  WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg; 11:34.

    12. Kulik DM, Uleryk EM, Maguire JL. (2013) Does this child have appendicitis? A systematic review of clinical prediction rules for children with acute abdominal pain. JClinEpidemiol; 66(1):95–104

    13. Ohle R et al. (2011) The Alvarado score for predicting acute appendicitis: a systematic review. BMCMed; 9:139

    14. Karami MY et al. (2017) Which one is better? Comparison of the acute inflammatory response, raja Isteri Pengiran Anak Saleha appendicitis and Alvarado scoring systems. Ann Coloproctol; 33(6):227–231

    15. Sartelli M et al. (2018) Prospective observational study on acute appendicitis worldwide (POSAW). World J Emerg Surg 13:19.

    16. Gorter RR et al. (2016) Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc 30(11):4668–4690

    17. Doria AS et al. (2006) US or CT for diagnosis of appendicitis in children and adults? A metaanalysis. Radiology241(1):83–94

    18. Chang ST, Jeffrey RB, Olcott EW (2014) Threestep sequential positioning algorithm during sonographic evaluation for appendicitis increases appendiceal visualization rate and reduces CT use. AJRAmJRoentgenol 203(5):1006–1012

    19. Bakker OJ et al. (2010) Guideline on diagnosis and treatment of acute appendicitis: imaging prior to appendectomy is recommended. Ned Tijdschr Geneeskd154:A303

    20. https://www.sages.org/publications/guidelines/guidelines-for-laparoscopicappendectomy/Oktober 2019

    21. Sahm M et al. (2013) Acute appendicitis—clinical health-service research on the current surgical therapy. ZentralblChir 138(3):270–277

    22. Sridhar AN et al. (2015) Impact of the increased use of preoperative imaging and laparoscopy on appendicectomy outcomes. Indian J Surg 77(2):356–360

    23. Tuggle KR et al. (2010) Laparoscopic versus open appendectomy in complicated appendicitis: a review of the NSQIP database. J Surg Res 163(2):225–228

    24. van Dijk ST et al. (2018) Meta-analysis of inhospital delay before surgery as a risk factor for complications in patientswith acute appendicitis. Br JSurg105(8):933–945

    25. Busch M et al. (2011) In-hospital delay increases the risk of perforation in adults with appendicitis. World JSurg35(7):1626–1633

    25a. Li J, Xu R, Hu D-M, Zhang Y, Gong T-P, Wu X-L (2019) Effect of delay to operation on outcomes in patients with acute appendicitis: a systematic review and meta-analysis. J Gastrointest Surg 23: 210–23

    25b. Cameron DB, Williams R, Geng Y, et al. (2018) Time to appendectomy for acute appendicitis: A systematic review. J Pediatr Surg53: 396–405

    26. Fugazzola P et al. (2019) Early appendectomy vs. conservative management in complicated acute appendicitis in children: ameta-analysis. J Pediatr Surg54(11):2234–2241

    27. Vons C et al. (2011) Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, noninferiority, randomised controlled trial. Lancet 377(9777):1573–1579

    28. Podda M et al. (2017) Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with metaanalysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics. Surgeon15(5):303–314

    29. Salminen P et al. (2018) Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in theAPPACrandomizedclinical trial. JAMA320(12):1259–1265

    29a. Prechal D, Damirov F, Grilli M, Ronellenfitsch U(2019) Antibiotic therapy for acute uncomplicated appendicitis: a systematic review and meta-analysis. Int J Colorectal Dis34: 963–71

    30. Podda M et al. (2019) Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: a systematic review and meta-analysis. Ann Surg 270(6):1028–1040.

    31. Simillis C et al. (2010) Ameta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery147(6):818–829

    32. Shekarriz S et al. (2019)Comparisonof conservative versus surgical therapy for acute appendicitis with abscess in five German hospitals. IntJColorectalDis34(4):649–655.

    33. Gavriilidis P et al. (2019) Acute appendicectomy or conservative treatment for complicated appendicitis (phlegmon or abscess)? A systematic review by updated traditional and cumulative

    meta-analysis. JClinMedRes11(1):56–64

    34. Dong Y et al. (2018) Meta-analysis of laparoscopic surgery versus conservative treatment for appendiceal abscess. ZhonghuaWei ChangWai Ke Za Zhi 21(12):1433–1438

    35. Mentula P, Sammalkorpi H, Leppaniemi A (2015) Laparoscopic surgery or conservative treatment for appendiceal abscess in adults? A randomized controlled trial.AnnSurg262(2):237–242

    36. Becker P, Fichtner-Feigl S, Schilling D (2018) Clinical management of appendicitis. Visc Med 34(6):453–458

    37. Al-Kurd A et al. (2018) Outcomes of interval appendectomy in comparison with appendectomy for acute appendicitis. JSurgRes 225:90–94

    38. Maita S, Andersson B, Svensson JF, Wester T (2020) Nonoperative treatment for nonperforated appendicitis in children: a systematic review and meta-analysis. Pediatr Surg Int; 36: 261–9

    39. Kessler U, Mosbahi S, Walker B et al. 2017) Conservative treatment versus surgery for uncomplicated appendicitis in children: a systematic review and meta-analysis. Arch Dis Child; 102: 1118–2

    40. Prechal D, Damirov F, Grilli M, Ronellenfitsch U (2019) Antibiotic therapy for acute uncomplicated appendicitis: a systematic review and meta-analysis. Int J Colorectal Dis; 34: 963–71

    41. Téoule P, de Laffolie J, Rolle U, Reißfelder C (2020)  Acute appendicitis in childhood and adulthood—an everyday clinical challenge. Dtsch Arztebl Int; 117: 764–74

  • Reviews

    Di Saverio S et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020 Apr 15;15(1):27.

    Krzyzak M, Mulrooney SM. Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and Treatment. Cureus. 2020 Jun 11;12(6):e8562.

    Zavras N, Vaos G. Management of complicated acute appendicitis in children: Still an existing controversy. World J Gastrointest Surg. 2020 Apr 27;12(4):129-137.

    Téoule P, Laffolie J, Rolle U, Reissfelder C. Acute Appendicitis in Childhood and Adulthood. Dtsch Arztebl Int. 2020 Nov 6;117(45):764-774.

    Sherratt FC, Allin BSR, Kirkham JJ, Walker E, Young B, Wood W, Beasant L; Appendicitis Core Outcome Set Study Group, Eaton S, Hall NJ. Core outcome set for uncomplicated acute appendicitis in children and young people. Br J Surg. 2020 Jul;107(8):1013-1022

    Harclerode TP, Gnugnoli DM. Percutaneous Abscess Drainage. 2020 Nov 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

    Ahmed A, Feroz SH, Dominic JL, Muralidharan A, Thirunavukarasu P. Is Emergency Appendicectomy Better Than Elective Appendicectomy for the Treatment of Appendiceal Phlegmon?: A Review. Cureus. 2020 Dec 12;12(12):e12045.

    Poprom N, Wilasrusmee C, Attia J, McEvoy M, Thakkinstian A, Rattanasiri S. Comparison of postoperative complications between open and laparoscopic appendectomy: An umbrella review of systematic reviews and meta-analyses. J Trauma Acute Care Surg. 2020 Oct;89(4):813-820

  • Guidelines

  • literature search

    Literature search on the pages of pubmed.