A Review of Conservative Treatment of Acute Appendicitis

J. F. Svensson; N. J. Hall; S. Eaton; A. Pierro; T. Wester

doi:10.1055/s-0032-1320014

European Journal of Pediatric Surgery, Table of Contents

Eur J Pediatr Surg 2012; 22(03): 185-194
DOI: 10.1055/s-0032-1320014

Review

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Review of Conservative Treatment of Acute Appendicitis

J. F. Svensson

¹Department of Women's and Children's Health, Karolinska Institutet, and Department of Paediatric Surgery, Astrid Lindgren Children's Hospital, Stockholm, Sweden

,

N. J. Hall

²UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom

,

S. Eaton

²UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom

,

A. Pierro

²UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom

,

T. Wester

¹Department of Women's and Children's Health, Karolinska Institutet, and Department of Paediatric Surgery, Astrid Lindgren Children's Hospital, Stockholm, Sweden

› Author Affiliations

Abstract

Appendicitis is a common condition in the pediatric population and appendectomy has been the traditional treatment. Both the urgency of the operation and the need for the appendectomy have recently been challenged. In children, this controversy focuses on operative management of perforated appendicitis and appendix abscesses. In adults, the debate has extended to management of nonperforated appendicitis. This review describes the evidence behind these challenges and updates a per-protocol meta-analysis of randomized controlled trials in adults. In the per-protocol meta-analysis, there was no difference between operative versus nonoperative management in failure of treatment. The complication rate was significantly lower in patients treated nonoperatively. However, in the nonoperative group, 10% of patients needed immediate surgery and 17% developed a recurrence during the 1-year follow-up. Overall, 73% of adults with suspected acute appendicitis may not need operative treatment. There are no data in the literature to support nonoperative treatment of acute appendicitis in children.

Keywords

acute appendicitis - appendectomy - pediatric population - conservative treatment

Full Text

References

References
1 Amyand C. Of an inguinal rupture, with a pin in the appendix caeca, incrusted with stone; and some observations on wounds in the guts. Philos Trans R Soc Lond 1736; 39: 329-336
2 Hutchinson R. Amyand's hernia. J R Soc Med 1993; 86 (2) 104-105
3 Geddes CR, McAlister VC. A surgical review of the priority claims attributed to Abraham Groves (1847-1935). Can J Surg 2009; 52 (5) E126-E130
4 McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. N Y Med J 1889; 50: 676-684
5 McBurney C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg 1894; 20 (1) 38-43
6 Morgenstern L. Charles McBurney (1845-1913). Afield from the appendix. Surg Endosc 1996; 10 (4) 385-386
7 Semm K. [Endoscopic intraabdominal surgery in gynecology]. Wien Klin Wochenschr 1983; 95 (11) 353-367
8 Ure BM, Spangenberger W, Hebebrand D, Eypasch EP, Troidl H. Laparoscopic surgery in children and adolescents with suspected appendicitis: results of medical technology assessment. Eur J Pediatr Surg 1992; 2 (6) 336-340
9 Aufderheide AC. The Scientific Study of Mummies. Cambridge, UK: Cambridge University Press; 2003
10 Bailey H. The Ochsner-Sherren (delayed) treatment of acute appendicitis: indications and technique. BMJ 1930; 1 (3603) 140-143
11 Coldrey E. Five years of conservative treatment of acute appendicitis. J Int Coll Surg 1959; 32: 255-261
12 Anonymous. Combined traditional Chinese and western medicine in acute appendicitis. Chin Med J (Engl) 1977; 3 (4) 266-269
13 Adams ML. The medical management of acute appendicitis in a nonsurgical environment: a retrospective case review. Mil Med 1990; 155 (8) 345-347
14 Gurin NN, Slobodchuk IuS, Gavrilov IuF. [The efficacy of the conservative treatment of patients with acute appendicitis on board ships at sea]. Vestn Khir Im I I Grek 1992; 148 (5) 144-150
15 Paudel GR, Agrawal CS, Regmi R, Agrawal S. Conservative treatment in acute appendicitis. JNMA J Nepal Med Assoc 2010; 50 (180) 295-299
16 Park H-C, Kim B-S, Lee BH. Efficacy of short-term antibiotic therapy for consecutive patients with mild appendicitis. Am Surg 2011; 77 (6) 752-755
17 Lien W-C, Lee W-C, Wang H-P, Chen YC, Liu KL, Chen CJ. Male gender is a risk factor for recurrent appendicitis following nonoperative treatment. World J Surg 2011; 35 (7) 1636-1642
18 Di Saverio S, Coccolini F, Pisano M , et al. Re: Male gender is a risk factor for recurrent appendicitis following nonoperative treatment. World J Surg 2012; 36 (2) 486-487 , author reply 488–489
19 Liu K, Ahanchi S, Pisaneschi M, Lin I, Walter R. Can acute appendicitis be treated by antibiotics alone?. Am Surg 2007; 73 (11) 1161-1165
20 Turhan AN, Kapan S, Kütükçü E, Yiğitbaş H, Hatipoğlu S, Aygün E. Comparison of operative and non operative management of acute appendicitis. Ulus Travma Acil Cerrahi Derg 2009; 15 (5) 459-462
21 Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995; 82 (2) 166-169
22 Styrud J, Eriksson S, Nilsson I , et al. Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial. World J Surg 2006; 30 (6) 1033-1037
23 Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 2009; 96 (5) 473-481
24 Vons C, Barry C, Maitre S , et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011; 377 (9777) 1573-1579
25 Malik AA, Bari SU. Conservative management of acute appendicitis. J Gastrointest Surg 2009; 13 (5) 966-970
26 Retraction note to: Conservative management of acute appendicitis. J Gastrointest Surg 2011; 15 (12) 2302
27 Horton MD, Counter SF, Florence MG, Hart MJ. A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient. Am J Surg 2000; 179 (5) 379-381
28 Varadhan KK, Humes DJ, Neal KR, Lobo DN. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. World J Surg 2010; 34 (2) 199-209
29 Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ 2012; 344: e2156
30 Ansaloni L, Catena F, Coccolini F , et al. Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials. Dig Surg 2011; 28 (3) 210-221
31 Liu K, Fogg L. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis. Surgery 2011; 150 (4) 673-683
32 Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev 2011; (11) CD008359
33 Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E. Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence. Can J Surg 2011; 54 (5) 307-314
34 Farahnak M, Talaei-Khoei M, Gorouhi F, Jalali A, Gorouhi F. The Alvarado score and antibiotics therapy as a corporate protocol versus conventional clinical management: randomized controlled pilot study of approach to acute appendicitis. Am J Emerg Med 2007; 25 (7) 850-852
35 Mason RJ, Moazzez A, Sohn H, Katkhouda N. Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis. Surg Infect (Larchmt) 2012; 13 (2) 74-84
36 Mason RJ. Surgery for appendicitis: is it necessary?. Surg Infect (Larchmt) 2008; 9 (4) 481-488
37 Wiegering VA, Kellenberger CJ, Bodmer N , et al. Conservative management of acute appendicitis in children with hematologic malignancies during chemotherapy-induced neutropenia. J Pediatr Hematol Oncol 2008; 30 (6) 464-467
38 Abeş M, Petik B, Kazil S. Nonoperative treatment of acute appendicitis in children. J Pediatr Surg 2007; 42 (8) 1439-1442
39 Weiner DJ, Katz A, Hirschl RB, Drongowski R, Coran AG. Interval appendectomy in perforated appendicitis. Pediatr Surg Int 1995; 10: 82-85
40 Bufo AJ, Shah RS, Li MH , et al. Interval appendectomy for perforated appendicitis in children. J Laparoendosc Adv Surg Tech A 1998; 8 (4) 209-214
41 Kogut KA, Blakely ML, Schropp KP , et al. The association of elevated percent bands on admission with failure and complications of interval appendectomy. J Pediatr Surg 2001; 36 (1) 165-168
42 Weber TR, Keller MA, Bower RJ, Spinner G, Vierling K. Is delayed operative treatment worth the trouble with perforated appendicitis is children?. Am J Surg 2003; 186 (6) 685-688 , discussion 688–689
43 Nadler EP, Reblock KK, Vaughan KG, Meza MP, Ford HR, Gaines BA. Predictors of outcome for children with perforated appendicitis initially treated with non-operative management. Surg Infect (Larchmt) 2004; 5 (4) 349-356
44 Vane DW, Fernandez N. Role of interval appendectomy in the management of complicated appendicitis in children. World J Surg 2006; 30 (1) 51-54
45 Henry MC, Gollin G, Islam S , et al. Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis. J Pediatr Surg 2007; 42 (1) 19-23 , discussion 23–24
46 Aprahamian CJ, Barnhart DC, Bledsoe SE, Vaid Y, Harmon CM. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences. J Pediatr Surg 2007; 42 (6) 934-938 , discussion 938
47 Whyte C, Levin T, Harris BH. Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management. J Pediatr Surg 2008; 43 (8) 1459-1463
48 Blakely ML, Williams R, Dassinger MS , et al. Early vs interval appendectomy for children with perforated appendicitis. Arch Surg 2011; 146 (6) 660-665
49 Myers AL, Williams RF, Giles K , et al. Hospital cost analysis of a prospective, randomized trial of early vs interval appendectomy for perforated appendicitis in children. J Am Coll Surg 2012; 214 (4) 427-434 , discussion 434–435
50 De Coppi P, Pozzobon M, Piccoli M , et al. Isolation of mesenchymal stem cells from human vermiform appendix. J Surg Res 2006; 135 (1) 85-91
51 Randal Bollinger R, Barbas AS, Bush EL, Lin SS, Parker W. Biofilms in the large bowel suggest an apparent function of the human vermiform appendix. J Theor Biol 2007; 249 (4) 826-831
52 Blomqvist PG, Andersson RE, Granath F, Lambe MP, Ekbom AR. Mortality after appendectomy in Sweden, 1987-1996. Ann Surg 2001; 233 (4) 455-460
53 Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002; 137 (7) 799-804 , discussion 804
54 Andersson RE. Small bowel obstruction after appendicectomy. Br J Surg 2001; 88 (10) 1387-1391
55 Duron JJ, Hay JM, Msika S , et al; French Association for Surgical Research. Prevalence and mechanisms of small intestinal obstruction following laparoscopic abdominal surgery: a retrospective multicenter study. Arch Surg 2000; 135 (2) 208-212
56 Zbar RI, Crede WB, McKhann CF, Jekel JF. The postoperative incidence of small bowel obstruction following standard, open appendectomy and cholecystectomy: a six-year retrospective cohort study at Yale-New Haven Hospital. Conn Med 1993; 57 (3) 123-127
57 Leung TT, Dixon E, Gill M , et al. Bowel obstruction following appendectomy: what is the true incidence?. Ann Surg 2009; 250 (1) 51-53
58 Sakorafas GH, Mastoraki A, Lappas C, Sampanis D, Danias N, Smyrniotis V. Conservative treatment of acute appendicitis: heresy or an effective and acceptable alternative to surgery?. Eur J Gastroenterol Hepatol 2011; 23 (2) 121-127
59 Andersson R, Hugander A, Thulin A, Nyström PO, Olaison G. Indications for operation in suspected appendicitis and incidence of perforation. BMJ 1994; 308 (6921) 107-110
60 Howie JGR. Too few appendectomies?. Lancet 1964; 1 (7345) 1240-1242
61 Luckmann R. Incidence and case fatality rates for acute appendicitis in California. A population-based study of the effects of age. Am J Epidemiol 1989; 129 (5) 905-918
62 Andersson R, Hugander A, Thulin A, Nyström PO, Olaison G. Indications for operation in suspected appendicitis and incidence of perforation. BMJ 1994; 308 (6921) 107-110
63 Svensson JF. Conservative treatment of acute appendicitis in children (CONSAPP Pilot). NCT01572558. Available at: http://clinicaltrials.gov/ct2/show/NCT01572558 . Updated April 4, 2012