1. Acute appendicitis – controversies over management revisited Joint Hospital Surgical Grand Round 27 th October 2012 KC Wong

2. Introduction Acute appendicitis (AA) – Prevalence 10/10 000 – Lifetime risk 7% – Peak incidence 10-19yo (23.3/10 000) Presentation – Uncomplicated – Complicated (phlegmon/ abscess/ generalised peritonitis)

3. Management Emergency appendicectomy – Gold standard for early inflammation/ generalised peritonitis

4. Management Conservative Treatment palpable mass: phlegmon/ abscess – Antibiotics, IVF, NPO – Drainage of abscess 10-20% – Interval appendicectomy (IA): 6-12/52 Uncomplicated AA ? Routinely necessary?

5. 1. Conservative management of acute appendicitis

6. Conservative management vs emergency surgery Treatment efficacy Antibiotic treatment – Avoided appendicectomy during the same hospital stay after an initial period of non-surgical treatment – Indication for surgery: persistent fever, abdominal pain or unstable hemodynamics at 48-72 hours – Percutaneous drainage =/= failure Surgical treatment – Confirmed appendicitis at operation or another appropriate surgical indication for operation

7. Complications – Major Re-operation Abscess formation Bowel obstruction Wound rupture/ hernia Anaesthesia- related/ cardiac events – Minor Prolonged post-op course Bladder dysfunction diarrhoea Conservative management vs emergency surgery

8. Conservative treatment- Uncomplicated AA

9. 279(90) 55(16) 74(24) 229(65) 38(11)

11. Conservative treatment- AA with phlegmon/ abscess

12. Conservative treatment- Complicated AA

14. Conservative management Emergency surgery remains the mainstay of treatment for acute appendicitis Selected patients with acute appendicitis may be treated conservatively with efficacy comparable to surgery and lower complication

15. 2. Necessity of IA following successful conservative management

16. Operative riskRecurrence ?Risk factorsCo-morbidities Age Necessity of Interval Appendicectomy

17. IA in Uncomplicated AA Recurrence –11% Complication –6.3% IA in AA with phlegmon/ abscess Recurrence –7.4% Complication –11% Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta- analysis. Andersson RE et al. Ann Surg. 2007 Nov;246(5):741-8. Review Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. Varadhan KK, et al. World J Surg. 2010 Feb;34(2):199-209. The Association of elevated percent bands on admission with failure and complications of interval appendectomy. Kelly A. Kogut et al. Journal of Pediatric Surgery 2001 January;36(1);165–168

18. High risk group for recurrence Male gender Retained faecolith Raised CRP level >4mg/dL Partial SBIO at presentation Most recurrence within the first 6 months Recurrence rate minimal after 2 years

19. Interval appendectomy – other factors to consider One Complication = One recurrence ?? Patient’s preference? Prompt medical attention possible? Longer hospital stay and absence from work Cost-effectiveness

20. Necessity of IA following successful conservative management IA is not routinely necessary and is reserved for patients with recurrent symptoms

21. 3. Problems of omitting interval appendicectomy

22. – 2% Crohn’s disease Ileocecal infection (tuberculosis, schistosomiasis) Neoplasms (carcinoid, adenocarcinoma) - 10.3% Metachronous/ synchronous tumor Incidental pathologies

23. Reported series evaluating outcomes of patients with appendiceal neoplasms Lead authorNumbner of patients Duration of study Incidence of neoplasms Proportion malignant Presentation as AA Rutledge34741979-19890.1% Hananel174010 years0.7%46% Connor79701979-19940.9%37%49% Hananel25201982-19960.8%36.4% Bucher25001991-20011.7%47%majority O’Donnell21541994-20031.0%50%>50% Smeenk1677441995-20050.9%24% Lee37442000-20050.7%17.9%majority

24. IA to avoid misdiagnosis? No!

25. Diagnostic investigations for high risk group (aged >/=40, anemia, associated symptoms) : -Clinical follow-up -Imaging (barium enema, CT) -Colonoscopy

27. Conclusion Acute appendicitis – selected patient may be treated in conservative approach with high success rate Interval appendectomy is not routinely necessary after successful conservative treatment, and is reserved for patients with recurrent symptoms Significant ileocecal pathologies underlie ~2% of acute appendicitis. Imaging and colonoscopy should be performed in selected high risk patients.

28. Reference 1.Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed. Sakorafas GH,et al. World J Gastrointest Surg. 2012 Apr 27;4(4):83-6. 2.Antibiotic therapy versus appendectomy for acute appendicitis: a meta- analysis. Varadhan KK, et al. World J Surg. 2010 Feb;34(2):199-209. 3.Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Andersson RE et al. Ann Surg. 2007 Nov;246(5):741-8. Review. 4.Male gender is a risk factor for recurrent appendicitis following nonoperative treatment. Lien WC et al. World J Surg. 2011 Jul;35(7):1636-42.

29. Reference 5.Management of appendiceal mass: controversial issues revisited. Meshikhes AW. J Gastrointest Surg. 2008 Apr;12(4):767-75. Epub 2007 Nov 13. Review. 6.A retrospective clinicopathological analysis of appendiceal tumors from 3,744 appendectomies: a single-institution study. Lee WS et al. Int J Colorectal Dis. 2011 May;26(5):617-21. Epub 2011 Jan 15. 7.Increased risk of neoplasm in appendicitis treated with interval appendectomy: single-institution experience and literature review. Carpenter SG et al. Am Surg. 2012 Mar;78(3):339-43. Review. 8.Watchful waiting versus interval appendectomy for patients who recovered from acute appendicitis with tumor formation: a cost-effectiveness analysis. Lai HW, et al. J Chin Med Assoc. 2005 Sep;68(9):431-4. 9.The Association of elevated percent bands on admission with failure and complications of interval appendectomy. Kelly A. Kogut et al. Journal of Pediatric Surgery 2001 January;36(1);165–168