12/6/2016

Management of acute appendicitis in adults

OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Managementofacuteappendicitisinadults
Authors
DouglasSmink,MD,MPH
DavidISoybel,MD

SectionEditor
MartinWeiser,MD

DeputyEditor
WenliangChen,MD,PhD

Contributordisclosures
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2016.|Thistopiclastupdated:May18,2016.
INTRODUCTIONThegoalofmanagementofacuteappendicitisisearlydiagnosisandpromptoperativeintervention.
However,thisgoalisnotalwayseasilyaccomplishedsincemanypatientsdonotseekmedicalattentioninatimely
mannerandthediagnosisofappendicitiscanbedifficult[1].Manysurgeonsuseanaggressiveapproach,acceptinga
certainnumberofnegativeappendectomies,traditionally15percent,althoughtheuseofadvancedabdominalimaging
appearstohavereducedthenegativeappendectomyratetolessthan10percent[2].
Themanagementofappendicitisinadultswillbereviewedhere.Thediagnosisanddifferentialdiagnosisofappendicitis,
appendicitisinpregnancy,andthediagnosisanddifferentialdiagnosisofabdominalpainingeneralarediscussed
separately.(See"Acuteappendicitisinadults:Clinicalmanifestationsanddifferentialdiagnosis"and"Acuteappendicitis
inpregnancy"and"Evaluationoftheadultwithabdominalpain"and"Causesofabdominalpaininadults".)
ROLEOFNONOPERATIVEMANAGEMENTAppendectomyremainsthestandardofcareformostpatientswith
uncomplicatedacuteappendicitis.Analternativestrategyisantibiotictherapy,supportivecare,andobservation,with
appendectomyreservedforthosewhodonotrespondtothistreatmentorthosewhodevelopcomplicated
appendicitis.Sometheorizethatperforatedandnonperforatedappendicitiscouldhavedifferentpatternsand
pathologicalprocesses[3].Theremaybeasubsetofpatientswhowillrespondtononoperativemanagementandfor
whomtheriskofrecurrentacuteappendicitisarelessthanthepotentialrisksassociatedwithappendectomy.However,
giventhatthesubsetofpatientsleastlikelytofailinitialnonoperativemanagement(37percentinthemetaanalysis
below)hasnotbeendefinitivelydetermined,wecontinuetorecommendappendectomyastheinitialtreatmentforthose
withacuteappendicitis,complicatedoruncomplicated,forthefollowingreasons:
Appendectomycangenerallybeperformedwithlowmorbidityandverylowmortality.
PreoperativeabdominalCTinterpretedasuncomplicatedappendicitiscannotexcludethepossibilityof
complicateddisease.Inonetrial,amongpatientsintheappendectomyarm,20percenthadcomplicated
appendicitisidentifiedatthetimeofsurgery[4].
Patientswithfecalithsonimaginghadahighrateofcomplicatedappendicitis(upto40percent).Thus,forthose
withafecalithidentifiedonradiographicimaging(eg,plainabdominalfilmsorCTscan),werecommendagainst
nonoperativemanagement[46].
Patientstreatednonoperativelyareatriskforprogressionofsymptomsordevelopingcomplicatedappendicitis.
Patientstreatednonoperativelyhaveanappreciablerateofrecurrentappendicitis(15to25percent)[4].
Nonoperativemanagementposesagreaterriskincertainpatients,particularlyelderlyandimmunocompromised
patients,sincetheseverityofthediseasecanbeunderestimated.(See'Specialconsiderations'below.)
OurrecommendationisinlinewithtreatmentguidelinesfromtheAmericanCollegeofSurgeons,theSocietyforSurgery
oftheAlimentaryTract,andtheWorldSocietyofEmergencySurgery[7].Allthreesocietiesrecommendappendectomy
(eitherlaparoscopicoropen)asthetreatmentofchoiceforappendicitis.
Forasmallminorityofpatientswitheitherpriorhistoryofsurgicalcomplicationsorseverephobiatoappendectomy,a
conservativeapproachcouldbeofferedasanalternativetoimmediatesurgery.
SeveralEuropeantrialsrandomlyassignedadultpatientswithadiagnosisofacuteuncomplicatedappendicitistoeither
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initialappendectomyorinitialantibiotictherapy.Afterreceivingeitherintravenousororalantibioticsinthehospitalfor
twodays,patientsassignedtoinitialantibioticswereeitherdischargedhomewithanadditionalsevendaysoforal
antibiotics,ortakentosurgeryforlackofclinicalimprovement(crossover)[4,812].
Severalsystematicreviewsandmetaanalysesbaseduponthesetrialscomparedthesafetyandefficacyofantibiotic
treatmentversusappendectomyfortheprimarytreatmentofuncomplicated,acuteappendicitis[1316].Patientstreated
withantibioticshadfewermajor(4.9versus8.4percent)orminor(2.2versus12.5percent)complicationscompared
withthosewhounderwentsurgery.Forevery100patientswhoweretreatedwithantibioticsinitially,92didnotrequire
surgeryduringthefirstmonth,but23experiencedrecurrentappendicitiswithinthefirstyear[16].Thespecificfindingsof
thetrialsareasfollows:
Mostpatientsassignedtotheantibioticfirstapproachwereabletoavoidappendectomyinitially,althoughupto
53percentofpatientscrossedovertosurgerywithinthefirst48hoursofantibiotictreatment.
Patientsintheantibioticfirstgrouphadfavorableclinicaloutcomes(includingreductioninwhitecellcount[9],
avoidanceofperitonitis[4],andgeneralsymptomreduction[8,10,11]).
Ascomparedwiththeappendectomygroup,patientsintheantibioticfirstgrouphadlowerorsimilarpainscores
[4,8,9],requiredfewerdosesofnarcotics[9],andhadaquickerreturntowork[8,9].
Ascomparedwiththeappendectomygroup,therateofperforationwasnothigherintheantibioticfirstgroup.
Afterinitialtreatmentsuccess,10to37percentofthepatientsintheantibioticfirstgroupeventuallyrequired
appendectomyforrecurrentappendicitisorsymptomsofabdominalpain(meantimetoappendectomy,4.2to7
months[4,9,10]).Aseparate,observationalstudyshowedanoverallrecurrencerateof13.8percentin159
patientstreatedinitiallywithantibioticsthenfollowedfortwoyears[17].
However,seriousquestionsremainregardingtheefficacyofusingantibioticsastheprimarytreatmentforappendicitis.
Asexamples:
Doesantibiotictreatmentincreasehospitalutilization,andthereforecost,bothduringtheinitialphaseoftreatment
andforrecurrences?
Doesthesuccessinavoidingimmediatesurgeryjustifythefearandburdenofpotentialrecurrenceormissed
appendicealneoplasm(especiallyinolderadults)?
Althoughhighriskpatients(eg,olderadults,immunocompromised,patientswithmedicalcomorbidities)could
potentiallybenefitthemostfromnonsurgicaltreatmentofappendicitis,theywereexcludedfromalltrialscited
above.Thus,theefficacyoftheantibioticfirstapproachtomanagementofappendicitisinthisgroupofpatients
remainsunknown.(See'Specialconsiderations'below.)
LargemulticenterrandomizedtrialsintheUSareneededbeforetheantibioticfirstapproachcouldbeconsidered
comparabletoappendectomy.Thus,wereiteratethattheantibioticfirstapproachshouldonlybeofferedtoselected
patients(eg,poorsurgicalcandidates,patientswhorefusesurgery)afteracarefulexplanationoftherisks.Ingeneral,
appendectomyisstillconsideredthestandardofcareinthetreatmentofacuteuncomplicatedappendicitis[18].
SURGICALOUTCOMES
LaparotomyversuslaparoscopyAnappendectomyisperformedbytheconventionalopenlaparotomyapproachor
bylaparoscopy.Thelaparoscopicapproachisusedtoperformanestimated58percentofallappendectomiesinthe
UnitedStates[1922].Theoperativeapproachinpatientswithasuspectedappendicitisdependsupontheconfidencein
thediagnosis,historyofpriorsurgery,thepatient'sage,gender,andbodyhabitus,andtheskillsofthesurgeon.
Randomizedtrialsandprospectiveandretrospectiveobservationalstudiesevaluatinglaparoscopicandopen
techniqueshavebeenperformedtoassessoutcomes[2124].Thepertinentfindingsinclude:
Atrendanalysisofprospectivelycollecteddataon7446patientsundergoingalaparoscopicappendectomyfound
thatcomplicationrateshavesignificantlydecreasedoveradecadeofobservation[22].Forproceduresperformed
attheendofthestudyperiodcomparedwithproceduresperformedatthebeginning,thereweresignificant
reductionsinthefollowingoutcomes:
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Conversionfromalaparoscopictoanopenprocedure(2.2to1.2percent)
Intraoperativecomplications(3.1to0.7percent)
Surgicalpostoperativecomplications(6.1to1.9percent)
Generalpostoperativecomplications(4.9to1.5percent)
Rateofreoperation(3.4to0.7percent)
Durationofhospitalstay(4.9to3.5days)
Ametaanalysisof56randomizedtrialsand11studiescomparedtheoutcomesofapproximately6000adultsand
childrenwithsuspectedacuteappendicitisundergoingeitherlaparoscopicappendectomyorconventionalopen
laparotomy[23].Therewerebothsignificantlybetterandworseoutcomesforthelaparoscopicapproachcompared
withtheconventionalopenlaparotomy.Therewerenosignificantdifferencesforadultoutcomescomparedwith
children.
Thesignificantlybetteroutcomeswiththelaparoscopicapproachincluded:
Alowerrateofwoundinfections(oddsratio[OR]0.43,95%CI0.340.54)
Lesspainonpostoperativeday1bytheVASpainscore(8mm,CI511mm)
Shorterdurationofhospitalstay(1.1days,CI0.71.5days)
Shorterdurationforreturnofbowelfunction(nodataprovided)
Thesignificantlyworseoutcomesforthelaparoscopicapproachincluded:
Ahigherrateofanintraabdominalabscess(OR1.77,CI1.142.76)
Alongeroperativetime(10minutes,CI615minutes)
Higheroperativeandinhospitalcosts
Outcomedataon235,473patientswithsuspectedacuteappendicitisundergoingalaparoscopicoropen
appendectomybetween2000and2005wereobtainedfromtheUSNationwideInpatientSample[20].The
frequencyoflaparoscopicappendectomiesincreasedfrom32to58percentoverthestudytimeperiod.The
proportionofpatientswithuncomplicatedappendicitiswassignificantlyhigherinthelaparoscopicgroup(76versus
69percent).
Patientsundergoingalaparoscopicappendectomyforuncomplicated(eg,nonperforated,noabscess)acute
appendicitisweresignificantlymorelikelytohaveashortermeanhospitalstay(1.5versus1.8days),higher
ratesofintraoperativecomplications(OR2.61,CI2.233.05),andhighercosts(22percent)comparedwith
patientstreatedbyanopenappendectomy.
Forpatientswithcomplicatedappendicitis,definedasanappendicealperforationorabscess,laparoscopic
approachwassignificantlyassociatedwithashortermeanhospitalstay(3.5versus4.2days),higherratesof
intraoperativecomplications(OR1.61,CI1.331.94),andhigherhospitalcosts(9percent)comparedto
patientsundergoinganopenappendectomyforcomplicatedappendicitis.
Althoughlaparoscopicappendectomyhasgainedwidespreadacceptance,thesedatashowthattherearebenefitsand
limitationstothelaparoscopicapproach.Asaresult,thechoiceoflaparoscopicoropenappendectomyisbestdecided
bythesurgeonbasedonpersonalexperience,institutionalcapabilities,severityofdisease,bodyhabitus,andother
factors.Thereareclinicalsettingswhenlaparoscopymaybethepreferredapproach.Theseinclude:
AnuncertaindiagnosisThelaparoscopicapproachprovidesanadvantageinpatientsinwhomthediagnosisis
uncertainsinceitpermitsinspectionofotherabdominalorgans.Thisbenefitmaybegreaterforwomenof
childbearingage,whotraditionallyhavehadhighernegativeappendectomyrates,andinwhomlaparoscopymay
revealothercausesofpelvicpathology[2528].Inastudyof181womenwhounderwentlaparoscopyfor
suspectedacuteappendicitis,86(48percent)werediagnosedwithagynecologicdisorderastheetiologyofthe
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symptoms[28].
ObesepatientsLaparoscopicappendectomyisusefulintheoverweightorobesepatient,sinceexposureofthe
rightlowerquadrantduringopenappendectomymayrequirelarger,morbidityproneincisions[2931].Ina
retrospectivereviewof13,330obesepatientsundergoingaprimaryappendectomyforconfirmedappendicitis,the
laparoscopicapproach(n=10,409patients)wasassociatedwitha57percentreductioninoverallmorbidity
comparedwithanopenappendectomy(5.23versus13.49percent,oddsratio[OR]0.43,95%CI0.360.52)[31].
Inaddition,themortalityratewasalsosignificantlylowerforthepatientsundergoingalaparoscopicappendectomy
(0.11versus0.58percent,OR0.47,0.320.65).
ElderlypatientsElderlypatientsmaybenefitsignificantlyfromalaparoscopicapproach,ashospitalstayis
shorteranddischargeratestohomearehigherinthispopulationthanwithanopenappendectomy.Ina
retrospectivereviewbaseduponoutcomedatafromtheNorthCarolinaHospitalAssociationPatientDataSystem
on29,244appendectomiesperformedinadults,2,722wereperformedinelderlypatients(definedasage>65
years)[32].Amongtheelderlypatients,laparoscopicappendectomyhadthefollowingbenefitscomparedwith
elderlypatientsundergoinganopenappendectomy:
Foruncomplicatedappendicitis,laparoscopicappendectomywasassociatedwiththefollowingsignificant
benefits:shorterlengthofhospitalstay(4.6versus7.3days),higherrateofdischargetohomeratherthana
stepdownfacility(91versus79percent),fewercomplications(13versus22percent),andlowermortality
rate(0.4versus2.1percent).
Foraperforatedappendix,laparoscopicappendectomywasassociatedwiththefollowingsignificant
benefits:shorterlengthofhospitalstay(6.8versus9.0days),higherrateofdischargetohome(87versus71
percent),andequivalentmortalityrates(0.37versus0.15percent).
DiseaseseverityscoreAscoringsystemhasbeenproposedtoassistincomparingoutcomesandtherapeutic
modalitiesbasedupontheoperativefindings[33].Thisscoringsystemofacuteappendicitisincludes:

Grade1Inflamed
Grade2Gangrenous
Grade3Perforatedwithlocalizedfreefluid
Grade4Perforatedwithregionalabscess
Grade5Perforatedwithdiffuseperitonitis

PREOPERATIVEPREPARATIONPatientswithacuteappendicitisrequireadequatehydrationwithintravenous
fluids,correctionofelectrolyteabnormalities,andperioperativeantibiotics[34].Thepatient'svitalsignsandurineoutput
shouldbecloselymonitored.AFoleycathetermayberequiredinseverelydehydratedpatients.However,oncethe
decisionhasbeenmadetoperformanoperationforacuteappendicitis,thepatientshouldproceedtotheoperating
roomwithaslittledelayaspossibletominimizethechanceofprogressiontoperforation.
AntibioticsProphylacticantibioticsareimportantforpreventingwoundinfectionandintraabdominalabscess
followingappendectomy[34].Thefloraoftheappendixreflectsthatofthecolonandincludesgramnegativeaerobes
andanaerobes.Patientsshouldreceiveprophylacticantibioticswithina60minute"window"beforetheinitialincision
[35,36].Theselectionofantibioticsissummarizedhereanddiscussedinmoredetailseparately.(See"Antimicrobial
prophylaxisforpreventionofsurgicalsiteinfectioninadults".)
AcuteappendicitisInpatientswithacutenonperforatedappendicitis,asinglepreoperativeantibioticdosefor
surgicalwoundprophylaxisisadequate.GuidelinesestablishedbytheMedicalLetterandtheSurgicalCare
ImprovementProjectsuggestthefollowingoptionsforcolorectalprocedures:asingledoseofcefoxitin(1to2gIV),
ampicillin/sulbactam(3gIV),thecombinationofcefazolin(2gif<120kgor3gif120kgIV)PLUSmetronidazole(500
mgIV),or,inpatientsallergictopenicillinsandcephalosporins,clindamycinPLUSoneofthefollowing:ciprofloxacin,
levofloxacin,gentamicin,oraztreonam(table1)[37,38].Postoperativeantibioticsareunnecessary[39].(See
"Antimicrobialprophylaxisforpreventionofsurgicalsiteinfectioninadults"and"Controlmeasurestopreventsurgical
siteinfectionfollowinggastrointestinalproceduresinadults",sectionon'Gastroduodenalprocedures'.)
PerforatedappendicitisInpatientswithperforatedappendicitis,theantibioticregimenshouldconsistofempiric
broadspectrumtherapywithactivityagainstgramnegativerodsandanaerobicorganismspendingcultureresults
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[40,41].Asinitialchoiceofanantibiotic,wesuggesteithermonotherapywithabetalactam/betalactamaseinhibitor
(piperacillintazobactamorticarcillinclavulanate)orthecombinationofathirdgenerationcephalosporinPLUS
metronidazole(eg,ceftriaxoneplusmetronidazole).Alternativeregimensareshowninatable(table2).
Regardlessoftheinitialempiricregimen,thetherapeuticregimenshouldberevisitedoncecultureandsusceptibility
resultsareavailable.Recoveryofmorethanoneorganismshouldsuggestpolymicrobialinfectionincludinganaerobes,
evenifnoanaerobesareisolatedinculture.Insuchcircumstances,anaerobiccoverageshouldbecontinued.
Combinationtherapywithasecondorthirdgenerationcephalosporinorafluoroquinoloneplusmetronidazoleis
adequateformostpatients.
Thedurationofantibiotictherapyinsuchpatientsisdiscussedelsewhere.(See"Antimicrobialapproachtointra
abdominalinfectionsinadults",sectionon'Durationoftherapy'.)
LAPAROSCOPICAPPENDECTOMY
PatientpreparationInthelaparoscopicapproach,anorogastrictubeistypicallyplacedtodecompressthestomach.
ThebladdercanbedecompressedeitherwithaFoleycatheter,orbyhavingthepatientvoidimmediatelypriorto
enteringtheoperatingroom.
PatientpositioningThepatientispositionedsupineontheoperatingroomtablewiththeleftarmtucked.Thevideo
monitorisplacedatthepatient'srightside,becauseoncepneumoperitoneumisperformed,thesurgeonandassistant
bothstandonthepatient'sleft.
PortplacementVariousportplacementshavebeenadvocatedforlaparoscopicappendectomy.Thesemethods
sharetheprincipleoftriangulationofinstrumentportsandtheappendixtoensureadequatevisualizationandexposure.
Inonemethod,pneumoperitoneumisobtainedthrougha12mmperiumbilicalport,throughwhichthelaparoscopeis
insertedandexploratorylaparoscopyperformed.Theothertwoportsareplacedunderdirectvision:a5mmportinthe
leftlowerquadrantanda5mmsuprapubicportinthemidline.Ifa5mmlaparoscopeisused,itcanbeplacedthrough
theleftlowerquadranttrocar,andtheumbilical12mmtrocarcanbeusedforastapler.Moststaplersrequirea12mm
port(figure1).
Whentheappendixislocatedintheretrocecalposition,goodtriangulationofinstrumentscanalsobeachievedwitha
12mmportplacedintheuppermidline.Thisportallowsinstrumentsorthelaparoscopetobepositionedforaccessto
thegutterbetweentherightcolonandtheabdominalwall.Ifthesuspicionforopenconversionishigh,allmidline
incisionsshouldbeorientedverticallysotheycaneasilybeincorporatedintoalowermidlineincision.
Analternativeabdominalaccessmethodtotriangulationofinstrumentportsistheumbilicalsingleincision
appendectomy[42,43].Large,prospectivestudiesareneededtodetermineifanyclinicaladvantageexistswiththis
approach.
MobilizationandresectionOncethediseasedappendixisidentified,anyadhesionstosurroundingstructurescan
belysedwithacombinationofbluntandsharpdissection.Ifaretrocecalappendixisencountered,divisionofthelateral
peritonealattachmentsofthececumtotheabdominalwalloftenimprovesvisualization.Caremustbetakentoavoid
underlyingretroperitonealstructures,specificallytherightureterandiliacvessels.
TheappendixormesoappendixcanbegentlygraspedwithaBabcockclampandretractedanteriorly.Theappendiceal
arteryisidentifiedanddividedbetweenhemostaticclips,usinganultrasonicscalpel,alaparoscopicgastrointestinal
anastomosis(GIA)staplerorothervesselligationdevice.Theappendixisclearedtoitsattachmentwiththececum,and
theappendicealbaseisdividedusingalaparoscopicgastrointestinalanastomosisstapler(GIA)stapler,takingcarenot
toleaveasignificantstump[44].Itissometimesnecessarytoincludepartofthececumwithinthestaplertoensurethat
thestaplesareplacedinhealthy,uninfectedtissue.
Theappendixisthenremovedthroughtheumbilicalport,usingaspecimenbagtoavoidtheriskofwoundinfection.
Theoperativefieldisinspectedforhemostasisandirrigatedwithsalineifneededandthenthefascialdefectandskin
incisionsareclosed.
OPENAPPENDECTOMY
IncisionThepatientshouldbereexaminedaftertheinductionofgeneralanesthesia,asthisallowsdeeppalpationof
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theabdomen.Ifamassrepresentingtheinflamedappendixcanbepalpated,theincisioncanbelocatedoverthemass.
Ifnoappendicealmassisdetected,theincisionshouldbecenteredoverMcBurney'spoint,onethirdofthedistance
fromtheanteriorsuperioriliacspinetotheumbilicus.Acurvilinearincisioninaskinfoldallowsforanexcellentcosmetic
result.
Itisimportantnottomaketheincisiontoomedialortoolateral.Anincisionplacedtoomedialopensontotheanterior
rectussheath,ratherthanthedesiredobliquemuscles,whileanincisionplacedtoolateralmaybelateraltothe
abdominalcavity.Somesurgeonspreferatransverseincision,however,becauseitiseasilyextendedtoincreased
exposureifneeded(figure2).
MobilizationandresectionThedissectionbeginsthroughthesubcutaneoustissuetotheexternalobliquefascia,
whichissharplyincisedlateraltotherectussheath.Usingamusclesplittingtechnique,theexternalobliqueisbluntly
separatedinthedirectionofthemusclefiberstheinternalobliqueandtransversusabdominusmusclesarebluntly
separatedinasimilarfashion.Theperitoneumissharplyentered,avoidinginjurytotheunderlyingintestine.
Thesurgeoncanoftenlocatetheappendixbysweepingafingerlaterallytomediallyintherightparacolicgutter.Thin
adhesionsbetweentheappendixandsurroundingstructuresmaygenerallybefreedwithbluntdissectionoccasionally,
sharpdissectionisrequiredformoredenseadhesions.Iftheappendixcannotbeidentifiedthroughpalpation,itcanbe
locatedbyfollowingtheteniaecolitoitsoriginatthececalbase.
Onceidentifiedandfreedfromadhesions,theappendixisdeliveredthroughtheincision.Themesoappendixmaybe
graspedwithaBabcockclamp,takingcarenottoteartheappendicealwallandcausespillageofentericcontents.The
appendicealartery,whichrunsinthemesoappendix,isdividedbetweenhemostatsandtiedwith30absorbablesuture.
Anonabsorbablepursestringsutureisplacedinthececalwallaroundtheappendix.Aftercrushingtheappendiceal
basewithaKellyclamp,theappendixisdoublytiedwith20absorbablesuture.Theappendixisexcisedwithascalpel,
andtheremainingstumpiscauterizedtopreventamucocele.Theappendicealstumpistypicallyinvertedintothe
cecumwhilethepursestringsutureistightened,althoughtheusefulnessofthisisdebatable[4549].Thesurgicalbedis
thenirrigatedwithsaline.
ClosureTheincisionisclosedinlayerswithrunning20absorbablesuture,beginningwiththeperitoneum,followed
bythetransversusabdominus,internaloblique,andexternaloblique.Irrigationisperformedateachlayer.Toimprove
analgesiaandlimitpostoperativenarcoticrequirements,theexternalobliquefasciamaybeinfusedwithlocal
anesthetic.Scarpa'sfasciaisclosedwithinterrupted30absorbablesuture,followedbyasubcuticularclosureor
staplesfortheskin.Innonperforatedappendicitis,theskinmaybeclosedprimarilywithalowlikelihoodofwound
infection.
PostoperativemanagementWithboththeopenandlaparoscopicapproaches,mostpatientsaredischargedwithin
24to48hoursofsurgery.Patientsmaybestartedonaclearliquiddietpostoperativelyandadvancedtoregulardietas
tolerated.Antibioticsarenotrequiredpostoperativelyinnonperforatedappendicitis.
PERFORATEDAPPENDICITISThetimecourseofprogressionofappendicitistonecrosisandperforationvaries
amongpatients.Approximately20percentofpatientswithperforatedappendicitispresentwithin24hoursoftheonset
ofsymptoms[50].Althoughperforationisamajorconcernwhenevaluatingapatientwithmorethan24hoursof
symptoms,perforationcandevelopmorerapidlyandshouldalwaysbeconsidered.
Patientswithperforatedappendicitismayappearacutelyillandhavesignificantdehydrationandelectrolyte
abnormalities,particularlyiffeverandvomitinghavebeenpresentforaconsiderabletime.Thepainusuallylocalizesto
therightlowerquadrantiftheperforationhasbeenwalledoffbysurroundingintraabdominalstructuressuchasthe
omentum,orcanbediffuseifgeneralizedperitonitisensues.
Otherunusualpresentationsofappendicealperforationcanoccur,suchasretroperitonealabscessformationdueto
perforationofaretrocecalappendixorliverabscessformationduetohematogenousspreadofinfectionthroughthe
portalvenoussystem.Anenterocutaneousfistulacanresultfromanintraperitonealabscessthatfistulizestotheskin.
Appendicealperforationcanresultinasmallbowelobstruction,manifestedbybiliousvomitingandobstipation.High
feversandjaundicecanbeseenwithpylephlebitis(septicportalveinthrombosis)andcanbeconfusedwithcholangitis.
Themanagementofappendicealperforationwilldependonthenatureoftheperforation.Afreeperforationcancause
intraperitonealdisseminationofpusandfecalmaterial.Urgentlaparotomyisnecessaryforfreeperforationwith
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appendectomyandirrigationanddrainageoftheperitonealcavity.Thesepatientsaretypicallyquiteillandmaybe
septic.Thediagnosisisnotalwaysappreciatedbeforeexplorationandamidlineincisionisprudent.Ifthediagnosisof
perforatedappendicitisiscertain,arightlowerquadrantincisioncanbeused.
Formanagementofacontainedperforation,nonoperativetreatmentisanoption.(See'Nonoperativeapproach'below.)
Treatmentshouldbeindividualizedforeachpatient,basedontheclinicalsituationandthehospital'scapabilities.
IncisionOperativetechniqueissimilarinappendectomiesforperforatedornonperforatedappendicitis.Inanopen
appendectomyforperforation,alargerincisionmaybeneededtoprovideadequateexposurefordrainageof
abscesses,entericcontents,andpurulentmaterial.Insomeinstances,alowermidlineincisionispreferabletoaright
lowerquadrantincision.Inbothopenandlaparoscopicapproaches,thegoalistoremoveanyinfectedmaterialand
drainallabscesscavities.Copiousirrigationisusedtoreducethelikelihoodofpostoperativeabscessformation.Once
theappendixandinfectedmaterialhavebeenremoved,themusclelayersoftheopenincisionareclosedaspreviously
described.
DrainsPeritonealdrainsarenotnecessary,astheydonotreducetheincidenceofwoundinfectionorabscessafter
appendectomyforperforatedappendicitis[51,52].Asystematicreviewidentifiedfivetrialsexaminingtheuseofdrains
afteremergencyappendectomy[53].Therewerenosignificantdifferencesbetweenthegroupsforintraperitoneal
abscessorwoundinfection.Thelengthofhospitalstaywassignificantlylongerforthedrainagecomparedwithno
drainage.
ClosureSkinclosuretechniquesincludeprimaryclosure,loosepartialclosure,andclosurewithsecondaryintention.
Becauseofwoundinfectionratesrangingfrom3050percentwithprimaryclosureofgrosslycontaminatedwounds,
manyadvocatedelayedprimaryorsecondaryclosure[54,55].However,acostutilityanalysisofcontaminated
appendectomywoundsshowedprimaryclosuretobethemostcosteffectivemethodofwoundmanagement[56].
Ourtechniqueofskinclosureisinterruptedpermanentsuturesorstaplesevery2cmwithloosewoundpackingin
between.Removalofthepackingin48hoursoftenleavesanexcellentcosmeticresultwithanacceptableincidenceof
woundinfection.Ifheavyfecalcontaminationispresent,theskinisoftenleftopentoclosesecondarily.
PostoperativemanagementPostoperatively,thesepatientsoftenhaveanileus,anddietshouldonlybeadvanced
astheclinicalsituationwarrants.Patientsmaybedischargedoncetheytoleratearegulardiet,usuallyinfivetoseven
days.
Thedurationofantibiotictherapyinsuchpatientsisdiscussedelsewhere.(See"Antimicrobialapproachtointra
abdominalinfectionsinadults",sectionon'Durationoftherapy'.)
NonoperativeapproachPatientswhopresent24to72hoursaftertheonsetofsymptomsusuallyundergo
immediateappendectomy.Incontrast,patientswhopresentwithalongerdurationofsymptoms(morethanfivedays)
andhavefindingslocalizedtotherightlowerquadrantshouldbetreatedinitiallywithantibiotics,intravenousfluids,and
bowelrest.Thesepatientswilloftenhaveapalpablemassonphysicalexaminationacomputedtomography(CT)scan
mayrevealaphlegmonorabscess.Fortunately,manyofthesepatientswillrespondtononoperativemanagementsince
theappendicealprocesshasalreadybeen"walledoff".
Immediatesurgeryinpatientswithalongdurationofsymptomsandphlegmonformationisassociatedwithincreased
morbidity,duetodenseadhesionsandinflammation.Underthesecircumstances,appendectomyoftenrequires
extensivedissectionandmayleadtoinjuryofadjacentstructures.Complicationssuchasapostoperativeabscess,or
enterocutaneousfistulamayensue,necessitatinganileocolectomyorcecostomy.Becauseofthesepotential
complications,anonoperativeapproachcanbeconsideredifthepatientisnotillappearing[5760].
Ifimagingstudiesdemonstrateanabscesscavity,CTorultrasoundguideddrainagecanoftenbeperformed
percutaneouslyortransrectally[6062].Studiessuggestthatthisapproachtoappendicealabscessesresultsinfewer
complicationsandshorteroveralllengthofstay[59,63,64].Percutaneousdrainage,generallywithCTguidance,isa
temporizingtreatmentoptionforperforatedappendicitis.Patientswhoareclinicallyhealthybuthaveawell
circumscribedabscess,orthosewhoappeartoosicktowithstandanoperation,areideallysuitedtoundergo
percutaneousdrainage.Thisallowsinflammationtosubside,sometimesnegatingtheneedforextendedbowel
resection,suchasileocecectomy.
Nonoperativemanagementincludesintravenousantibioticsandfluidsaswellasbowelrest.Patientsshouldbeclosely
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monitoredinthehospitalduringthistime.Treatmentfailure,asevidencedbybowelobstruction,sepsis,orpersistent
pain,fever,orleukocytosis,requiresimmediateappendectomy.Iffever,tenderness,andleukocytosisimprove,dietcan
beslowlyadvanced,usuallywithinthreetofivedays.Patientsaredischargedhomewhenclinicalparametershave
normalized.
Thedurationofantibiotictherapyinsuchpatientsisdiscussedelsewhere.(See"Antimicrobialapproachtointra
abdominalinfectionsinadults",sectionon'Durationoftherapy'.)
IntervalappendectomyUsingtheinitialnonoperativeapproachoutlinedabove,morethan80percentofpatients
whopresentwitha"walledoff"appendicealprocesscanbesparedanappendectomyatthetimeofinitialpresentation.
Traditionally,anintervalappendectomyhasbeenrecommendedforthesepatientssixtoeightweeksafterpresentation
fortwoprimaryreasons[65]:
Topreventrecurrenceofappendicitis[8,66].
Toexcludeneoplasms(suchascarcinoid,adenocarcinoma,mucinouscystadenoma,andcystadenocarcinomas)
[6769],especiallyinolderadultswhohavehigherincidencesofappendicealneoplasm[70].Olderpatientsshould
alsohaveacolonoscopyorbariumenematoruleoutcecalpathology.(See"Canceroftheappendixand
pseudomyxomaperitonei".)
Theneedforintervalappendectomyisdebated,withsomestudiessuggestingthatintervalappendectomyis
unnecessary[71,72].Inaretrospectivereviewof1012patientstreatednonoperativelyforacuteappendicitis,864
patientsdidnotundergoanintervalappendectomy[72].Ofthose864patients,39(4.5percent)requiredan
appendectomyatamedianfollowupoffouryears.Ametaanalysisof61observationalstudiesinwhichanappendiceal
abscessorphlegmonwaspresentin3.8percentofpatientswithappendicitisfoundthatimmediatesurgerywas
associatedwithhighermorbiditythannonsurgicaltreatment[71].Aftersuccessfulnonsurgicaltreatment,amalignant
diseasewasdetectedin1.2percentofcasesandanimportantbenigndiseasein0.7percent.Recurrentappendicitis
developedin7.4percentofcases(95%CI3.711.1).
Forthesereasons,itisourpracticeistorecommendintervalappendectomyformostadultpatients.Colonoscopy
shouldbeconsideredpriortoappendectomyinpatientsover50whohavenothadarecentcolonoscopy.
COMPLICATIONSThemostcommoncomplicationfollowingappendectomyisinfection(eitherasimplewound
infectionoranintraabdominalabscess).Bothoccurtypicallyinpatientswithperforatedappendicitistheyareveryrare
inthosewithsimpleappendicitis.Thoroughirrigationandbroadspectrumantibioticsareusedtominimizetheincidence
ofpostoperativeinfections.Thepracticeofdelayedprimaryclosurehasnotbeenestablishedtobebeneficial[73].
Thus,werecommendprimaryclosureofthewoundfollowingopenappendectomy.
Therateofsurgicalsiteinfectionsforalaparoscopicappendectomycomparedwithanopenappendectomywas
evaluatedinaretrospectivereviewof39,950patientsidentifiedfromtheAmericanCollegeofSurgeonsNational
SurgicalQualityImprovementProgramdatabase[74].
IncisionalinfectionsPatientsundergoingalaparoscopicappendectomy(n=30,575)hadsignificantlyfewer
incisionalinfections(1.7versus5.2percent)comparedwithpatientsundergoinganopenappendectomy(n=
9375).TheprotectiveeffectofalaparoscopicappendectomywasgreatestforpatientswithClassIVwounds(n=
8652,OR3.03,95%CI2.443.85)butwasalsosignificantforpatientswithwoundclassIIandII(n=31,298,OR
2.44,95%CI2.042.94)(table3).
OrganspaceinfectionsIncontrast,amultivariateanalysisfoundthatpatientsundergoingalaparoscopic
appendectomyweresignificantlymorelikelytohaveanorganspaceinfection(OR1.44,95%CI1.211.73).The
deleteriousassociationwasreportedforwoundclassIIorIII(OR1.67,95%CI1.182.46)andwoundclassIV(OR
1.36,95%CI1.111.68)(table3).
Anuncommoncomplicationispylephlebitis,whichreferstothrombosisandinfectionwithintheportalvenoussystem.It
canoccurfollowinganyintraabdominalinfection.Thiscomplicationhasbecomeexceedinglyrareinthemoderneraof
antibiotics,butshouldbeconsideredinpatientswithfeverandabnormalliverfunctiontests.(See"Pylephlebitis".)
SPECIALCONSIDERATIONS
NormalappendixThediagnosisofappendicitiscanbeuncertain.Insomehistoricalstudies,morethan15percentof
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patientswithsuspectedappendicitishaveanormalappendixatlaparotomy,withhigherpercentagesininfants,the
elderlyandyoungwomen[75].However,theuseofimagingstudiesappearstohavereducedthenegative
appendectomyratetolessthan10percent[2].
Ifanuninflamedappendixisencounteredatappendectomy,itisimportanttosearchforothercausesofthepatient's
symptoms,includingterminalileitis,cecalorsigmoiddiverticulitisoraperforatingcoloncarcinoma,Meckel's
diverticulitis,mesentericadenitis,oruterine,fallopian,orovarianpathologyinafemale.Ifnecessary,therightlower
quadrantincisionmaybeextendedmediallytoaffordexposuretoleftsidedpelvicorgans.
Eveniftheappendixappearsnormal,earlyintramuralorserosalinflammatorychangescansometimesbefoundin
subsequentmicroscopicevaluation[76,77].Accordingly,thenormalappearingappendixshouldberemoved.Moreover,
ifrightlowerquadrantpainrecurs,appendicitiscanbeexcludedfromthedifferentialdiagnosis[7880].
ElderlypatientsOneinevery2000adultsoverage65willdevelopappendicitisannually,makingappendicitisan
importantcauseofabdominalpaininthisagegroup.Theelderlytendtohaveadiminishedinflammatoryresponse,
resultinginalessremarkablehistoryandphysicalexamination[81].Forthesereasons,olderpatientsoftendelay
seekingmedicalcareandasaresult,theyhaveaconsiderablyhigherrateofperforationatthetimeofpresentation
[82,83].Thesepatientsmayhavecardiac,pulmonary,andrenalconditionswithresultingmorbidityandmortalityfrom
perforation.Inoneseries,themortalityfromperforatedappendicitisinpatientsoverage80was21percent[84].In
addition,diverticulitisandcolonicneoplasmsaremorecommoninthisagegroupandcanmimicappendicitis.Elderly
patientscanalsohavearedundantsigmoidcolonthatcancauserightsidedpainfromsigmoiddisease.Accordingly,
promptCTscanningcanimprovediagnosticaccuracyinthispopulation[85].
Laparoscopicappendectomycanbeusedsuccessfullyintheelderlypopulationandresultsinshorterhospitalizationfor
olderpatientswithbothperforatedandnonperforatedappendicitis[32,86].Astudyof2722appendectomiesinpatients
over65yearsofagedemonstratedasignificantlyshorterlengthofstay(4.6versus7.3days)andahigherrateof
dischargetohome(91.4versus78.9percent),fewercomplications(13.0versus22.4percent),andalowermortality
rate(0.4versus2.1percent)thanwithopenoperation[32].Itisnotablethatthisstudyshowedfewercomplicationswith
laparoscopicappendectomythanopenoperation,whichdiffersfromotherlargepopulationbasedstudies[19,20].
ImmunocompromisedpatientsImmunocompromisedpatientsareincreasinglycommoninsurgicalpracticeand
includeorgantransplantpatientsandthosereceivingimmunosuppressivetherapyforautoimmunediseases,cancerand
AIDS.Althoughcertaincausesofabdominalpainarespecifictotheimmunocompromisedstate,appendicitisremainsa
concern[87,88].(See"SurgicalissuesinHIVinfection".)
Theimmunocompromisedaresusceptibletoinfection,andtheirimmuneresponseisbluntedduetoimmunosuppressive
medicationordisease.Asaresult,theymaynotexhibitthetypicalsignsandsymptomsofappendicitis,andmayhave
onlymildtendernessonexamination.Inaddition,laboratoryandradiologicaltestsmaynotshowtheexpectedlevelof
inflammation.Anexpandeddifferentialdiagnosisincludesbutisnotlimitedtoopportunistic(mycobacterial)andviral
(cytomegalovirus)infections,fungalinfections,secondarymalignancies(lymphomaandKaposi'ssarcoma),and
typhlitis.Becauseofthebroaddifferentialdiagnoses,thereisoftendelayinreachingadiagnosisandpresentationto
surgicalevaluation,whichcanincreasetheriskofperforation[87,89].
CTisparticularlyusefulinthispatientpopulation,asitmaynotonlydiagnoseappendicitis,butmayeliminateor
diagnoseotherpotentialcausesforthepatient'ssymptoms.Ifappendicitisisstronglysuspected,operationshouldnot
bedelayed,asthereisnospecificcontraindicationtooperationinimmunocompromisedpatients.
ChildrenAppendicitisinchildrenisdiscussedindetailseparately.(See"Acuteappendicitisinchildren:Diagnostic
imaging"and"Acuteappendicitisinchildren:Clinicalmanifestationsanddiagnosis"and"Acuteappendicitisinchildren:
Management".)
PregnancyPregnancyposesuniquechallengesinthediagnosisofappendicitis.Acuteappendicitisinpregnancyis
discussedindetailseparately.(See"Acuteappendicitisinpregnancy".)
AppendicealneoplasmsNeoplasmsoftheappendixarerare,occurringinlessthanonepercentof
appendectomies.Patientsmaypresentwithsymptomsofappendicitis,apalpablemass,intussusception,urologic
symptoms,oranincidentallydiscoveredmassonabdominalimagingoratlaparotomyforanotherpurpose.Itisnot
uncommonforpatientswithanappendicealneoplasmtohaveacuteappendicitisaswell[90].Typically,thediagnosisis
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notappreciateduntillaparotomyorpathologicevaluationoftheappendectomyspecimen.Themostcommon
appendicealtumorsincludecysticneoplasms,carcinoidtumors,adenocarcinoma,andmetastases.Othertumorshave
beenreportedbutareextremelyrare,suchaslymphoma,stromaltumors(leiomyomaandleiomyosarcoma),and
Kaposi'ssarcoma[68].
PrimaryadenocarcinomaoftheappendixStandardtreatmentisrighthemicolectomyandreoperationis
recommendedifthediagnosisismadeonpathologicevaluationofanappendectomyspecimen.Thisisdiscussedin
detailelsewhere.(See"Canceroftheappendixandpseudomyxomaperitonei".)
CysticneoplasmsandpseudomyxomaperitoneiSometimesreferredtoasmucoceles,mucinousneoplasms
oftheappendixincludeaspectrumofdiseasesincludingsimplecyst,mucinouscystadenoma,mucinous
cystadenocarcinoma,andpseudomyxomaperitonei.Ifthereisanypreoperativesuspicionofanappendicealtumor,care
mustbetakentoavoidspillageofmucinsecretingcellsthroughouttheabdomen.Thesetumorsarediscussedindetail
elsewhere.(See"Canceroftheappendixandpseudomyxomaperitonei".)
CarcinoidtumoroftheappendixAsnotedabove,appendicitiscanuncommonlybecausedbyacarcinoidthat
obstructstheappendiceallumen.Simpleappendectomyissufficientinmostcasesofappendicealcarcinoidwhileright
hemicolectomyisindicatedifthetumoris>2cmindiameteroriftheadjacentmesentericnodesareinvolved.
Managementofcarcinoidtumorsisdiscussedelsewhereindetail.(See"Canceroftheappendixandpseudomyxoma
peritonei"and"Clinicalcharacteristicsofcarcinoidtumors".)
ChronicappendicitisChronicappendicitisreferstothepathologicfindingofchronicinflammationorfibrosisofthe
appendixfoundinasubsetofpatientsundergoingappendectomy[91,92].Thesepatientsareclinicallycharacterizedby
prolonged(>7days)rightlowerquadrantpainthatmaybeintermittentandanormalwhitebloodcellcount.Most
patientshaveresolutionofpainwithappendectomy.Chronicappendicitismaybepresentin14to30percentofadults
undergoingappendectomy[91,92]butismuchrarerinchildren.
Recurrentappendicitiscanoccurbutisalsorareinchildrensuchcasesmaybecausedbyacarcinoidtumorora
retainedforeignbody(eg,fecalith)inthelumenoftheappendix[93].Stumpappendicitisisaformofrecurrent
appendicitisthatisrelatedtoincompleteappendectomythatleavesanexcessivelylongstumpafteropenor
laparoscopicsurgery.(See"Acuteappendicitisinchildren:Management",sectionon'Late'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsandBeyond
theBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,and
theyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestfor
patientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicsto
yourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfoand
thekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Appendicitisinadults(TheBasics)")
SUMMARYANDRECOMMENDATIONSSurgeryremainsthegoldstandardforthetreatmentofappendicitis.
Thepreoperativepreparationforappendectomyincludesintravenoushydration,correctionofelectrolyte
abnormalities,andperioperativeantibiotics.(See'Preoperativepreparation'above.)
Bothopenandlaparoscopicapproachestoappendectomyareappropriateforallpatients.Patientstreatedwitha
laparoscopicappendectomyhavesignificantlyfewerwoundinfections,lesspain,andashorterdurationofhospital
stay,buthigherratesofreadmission,intraabdominalabscessformation,andhigherhospitalcosts.(See'Surgical
outcomes'above.)
Anappendectomyratherthanmedicalmanagementwithantibioticsaloneisthegoldstandardforpatientswitha
historyandclinicalfindings,andradiographicimages,consistentwithappendicitis.Althoughsomepatientsdowell
withantibiotictherapyalone,theyareatriskofrecurrentappendicitis.(See'Roleofnonoperativemanagement'
above.)
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Atemporizingnonoperativeapproachwithantibiotics,hydration,bowelrest,andpercutaneousimageguided
abscessdrainageisusedasneededforpatientswithoverfivedaysofsymptomsandanimagingstudythat
revealstheformationofaphlegmonoranabscess.(See'Nonoperativeapproach'above.)
Followingatemporizing,nonoperativemanagementforappendicealabscessorphlegmon,anelective
appendectomyisperformedformostpatients,typicallysixtoeightweeksfollowinginitialpresentation.(See
'Intervalappendectomy'above.)
Ifanormalappearingappendixisidentifiedduringsurgicalexplorationforrightlowerabdominalpain,an
appendectomyshouldbeperformed.Itisimportanttosearchforothercausesofthepatient'ssymptoms,including
terminalileitis,cecalorsigmoiddiverticulitisoraperforatingcoloncarcinoma,Meckel'sdiverticulitis,mesenteric
adenitis,oruterine,fallopian,orovarianpathologyinafemale.(See'Normalappendix'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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