Management of appendicitis: appendicectomy, antibiotic therapy, or both?

Abstract

Introduction: Appendicitis is a global disease with an incidence of 7–12% in the population of the USA and Europe but is low and rising in the developing world. It is the most common acute general surgical emergency, but as no investigation is accurate, the diagnosis has to rely on clinical symptoms and signs and, thus, frequently misdiagnosed. The aim of the study was to debate the arguments for managing appendicitis (operative, nonoperative, or both). Patients and methods: Electronic searches of the MEDLINE (PubMed) database, Cochrane Library, and Science Citation Index were performed to identify original published studies on appendicitis and the pre-COVID-19 (coronavirus disease 2019) and post-COVID-19 management. Relevant articles were searched from relevant chapters in specialized texts, and all have been included. Discussion: There are indications for operative (surgery), nonoperative (antibiotics), or both in the management of acute appendicitis. Although laparoscopic appendicectomy is becoming the gold standard of treatment, knowledge of the pros and cons of this approach versus the open approach is important. The controversy in the management of the appendix mass/abscess between an expedient appendicectomy or a combination of conservative management (antibiotics) and interval appendicectomy remains. Conclusion: Laparoscopic appendicectomy is becoming the gold standard for the treatment of appendicitis. However, the advantages of the innovations in minimally invasive and endoscopic surgery are unlikely to render formal open appendicectomy obsolete. Nonoperative management with antibiotics may suffice in selected cases with uncomplicated appendicitis. It is imperative that patients are counseled appropriately if primary antibiotic treatment is to be routinely offered as first-line therapy.

Early Operative Management of Complicated Appendicitis Is Associated With Improved Surgical Outcomes in Adults: a Comprehensive Systematic Review

“…However, there is no evidence to indicate the proportion of patients likely to develop diffuse sepsis because the antibiotic treatment alters the pattern of disease by replacing the risks of perforation with the lesser risk associated with surgery. 2 Several older studies, including two meta-analyses of complicated appendicitis, have shown that immediate operative management is associated with higher rates of complications. On the other hand, a small randomized trial in adults with an abscess demonstrated that immediate laparoscopic surgery was associated with fewer readmissions and CT scans, as well as fewer complications and re-interventions.…”