Into the 18th century, descriptions of inflammatory diseases of the appendix appeared only as solitary case reports with conflicting nomenclature and an unclear natural history.1 Only in the mid-19th century, when nitrous oxide and chloroform anesthesia granted a degree of safety to laparotomy, did early operation for appendicitis gain favor.1 In contrast to these humble beginnings, appendectomy is now the most common emergency operation in the United States, with more than 300,000 appendectomies performed annually.2
Acute appendicitis arises from luminal obstruction by external compression (eg, lymphadenopathy) or internal obstruction by fecalith, tumor, ingested debris, or more rarely, parasites. If untreated, mucosal and serosal ischemia develops, followed by perforation with resultant peritoneal contamination and sepsis. The rise of antibiotics as a complement to surgical management has markedly decreased the septic consequences and mortality associated with this disease.
The diagnosis and management of appendicitis have changed in recent decades. Perhaps most significant is the acceptance of the laparoscopic approach for appendectomy, which will be discussed in this chapter.3 New imaging modalities, including computed tomography and ultrasound, have improved preoperative diagnosis and reduced the traditional 20% negative appendectomy rate associated with diagnosis on the basis of physical examination alone.4 Increasing use of clinical scoring systems has further refined diagnostic accuracy.5,6 Controversies persist, however, particularly regarding the utility of interval appendectomy for complex appendicitis,7 the use of irrigation in laparoscopic appendectomy,8 and guidelines for nonoperative versus operative management.9
Historically, patients and surgeons have been reluctant to approach appendicitis nonoperatively, and randomized clinical trials demonstrate very high dropout or crossover rates from nonoperative arms.10 As a result, most studies evaluating appendicitis are small and observational, with few randomized controlled trials. Similarly, the data on appendiceal cancers, which are rare but clinically relevant, exist primarily in the form of case series.11 This chapter will review the available evidence directing the management of appendicitis and appendiceal malignancy, with the caveat that data quality is poor. Despite the paucity of rigorous studies, the importance of appendiceal disease to general surgery practice warrants careful consideration of the available data.
Laparoscopic versus open appendectomy: Outcomes comparison based on a large administrative database.
Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, Pietrobon R
Ann Surg. 2004;239(1):43–52.Takeaway Point: Laparoscopic appendectomy is associated with decreased length of hospital stay, decreased in-hospital morbidity, and increased rate of routine discharge compared with open appendectomy.
Commentary: Despite numerous case series and small randomized clinical trials, for years after the introduction of laparoscopic appendectomy there was no clear consensus regarding the comparative effectiveness of the laparoscopic versus open approach. This is the first study comparing length of hospital stay, in-hospital mortality and morbidity, and rate of routine discharge in patients undergoing laparoscopic and open appendectomy, using a representative US nationwide database. Overall, the authors report significant benefits to the laparoscopic approach. Although this is a retrospective database study with no long-term follow-up, this study contributed to the nationwide adoption of laparoscopic appendectomy as standard of care for acute appendicitis.
Introduction: The first laparoscopic appendectomy was performed in 1981. Since its introduction into surgical practice, numerous case series and small single institution trials have compared laparoscopic appendectomy (LA) with open appendectomy (OA), but no consensus regarding the effectiveness of each procedure has been reached.
Objectives: To compare the short-term impact of LA and OA based on a large administrative database.
Trial Design: Retrospective review of a large nationwide administrative database.
Inclusion Criteria: Patients in Nationwide Inpatient Sample (NIS) database with procedure codes for laparoscopic or open appendectomy.
Exclusion Criteria: Appendicolithiasis, appendicopathia oxyurica, and incidental appendectomies or primary diagnosis other than appendicitis.
Intervention: Laparoscopic versus open appendectomy.
Primary Endpoint: Length of hospital stay, in-hospital complications, in-hospital mortality, rate of routine discharge.
Secondary Endpoints: Above endpoints stratified by presence of abscess or perforation.
Sample Size: 43,757 patients selected from the Nationwide Inpatient Sample (NIS) of 1000 community hospitals in 22 US states in 1997; 7618 underwent laparoscopic appendectomy and 36,139 underwent open appendectomy.
Statistical Analysis: Student’s t-tests, χ2 test, analysis of variance, multiple linear regression models, exponentiating estimated log-transformed length of stay, multiple logistic regression analyses.
Baseline Data: Patients in the laparoscopic group were more likely Caucasian (63.5% vs. 56.7%, p 0.003) and female (49.8% vs. 39.6%, p < 0.0001) with higher median income (p 0.02). Patients who underwent open appendectomy were overall sicker, with a higher Devo Index (p < 0.0001) and significantly higher rates of hypertension, congestive heart failure, and diabetes. Patients in the open group also had higher rates of appendiceal perforation (21% vs. 16.1%, p < 0.0001) and appendiceal abscess (14% vs. 7%, p < 0.0001).
Outcomes: After adjusting for other risk factors, the laparoscopic appendectomy group had a shorter median hospital stay (p < 0.0001), higher rate of routine discharge (p < 0.0001), lower overall complication rate (p 0.02), decreased rate of gastrointestinal complications (p 0.02), and lower rate of infections (p < 0.001). When stratified by presence of appendiceal abscess or perforation, patients undergoing laparoscopic appendectomy still had shorter length of stay (p < 0.001), and higher rate of routine discharge (p < 0.0001).
Conclusion: Laparoscopic appendectomy has significant advantages over open appendectomy, including decreased hospital length of stay, decreased in-hospital morbidity, and increased rate of routine discharge.
Limitations: Adults only, retrospective database study, outpatient follow-up data not captured, patients with perforation and abscess more likely to undergo open than laparoscopic procedures. Patients with appendicoliths were excluded which may impact generalizability. Large administrative database, so some miscoding is possible.
Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis.
Kaminski A, Liu IL, Applebaum H, Lee SL, Haigh PI
Arch Surg. 2005;140(9):897–901.Takeaway Point: Interval appendectomy following initial nonoperative treatment of acute appendicitis may not be justified.
Commentary: Classically, interval appendectomy is performed 6–10 weeks after initial nonoperative management of acute appendicitis. Small case series have demonstrated recurrence rates of anywhere between 512 and 35%.13 This is a retrospective cohort study examining the natural history of patients treated nonoperatively for an initial episode of acute appendicitis. The authors utilize an insurance database and determine that overall recurrence rate after nonoperative management for acute appendicitis is 5%, with a mean follow-up time of 4 years. Given the low recurrence rate, the authors argue that routine interval appendectomy is not justified. This is a database study, and has a number of important limitations. The number of false-positive diagnoses cannot be ascertained, as patients were identified on the basis of ICD-9 code and no imaging confirmation was required. The study includes both children and adults, and does not specify differences in antibiotic duration or treatment regimens. Additionally, patients have a wide range of follow-up, and 4 years may be insufficient, especially in a pediatric population, to judge the true risks and benefits of foregoing interval appendectomy. Despite these limitations, this remains one of the largest studies to date on the subject of interval appendectomy after nonoperative management of acute appendicitis, and provides important evidence on the natural history of this disease.
Introduction: Initial nonoperative management in patients presenting with acute appendicitis complicated by abscess or phlegmon has been shown to be safe and effective. The risk of recurrent appendicitis ranges from 5 to 37% in small studies with limited follow-up periods. In the pediatric population, interval appendectomy after initial nonoperative management is common, despite lack of strong evidence to support this practice.
Objectives: To determine whether interval appendectomy is justified following initial nonoperative treatment of acute appendicitis.
Trial Design: Retrospective cohort study.
Inclusion Criteria: ICD-9 code for acute appendicitis, initial nonoperative management.
Exclusion Criteria: None.
Intervention: Interval appendectomy or nonoperative treatment with or without percutaneous drainage of abscess.
Primary Endpoints: Recurrent appendicitis following nonoperative management.
Secondary Endpoint: Hospital length of stay.
Sample Size: 32,938 patients were initially identified with acute appendicitis from 12 acute care hospitals in the Southern California Kaiser Permanente Discharge Abstract Database between January 1992 and December 2004; of these, 1012 were managed nonoperatively.
Statistical Analysis: Cox proportional hazards regression modeling, Kaplan–Meier method with log-rank test, Wilcoxon rank sum test.
Baseline Data/Outcomes: 1012 patients were treated initially with nonoperative management; of these 148 had an interval appendectomy. Of the 864 that did not have interval appendectomy, 39 had a recurrence (5%).
Of these, 22 underwent appendectomy, 2 underwent cecectomy, 2 underwent right hemicolectomy, and 13 were treated nonoperatively for a second time. Median length of stay for the second hospitalization in the recurrent appendicitis group was 4 days compared with 6 days in the interval appendectomy group (p 0.006); however, the median cumulative length of stay (including the first and second hospital stays) in the patients who recurred was the same as those who underwent interval appendectomy. Patients were followed for a median of 4 years, with follow-up ranging from 6 months to 12 years. 26 patients were lost to follow-up.
Conclusion: For patients with acute appendicitis initially treated nonoperatively, the recurrence rate is low and routine interval appendectomy is not justified.
Limitations: Retrospective study, does not separate children and adults, does not specify differences in antibiotic duration/treatment regimens between treatment groups, does not account for patients with follow-up at outside hospitals. Significant variations in follow-up time and no breakdown of recurrence rate by year. Diagnosis of acute appendicitis was based on ICD-9 codes and the rate of false positive diagnoses cannot be determined.
Malignancies of the appendix: Beyond case series reports.
McGory ML, Maggard MA, Kang H, O’Connell JB, Ko CY
Dis Colon Rectum. 2005;48(12):2264–2271.Takeaway Point: A substantial number of patients with appendiceal carcinoma, both carcinoid and noncarcinoid, may not receive adequate surgical resection.
Commentary: While prior discussions of appendiceal cancer have focused on carcinoid tumors, this study shows that noncarcinoid tumors are far more common. The literature to date shows no clear consensus on optimal treatment for noncarcinoid appendiceal cancer. As these are rare tumors, it is difficult to perform a study with a large sample size, which is why reviewing the SEER database is advantageous in this population. There are, however, limitations encountered when using this database, including the fact that tumor location, patient comorbidities, reason for appendectomy, and information regarding adjuvant chemotherapy/radiation are not included in the database. Additionally, SEER collected data on operations between 1973 and 2001; during and since that time, recommendations for appendiceal cancer have changed. This paper highlights the difficulty in obtaining high quality evidence for a rare disease, and the need for further studies and better clinical guidelines.
Introduction: Appendiceal carcinomas are extremely rare, with an incidence of less than 1 per 1,000,000 people per year. The majority of these tumors are diagnosed incidentally during routine appendectomy. Most current guidelines recommend appendectomy for carcinoid tumors ≤1 cm, and right hemicolectomy for all noncarcinoid invasive subtypes as well as for carcinoids ≥2 cm or located at the base of the appendix or invading the mesoappendix. The recommendations for management of carcinoid tumors are much more homogeneous than those for noncarcinoid tumors, as these are rare cancers and difficult to study.
Objectives: To evaluate the epidemiology and survival outcomes of five histologic types of appendiceal carcinoma, accounting for tumor size.
Trial Design: Retrospective review of Surveillance, Epidemiology, and End Results (SEER) database.
Inclusion Criteria: All appendiceal cancer patients in SEER database.
Exclusion Criteria: None.
Intervention: None (retrospective database review).
Primary Endpoint: Tumor incidence, stage, 5-year survival determined for each histological type.
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