Acute Appendicitis - Current Problems in Surgery.

Current Problems in Surgery 50 (2013) 54–86
Contents lists available at SciVerse ScienceDirect
Current Problems in Surgery
journal homepage: www.elsevier.com/locate/cpsurg
Acute Appendicitis: Controversies in Diagnosis

and Management
Curtis J. Wray, MD, Lillian S. Kao, MD, MS, Stefanos G. Millas, MD,
Kuojen Tsao, MD, Tien C. Ko, MD
Challenges in the Diagnosis of Acute Appendicitis
Appendicitis is a common problem; there are more than 300,000 hospital discharges for
appendicitis in the United States per year.1 Although the clinical scenario of periumbilical pain
migrating to the right lower quadrant is classically associated with acute appendicitis, the
presentation is rarely typical and the diagnosis cannot always be based on history and physical
examination alone. Diagnostic errors are common, with over-diagnosis leading to negative
appendectomies and with delays in diagnosis leading to perforations. The misdiagnosis of
appendicitis has significant economic ramifications; in a nationwide study of administrative data
over a 1-year period in the late 1990s, a negative appendectomy rate of 15% resulted in more than
$740 million in hospital charges.2
Diagnostic strategies for evaluating patients with abdominal pain and for identifying patients
with suspected appendicitis should all start with a thorough history and physical examination. The
Surgical Infection Society (SIS) and Infectious Diseases Society of America (IDSA) published
guidelines that recommend the establishment of local pathways for the diagnosis and management
of acute appendicitis.3 The guidelines note that the combination of clinical and laboratory findings of
characteristic abdominal pain, localized tenderness, and laboratory evidence of inflammation will
identify most patients with suspected appendicitis.3 Other diagnostic strategies may include
radiologic imaging or the use of scoring systems with or without computer support. Ultimately, the
‘‘gold standard’’ for a positive diagnosis is the histopathologic confirmation of appendicitis, although
standard criteria are lacking.4 A negative diagnosis may be confirmed by intra-operative findings or
clinical follow-up or both.
There are different measures for evaluating a diagnostic test or strategy (Table 1). Sensitivity
refers to the proportion of true positive tests among all patients who have the disease (A/[Aþ C]).
Specificity refers to the proportion of true negatives among all patients who do not have the disease
(D/[Bþ D]). Highly sensitive tests rule disease out, whereas highly specific tests rule disease in.
Accuracy refers to the proportion of true positives and negatives among all patients tested ([A þ D]/
[A þB þC þD]). The positive predictive value of a test refers to the proportion of true positives among
all patients who test positive (A/[Aþ B]), whereas the negative predictive value refers to the
proportion of true negatives among all patients who test negative (D/[Cþ D]). The predictive values
of a test should be applied with caution to local patients as they depend upon the incidence
0011-3840/$ - see front matter & 2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1067/j.cpsurg.2012.10.001
Descargado para RAFAEL EDUARDO ARRAUT GAMEZ (rafaele.arrautg@unilibre.edu.co) en Free University de ClinicalKey.es por Elsevier en
agosto 17, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos
reservados.
C.J. Wray et al. / Current Problems in Surgery 50 (2013) 54–86 55
TABLE 1
2 2 Table for calculating sensitivity, specificity, predictive values, and likelihood ratios
Disease positive Disease negative
Test positive True positives (A) False negatives (B) A þ B

Test negative False positives (C) True negatives (D) C þ D
A þ C B þ D A þ B þ C þ D
TABLE 2
Named clinical signs associated with acute appendicitis
Name Description
Dunphy’s sign Increased right lower quadrant pain with coughing

Obturator sign Increased pain with flexion and internal rotation of the hip
Psoas sign Increased pain with passive extension of the right hip (can be elicited with the
patient lying on the left side)
Rovsing’s sign Increased right lower quadrant pain during palpation in the left lower quadrant
(frequency of new cases) or prevalence (frequency of all cases) of the disease in the population
tested.
Clinicians order diagnostic tests because the results may change the management of the
patient. In the setting of abdominal pain, if the test suggests a high probability of acute
appendicitis, then the clinician may choose to perform an appendectomy. If the test suggests a low
probability of acute appendicitis, then the clinician may choose to discharge the patient.
Likelihood ratios (LRs), which are calculated from sensitivity and specificity, assist the clinician in
calculating these post-test probabilities. LR þ refers to the ratio of the chance that the test would
be positive in patients with the disease vs the chance that the test would be positive in patients
without the disease. LR similarly refers to the ratio of the chance that the test would be negative
in patients with the disease vs the chance that the test would be negative in patients without the
disease. A test with an LR of 1 does not offer any new information.5 A disease is strongly ruled in if
the LR þ is greater than 10 and strongly ruled out if the LR is less than 0.1. LRs unlike predictive
values are not affected by disease prevalence, and they can be applied to individual patients to
inform clinical decision-making.
History and Physical Examination
Despite advances in diagnostic tests, appendicitis remains a clinical diagnosis. Clinical symptoms
elicited by the history may include fever, nausea, vomiting, anorexia, migration of pain to the right
lower quadrant, and aggravation of pain by movement. Physical examination may reveal signs of
peritoneal irritation in the right lower quadrant or diffusely. Rectal examination may reveal
tenderness. Furthermore, there are a variety of named signs that may be associated with
appendicitis depending upon the location of the inflamed appendix (Table 2) (ie, pain caused by
passive extension of the hip caused by a retrocecal appendix irritating the iliopsoas muscle or the
psoas sign).
The signs and symptoms described above are common and nonspecific; each individual sign and
symptom is only weakly predictive of appendicitis (Table 3).4 Furthermore, the differential diagnosis
for right lower quadrant abdominal pain is wide and varies with age and gender. When signs and
symptoms were compared between children and adults, they were similarly predictive of
appendicitis, with the exception of right lower quadrant pain which had a much higher LRþ in
adults than in children.6,7 Another limitation of relying on clinical findings alone is that elicitation of
physical signs is subjective; multiple studies have demonstrated poor inter-rater reliability between
reservados.
56 C.J. Wray et al. / Current Problems in Surgery 50 (2013) 54–86
TABLE 3
Sensitivities, specificities, and likelihood ratios for common clinical symptoms, signs, laboratory values, and radiologic tests
(95% confidence intervals provided in parentheses if available)
Sensitivity Specificity LR þ LR
History (symptoms)
Fever4 1.64 (0.89-3.01) 0.61 (0.49-0.77)
Fever6 (children) 1.2 (1.1-1.4) 0.53 (0.29-0.97)
Anorexia4 1.27 (1.14-1.41) 0.59 (0.45-0.77)
Anorexia (children)6 1.4 (1.2-1.6) 0.57 (0.44-0.73)
Vomiting4 1.63 (1.45-1.84) 0.75 (0.69-0.80)
Vomiting (children)6 1.4 (1.3-1.6) 0.57 (0.47-0.69)
Right lower quadrant pain (adults)7 0.81 0.53 7.31-8.46 0-0.28
Right lower quadrant pain (children)6 1.2 (1.0-1.5) 0.56 (0.43-0.73)
Pain migration4 2.06 (1.63-2.60) 0.52 (0.40-0.69)
Pain migration (children)16 1.9 (1.4-2.5) 0.72 (0.62-0.85)
Physical examination (signs)

Rebound tenderness4 1.99 (1.61-2.45) 0.39 (0,32-0.48)
Rebound tenderness (children)6 3.0 (2.3-3.9) 0.28 (0.14-0.55)
Guarding or rigidity4 2.36 (1.76-3.15) 0.70 (0.61-0.80)
Psoas sign4 2.31 (1.36-3.91) 0.85 (0.76-0.95)
Laboratory values
WBC ( 109/L) Z 104 2.47 (2.06-2.95) 0.26 (0.18-0.36)
WBC 4 14.9 or 4 10 (children)6 2.0 (1.3-2.9) 0.22 (0.17-0.30)
WBC ( 109/L) Z 154 3.47 (1.55-7.77) 0.81 (0.69-0.95)
WBC 4 14.9 or 4 15 (children)6 1.7 (0.83-3.4) 0.77 (0.52-1.1)
Proportion of polymorphonuclear cells (%) 4 75% 2.44 (1.60-3.74) 0.24 (0.11-0.50)
CRP level (mg/L) 4 10 1.97 (1.58-2.45) 0.32 (0.20-0.51)
CRP level (mg/L) 4 20 2.39 (1.67-3.41) 0.47 (0.28-0.81)
Radiologic tests
Ultrasound (adults)25 83% (78%-87%) 93% (90%-96%) 12 0.2
Ultrasound (children)25 88% (86%-90%) 94% (92%-95%) 15 0.1
CT (adults)25 94% (92%-95%) 94% (94%-96%) 16 0.06
CT (children)25 94% (92%-97%) 95% (94%-97%) 19 0.06
Scoring systems
Alvarado (Z 7)6 4.0 (3.2-4.9) 0.20 (0.09-0.41)
Pediatric Appendicitis Score (Z 6)42 82% 65% 2.4 (2.0-2.8) 0.27 (0.20-0.37)
Ruptured appendicitis scoring system (in 92% 81% 4.9 0.1
children, Z4)35
Ruptured appendicitis scoring system (in 68% 94% 11.3 0.33
children, Z7)35
trainees and attending physicians, as well as between subspecialists.8,9 For example, Yen and
colleagues reported that the inter-rater reliability for several common clinical findings such as
rebound tenderness and clinical diagnosis of peritonitis was poor to moderate between pediatric
emergency medicine physicians and senior surgical residents.8 However, when used in combination
with laboratory values, the diagnostic utility of the clinical findings increases significantly.
Laboratory Values
Laboratory values that have been associated with acute appendicitis include: leukocytosis, left
shift, and elevated markers of inflammation such as C-reactive protein (CRP) and erythrocyte
sedimentation rate (Table 3).4,6 As with the clinical symptoms and signs, each individual laboratory
test value is only weakly discriminatory and predictive of acute appendicitis.4 However, combinations
of clinical findings and laboratory values or combinations of multiple laboratory values are more
discriminatory and predictive.4 For example, the presence of guarding or rebound and a white blood
cell (WBC) count of greater than or equal to 10 109/L has an LRþ of 11.34 (95% confidence interval
reservados.
[CI] 6.65-19.56), whereas the absence of both of these variables has an LR D of 0.14 (95% CI 0.08-
0.24).4 A meta-analysis by Anderson revealed that the greatest discriminators and predictors of acute
appendicitis included a history of migration of pain, clinical findings of peritoneal irritation, and
laboratory values reflecting an inflammatory response (ie, CRP).4
There have been numerous studies evaluating other potential serum and urinary markers of
appendicitis, including but not limited to inflammatory cytokines such as serum interleukin-6,
interleukin-8, and tumor necrosis factor alpha10,11; serum neutrophil proteins such as lactoferrin
and calprotectin12; and urinary markers such as leucine-rich a-2-glycoprotein.13 However, at best,
these studies may demonstrate that elevated levels distinguish patients with and without acute
appendicitis among those suspected of having the disease. Although these markers are promising,
none have been evaluated in a prospective trial comparing their use to conventional diagnostic
strategies and evaluating the effect of their use on clinical outcomes and costs.
Scoring Systems
There are several clinical scoring systems that have been used in the diagnosis of acute
appendicitis. Alvarado published his scoring system in 1986, also referred to as MANTRELS based on
the mnemonic for remembering the combination of 8 signs and symptoms (Table 4).14 The score
ranges from 0-10; a patient with a score of 5 or 6 is typically observed, whereas a patient with a
score of 7 or greater should undergo operation.14 Since then, there have been several studies
evaluating the diagnostic accuracy of the Alvarado score, modified versions of the Alvarado score
such as the Pediatric Appendicitis Score,15 and other scores such as the Kharbanda16 and Lintula17-19
scores (Table 3). In general, these clinical scoring systems have better LRs than individual symptoms
or signs alone. However, these scoring systems do not have sufficient discriminatory or predictive
ability to routinely be used alone to diagnose appendicitis. They have been used to determine the
need for further radiologic studies20 or as a guide for dictating clinical management.21
Radiologic Imaging
The use of radiologic imaging in the evaluation of abdominal pain and in the diagnosis of acute
appendicitis has increased over time.22 On one hand, imaging may be helpful in the evaluation of
patients with abdominal pain for ruling in or out other diagnoses or for preventing unnecessary
operations.23 On the other hand, imaging could potentially delay operative intervention, and in the
case of computed tomography (CT), radiologic imaging exposes patients to the risks of ionizing
radiation.24 Ultrasonography (US) does not expose patients to ionizing radiation but is more
operator dependent. In a meta-analysis of US and CT in children and adults, both US and CT were
highly specific (93%-95%) in children and adults, whereas CT was more sensitive than US25 (Table 2).
The Surgical Infection Society and Infectious Disease Society of America guidelines recommend use
TABLE 4
Alvarado or MANTRELS scoring system14
Variable Value
Symptoms Migration 1
Anorexia 1
Nausea-vomiting 1
Signs Tenderness in right lower quadrant 2

Rebound of pain 1
Elevation of temperature ( Z37.31C) 1
Laboratory Leukocytosis (White blood cell count 410,000/mL) 2

Shift to the left (4 75% neutrophils) 1
Total score 10
reservados.
of intravenous (IV) but not oral or rectal contrast,3 although a recent meta-analysis suggested that
noncontrast enhanced CT scan in adults had reasonably high sensitivity and specificity for clinical
decision-making (93% and 96%, respectively).26
The Surgical Infection Society and Infectious Disease Society of America guidelines recommend
helical CT with IV contrast as the test of choice when imaging is indicated in patients with suspected
appendicitis, with moderate supporting evidence from 1 or more well-designed but nonrandomized
trials.3,27 A recent meta-analysis evaluated the effect of CT on negative appendectomies, rates of
perforation, and time to surgery in patients with acute right lower quadrant pain.28 The meta-analysis
concluded that preoperative CT resulted in a reduced rate of negative appendectomies but an increase
in time to surgery, although there was no increase in rate of perforation.28 However, of the 28 studies
included in the analysis, only 2 were randomized, and most were retrospective cohort studies which
can be subject to multiple sources of bias.
There have been only a few randomized trials evaluating different strategies incorporating
radiologic imaging on clinical outcomes. Only 1 trial identified a difference in accuracy. Lee and
colleagues compared a strategy of mandatory vs selective CT scanning in patients with suspected
appendicitis and less than 72 hours of symptoms. There were fewer negative appendectomies (2.6%
vs 13.9%, P ¼ 0.07) and perforations (10.3% vs 18.4%, P ¼ 0.24) in the group undergoing mandatory
scans.29 Another trial reported that CT scanning changed management in 26% of patients.30 Walker
and colleagues compared CT scanning to standard management in patients with suspected
appendicitis who clinically warranted either observation or operation. Standard management
included observation with serial examinations, ultrasound, CT, or operation. Two additional trials of
CT scanning vs clinical assessment in patients with suspected appendicitis, 1 in women only,
identified no differences in diagnostic accuracy, length of stay, perforation rate, or costs or
charges.31,32 However, these trials were small, single-center trials and underpowered to identify a
small difference in clinical outcome.
The use of radiologic imaging in the diagnosis of acute appendicitis has increased over time.
Population-based analyses of regional administrative data in the 1980s and 1990s demonstrated a
significant increase in the use of US and CT, but no change in the rate of ruptured or negative
appendectomies.22,33 A more recent follow-up study from the Washington state Surgical Care and
Outcomes Assessment Program showed wide variability in the use of radiologic imaging across the
15 participating hospitals, ranging from 56%-97%.34 There was also a significant difference in the rate
of negative appendectomies, which was correlated to the accuracy of the radiologic studies.34 This
study demonstrates that although the reported accuracy of radiologic imaging tests is high in the
published literature, it is important to their diagnostic accuracy within each institution to evaluate
their ‘‘real-world’’ utility.
Perforated vs Nonperforated Appendicitis
Distinguishing whether or not a patient is likely to have perforated vs nonperforated appendicitis

preoperatively may be helpful in terms of counseling the patient about alternatives for management
(ie, early vs delayed appendectomy), risk for complications, and the expected postoperative course.
The Anderson meta-analysis identified 4 studies that presented data for perforated appendicitis.
Based on these studies, high values of laboratory markers of inflammation such as a WBC and
granulocyte count and the CRP level were relatively strong predictors of perforated appendicitis,
whereas low values were relatively strong predictors of not having perforated appendicitis.4
Williams and colleagues developed a ruptured appendicitis scoring system for children based on 5
variables, including components of history, physical examination, laboratory values, and CT
findings.35 When the scoring system was applied to the study patient population, it increased the
specificity of the pediatric surgeon’s preoperative assessment from 83%-98%.35 This was a single-
center study that has not been validated in other centers or in adult patients. However, it
demonstrates how a combination of clinical findings and test results can improve the diagnostic
accuracy for perforated appendicitis.
reservados.
Future Directions
The above list of diagnostic tests and strategies is by no means comprehensive. Research is
ongoing to identify accurate, efficient, and cost-effective methods of diagnosis. Advances have
included using molecular techniques for profiling gene and protein expression to identify novel
markers for appendicitis.13,36,37 Imaging alternatives to CT scans such as bedside surgeon-performed
ultrasound,38 magnetic resonance imaging,39 or low radiation CT scanning40 are being investigated
in terms of their diagnostic accuracy and their potential to reduce exposure to radiation. Another
avenue of investigation is the use of machine learning and advanced statistical models for informing
decision-making.41 As advances in technology and diagnostic strategies are made, any improve-
ments in accuracy must be balanced against the costs and potential harms.
Conclusions
Acute appendicitis is a common problem that continues to pose diagnostic dilemmas for
clinicians. Although clinical findings alone may not be sufficient for establishing a diagnosis of
appendicitis, the importance of a thorough history and physical examination should not be
underestimated. If additional tests are warranted, their risks and benefits should be considered
along with the likelihood that such tests will change the management. Advances in molecular
methods, imaging technology, and computer decision support hold promise for the future, but
further investigation is necessary to ensure the accuracy, efficiency, and cost-effectiveness of novel
diagnostic strategies for acute appendicitis.
Antibiotics vs Appendectomy for Acute Uncomplicated Appendicitis
Appendectomy for acute appendicitis is one of the most common surgical procedures performed
worldwide. In the United States, appendectomy incurs considerable indirect costs resulting from
time lost from work, school, or usual activities after the procedure.42 The individual lifetime risk of
appendicitis is 8.6% for men and 6.7% for women.43 Uncomplicated acute appendicitis is considered
almost universally to be an indication for an appendectomy. In 1889, open appendectomy was
accepted as the treatment standard, because it saved lives, and since that time, the dictum that
surgical removal of the appendix is necessary has been largely unchallenged.44 Almost all surgeons
regard acute appendicitis as an invariably progressive inflammatory condition that over time
will eventually lead to perforation. Thus, early surgical exploration and appendectomy is
advocated for source control. However, appendectomy for nonperforated appendicitis is not
without associated harm. The long-term risk of small bowel obstruction is estimated at 1.3% at 30
years after appendectomy.45 In addition, the ‘‘negative’’ appendectomy rate ranges from 10%-20%
despite the widespread use of CT scans.46-48
Meanwhile, nonoperative management with antibiotics has been established as the treatment for
various intra-abdominal infections such as uncomplicated diverticulitis, salpingitis, and neonatal
enterocolitis.49 It is surprising that nonoperative management of uncomplicated acute appendicitis
remains largely unexplored despite evidence that it often resolves, either spontaneously or with
antibiotic therapy, and has been shown by limited studies to have outcomes equivalent to those of
appendectomy.50,51 Accordingly, it may be reasonable to call into question the assumptions and
‘‘evidence’’ that have supported appendectomy for this condition.
Evidence for Spontaneous Resolution of Appendicitis
Widespread CT scan utilization for the diagnosis of appendicitis has resulted in a significant
increase in the number of studies performed annually.52 This has led to several interesting
observations regarding the possibility of spontaneous resolution of appendicitis from several
centers. Inclusion of a CT scan result in the Alvarado score has been shown to increase the rate of
reservados.
appendectomy. When classified as having a low likelihood of appendicitis (Alvarado score r 4),
patients who underwent a CT scan had an appendectomy rate of 48%.52 In contrast, those with an
Alvarado score r 4 who did not undergo a CT scan had an appendectomy rate of only 12%.
Decadt and colleagues made a comparable observation for those patients who presented with
nonspecific abdominal pain.53 The investigators used diagnostic laparoscopy instead of CT scan in
the management of patients with nonspecific abdominal pain. Patients were randomized to either
(1) diagnostic laparoscopy or (2) nonoperative management (with operative intervention if
peritonitis developed). The appendectomy rate was 39% for those randomized to diagnostic
laparoscopy and 13% for those managed nonoperatively.
There are also modest epidemiologic data for spontaneous resolution of acute appendicitis.
Andersson and colleagues performed a meta-analysis of studies examining the epidemiology of
appendicitis.54 This meta-analysis included more than 50,000 patients from 15 geographic areas who
had undergone appendectomy for acute appendicitis. In this study, the incidence of perforated
appendicitis was equivalent regardless of geographic area, time, and gender. However, the incidence of
acute nonuncomplicated appendicitis differed significantly and correlated strongly to the incidence of
removal of a normal appendix and was inversely related to diagnostic accuracy. This led the authors to
conclude that the observed incidence of uncomplicated appendicitis was influenced by the willingness
to perform appendectomy in cases of suspected appendicitis. A high rate of appendectomy in suspected
cases increases the proportion of confirmed cases presumably by adding instances of self-limited
inflammation that otherwise would escape detection.55 These indirect findings and evidence are
suggestive that uncomplicated, acute appendicitis may be initially managed nonoperatively.
Nonoperative Management of Acute Appendicitis
Several reports have appeared in the literature over the last half-decade describing nonoperative
management of acute, uncomplicated appendicitis (Fig 1).56-59 The trial that has received the most
attention was conducted in Sweden. All patients older than 18 years with presumed appendicitis
were eligible for inclusion. Appendicitis was diagnosed by the physician based on clinical history,
laboratory tests, US, CT, and physical examination. A total of 369 consecutive patients were allocated
to antibiotic treatment or surgery (Fig 2); allocation was determined by odd or even date of birth.
All included patients remained in their allocated groups during follow-up, even when intention to
treat was abandoned owing to criteria defined in the protocol. Patients allocated to antibiotic
treatment could have surgery without any predetermined specification if the surgeon in charge
deemed it necessary or if the patient preferred initial operation. Study patients received intravenous
(IV) antibiotics (cefotaxime 1 g twice and metronidazole 1.5 g once) for at least 24 hours. During this
time patients received IV fluids with no oral intake. Patients whose clinical status had improved the
following morning were discharged to continue with per os antibiotics (ciprofloxacin 500 mg twice
per day and metronidazole 400 mg 3 times per day) for a total of 10 days. In patients whose clinical
condition had not improved, IV treatment was prolonged.
This study was conducted from May 2006-September 2007 and included 369 eligible consecutive
patients. There were 202 patients in the study group (antibiotics) and 167 patients in the control
group (appendectomy). In the study group, 106 (52.5%) completed the intended antibiotic
treatment, and 154 (92.2%) in the control group underwent an appendectomy. Reasons for
nonfulfillment of scheduled treatment included patient preference for the other treatment (33
patients; 30.3%), the surgeon deciding that surgery was necessary based on clinical evaluation (19
patients; 17.4%), and surgery being deemed necessary without any further specification (45
patients; 41.3%). Of 108 patients who initially improved without surgery, 15 (13.9%) had recurrent
appendicitis at a median follow-up time of 1 year. One third of recurrences appeared within 10 days
following discharge from the hospital. Of the 15 patients with recurrence, 12 had surgery (4 patients
had gangrenous or perforated appendicitis and 1 patient underwent ileocecal resection) and 3 had
a second round of antibiotic treatment with success. Appendectomy was performed according to the
authors’ usual practice: single-dose antibiotic prophylaxis, open or laparoscopic technique, and
postoperative antibiotic treatment when the appendix was gangrenous or perforated.
reservados.
FIG 1. Randomized trials of appendectomy vs antibiotics alone for the treatment of acute appendicitis. (Reprinted with
permission from Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E. Antibiotics versus appendectomy in the
management of acute appendicitis. Can J Surg. 2011;54:43-53.)
Efficacy in the study group according to intention to treat was 48.0% (97 of 202). Eleven of 119
(9.2%) patients who primarily received antibiotics had an appendectomy owing to clinical
progression. The preoperative characteristics of these patients were similar to those of the patients
who fulfilled the antibiotic treatment. Of 250 surgically explored patients, 223 (89.2%) had
appendicitis. Primary treatment efficacy was 90.8% for antibiotic therapy compared to 89.2% for
surgical exploration analyzed per protocol. Major complications and total hospital cost for the
primary admission were both lower in the antibiotic treatment group.
One of the largest retrospective series reporting nonoperative management of appendicitis comes
from Japan.60 In this retrospective study, Shindoh and colleagues reviewed their institutional
experience with nonoperative management of appendicitis. In this report, 367 patients met
inclusion criteria (right lower quadrant pain, WBC 4 9000 or CRP 4 1.0 mg/dL). The authors
describe the following 3 study groups: (1) initial operation or appendectomy, (2) nonoperative
group, and (3) initial nonoperative group converted to surgery (failure). In the nonoperative groups,
patients received antibiotics and were evaluated 24 hours later. If the physical examination or
laboratory parameters worsened, surgical management was considered. In this cohort, 143 (39%)
underwent initial operation (group 1), whereas 224 (61%) were managed with initial antibiotic
therapy. In the initial nonoperative group, 91 patients did not respond to antibiotics and underwent
appendectomy. Factors predictive of failure included CRP (odds ratio [OR] 5.5, 95% CI: 1.94-17.29)
and the presence of an appendicolith (OR 4.7, 95% CI: 1.15-24.46). Of note, in this study recurrence
of appendicitis was observed in 4.7% of patients initially managed nonoperatively.
reservados.
FIG 2. Consort diagram. (Reprinted with permission from Hansson et al.59)
Conclusions
The data and available evidence regarding nonoperative management of acute appendicitis is
provocative. At this time, however, level I data to suggest this is an alternative treatment option are
not universally accepted. Despite the fact that appendectomy has been regarded as standard
treatment for appendicitis for more than 100 years, there have been reports of patients being managed
successfully without an operation. To date, there have been few randomized studies of nonoperative
vs operative therapy for acute appendicitis, and none have been conducted in the United States. Yet
there is some suggestion that a select group of patients may be managed nonoperatively. At best, we
should consider the available data as hypothesis generating and not hypothesis confirming.
One of the inherent difficulties and biases in conducting a well-planned randomized clinical trial
centers on pathologic confirmation of appendicitis. On one hand, for those patients with ‘‘suspected’’
appendicitis who receive antibiotics only, treatment successes may cause one to consider the underlying
diagnosis (‘‘Is it really appendicitis?’’). On the other hand, the number of patients who undergo a
negative appendectomy is not zero and exposure of these patients to surgical risks and complications is
a valid concern. The report by Hansson and colleagues demonstrated a 3-fold increased rate of
complications in the appendectomy group when compared to the nonoperative, antibiotic only group.
The data presented herein are suggestive that in selected patients with acute, uncomplicated
appendicitis, antibiotic treatment seems to be an appropriate alternative to conventional
appendectomy. Multivariate analysis of patient characteristics failed to demonstrate any logistic
model for inclusion or rejection of patients for the specified treatments. Furthermore, it confirmed that
reservados.
FIG 3. Intraoperative image of simple acute appenditis. (Photo Courtesy Kuojen Tsao, MD.)
CRP is not a significant predictor in the assessment of the phlegmonous and gangrenous appendix,
unlike total blood leucocyte count. Therefore most patients older than 18 years without obvious signs
of intra-abdominal perforation can be offered antibiotic treatment as first-line therapy. Clinical
progression and surgical judgment may then determine whether there is a real need for surgical
exploration in an expected subgroup of 5%-10% of all patients appearing with suspected or established
appendicitis. The benefit would be a significantly reduced frequency of major complications related to
surgery. The possible drawbacks to treating acute appendicitis with antibiotics do not appear relevant,
despite the well-recognized risk of increased environmental burden and antibiotic resistance; major
complications following unnecessary surgery seem a more pertinent risk to patients.
Another inherent problem with deciphering the issue of antibiotic therapy is the fact that getting
clinicians to agree upon a consensus definition for acute, uncomplicated appendicitis remains
problematic. In all likelihood, there is an arbitrary cut-off or threshold by which certain patients
probably have a milder form of the disease (Fig 3) and would likely respond to systemic antibiotics
alone. Above this arbitrary threshold, antibiotic therapy is unlikely to be effective in eradicating the
infection (Fig 4). To resolve this dilemma, a few of these studies have completed multivariate
analyses and found that presence of the fecaliths is predictive of failure. Further studies are needed
to create informed multivariate models that adjust for all of the important clinical covariates. This
effort may accurately predict which patients may or may not respond to systemic antibiotic therapy
alone for the treatment of appendicitis.
Management of Complicated Appendicitis
In the United States, approximately 11 of 10,000 people will develop acute appendicitis over their
lifetime, with the typical age of onset between the ages of 11 and 19 years.61 Of these, an estimated
2%-6% of patients will present with an appendiceal mass, either in the form of an inflammatory
phlegmon or abscess.62 The optimal management of acute appendicitis complicated by an
inflammatory phlegmon or abscess remains controversial. There is no consensus in the surgical
literature on whether to proceed immediately with appendectomy or initial nonoperative
management in this setting of complicated appendicitis. Another dilemma in the management of
appendicitis initially managed conservatively with antibiotics is whether or not to perform an
appendectomy at a later date (interval appendectomy). The data are disparate regarding actual
recurrence rates of appendicitis following nonoperative management, but they are commonly
reservados.
FIG 4. Intraoperative image of appendicitis with perforation and gangrenous tip. (Photo Courtesy Kuojen Tsao, MD.)
FIG 5. CT scan demonstrating appendiceal abscess containing air-fluid levels.
reported between 5% and 20%.63-65 In addition to recurrent appendicitis, a clinical concern in older
patients who present with a cecal phlegmon is malignancy. In these cases, interval appendectomy
allows the correct pathologic diagnosis to be made.66 The effect of these management decisions on
duration of hospital stay, number of interventions, healthcare costs, and overall patient satisfaction
must be considered.
Appendiceal Abscess
Appendiceal abscess is commonly associated with delay in presentation, fever, leukocytosis, and
a palpable mass in the right lower quadrant (Figs 5 and 6). The diagnosis is confirmed with CT or US.
Management of these patients remains controversial with the traditional nonsurgical approach of
percutaneous drainage and IV antibiotics with or without interval appendectomy vs immediate
appendectomy and surgical drainage of the abscess. The evidence supporting both approaches is
reservados.
FIG 6. CT scan demonstrating appendiceal abscess with rim-enhancing wall.
weak, as most studies are retrospective and often combine patients with appendiceal abscess and
phlegmon into a single cohort called ‘‘appendiceal mass.’’ Several meta-analyses have been
performed to try to identify differences between the 2 treatment strategies. Andersson and
Petzold performed a meta-analysis on 19 retrospective studies from 1969-2005. The limitation of
this study is the lack of uniform definition of appendiceal abscess vs phlegmon. Nevertheless, the
meta-analysis revealed that nonsurgical treatment failed in 7.6% of patients (CI 3.2-12.0).
Immediate appendectomy is associated with a higher morbidity with an OR of 3.3 (CI: 1.9-5.6).
Based on these findings, the authors recommend nonsurgical management of patients with
appendiceal abscess.67 Similar conclusions were reached by Simillis and colleagues who
performed a meta-analysis of 16 retrospective studies and 1 nonrandomized prospective study
from 1969-2007 comparing immediate appendectomy (725 patients) vs nonsurgical treatment
(847 patients).68 Immediate appendectomy is associated with greater incidence of ileus or bowel
obstruction, abdominal or pelvic abscess, and wound infection compared to nonsurgical
treatment. There was no difference in the overall duration of hospitalization, but the immediate
appendectomy group required more reoperations. The higher rate of complications associated
with immediate appendectomy has been attributed to greater inflammatory response to surgery
in the setting of infection, as well as the technical difficulty with inflamed tissue. Most of the
studies analyzed in these meta-analyses utilized open appendectomy techniques. The potential
disadvantages of early operation may be mitigated by the laparoscopic techniques. Laparo-
scopic appendectomy results in less local inflammation due to better visualization and
instrumentation.69
St. Peter and colleagues conducted a prospective randomized trial comparing immediate
laparoscopic appendectomy to nonsurgical treatment in 40 pediatric patients presenting with
appendiceal abscess.70 Immediate laparoscopic appendectomy tends toward longer operative time
(61 minutes vs 42 minutes) compared with interval laparoscopic appendectomy performed at 10
weeks from initial presentation (Fig 7). The immediate appendectomy group had fewer health care
visits and few CT scans. However, there was no difference in recurrent abscess rate, total length of
hospitalization, or total charges. They conclude that immediate laparoscopic appendectomy is as
safe as nonsurgical management. The safety of immediate laparoscopic appendectomy for
appendiceal abscess is supported by several other retrospective or uncontrolled studies.71-74 The
infectious complications of immediate appendectomy can be reduced by improved laparoscopic
techniques, such as use of extraction bag, endostaplers rather than endoloops, and limited irrigation
to avoid bacterial contamination.75,76
Appendiceal Phlegmon
The management of acute appendicitis complicated by an appendiceal phlegmon typically

involves 1 of 3 treatment strategies. The first, and most commonly accepted, is initial treatment with
reservados.
FIG 7. Results from pilot trial of appendectomy for perforated appendicitis with abscess. (Reprinted with permission from St
Peter et al.70)
broad spectrum antibiotics and IV fluids until the acute inflammation subsides; appendectomy is
then performed on an interval basis. Another strategy involves appendectomy upon initial
presentation. Lastly, following resolution of the acute inflammation with broad spectrum antibiotics,
the patient is managed expectantly without interval appendectomy. Prospective data comparing
these strategies are sparse, with most systematic reviews drawing heavily upon retrospective data.
At present, there is no agreed upon approach for the management of an appendiceal phlegmon. A
recently published survey of a group of general surgeons in England found that 75% still favor interval
appendectomy following resolution of symptoms.77 Proponents for interval appendectomy state that
removing the appendix is a technically easier operation once the acute inflammation subsides,
potentially avoiding inadvertent injury to adjacent loops of involved bowel, as well as extended
resection of the cecum or ascending colon.66 Although the risk of recurrent appendicitis remains small
after successful nonoperative treatment of an appendiceal phlegmon, proponents of interval
appendectomy state that the risk of interval appendectomy is also small and eliminates the possibility
of recurrent appendicitis.63 In a recent systematic review published by Hall and colleagues, 127 children
were managed without planned interval appendectomy.78 The incidence of recurrent appendicitis
ranged from 0%-42% in the 3 studies included in the review, with an overall risk of 20.5% (95% CI 14.3-
28.4) (Fig 8). The complication rates following interval appendectomy were also published in this
review, with an overall incidence of 3.4% (95% CI, 2.2-5.1) (Fig 9). The authors conclude that the
likelihood of recurrent appendicitis as well as the risk of complication after interval appendectomy are
both sufficiently low that the decision to proceed with interval appendectomy is typically based on
clinical criteria. Unfortunately, these data are from retrospective studies; prospective data from a
randomized trial comparing these 2 approaches will help further guide surgical management.
Interval Appendectomy
Interval appendectomy provides a tissue diagnosis when diagnostic uncertainty exists. This is
particularly important in adults because the differential diagnosis of an inflammatory mass in the right
lower quadrant can be quite extensive, with neoplastic etiologies of particular concern. In a systematic
review and meta-analysis by Andersson and colleagues, 2771 included patients were initially treated
nonoperatively for an appendiceal phlegmon or abscess.65 On follow-up, 31 patients were found to
have a malignant diagnosis. In patients younger than 40 years with an appendiceal mass, only 4 were
found to have a malignant diagnosis on follow-up: 2 children had carcinoid of the appendix, a 26 year
old woman presented with an ovarian malignancy, and a 25 year old man presented with metastatic
gastric cancer. The overall estimate of a malignant diagnosis was 1.2% (95% CI 0.6%-1.7%), with an
incidence of 0.2% (95% CI 0.0%-0.05%) in children. Inflammatory bowel disease was established as a
diagnosis during follow-up in 0.7% of patients (95% CI 0.2%-11.9%), with a higher incidence again seen
in adults. Although primarily retrospective, these data underscore the need for follow-up, either with
CT scan or colonoscopy, after successful treatment of an appendiceal phlegmon in adults.65
reservados.
FIG 8. Incidence of recurrent appendicitis in individual studies included in this systematic review. Overall incidence 20.5%
(95% CI, 14.3-28.4) was calculated using binomial multilevel regression model. (Reprinted with permission from Hall et al.78)
The presence of an appendicolith associated with an appendiceal phlegmon deserves special

mention because its presence has been used as a guide to proceed with interval appendectomy
following successful nonoperative management. A retrospective cohort study published by Ein and
colleagues reviewed the outcomes of 96 pediatric patients with appendicitis who presented with
either an inflammatory mass or phlegmon and were initially managed nonoperatively by the staff
surgeon.79 Six patients who failed initial nonoperative management underwent appendectomy and
were excluded. Forty-one patients were scheduled for elective appendectomy by their surgeon and
were also excluded from analysis. The remaining patients were included in the study and their
outcomes over a 2-year period were reported. Of these, 37% had an appendicolith and 63% did not.
The overall recurrence rate for appendicitis was 42%; in patients with an appendicolith, the
recurrence rate was 72% compared to 26% in patients without an appendicolith (relative risk of 2.8 in
patients with an appendicolith) (Table 5). The authors conclude that the presence of an
appendicolith predicts failure of nonoperative management of peri-appendiceal phlegmon or
abscess. It is important to note that the overall recurrence rate of appendicitis in this study is higher
than what is typically reported elsewhere in the literature, and this may influence the true effect of
an appendicolith on failure of nonoperative management. Unfortunately, there are no data from a
randomized, prospective trial evaluating whether or not the presence of an appendicolith is
predictive of failure of initial nonoperative management of ruptured appendicitis with phlegmon or
abscess. As such, any conclusions from this study should be viewed as hypothesis-generating for a
future randomized controlled trial.
In deciding whether or not to proceed with routine interval appendectomy following successful
nonoperative management of an appendiceal phlegmon or abscess, the effect of cost must also be
considered. A cost analysis of interval appendectomy following successful nonoperative manage-
ment of periappendiceal phlegmon or abscess was conducted by Raval and colleagues80 In this
study, a decision tree analysis was created with outcome probabilities obtained from literature
review and cost estimates from the Healthcare Cost and Utilization Project Kids’ Inpatient
Database.81 It should be noted that the Kids’ Inpatient Database provides a conversion factor for
translating total charges into costs. With an estimated probability of successful observation set at
0.85, the cost of observation was calculated to be $3080.78 as opposed to $5034.58 seen in the
interval appendectomy arm. Using one-way sensitivity analysis, cost savings were observed up to a
reservados.
FIG 9. Incidence of complications after interval appendectomy. Overall incidence 3.4% (95% CI 2.2-5.1). (Reprinted with
permission from Hall et al.78)
TABLE 5
Effect of presence of appendicolith on recurrence
No. of patients Recurrence
No appendicolith 31 (63) 8 (26)

Appendicolith 18 (37) 13 (72)*
Total 49 21 (43)
Recurrence, values are presented as n (%).

n
P o 0.004.
Reprinted with permission from Ein SH, Langer et al.79
0.60 probability of successful observation (Fig 10). Stated another way, this represents a
0.4 probability of recurrent appendicitis following observation, which is similar to the recurrence
rate published by Ein and colleagues79 Thus, even in a patient population with a relatively high
likelihood of recurrent appendicitis, the cost analysis does not recommend proceeding with elective
interval appendectomy.
Although prospective data on the management of periappendiceal phlegmon or abscess are
limited, 2 recently published randomized trials in children address the question of whether or not to
reservados.
FIG 10. One-way sensitivity analysis of the probability of successful observation demonstrating a threshold of 0.60.
(Reprinted with permission Raval et al.80)
offer an appendectomy on initial presentation vs interval appendectomy82,83. It is important to note

that these trials include interval appendectomy as a treatment arm; foregoing appendectomy
altogether was not specifically investigated. In the study published by St. Peter and colleagues, 40
children with appendicitis complicated by phlegmon or abscess were randomized to either
immediate appendectomy or initial nonoperative management followed by scheduled interval
appendectomy in 6 weeks.83 Of note, this is a pilot study in which an outcome variable was not
defined or used in a sample size calculation. The number of patients chosen to be enrolled into the
study was based on the anticipated clinical volume over a study period of 2 years. Patients who were
offered initial appendectomy had a longer operative time (20 minutes), fewer CT scans, and fewer
total healthcare visits. Otherwise, the total length of hospital stay, hospital charges, and recurrent
intra-abdominal abscess rates were similar between the 2 groups.
Randomized Trial of Interval Appendectomy
A more robust randomized trial was conducted by Blakely and colleagues with 131 total patients
enrolled: 64 receiving initial appendectomy and 67 assigned to interval appendectomy.82 This study
was powered to detect a 5-day difference in return to normal activity and intention-to-treat
analyses were performed. The primary outcome of time to return to normal activity was chosen as it
is readily measured and functions as a composite of many objective and subjective measures. In the
primary appendectomy group, time to normal activity was 13.8 [7.5] days (mean [standard
deviation]) vs 19.4 (8.7) days in the interval appendectomy group (P o 0.001). Of note, the relative
risk of any adverse effect associated with interval appendectomy was 1.86 (95% CI 1.21-2.87);
reservados.
specific outcomes measured included intra-abdominal abscess, small bowel obstruction, unplanned
readmission, and recurrent appendicitis, and these were all seen with higher frequency in the
interval appendectomy group. The authors conclude that early appendectomy significantly reduced
the time away from normal activity and showed a significantly lower adverse event rate.
Future Directions
The optimal management strategy of an appendiceal phlegmon or abscess remains elusive as most
recommendations are based on retrospective data, but recent randomized trials in children indicate
that early appendectomy results in faster return to normal activity with favorable complication rates
when compared to interval appendectomy.82 Performing an interval appendectomy following
successful nonoperative management with antibiotics and percutaneous drainage, as needed, has yet
to be evaluated in a randomized trial. The clinical decision to perform an interval appendectomy in
the setting of an appendicolith is based on a retrospective cohort study published by Ein and
colleagues79 As stated previously, the incidence of recurrent appendicitis in this cohort was higher
than that seen in other series, and thus influences the recommendation to proceed with interval
appendectomy. Higher-quality evidence from prospective, randomized trials will help surgeons
decide whether or not interval appendectomy in the setting of an appendicolith is appropriate.
Surgical Options for Acute Appendicitis
Laparoscopic vs Open Appendectomy
The open appendectomy was initially described by McBurney in 1894, and has remained
relatively unchanged since its introduction. In 1983, Semm described a laparoscopic approach for
removing the appendix, advocating the advantages of laparoscopic surgery for one of the most
frequently performed surgical procedures.84 Because open appendectomy typically involves a small
incision, short hospital stay, rapid return to normal activity, and low postoperative morbidity,
demonstrating clear superiority of 1 approach over the other has been elusive. Although many
randomized control trials comparing open vs laparoscopic appendectomy have been performed,
many contain methodological flaws, including inadequate allocation concealment, lack of reporting
of randomization method, failure of adequate blinding, lack of analysis by intention-to-treat, and
incomplete follow-up data.85 That being said, these randomized trials, as well as systematic reviews
and meta-analyses of these studies, have provided a great deal of insight into the specific benefits
and drawbacks of each approach. In deciding between a laparoscopic and open approach, specific
issues that must be considered include learning curve, operative time, associated morbidity, cost,
pain, cosmesis, hospital length of stay, and time to return to normal activity. Unfortunately,
measures vary across studies and conclusions have been inconsistent.
Predictors of Surgical Choice
A large retrospective review of prospectively acquired data comparing outcomes of laparoscopic vs

open appendectomy in 222 hospitals participating in the American College of Surgeons National Surgical
Quality Improvement Program (ACS NSQIP) was conducted by Ingraham and colleagues86 Over the
course of 3 years (2005-2008), 32,683 patients in the database underwent appendectomy at these
institutions, with 24,969 performed laparoscopically (76.4%) and 7,714 (23.6%) performed using an open
technique. Risk factors among patients undergoing laparoscopic vs open appendectomy were evaluated.
Patients undergoing open appendectomy were more likely to be older, of normal weight, higher ASA
class, and more likely to have a variety of comorbidities; these are summarized in (Table 6). The analysis
of 30-day outcomes following laparoscopic vs open appendectomy showed overall morbidity, serious
morbidity, surgical site infection, and serious morbidity or mortality (Table 7) to be higher in patients
undergoing open appendectomy, although these complications were generally low in both groups.
reservados.
TABLE 6
Distribution of patient risk factors associated with 32,683 appendectomies performed at 222 NSQIP hospitals
Risk factor Open (n ¼ 7,714; Laparoscopic (n ¼ Total (n ¼ P value

23.6%) 24,969; 76.4%) 32,683)
Postoperative diagnosis o 0.0001

Peritonitis or abscess 2,704 (26.89) 3,331 (13.34) 5,405 (16.54)
No perforation or peritonitis or abscess or 5,640 (73.11) 21,638 (86.66) 27,278 (83.46)
rupture
Age (mean 7 SD) 40.2 7 17.2 37.3 7 15.8 38.0 7 16.2 o 0.0001
Gender o 0.0001
Female 3,260 (42.26) 11,808 (47.29) 15,068 (46.10)
Male 4,454 (57.74) 13,161 (52.71) 17,615 (53.90)
Race o 0.0001
White 4,809 (62.34) 16,527 (66.19) 21,336 (65.28)
Black 445 (5.77) 1,479 (5.92) 1,924 (5.89)
Other 2,460 (31.89) 6,963 (27.89) 9,423 (28.83)
Body mass index 0.0001

Normal 2,577 (33.41) 8,079 (32.36) 10,656 (32.60)
Overweight 2,266 (29.38) 7,372 (29.52) 9,638 (29.49)
Obese 1,603 (20.78) 5,827 (23.34) 7,430 (22.73)
Underweight 159 (2.06) 470 (1.88) 629 (1.92)
Unknown 1,109 (14.38) 3,221 (12.90) 4,330 (13.25)
ASA class o 0.0001

1—No disturbance 2,850 (36.95) 9,541 (38.21) 12,391 (37.91)
2—Mild disturbance 3,890 (50.43) 13,146 (52.65) 17,036 (52.12)
3—Severe disturbance 878 (11.38) 2,128 (8.52) 3,006 (9.20)
4—Life threatening 96 (1.24) 154 (0.62) 250 (0.76)
Functional status o 0.0001

Independent 7,532 (97.64) 24,620 (98.60) 32,152 (98.38)
Partially dependent 182 (2.36) 349 (1.40) 531 (1.62)
Diabetes 339 (4.39) 953 (3.82) 1,292 (3.95) 0.02
Renal failure (dialysis or acute renal failure) 26 (0.34) 39 (0.16) 65 (0.20) 0.002
Dyspnea 163 (2.11) 315 (1.26) 478 (1.46) o 0.0001
Ascites 96 (1.24) 279 (1.12) 375 (1.15) 0.36
Alcohol use 213 (2.76) 510 (2.04) 723 (2.21) 0.0002
Current smoker within 1 y 1,627 (21.09) 5,418 (21.70) 7,045 (21.56) 0.26
Chronic obstructive pulmonary disease 106 (1.37) 181 (0.72) 287 (0.88) o 0.0001
Pneumonia 12 (0.16) 18 (0.07) 30 (0.09) 0.03
Steroid use for chronic condition 81 (1.05) 175 (0.70) 256 (0.78) 0.002
Bleeding disorder 199 (2.58) 451 (1.81) 650 (1.99) o 0.0001
Congestive heart failure 13 (0.17) 14 (0.06) 27 (0.08) 0.003
Hypertension requiring medication 1,369 (17.75) 3,561 (14.26) 4,930 (15.08) o 0.0001
Coronary artery disease* 275 (3.56) 586 (2.35) 861 (2.63) o 0.0001
Peripheral vascular diseasey 39 (0.51) 44 (0.18) 83 (0.25) o 0.0001
Disseminated cancer 15 (0.19) 44 (0.18) 59 (0.18) 0.74
Weight loss (4 10% loss in last 6 mo) 8 (0.10) 43 (0.17) 51 (0.16) 0.18
Chemotherapy for malignancy within 30 d 22 (0.29) 54 (0.22) 76 (0.23) 0.27

preoperatively
Radiotherapy for malignancy in last 90 d 8 (0.10) 14 (0.06) 22 (0.07) 0.16
reservados.
TABLE 6 (continued )
Risk factor Open (n ¼ 7,714; Laparoscopic (n ¼ Total (n ¼ P value

23.6%) 24,969; 76.4%) 32,683)
Neurologic disorderz 134 (1.74) 299 (1.20) 433 (1.32) 0.0003
Transfusion99,y 3 (0.04) 1 (0.00) 4 (0.01) 0.02
Preoperative sepsisz 2,955 (38.31) 8,795 (35.22) 11,750 (35.95) o 0.0001
ASA, American Society of Anesthesiology; CVA, cerebrovascular accident; SD, standard deviation.
n
History of angina in the month prior to the index operation, history of myocardial infarction 6 mo before the index
operation, previous percutaneous cardiac intervention, or previous cardiac surgery.
y
History of revascularization or amputation for peripheral vascular disease and rest pain or gangrene.
z
CVA or stroke with or without neurologic deficit, history of transient ischemic attacks (TIA), hemiplegia, paraplegia,
impaired sensorium, quadriplegia.
99
Transfusion 4 4 U packed red blood cells 72 h before surgery.
y
Significance calculated via Fisher’s exact test owing to small sample sizes.
z
Preoperative systemic inflammatory response syndrome or sepsis.
Reprinted with permission from Ingraham et al.86
TABLE 7
Comparison of 30-day outcomes after laparoscopic vs open appendectomy at 222 NSQIP hospitals (2005–2008)
Outcomes Open (n ¼ 7,714; Laparoscopic (n ¼ 24,969; Total (n ¼ P value

23.6%) 76.4%) 32,683)
Overall morbidity 682 (8.84) 1,114 (4.46) 1,796 (5.50) o 0.0001
Serious morbidity 326 (4.23) 644 (2.58) 970 (2.97) o 0.0001
SSI 513 (6.65) 814 (3.26) 1,327 (4.06) o 0.0001
Serious morbidity or mortality 329 (4.26) 649 (2.60) 978 (2.99) o 0.0001
Mortality 10 (0.13) 18 (0.07) 28 (0.09) 0.13
Individual morbities
Superficial SSI 300 (3.89) 314 (1.26) 614 (1.88) o 0.0001
Deep incisional SSI 76 (0.99) 60 (0.24) 136 (0.42) o 0.0001
Organ space SSI 133 (1.72) 448 (1.79) 581 (1.78) 0.68
Wound disruption 35 (0.45) 15 (0.06) 50 (0.15) o 0.0001
Pneumonia 33 (0.43) 61 (0.24) 94 (0.29) 0.01
Unplanned intubation 30 (0.39) 36 (0.14) 66 (0.20) o 0.0001
Pulmonary embolism 6 (0.08) 21 (0.08) 27 (0.08) 0.87
Failure to wean (on ventilator 24 (0.31) 26 (0.10) 50 (0.15) o 0.0001
4 48 h)
Renal failure 10 (0.13) 21 (0.08) 31 (0.09) 0.26
Urinary tract infection 28 (0.36) 92 (0.37) 120 (0.37) 0.94
Neurologic event 1 (0.01) 8 (0.03) 9 (0.03) 0.70*
Cardiac arrest requiring CPR 7 (0.09) 8 (0.03) 15 (0.05) 0.03*
Myocardial infarction 5 (0.06) 3 (0.01) 8 (0.02) 0.02*
Bleeding 1 (0.01) 9 (0.04) 10 (0.03) 0.47*
DVT 9 (0.12) 11 (0.04) 20 (0.06) 0.03*
Sepsis or septic shock 167 (2.16) 288 (1.15) 455 (1.39) o 0.0001
CPR, cardiopulmonary resuscitation; DVT, deep vein thrombosis; NSQIP, National Surgical Quality Improvement Program; SSI,
surgical site infection.
n
Utilizing Fisher’s exact test.
Reprinted with permission from Ingraham et al.86
Patients with complicated appendicitis had a significantly lower likelihood of developing a superficial or
deep incisional surgical site infection after laparoscopic appendectomy compared to open appendectomy;
the likelihood of developing a deep organ space surgical site infection was higher in the laparoscopic
reservados.
group. In uncomplicated appendicitis, the risk of both superficial and deep surgical site infection was
lower in the laparoscopic group. Although this study evaluates a large number of patients across multiple
hospital systems, the data are limited in that retrospective reviews cannot account for specific clinical
reasons for why 1 treatment was chosen over another, in this case laparoscopic vs open appendectomy.
As such, these clinical decisions function as an uncontrolled confounder. Other limitations acknowledged
by the authors include generalizability of the results to non-NSQIP centers and data being limited to those
that are collected in the NSQIP database. That being said, the authors conclude that the available evidence
from the American College of Surgeons NSQIP database indicates that a laparoscopic approach is
associated with fewer complications when compared to an open procedure.
A Cochrane review of 67 trials comparing laparoscopic and open appendectomy was updated in
2010.87 Of these studies, the vast majority (56) were conducted in adults. The interventions used in
the included trials were fairly similar; in laparoscopic cases, 3 trocars were typically used and the
appendiceal stump was secured primarily with looped sutures, although 3 trials did use an
endoscopic stapler. Antibiotic usage was stated as being the same in both groups for each included
trial. Specific outcomes assessed by the included trials most frequently included operating time,
complication rates, hospital stay, pain, and return to normal activity. It is important to note that
although all participants in the included trials were randomized to either laparoscopic or open
appendectomy, the quality of these trials was judged to be moderate to poor, with many of the
included studies having similar flaws. Specifically, only 42 trials took adequate measures to ensure
that the process of randomization was adequately concealed. Furthermore, protocol violations were
seen in nearly all trials with inconsistent analysis on an intention-to-treat basis.
Surgical Complications
Although a variety of complications were evaluated among the 67 trials in the meta-analysis, due
to inconsistencies in the definition and reporting of these complications, the authors only examined
2 specific complications in their analysis: wound infection and intra-abdominal abscess. Following
laparoscopic appendectomy, wound infections were approximately one half as likely when
compared to open appendectomy (OR 0.43; 95% CI 0.34-0.54). This is a highly significant difference
based on nearly 6000 appendectomies. Conversely, laparoscopic appendectomy was associated with
a nearly 3-fold increase in the likelihood of intra-abdominal abscess when compared to an open
technique (OR 1.77; 95% CI 1.14-2.76). These results are similar to the findings published in the
NSQIP analysis by Ingraham and colleagues86 Operative time was 10 minutes longer for laparoscopic
appendectomy (95% CI 6-15 minutes), but this difference has been getting smaller with more
recently published trials. Laparoscopic appendectomy was also associated with lower postoperative
pain, shorter hospital stay (1.1 days; 95% CI 0.7-1.5), and faster return to normal activity (5 days;
95% CI 4-7), although these results are highly heterogeneous and further study is warranted.
Hospital and operational costs are higher with laparoscopic appendectomy, but again, these results
are strongly heterogeneous. The authors conclude that laparoscopic appendectomy confers many
benefits over open appendectomy, and should be strongly considered as the preferred approach
where surgical expertise is appropriate and equipment is available and affordable.
Conclusions
The question of whether or not appendectomy should be performed via an open or laparoscopic
technique has been inherently difficult to answer because both approaches offer similar advantages,
namely, a small incision, low incidence of complications, a short hospital stay, and rapid return to
normal activity. Although multiple randomized trials and meta-analyses of these trials have been
conducted and published, the data indicate that the choice of surgical approach ultimately remains
up to the surgeon. As stated in the Cochrane review, is avoiding 3 superficial surgical site infections
for 1 intra-abdominal abscess a reasonable choice? As experience with laparoscopic appendectomy
increases and the equipment becomes more ubiquitous, the estimated complication profiles of both
operations will become more accurate and precise, and this question can be suitably answered.
reservados.
Pediatric Appendectomy
Acute appendicitis is one of the most common surgical diagnoses in pediatrics, with an estimated
incidence of 59,000-70,000 children per year in the United States.88,89 Appendicitis occurs in all age
groups, but is rare in younger children. Although the highest incidence is in older children, with 25
cases per 10,000 pediatric patients per year between the ages of 10 and 17 years, there is a reported
rate of 1-2 cases per 10,000 in children younger than 4 years of age. In most cases in the United
States, this results in an appendectomy in an estimated 7%-8% of the general population.7,43,90,91
Subsequently, appendectomy is one of the most common operations performed in children.
Prognosis
In general the prognosis for pediatric appendicitis is excellent. The mortality rate for appendicitis is
0.1%-1% with the highest proportion in younger children.88,92 Death in infants and neonates is mostly
likely due to (1) failure to recognize disease due to its clinical presentation, which is similar to other
common conditions in this age group; and (2) the inability of the younger patient to communicate
abdominal pain or to manifest systemic symptoms, such as fever. However, there remains significant
morbidity and at the time of diagnosis, the rate of perforated appendicitis has been estimated up to 30%.93
For the same reasons attributed to higher mortality, the rate of perforation has been reported as high as
80%-100% for children younger than 3 years, compared with 10%-20% in children 10-17 years of age.88,92
In general, the diagnosis and treatment strategies for pediatric acute appendicitis are not much different
compared to adult therapies. Appendectomy is indicated based on the diagnosis of acute appendicitis
which, in most cases, can be made clinically. Utilizing history from the patient or caretaker or both, as well
as physical signs of localized peritonitis in the right lower quadrant of the abdomen, acute appendicitis
should be strongly considered. In equivocal cases, adjunctive imaging such as US or computerized
tomography (CT) has proven to be effective.94 With increased utilization of routine imaging studies, the
negative appendectomy rate has decreased to 2%-3% without increasing the perforation rate.93,95
Challenges in the treatment of acute appendicitis are generally the same in adult and pediatric
patients. Key issues regarding diagnosis,35,39 surgical technique,96,97 and antibiotic therapy98,99
remain unanswered for all patient populations. These specific issues related to the treatment of
acute appendicitis are addressed elsewhere in this issue. However, there are specific considerations
for pediatric appendectomy that remain controversial. These include the increasing adoption of
single-incision or single-port laparoscopic appendectomy (SILS) and the initial nonoperative
management of acute appendicitis with or without subsequent interval appendectomy.
The surgical treatment of acute appendicitis has evolved over the last 2 decades. Since
McBurney’s first description in 1894,100 the transverse or oblique right lower quadrant incision for
appendectomy is the incision of choice for the open approach in children. The abdominal muscles
are split with the mesoappendix divided prior to excision of the appendix at the base. The
appendiceal stump can be closed with a simple ligation, ligation with inversion using a purse-string,
or to inversion without ligature. The classic open appendectomy approach described by McBurney
is still widely utilized in children, especially in younger patients with thin body habitus.
In recent years, laparoscopic appendectomy has gained wide adoption and has been shown to
improve patient outcome in multiple reports.101-106 Some authors have suggested that the
minimally invasive technique is the preferred approach among pediatric surgeons,107 whereas
others have demonstrated heterogeneity in surgical approaches.108 Although there remains a
paucity of high-level clinical evidence to support this superior efficacy,87,109 it is indisputable that
laparoscopic appendectomy is widely utilized and, at times, expected by patients and their families
in the surgical treatment of acute appendicitis in children.
Laparoscopic Appendectomy
The first case of laparoscopic appendectomy was described by Semm in 1983, and was carried out
as an incidental procedure during a pelvic exploration.84 In the last 30 years, controlled studies and
reservados.
meta-analysis in adult patients have demonstrated advantages with laparoscopic appendectomy,

including fewer wound infections, faster return to normal activity, and decreased length of
hospitalization.102,104 However, not until the 1990s was laparoscopic appendectomy established as
a reasonable approach in the treatment of pediatric acute appendicitis.101,105 The reported
advantages of laparoscopic appendectomy, compared to open surgery in children, are similar to
those in adults which include shorter hospitalization, fewer wound infections, earlier return to
normal activity, and better cosmesis.101,103,105,110-113
The standard approach to laparoscopic appendectomy in children usually involves a 3-trocar
technique. A 10- to 12-mm cannula is placed in the umbilicus to allow the passage of laparoscopic
instruments, the telescope, a ligation device such as a stapler, and the retrieval of the appendix. Two
5 mm cannulae are then placed in the left lower quadrant and midline immediately over the pubis.
Various methods, such as endoscopic clips, endoscopic staplers, or thermocoagulating devices,
can be used for division of the mesoappendix.101,105,114 Similarly, the base of the appendix can be
ligated inside the abdomen with endoloops, endoscopic sutures, or staplers, or can be secured
extracorporeally.105,114,115
Single-Incision or Single-Port Laparoscopic Appendectomy
In the evolving era of ‘‘scarless surgery,’’ SILS has been utilized for appendectomy. A single-
incision laparoscopic-assisted appendectomy for acute appendicitis was first reported in adults
patients in 1992.116 Soon thereafter, this surgical approach began to be reported in children, with
the first reports utilizing a single umbilical incision with a laparoscopic-assisted appendectomy, in
which the appendectomy was performed after exteriorization through the umbilical incision.117
Since then, several techniques under the auspices of SILS have been utilized including natural orifice
transluminal endoscopic surgery and many variations of single-incision techniques.118-121
In general, there are various approaches to SILS for appendectomy ranging from single-port SILS
which utilizes conventional or specialized instruments through a single skin incision, without regard
to number of fascia incisions122-126 to a single-incision, laparoscopic-assisted operation in which the
appendix is exteriorized and open techniques are utilized.122,124,127 The touted advantages of the
SILS approach to appendectomy are similar to general laparoscopy compared to open operations,
including less pain, faster recovery, and better cosmesis. However, critics countered these with
concerns about increased costs, longer operation times, and higher complication rates.124
Unfortunately, comparative evidence for SILS appendectomy in children has been limited despite
its widespread adoption into clinical practice. In adult studies comparing SILS with conventional
3-port laparoscopic appendectomy, advantages in cosmetic outcomes were at the cost of longer
operation times and substantial early postoperative pain.123 Oltmann and colleagues128 reported
that SILS with appendectomy is feasible and safe in the pediatric population. Although operating
times were longer than the conventional 3-port laparoscopic appendectomy, the authors suggested
these should improve with better instrumentation and experience. St. Peter and colleagues127
reported on the only randomized control trial comparing SILS-assisted appendectomy to
conventional 3-port laparoscopic appendectomy in 160 children with nonperforated acute
appendicitis. Utilizing an extracorporeal appendectomy, there was a nonsignificant difference
in wound infection rates of 3.3% for SILS patients compared to 1.7% for conventional laparoscopy.
Although there was a statistically significant difference in operative time between the 2 approaches,
the SILS technique was only 5.4 minutes longer (29.8 7 11.6 vs 35.2 7 14.5 minutes).
The investigators suggested that the difference was not clinically relevant and both techniques
had comparable outcomes.
Clinical evidence that supports the laparoscopic approach for complicated (perforated or intra-
abdominal abscess) appendicitis remains controversial. The concern over greater incidence of intra-
abdominal abscess following the laparoscopic approach was reported in some studies129-131 but not
supported by others.110,113 Because of the increased morbidity associated with complicated disease,
some surgeons have opted for an initial nonoperative approach.127,132,133 Using nonoperative
treatment for complicated appendicitis followed by interval appendectomy obviates the need to
reservados.
manage the inflammatory environment in the acute stage. Such a strategy has been shown to be
successful in treating most of the cases of complicated appendicitis with shorter hospitalization,
lower charges, and lower morbidity.134,135
Pediatric Interval Appendectomy
Although early appendectomy remains the accepted conventional treatment for simple acute
appendicitis in adults and children, the treatment strategy for complicated disease, such as
perforated appendicitis and appendiceal mass, is controversial.134-138 With early appendectomy,
patients undergo an urgent appendectomy within the first 24 hours of hospitalization, and any intra-
abdominal abscess is drained during the operation. Alternatively, with interval appendectomy, the
appendectomy is planned for 6-8 weeks after the initial diagnosis, after the patient has been
discharged and is back to normal activity. Intra-abdominal abscesses are percutaneously drained,
if possible. Several retrospective studies have reported that interval appendectomy has shown
the benefits of reducing major complications, fewer wound infections, and shortening the
hospital stay, as well as decreasing the overall cost of treatment.68,134,135,139 The need and timing
for interval appendectomy at 2-3 months following initial medical management remains
unclear.132,134
Recent evidence has shown that acute appendicitis can be treated successfully nonoperatively in
adults and children.58,140-142 Two meta-analyses have demonstrated that conservative treatment
with antibiotics only is associated with a lower risk of complications without differences in length of
hospitalization.68,143 However, the success of initial nonoperative treatment of complicated
appendicitis has stimulated some surgeons to question the need for subsequent interval
appendectomy. Some have suggested that interval appendectomy is unnecessary.78,144,145 Others
support the need for interval appendectomy based on the risk of recurrent appendicitis.142,146
Conclusion
Appendectomy is one of the most common surgical procedures in children. Evolution of the
clinical practice in the treatment of acute appendicitis in children has resulted in an extremely low
mortality rate. As such, clinical research has focused on reduction in morbidity. Despite the
frequency of acute appendicitis in children, there remains a paucity of evidence-based treatment
guidelines and lack of consensus on treatment strategies.
Management of the Unanticipated Appendiceal Neoplasm
An unanticipated appendiceal neoplasm may be encountered at any elective or emergency

abdominal operation. It is estimated that nearly 50% of cases manifest as appendicitis, but variable
presentations have also been reported.147 The pathology and behavior of appendiceal neoplasms are
diverse, which only complicates the confusing classification and terminology.148 Increasingly, an
appendiceal neoplasm may be suspected on radiological cross-sectional imaging for diagnosis or
staging of abdominal disease. In a number of cases, an appendiceal neoplasm is discovered on
histopathologic analysis of an appendectomy specimen. Unfortunately, these factors lead to
diagnostic and therapeutic challenges, particularly for those surgeons who provide predominantly
emergency surgical services. The aim of this review is to summarize the incidence, classification,
presentation, and management of the common appendiceal neoplasms. Algorithms to assist
therapeutic decisions and management of unexpected appendiceal neoplasms will be discussed.
Appendiceal Neoplasms
Embryologically, the appendix arises as a small diverticulum of the cecum, and any neoplastic
pathology of the colon can occur in the appendix.149 Appendiceal neoplasms are thought to account
reservados.
TABLE 8
Classification of appendiceal neoplasms
Primary
Epithelial
Benign
Hyperplastic polyp and diffuse mucosal hyperplasia
Serrated adenoma
Colonic type adenomas
Malignant
Low-grade mucinous neoplasms
Adenocarcinoma or high-grade mucinous neoplasms
Nonepithelial
Carcinoid tumors
Classical carcinoid
Goblet cell carcinoids or adenocarcinoids
Mesenchymal tumors
GIST
Neuroma
Leiomyoma or sarcoma Kaposi’s sarcoma lymphoma
Secondary
Ovarian
Colonic
Rare, such as melanoma
GIST, gastrointestinal stromal tumor.

Reprinted with permission from Murphy et al.157
for 0.4%-1% of all gastrointestinal malignancies.150 Their clinical presentation is unpredictable, as

most manifest with appendicitis as a consequence of luminal obstruction. Some appendiceal lesions
are obvious at operation, but a number are found only on histopathologic analysis of appendectomy
specimens. In reports of several large series, appendiceal neoplasms were found in 0.7%-1.7%
of specimens.151
The classification of appendiceal neoplasms has been controversial.152-154 Although several
classifications have been suggested, lack of standard terminology for both benign and malignant
lesions has hampered valid comparisons between studies.155 Several investigators have proposed a
simple classification of epithelial appendiceal neoplasms.156,157 This classification schema includes
carcinoid neoplasms, resulting in an inclusive classification system for appendiceal neoplasms
(Table 8).
Nonepithelial Tumors of the Appendix
Carcinoid Tumors
Carcinoid tumors can arise from the neuroendocrine cells of any part of the gastrointestinal tract,
and are the most common primary neoplasm in the appendix.158,159 The annual incidence of
neuroendocrine tumors of the appendix is 0.16 per 100,000, with a comparable frequency in men
and women.160 Little is known about the epidemiology of these tumors and associated risk
factors.161 Appendiceal carcinoids are detected in 0.3%-0.9% of appendectomy specimens, and
commonly present as appendicitis (50% of cases) or as an incidental lesion at appendectomy,
laparotomy, or laparoscopy.162 A carcinoid of the appendix is most likely to be located in the tip or
distal third of the appendix, and is usually a small, round, well-demarcated, globular swelling.163,164
These features may help to identify an appendiceal tumor found at operation as a carcinoid and may
assist management decisions.
Small carcinoids of the appendix rarely metastasize, unlike those in other locations in the
gastrointestinal tract. Adverse prognostic features with an increased risk of metastasis include
tumors greater than 2 cm and meso-appendiceal extension.165 Most carcinoids are small and can be
reservados.
treated by simple appendectomy.166 There is agreement, however, that a right hemicolectomy

should be performed if carcinoids are larger than 2 cm or when there is involvement of the base of
the appendix or the mesoappendix.167 Data from the National Cancer Institute’s Surveillance,
Epidemiology and End Results (SEER) database from 1973-2004 demonstrated the distribution of
localized, regional, and distant disease to be 60%, 28%, and 12% respectively.160 However, data from
other sources have demonstrated higher 5-year survival rates (up to 94%) for those patients with
localized disease.168
Surgical therapy remains the only potentially curative treatment for well-differentiated carcinoid
tumors of the appendix. Small (o1 cm) carcinoid tumors confined to the tip of the appendix that are
completely excised can be considered cured if there is no evidence of lymphovascular invasion.
However, there are a few situations that require additional consideration. Approximately 10% of
patients will be found to have the base of the appendix involved with tumor. Most appendiceal
carcinoids are typically considered benign; however, deep invasion or regional metastases have been
reported among tumors 1-2 cm.167 Careful pathologic examination of the specimen is mandatory.
Epithelial Lesions of the Appendix
Malignant Epithelial Lesions
Malignant epithelial tumors of the appendix range from low-grade mucinous neoplasms to
invasive adenocarcinomas. This range incorporates a spectrum of disease, often difficult to classify
histopathologically, with only the clinical behavior over time truly defining the biologic nature of the
tumor. Ronnett and colleagues have classified appendiceal mucinous neoplasms into 3 groups:
disseminated peritoneal adenomucinosis, peritoneal mucinous carcinomatosis, and an intermediate
group.169,170 Others have classified mucinous neoplasms into low-grade mucinous neoplasms and
adenocarcinoma (high-grade neoplasms).171,172 In light of the difficulties regarding pathologic
classification and uncertain clinical behavior, it is recommended that all patients with an
appendiceal neoplasm be discussed at a multidisciplinary gastrointestinal oncology conference.
Low-Grade Mucinous Neoplasms
A variety of terms have been used to describe appendiceal mucinous lesions that are not frankly
malignant, including cystadenomas, mucinous tumor of unknown or uncertain potential,
disseminated peritoneal adenomucinosis, malignant mucocele, and ‘‘borderline’’ appendiceal
tumors.150,160 These tumors may spread in the peritoneal cavity, producing mucinous intraper-
itoneal ascites, resulting in pseudomyxoma peritonei (PMP).148,173 The precise etiology and
pathophysiology of PMP is a matter of some debate. Some suggest that mucinous material outside
the appendix, including mucin-producing cells, arises from a ruptured adenoma, and that only
if there is histologic evidence of infiltrative invasion should the condition be categorized as
‘‘adenocarcinoma.’’170,174,175 An alternate view considers any production of mucin by epithelium
outside the appendix to indicate a mucinous carcinoma, which may vary from low-grade to high-
grade mucinous adenocarcinoma.176
Many institutions use the term ‘‘low-grade mucinous neoplasm’’ to describe lesions with scant
mucinous epithelium that demonstrate varying degrees of cellular atypia in conjunction with
extracellular mucin accumulation.156 Some cases show evidence of extra-appendiceal mucin with
or without obvious rupture of the appendix. These lesions often present with acute appendicitis or a
right lower quadrant mass.177,178 Others present with abdominal swelling secondary to mucin, or
mucin in a hernia sac.179,180 (Fig 11). Many cases are incidental findings at laparotomy, laparoscopy,
or other radiologic imaging.181 The prognosis of these neoplasms is dependent upon whether they
have perforated and whether mucin and epithelial cells are present outside the appendix.182,183
Perforated low-grade mucinous neoplasms with extra-appendiceal mucin almost inevitably
result in PMP, although this phenomenon may take several years to manifest clinically. Such
reservados.
FFS
R L
RD: 380
Tilt: 0 Z: 1
mA : 487 C : 50
KVp: 120 W: 400
A cq no: 1 DFO V :38x38cm
FIG 11. CT scan demonstrating mucocoele (identified by arrow) in right lower quadrant.
perforated tumors are best treated with macroscopic tumor removal (cytoreduction) combined with
an intraperitoneal chemotherapy regimen.184-187 The rationale for this intensive treatment is based
on the likely pathophysiology of PMP. As an appendiceal adenoma enlarges and occludes the
appendiceal lumen, it leads to distention with mucinous tumor cells and mucus. Eventually,
perforation occurs as the primary lesion continues to grow slowly, but due to appendiceal rupture
epithelial cells within the peritoneal cavity also proliferate and produce large quantities of mucus.
Due to the rarity of mucoceles and mucinous appendiceal neoplasms, the epidemiology of PMP is
not well understood. A recent population-based study from The Netherlands examined 167,744
appendectomy specimens.188 A mucocele or epithelial neoplasm was identified in 1482 patients
(0.9%). A benign lesion (including mucocele) was found in 1 of every 150 appendices (0.7%) and
malignancy in 1 of every 460 appendices (0.2%). One of every 163 resected appendices (0.6%)
contained an epithelial neoplasm: 56% mucinous and 44% nonmucinous. The mucinous epithelial
neoplasms were benign in 73% and malignant in 27%, whereas this distribution was 53% vs 47% for
the nonmucinous epithelial neoplasms. One of 11 patients (9%) with a primary epithelial
appendiceal lesion (including mucocele) developed PMP. The chance of developing PMP was
significantly higher in patients with a mucinous epithelial neoplasm (20%) as compared with
patients with either a mucocele (2%) or a nonmucinous epithelial neoplasm (3%) (P o 0.001).
Appendiceal Adenocarcinoma
Appendiceal adenocarcinomas are rare, with reported incidences varying from 0.08%–0.1% of all
appendectomies.189 These patients usually present with right lower quadrant pain or an abdomino-
pelvic mass, and up to 88% may present with symptoms consistent with appendicitis.190 The extent
of disease may be such that an appendiceal primary is impossible to confirm or exclude even at
laparotomy or autopsy, and extensive investigations are frequently inappropriate with such
advanced disease. Reported series of appendiceal adenocarcinoma are difficult to compare, as
terminology and classification of these lesions have not been consistent.191 Adenocarcinoma of the
appendix has traditionally been treated by right hemicolectomy, with improved survival in patients
undergoing right hemicolectomy compared with appendectomy alone.192,193
Incidental Finding at Operation
An appendiceal tumor may be encountered during an operation for appendicitis or an abnormal

appendix may be noted incidentally, during an open or laparoscopic procedure (see algorithm in
reservados.
Tumor identified
during operation
Yes
No
Tumor<2cm Right hemicolectomy
Yes
Base of No
appendix/meso- Right hemicolectomy
appendix univolved
Yes
No
Evidence of Appendectomy+
perforation tissue biopsy
Yes
No
Evidence of peritoneal Appendectomy+
mucin/mucinous ascites tissue biopsy
Yes
If appendectomy not
possible, tissue biopsy,
peritoneal lavage
FIG 12. Algorithm for the management of unanticipated appendiceal tumors.
Fig 12). Initial assessment of the appendiceal tumor should include noting its size and identifying
features typical of one of the more common appendiceal neoplasms (solid vs cystic consistency).
In addition, inspection and palpation of the appendiceal base and mesoappendix, as well as
an assessment of whether or not the appendix is perforated, provides additional critical
information.
The operating surgeon should look carefully for evidence of extra-appendiceal disease, such
as mucin (which should always be sent for cytologic analysis), local lymphadenopathy, or
obvious disseminated metastatic spread. Sites of possible primary disease (including the ovaries in
female patients) and synchronous colorectal malignancies should also be sought. Laparoscopy
facilitates an examination of the peritoneal cavity, although it lacks the tactile input achievable at
laparotomy.194
If the tumor is confined to the appendix, smaller than 2 cm, without evidence of meso-
appendiceal involvement, and not involving the base of the appendix, appendectomy is appropriate
treatment.195 Rarely will definitive pathology require further surgical intervention. The evidence
examining the role of laparoscopic appendectomy for the resection of these neoplasms is limited. If
there is concern at laparoscopy, particularly if an appendiceal neoplasm is greater than 2 cm, the
procedure should be converted to a standard laparotomy.196 Midline ports should be considered
because these locations facilitate a much easier excision should a secondary procedure be performed
at a later date. Extreme care should be taken to ensure the mesoappendix is resected satisfactorily
and that there is an extensive washout of the peritoneal cavity and surgical wounds.
It is of critical importance that appendiceal neoplasms are removed intact. This can be
challenging with a large mucin-filled appendix, and may require a larger incision or conversion to
an open operation. If the appendix has ruptured just before removal or during the operation,
it is important to remove all free mucin and perform a thorough peritoneal lavage. Such patients,
and those who present with a perforated mucinous neoplasm, without evidence of any
extra-appendiceal spread, are at risk of developing PMP and require careful postoperative
surveillance. An initial CT scan of the abdomen and pelvis as well as the following tumor markers
provides baseline measurements: carcinoembryonic antigen, cancer antigen CA-125, and
CA-19-9.
reservados.
References
1. DeFrances CJ, Cullen KA, Kozak LJ. National Hospital Discharge Survey: 2005 annual summary with detailed diagnosis
and procedure data. Vital and health statistics Series 13, Data from the National Health Survey. 2007:1-209.
2. Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg.
2002;137:799–804. [discussion].
3. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults
and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect.
2010;11:79–109.
4. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91:28–37.
5. Halkin A, Reichman J, Schwaber M, Paltiel O, Brezis M. Likelihood ratios: getting diagnostic testing into perspective. QJM.
1998;91:247–258.
6. Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? J Am Med Assoc.
2007;298:438–451.
7. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? J Am Med Assoc. 1996;276:1589–1594.
8. Yen K, Karpas A, Pinkerton HJ, Gorelick MH. Interexaminer reliability in physical examination of pediatric patients with
abdominal pain. Arch Pediatr Adolesc Med. 2005;159:373–376.
9. Kharbanda AB, Fishman SJ, Bachur RG. Comparison of pediatric emergency physicians’ and surgeons’ evaluation and
diagnosis of appendicitis. Acad Emerg Med. 2008;15:119–125.
10. Sack U, Biereder B, Elouahidi T, Bauer K, Keller T, Trobs RB. Diagnostic value of blood inflammatory markers for detection
of acute appendicitis in children. BMC Surg. 2006;6:15.
11. Allister L, Bachur R, Glickman J, Horwitz B. Serum markers in acute appendicitis. J Surg Res. 2011;168:70–75.
12. Thuijls G, Derikx JP, Prakken FJ, et al. A pilot study on potential new plasma markers for diagnosis of acute appendicitis.
Am J Emerg Med. 2011;29:256–260.
13. Kentsis A, Lin YY, Kurek K, et al. Discovery and validation of urine markers of acute pediatric appendicitis using high-
accuracy mass spectrometry. Ann Emerg Med. 2010;55:62–70. [e4].
14. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15:557–564.
15. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002;37:877–881.
16. Kharbanda AB, Taylor GA, Fishman SJ, Bachur RG. A clinical decision rule to identify children at low risk for appendicitis.
Pediatrics. 2005;116:709–716.
17. Lintula H, Kokki H, Pulkkinen J, Kettunen R, Grohn O, Eskelinen M. Diagnostic score in acute appendicitis. Validation of a
diagnostic score (Lintula score) for adults with suspected appendicitis. Langenbecks Arch Surg. 2010;395:495–500.
18. Lintula H, Kokki H, Kettunen R, Eskelinen M. Appendicitis score for children with suspected appendicitis. A randomized
clinical trial. Langenbecks Arch Surg. 2009;394:999–1004.
19. Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M. A diagnostic score for children with suspected appendicitis.
Langenbecks Arch Surg. 2005;390:164–170.
20. Rezak A, Abbas HM, Ajemian MS, Dudrick SJ, Kwasnik EM. Decreased use of computed tomography with a modified
clinical scoring system in diagnosis of pediatric acute appendicitis. Arch Surg. 2011;146:64–67.
21. Farahnak M, Talaei-Khoei M, Gorouhi F, Jalali A. 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;25:850–852.
22. Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll
Surg. 2005;201:933–939.
23. Flum DR, Cuschieri J, Florence M, et al. Letter regarding negative appendectomy and imaging accuracy in the
Washington State Surgical Care and Outcomes Assessment Program. Ann Surg. 2009;249:699–700.
24. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:
2277–2284.
25. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-
analysis. Radiology. 2006;241:83–94.
26. Hlibczuk V, Dattaro JA, Jin Z, Falzon L, Brown MD. Diagnostic accuracy of noncontrast computed tomography for
appendicitis in adults: a systematic review. Ann Emerg Med. 2010;55:51–59. [e1].
27. Solomkin JS. Evaluating evidence and grading recommendations: the SIS/IDSA guidelines for the treatment of
complicated intra-abdominal infections. Surg Infect. 2010;11:269–274.
28. Krajewski S, Brown J, Phang PT, Raval M, Brown CJ. Impact of computed tomography of the abdomen on clinical
outcomes in patients with acute right lower quadrant pain: a meta-analysis. Can J Surg. 2011;54:43–53.
29. Lee CC, Golub R, Singer AJ, Cantu Jr R, Levinson H. Routine versus selective abdominal computed tomography scan in the
evaluation of right lower quadrant pain: a randomized controlled trial. Acad Emerg Med. 2007;14:117–122.
30. Walker S, Haun W, Clark J, McMillin K, Zeren F, Gilliland T. The value of limited computed tomography with rectal
contrast in the diagnosis of acute appendicitis. Am J Surg. 2000;180:450–454. [discussion 4-5].
31. Hong JJ, Cohn SM, Ekeh AP, Newman M, Salama M, Leblang SD. A prospective randomized study of clinical assessment
versus computed tomography for the diagnosis of acute appendicitis. Surg Infect. 2003;4:231–239.
32. Lopez PP, Cohn SM, Popkin CA, Jackowski J, Michalek JE. The use of a computed tomography scan to rule out appendicitis
in women of childbearing age is as accurate as clinical examination: a prospective randomized trial. Am Surg. 2007;73:
1232–1236.
33. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A population-based
analysis. J Am Med Assoc. 2001;286:1748–1753.
34. Cuschieri J, Florence M, Flum DR, et al. Negative appendectomy and imaging accuracy in the Washington State Surgical
Care and Outcomes Assessment Program. Ann Surg. 2008;248:557–563.
reservados.
35. Williams R.F., Blakely M.L., Fischer P.E., et al. Diagnosing ruptured appendicitis preoperatively in pediatric patients. J Am
Coll Surg. 2009;208: 819-825; [discussion 26-8].
36. Murphy CG, Glickman JN, Tomczak K, et al. Acute appendicitis is characterized by a uniform and highly selective pattern
of inflammatory gene expression. Mucosal Immunol. 2008;1:297–308.
37. Muenzer JT, Jaffe DM, Schwulst SJ, et al. Evidence for a novel blood RNA diagnostic for pediatric appendicitis: the
riboleukogram. Pediatr Emerg Care. 2010;26:333–338.
38. Burford JM, Dassinger MS, Smith SD. Surgeon-performed ultrasound as a diagnostic tool in appendicitis. J Pediatr Surg.
2011;46:1115–1120.
39. Leeuwenburgh MM, Lameris W, van Randen A, Bossuyt PM, Boermeester MA, Stoker J. Optimizing imaging in suspected
appendicitis (OPTIMAP-study): a multicenter diagnostic accuracy study of MRI in patients with suspected acute
appendicitis. Study Protocol. BMC Emerg Med. 2010;10:19.
40. Kim S.Y., Lee K.H., Kim K., et al. Acute appendicitis in young adults: low- versus standard-radiation-dose contrast-
enhanced abdominal CT for diagnosis. Radiology. 2011;260:437–445.
41. Hsieh CH, Lu RH, Lee NH, Chiu WT, Hsu MH, Li YC. Novel solutions for an old disease: diagnosis of acute appendicitis
with random forest, support vector machines, and artificial neural networks. Surgery. 2011;149:87–93.
42. DeFrances CJ, Podgornik MN. 2004 National Hospital Discharge Survey. Advance Data. 2006:1-19.
43. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States.
Am J Epidemiol. 1990;132:910–925.
44. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. N Y Med J.
1889;50:676–684.
45. Tingstedt B, Johansson J, Nehez L, Andersson R. Late abdominal complaints after appendectomy—readmissions during
long-term follow-up. Dig Surg. 2004;21:23–27.
46. Simpson J, Samaraweera AP, Sara RK, Lobo DN. Acute appendicitis—a benign disease? Ann R Coll Surg Engl. 2008;90:
313–316.
47. Rao PM, Rhea JT, Rattner DW, Venus LG, Novelline RA. Introduction of appendiceal CT: impact on negative
appendectomy and appendiceal perforation rates. Ann Surg. 1999;229:344–349.
48. Coursey CA, Nelson RC, Patel MB, et al. Making the diagnosis of acute appendicitis: do more preoperative CT scans mean
fewer negative appendectomies? A 10-year study. Radiology. 2010;254:460–468.
49. Mason RJ. Surgery for appendicitis: is it necessary? Surg Infect. 2008;9:481–488.
50. Eriksson S, Granstrom L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute
appendicitis. Br J Surg. 1995;82:166–169.
51. Winn RD, Laura S, Douglas C, Davidson P, Gani JS. Protocol-based approach to suspected appendicitis, incorporating the
Alvarado score and outpatient antibiotics. ANZ J Surg. 2004;74:324–329.
52. Petrosyan M, Estrada J, Chan S, et al. CT scan in patients with suspected appendicitis: clinical implications for the acute
care surgeon. Eur Surg Res. 2008;40:211–219.
53. Decadt B, Sussman L, Lewis MP, et al. Randomized clinical trial of early laparoscopy in the management of acute non-
specific abdominal pain. Br J Surg. 1999;86:1383–1386.
54. Andersson R, Hugander A, Thulin A, Nystrom PO, Olaison G. Indications for operation in suspected appendicitis and
incidence of perforation. Br Med J. 1994;308:107–110.
55. Howie JG. Too few appendicectomies?. Lancet. 1964;1:1240–1242.
56. 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;25:850–852.
57. Malik AA, Bari SU. Conservative management of acute appendicitis. J Gastrointest Surg. 2009;13:966–970.
58. 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;30:1033–1037.
59. Hansson J, Korner 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;96:473–481.
60. Shindoh J, Niwa H, Kawai K, et al. Predictive factors for negative outcomes in initial non-operative management of
suspected appendicitis. J Gastrointest Surg. 2010;14:309–314.
61. Buckius MT, McGrath B, Monk J, Grim R, Bell T, Ahuja V. Changing epidemiology of acute appendicitis in the United
States: study period 1993-2008. J Surg Res. 2012;175:185–190.
62. Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass—is it necessary?
Surgeon. 2007;5:45–50.
63. Puapong D, Lee SL, Haigh PI, Kaminski A, Liu IL, Applebaum H. Routine interval appendectomy in children is not
indicated. J Pediatr Surg. 2007;42:1500–1503.
64. Tekin A, Kurtoglu HC, Can I, Oztan S. Routine interval appendectomy is unnecessary after conservative treatment of
appendiceal mass. Colorectal Dis. 2008;10:465–468.
65. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-
analysis. Ann Surg. 2007;246:741–748.
66. Lugo JZ, Avgerinos DV, Lefkowitz AJ, et al. Can interval appendectomy be justified following conservative treatment of
perforated acute appendicitis? J Surg Res. 2010;164:91–94.
67. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-
analysis. Ann Surg. 2007;246:741–748.
68. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute
appendectomy for complicated appendicitis (abscess or phlegmon). Surgery. 2010;147:818–829.
69. Schietroma M, Piccione F, Carlei F, et al. Peritonitis from perforated appendicitis: stress response after laparoscopic or
open treatment. Am Surg. 2012;78:582–590.
reservados.
70. St Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy versus initial nonoperative management and
interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg.
2010;45:236–240.
71. Kang KJ, Lim TJ, Kim YS. Laparoscopic appendectomy is feasible for the complicated appendicitis. Surg Laparosc Endosc
Percutan Tech. 2000;10:364–367.
72. Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic versus open appendectomy for complicated appendicitis.
J Am Coll Surg. 2007;205:60–65.
73. Goh BK, Chui CH, Yap TL, et al. Is early laparoscopic appendectomy feasible in children with acute appendicitis
presenting with an appendiceal mass? A prospective study. J Pediatr Surg. 2005;40:1134–1137.
74. Senapathi PS, Bhattacharya D, Ammori BJ. Early laparoscopic appendectomy for appendicular mass. Surg Endosc.
2002;16:1783–1785.
75. Cash C, Frazee R. Improvements in laparoscopic treatment for complicated appendicitis. J Laparoendosc Adv Surg Tech A.
2012;22:581–583.
76. Gupta R, Sample C, Bamehriz F, Birch DW. Infectious complications following laparoscopic appendectomy. Can J Surg.
2006;49:397–400.
77. Ahmed I, Deakin D, Parsons SL. Appendix mass: do we know how to treat it? Ann R Coll Surg Engl. 2005;87:191–195.
78. Hall NJ, Jones CE, Eaton S, Stanton MP, Burge DM. Is interval appendicectomy justified after successful nonoperative
treatment of an appendix mass in children? A systematic review. J Pediatr Surg. 2011;46:767–771.
79. Ein SH, Langer JC, Daneman A. Nonoperative management of pediatric ruptured appendix with inflammatory mass or
abscess: presence of an appendicolith predicts recurrent appendicitis. J Pediatr Surg. 2005;40:1612–1615.
80. Raval MV, Lautz T, Reynolds M, Browne M. Dollars and sense of interval appendectomy in children: a cost analysis.
J Pediatr Surg. 2010;45:1817–1825.
81. HCUP-US KID Overview.
82. Blakely ML, Williams R, Dassinger MS, et al. Early vs interval appendectomy for children with perforated appendicitis.
Arch Surg. 2011;146:660–665.
83. St Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy versus initial nonoperative management and
interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg.
2010;45:236–240.
84. Semm K. Endoscopic appendectomy. Endoscopy. 1983;15:59–64.
85. Meeks DW, Kao LS. Controversies in appendicitis. Surg Infect. 2008;9:553–558.
86. Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, Esposito TJ. Comparison of outcomes after laparoscopic versus
open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals. Surgery. 2010;148:625–635. [discussion 35-7].
87. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane
Database Syst Rev. 2010;10:CD001546.
88. Guthery SL, Hutchings C, Dean JM, Hoff C. National estimates of hospital utilization by children with gastrointestinal
disorders: analysis of the 1997 kids’ inpatient database. J Pediatr. 2004;144:589–594.
89. Popovic JR. 1999 National Hospital Discharge Survey: annual summary with detailed diagnosis and procedure data.
Vital and health statistics Series 13. Data from the National Health Survey. 2001;i-v:1-206.
90. Brender JD, Marcuse EK, Weiss NS, Koepsell TD. Is childhood appendicitis familial? Am J Dis Child. 1985;139:338–340.
91. Gauderer MW, Crane MM, Green JA, DeCou JM, Abrams RS. Acute appendicitis in children: the importance of family
history. J Pediatr Surg. 2001;36:1214–1217.
92. Pledger HG, Fahy LT, van Mourik GA, Bush GH. Deaths in children with a diagnosis of acute appendicitis in England and
Wales 1980-4. Br Med J (Clin Res Ed). 1987;295:1233–1235.
93. Ponsky TA, Huang ZJ, Kittle K, et al. Hospital- and patient-level characteristics and the risk of appendiceal rupture and
negative appendectomy in children. J Am Med Assoc. 2004;292:1977–1982.
94. Dilley A, Wesson D, Munden M, et al. The impact of ultrasound examinations on the management of children with
suspected appendicitis: a 3-year analysis. J Pediatr Surg. 2001;36:303–308.
95. Newman K, Ponsky T, Kittle K, et al. Appendicitis 2000: variability in practice, outcomes, and resource utilization at
thirty pediatric hospitals. J Pediatr Surg. 2003;38:372–379. [discussion-9].
96. Toki A, Ogura K, Horimi T, et al. Peritoneal lavage versus drainage for perforated appendicitis in children. Surg Today.
1995;25:207–210.
97. Cervantes-Sanchez CR, Gutierrez-Vega R, Vazquez-Carpizo JA, Clark P, Athie-Gutierrez C. Syringe pressure irrigation of
subdermic tissue after appendectomy to decrease the incidence of postoperative wound infection. World J Surg.
2000;24:38–41. [discussion-2].
98. Thomson SR, Carle G, Reid TM, Davidson AI, Miller SS. Antibiotic prophylaxis in non-perforated appendicitis of
childhood: tetracycline lavage compared with peroperative intravenous cefuroxime and metronidazole. J Hosp Infect.
1987;9:158–161.
99. St Peter SD, Tsao K, Spilde TL, et al. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic
regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008;43:981–985.
100. McBurney IV C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of
operating. Ann Surg. 1894;20:38–43.
101. Valla JS, Limonne B, Valla V, et al. Laparoscopic appendectomy in children: report of 465 cases. Surg Laparosc Endosc.
1991;1:166–172.
102. Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B. A prospective, randomized comparison of laparoscopic
appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group. Am J Surg. 1995;169:
208–212. [discussion 12-3].
103. Hay SA. Laparoscopic versus conventional appendectomy in children. Pediatr Surg Int. 1998;13:21–23.
104. Golub R, Siddiqui F, Pohl D. Laparoscopic versus open appendectomy: a metaanalysis. J Am Coll Surg. 1998;186:545–553.
105. el Ghoneimi A, Valla JS, Limonne B, et al. Laparoscopic appendectomy in children: report of 1,379 cases. J Pediatr Surg.
1994;29:786–789.
reservados.
106. Chung RS, Rowland DY. Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia
repairs. Surg Endosc. 1999;13:689–694.
107. Ostlie DJ. Single-site umbilical laparoscopic appendectomy. Semin Pediatr Surg. 2011;20:196–200.
108. Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: a survey of North American
Pediatric Surgeons. J Pediatr Surg. 2004;39:875–879. [discussion-9].
109. Sauerland S., Lefering R., Neugebauer E.A. Laparoscopic versus open surgery for suspected appendicitis. Cochrane
Database Syst Rev. 2002:CD001546.
110. Meguerditchian AN, Prasil P, Cloutier R, Leclerc S, Peloquin J, Roy G. Laparoscopic appendectomy in children: a favorable
alternative in simple and complicated appendicitis. J Pediatr Surg. 2002;37:695–698.
111. Kokoska ER, Murayama KM, Silen ML, Miller TA, Dillon PA, Weber TR. A state-wide evaluation of appendectomy in
children. Am J Surg. 1999;178:537–540.
112. Gilchrist BF, Lobe TE, Schropp KP, et al. Is there a role for laparoscopic appendectomy in pediatric surgery? J Pediatr Surg.
1992;27:209–212. [discussion 12-4].
113. Canty Sr. TG, Collins D, Losasso B, Lynch F, Brown C. Laparoscopic appendectomy for simple and perforated appendicitis
in children: the procedure of choice? J Pediatr Surg. 2000;35:1582–1585.
114. Kellnar S, Trammer A, Till H, Lochbuhler H. Endoscopic appendectomy in childhood—technical aspects. Eur J Pediatr
Surg. 1994;4:341–343.
115. Mohsen AA. Endocoagulator control of the mesoappendix for laparoscopic appendectomy. J Laparoendosc Surg. 1994;4:
435–440.
116. Pelosi MA, Pelosi 3rd MA. Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). J Reprod
Med. 1992;37:588–594.
117. Valla J, Ordorica-Flores RM, Steyaert H, et al. Umbilical one-puncture laparoscopic-assisted appendectomy in children.
Surg Endosc. 1999;13:83–85.
118. Tam YH, Lee KH, Sihoe JD, Chan KW, Cheung ST, Pang KK. Initial experience in children using conventional laparoscopic
instruments in single-incision laparoscopic surgery. J Pediatr Surg. 2010;45:2381–2385.
119. Ponsky TA, Diluciano J, Chwals W, Parry R, Boulanger S. Early experience with single-port laparoscopic surgery in
children. J Laparoendosc Adv Surg Tech A. 2009;19:551–553.
120. Muensterer OJ, Puga Nougues C, Adibe OO, Amin SR, Georgeson KE, Harmon CM. Appendectomy using single-incision
pediatric endosurgery for acute and perforated appendicitis. Surg Endosc. 2010;24:3201–3204.
121. Garey CL, Laituri CA, Ostlie St DJ, Peter SD. A review of single site minimally invasive surgery in infants and children.
Pediatr Surg Int. 2010;26:451–456.
122. Visnjic S. Transumbilical laparoscopically assisted appendectomy in children: high-tech low-budget surgery. Surg
Endosc. 2008;22:1667–1671.
123. Vidal O, Valentini M, Ginesta C, et al. Laparoendoscopic single-site surgery appendectomy. Surg Endosc. 2010;24:
686–691.
124. Sesia SB, Haecker FM, Kubiak R, Mayr J. Laparoscopy-assisted single-port appendectomy in children: is the postoperative
infectious complication rate different? J Laparoendosc Adv Surg Tech A. 2010;20:867–871.
125. Kossi J, Luostarinen M. Initial experience of the feasibility of single-incision laparoscopic appendectomy in different
clinical conditions. Diagn Ther Endosc. 2010;2010:240260.
126. Chandler NM, Danielson PD. Single-incision laparoscopic appendectomy vs multiport laparoscopic appendectomy in
children: a retrospective comparison. J Pediatr Surg. 2010;45:2186–2190.
127. St Peter SD, Adibe OO, Juang D, et al. Single incision versus standard 3-port laparoscopic appendectomy: a prospective
randomized trial. Ann Surg. 2011;254:586–590.
128. Oltmann SC, Garcia NM, Ventura B, Mitchell I, Fischer AC. Single-incision laparoscopic surgery: feasibility for pediatric
appendectomies. J Pediatr Surg. 2010;45:1208–1212.
129. Tang E, Ortega AE, Anthone GJ, Beart Jr. RW. Intraabdominal abscesses following laparoscopic and open appendectomies.
Surg Endosc. 1996;10:327–328.
130. Krisher SL, Browne A, Dibbins A, Tkacz N, Curci M. Intra-abdominal abscess after laparoscopic appendectomy for
perforated appendicitis. Arch Surg. 2001;136:438–441.
131. Horwitz JR, Custer MD, May BH, Mehall JR, Lally KP. Should laparoscopic appendectomy be avoided for complicated
appendicitis in children? J Pediatr Surg. 1997;32:1601–1603.
132. Oliak D, Yamini D, Udani VM, et al. Nonoperative management of perforated appendicitis without periappendiceal mass.
Am J Surg. 2000;179:177–181.
133. Blakely ML, Williams R, Dassinger MS, et al. Early vs interval appendectomy for children with perforated appendicitis.
Arch Surg. 2011;146:660–665.
134. 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;36:165–168.
135. Bufo AJ, Shah RS, Li MH, et al. Interval appendectomy for perforated appendicitis in children. J Laparoendosc Adv Surg
Tech A. 1998;8:209–214.
136. Vakili C. Operative treatment of appendix mass. Am J Surg. 1976;131:312–314.
137. Samuel M, Hosie G, Holmes K. Prospective evaluation of nonsurgical versus surgical management of appendiceal mass.
J Pediatr Surg. 2002;37:882–886.
138. Samelson SL, Reyes HM. Management of perforated appendicitis in children—revisited. Arch Surg. 1987;122:691–696.
139. Vane DW, Fernandez N. Role of interval appendectomy in the management of complicated appendicitis in children.
World J Surg. 2006;30:51–54.
140. Emil S, Duong S. Antibiotic therapy and interval appendectomy for perforated appendicitis in children: a selective
approach. Am Surg. 2007;73:917–922.
141. Hansson J, Korner 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;96:473–481.
reservados.
142. Ho CM, Chen Y, Lai HS, Lin WH, Hsu WM, Chen WJ. Comparison of critical conservative treatment versus emergency
operation in children with ruptured appendicitis with tumor formation. J Formos Med Assoc. 2004;103:359–363.
143. Varadhan KK, Humes DJ, Neal KR, Lobo DN. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-
analysis. World J Surg. 2010;34:199–209.
144. Kaminski A, Liu IL, Applebaum H, Lee SL, Haigh PI. Routine interval appendectomy is not justified after initial
nonoperative treatment of acute appendicitis. Arch Surg. 2005;140:897–901.
145. Puapong D, Lee SL, Haigh PI, Kaminski A, Liu IL, Applebaum H. Routine interval appendectomy in children is not
indicated. J Pediatr Surg. 2007;42:1500–1503.
146. Mazziotti MV, Marley EF, Winthrop AL, Fitzgerald PG, Walton M, Langer JC. Histopathologic analysis of interval
appendectomy specimens: support for the role of interval appendectomy. J Pediatr Surg. 1997;32:806–809.
147. Connor SJ, Hanna GB, Frizelle FA. Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors
from 7,970 appendectomies. Dis Colon Rectum. 1998;41:75–80.
148. Misdraji J. Appendiceal mucinous neoplasms: controversial issues. Arch Pathol Lab Med. 2010;134:864–870.
149. Schumpelick V, Dreuw B, Ophoff K, Prescher A. Appendix and cecum. Embryology, anatomy, and surgical applications.
Surg Clin North Am. 2000;80:295–318.
150. Deans GT, Spence RA. Neoplastic lesions of the appendix. Br J Surg. 1995;82:299–306.
151. Bucher P, Mathe Z, Demirag A, Morel P. Appendix tumors in the era of laparoscopic appendectomy. Surg Endosc.
2004;18:1063–1066.
152. Ellis L, Shale MJ, Coleman MP. Carcinoid tumors of the gastrointestinal tract: trends in incidence in England since 1971.
Am J Gastroenterol. 2010;105:2563–2569.
153. Low RN, Barone RM, Gurney JM, Muller WD. Mucinous appendiceal neoplasms: preoperative MR staging and
classification compared with surgical and histopathologic findings. AJR Am J Roentgenol. 2008;190:656–665.
154. Pai RK, Beck AH, Norton JA, Longacre TA. Appendiceal mucinous neoplasms: clinicopathologic study of 116 cases with
analysis of factors predicting recurrence. Am J Surg Pathol. 2009;33:1425–1439.
155. Carr NJ, Sobin LH. Epithelial noncarcinoid tumors and tumor-like lesions of the appendix. Cancer. 1995;76:2383–2384.
156. Misdraji J, Yantiss RK, Graeme-Cook FM, Balis UJ, Young RH. Appendiceal mucinous neoplasms: a clinicopathologic
analysis of 107 cases. Am J Surg Pathol. 2003;27:1089–1103.
157. Murphy EM, Farquharson SM, Moran BJ. Management of an unexpected appendiceal neoplasm. Br J Surg. 2006;93:
783–792.
158. Moertel CL, Weiland LH, Telander RL. Carcinoid tumor of the appendix in the first two decades of life. J Pediatr Surg.
1990;25:1073–1075.
159. Moertel CG, Sauer WG, Dockerty MB, Baggenstoss AH. Life history of the carcinoid tumor of the small intestine. Cancer.
1961;14:901–912.
160. Yao JC, Hassan M, Phan A, et al. One hundred years after ’’carcinoid’’: epidemiology of and prognostic factors for
neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008;26:3063–3072.
161. Hassan MM, Phan A, Li D, Dagohoy CG, Leary C, Yao JC. Risk factors associated with neuroendocrine tumors: A U.S.-based
case-control study. Int J Cancer. 2008;123:867–873.
162. Roggo A, Wood WC, Ottinger LW. Carcinoid tumors of the appendix. Ann Surg. 1993;217:385–390.
163. Moertel CG, Weiland LH, Nagorney DM, Dockerty MB. Carcinoid tumor of the appendix: treatment and prognosis. N Engl
J Med. 1987;317:1699–1701.
164. Moertel CG, Dockerty MB, Judd ES. Carcinoid tumors of the vermiform appendix. Cancer. 1968;21:270–278.
165. Groth SS, Virnig BA, Al-Refaie WB, Jarosek SL, Jensen EH, Tuttle TM. Appendiceal carcinoid tumors: predictors of lymph
node metastasis and the impact of right hemicolectomy on survival. J Surg Oncol. 2011;103:39–45.
166. Gouzi JL, Laigneau P, Delalande JP, et al. Indications for right hemicolectomy in carcinoid tumors of the appendix. The
French Associations for Surgical Research. Surg Gynecol Obstet. 1993;176:543–547.
167. Boudreaux JP, Klimstra DS, Hassan MM, et al. The NANETS consensus guideline for the diagnosis and management of
neuroendocrine tumors: well-differentiated neuroendocrine tumors of the jejunum, ileum, appendix, and cecum.
Pancreas. 2010;39:753–766.
168. McGory ML, Maggard MA, Kang H, O’Connell JB, Ko CY. Malignancies of the appendix: beyond case series reports. Dis
Colon Rectum. 2005;48:2264–2271.
169. Ronnett BM, Zahn CM, Kurman RJ, Kass ME, Sugarbaker PH, Shmookler BM. Disseminated peritoneal adenomucinosis
and peritoneal mucinous carcinomatosis. A clinicopathologic analysis of 109 cases with emphasis on distinguishing
pathologic features, site of origin, prognosis, and relationship to ’’pseudomyxoma peritonei’’. Am J Surg Pathol. 1995;19:
1390–1408.
170. Ronnett BM, Yan H, Kurman RJ, Shmookler BM, Wu L, Sugarbaker PH. Patients with pseudomyxoma peritonei associated
with disseminated peritoneal adenomucinosis have a significantly more favorable prognosis than patients with
peritoneal mucinous carcinomatosis. Cancer. 2001;92:85–91.
171. Miner TJ, Shia J, Jaques DP, Klimstra DS, Brennan MF, Coit DG. Long-term survival following treatment of
pseudomyxoma peritonei: an analysis of surgical therapy. Ann Surg. 2005;241:300–308.
172. Moran BJ, Cecil TD. The etiology, clinical presentation, and management of pseudomyxoma peritonei. Surg Oncol Clin N
Am. 2003;12:585–603.
173. Wells Jr SA. One of the most difficult management problems in surgery is pseudomyxoma peritonei. Foreword. Curr
Probl Surg. 2008;45:521.
174. Rao P, Pinheiro Jr. N, Franco M, et al. Pseudomyxoma peritonei associated with primary mucinous borderline tumor of
the renal pelvicalyceal system. Arch Pathol Lab Med. 2009;133:1472–1476.
175. Ardavanis A, Sykoutri D, Kountourakis P, et al. Paraneoplastic cerebellar degeneration in a patient with pseudomyxoma
peritonei and breast cancer: case report and literature review. In Vivo. 2009;23:835–838.
176. Winder T, Lenz HJ. Mucinous adenocarcinomas with intra-abdominal dissemination: a review of current therapy.
Oncologist. 2010;15:836–844.
177. Bevan KE, Mohamed F, Moran BJ. Pseudomyxoma peritonei. World J Gastrointest Oncol. 2010;2:44–50.
reservados.
178. Esquivel J, Sugarbaker PH. Clinical presentation of the Pseudomyxoma peritonei syndrome. Br J Surg. 2000;87:
1414–1418.
179. Sugarbaker PH. The natural history, gross pathology, and histopathology of appendiceal epithelial neoplasms. Eur J Surg
Oncol. 2006;32:644–647.
180. Sugarbaker PH. Epithelial appendiceal neoplasms. Cancer J. 2009;15:225–235.
181. Abdu B, Hobgood D, Stallings S, Depasquale S. Incidental finding of pseudomyxoma peritonei at primary cesarean
section. Am J Perinatol. 2009;26:633–635.
182. Baratti D, Kusamura S, Nonaka D, Cabras AD, Laterza B, Deraco M. Pseudomyxoma peritonei: biological features are the
dominant prognostic determinants after complete cytoreduction and hyperthermic intraperitoneal chemotherapy. Ann
Surg. 2009;249:243–249.
183. Baratti D, Kusamura S, Nonaka D, et al. Pseudomyxoma peritonei: clinical pathological and biological prognostic factors
in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Ann Surg Oncol.
2008;15:526–534.
184. Moran B, Baratti D, Yan TD, Kusamura S, Deraco M. Consensus statement on the loco-regional treatment of appendiceal
mucinous neoplasms with peritoneal dissemination (pseudomyxoma peritonei). J Surg Oncol. 2008;98:277–282.
185. Mirnezami AH, Moran BJ, Cecil TD. Sugarbaker procedure for pseudomyxoma peritonei. Tech Coloproctol. 2009;13:
373–374.
186. Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome?
Lancet Oncol. 2006;7:69–76.
187. Jarvinen P, Jarvinen HJ, Lepisto A. Survival of patients with pseudomyxoma peritonei treated by serial debulking.
Colorectal Dis. 2010;12:868–872.
188. Smeenk RM, van Velthuysen ML, Verwaal VJ, Zoetmulder FA. Appendiceal neoplasms and pseudomyxoma peritonei: a
population based study. Eur J Surg Oncol. 2008;34:196–201.
189. McCusker ME, Cote TR, Clegg LX, Sobin LH. Primary malignant neoplasms of the appendix: a population-based study
from the surveillance, epidemiology and end-results program, 1973–1998. Cancer. 2002;94:3307–3312.
190. Ito H, Osteen RT, Bleday R, Zinner MJ, Ashley SW, Whang EE. Appendiceal adenocarcinoma: long-term outcomes after
surgical therapy. Dis Colon Rectum. 2004;47:474–480.
191. Kabbani W, Houlihan PS, Luthra R, Hamilton SR, Rashid A. Mucinous and nonmucinous appendiceal adenocarcinomas:
different clinicopathological features but similar genetic alterations. Mod Pathol. 2002;15:599–605.
192. Nitecki SS, Wolff BG, Schlinkert R, Sarr MG. The natural history of surgically treated primary adenocarcinoma of the
appendix. Ann Surg. 1994;219:51–57.
193. Lo NS, Sarr MG. Mucinous cystadenocarcinoma of the appendix. The controversy persists: a review. Hepatogastroenter-
ology. 2003;50:432–437.
194. Lau H, Yuen WK, Loong F, Lee F. Laparoscopic resection of an appendiceal mucocele. Surg Laparosc Endosc Percutan Tech.
2002;12:367–370.
195. Stocchi L, Wolff BG, Larson DR, Harrington JR. Surgical treatment of appendiceal mucocele. Arch Surg. 2003;138:
585–589. [discussion 9-90].
196. Chiu CC, Wei PL, Huang MT, Wang W, Chen TC, Lee WJ. Laparoscopic resection of appendiceal mucinous cystadenoma.
J Laparoendosc Adv Surg Tech A. 2005;15:325–328.
reservados.

Acute Appendicitis - Current Problems in Surgery.

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Acute Appendicitis - Current Problems in Surgery.

Uploaded by

Copyright:

Available Formats

Current Problems in Surgery 50 (2013) 54–86

Contents lists available at SciVerse ScienceDirect

Current Problems in Surgery

journal homepage: www.elsevier.com/locate/cpsurg

Acute Appendicitis: Controversies in Diagnosis

Challenges in the Diagnosis of Acute Appendicitis

Disease positive Disease negative

Test positive True positives (A) False negatives (B) A þ B

Dunphy’s sign Increased right lower quadrant pain with coughing

History and Physical Examination

Physical examination (signs)

Signs Tenderness in right lower quadrant 2

Laboratory Leukocytosis (White blood cell count 410,000/mL) 2

Perforated vs Nonperforated Appendicitis

Distinguishing whether or not a patient is likely to have perforated vs nonperforated appendicitis

Antibiotics vs Appendectomy for Acute Uncomplicated Appendicitis

Evidence for Spontaneous Resolution of Appendicitis

Nonoperative Management of Acute Appendicitis

FIG 2. Consort diagram. (Reprinted with permission from Hansson et al.59)

Management of Complicated Appendicitis

FIG 5. CT scan demonstrating appendiceal abscess containing air-ﬂuid levels.

FIG 6. CT scan demonstrating appendiceal abscess with rim-enhancing wall.

The management of acute appendicitis complicated by an appendiceal phlegmon typically

The presence of an appendicolith associated with an appendiceal phlegmon deserves special

No. of patients Recurrence

No appendicolith 31 (63) 8 (26)

Recurrence, values are presented as n (%).

offer an appendectomy on initial presentation vs interval appendectomy82,83. It is important to note

Randomized Trial of Interval Appendectomy

Surgical Options for Acute Appendicitis

Laparoscopic vs Open Appendectomy

Predictors of Surgical Choice

A large retrospective review of prospectively acquired data comparing outcomes of laparoscopic vs

Risk factor Open (n ¼ 7,714; Laparoscopic (n ¼ Total (n ¼ P value

Postoperative diagnosis o 0.0001

Body mass index 0.0001

ASA class o 0.0001

Functional status o 0.0001

Diabetes 339 (4.39) 953 (3.82) 1,292 (3.95) 0.02

Dyspnea 163 (2.11) 315 (1.26) 478 (1.46) o 0.0001

Ascites 96 (1.24) 279 (1.12) 375 (1.15) 0.36

Alcohol use 213 (2.76) 510 (2.04) 723 (2.21) 0.0002

Pneumonia 12 (0.16) 18 (0.07) 30 (0.09) 0.03

Bleeding disorder 199 (2.58) 451 (1.81) 650 (1.99) o 0.0001

Congestive heart failure 13 (0.17) 14 (0.06) 27 (0.08) 0.003

Peripheral vascular diseasey 39 (0.51) 44 (0.18) 83 (0.25) o 0.0001

Disseminated cancer 15 (0.19) 44 (0.18) 59 (0.18) 0.74

Chemotherapy for malignancy within 30 d 22 (0.29) 54 (0.22) 76 (0.23) 0.27

Radiotherapy for malignancy in last 90 d 8 (0.10) 14 (0.06) 22 (0.07) 0.16

Risk factor Open (n ¼ 7,714; Laparoscopic (n ¼ Total (n ¼ P value

Neurologic disorderz 134 (1.74) 299 (1.20) 433 (1.32) 0.0003

Transfusion99,y 3 (0.04) 1 (0.00) 4 (0.01) 0.02

Preoperative sepsisz 2,955 (38.31) 8,795 (35.22) 11,750 (35.95) o 0.0001

Outcomes Open (n ¼ 7,714; Laparoscopic (n ¼ 24,969; Total (n ¼ P value

Overall morbidity 682 (8.84) 1,114 (4.46) 1,796 (5.50) o 0.0001

Serious morbidity 326 (4.23) 644 (2.58) 970 (2.97) o 0.0001

SSI 513 (6.65) 814 (3.26) 1,327 (4.06) o 0.0001

Mortality 10 (0.13) 18 (0.07) 28 (0.09) 0.13

meta-analysis in adult patients have demonstrated advantages with laparoscopic appendectomy,

Single-Incision or Single-Port Laparoscopic Appendectomy

Pediatric Interval Appendectomy

Management of the Unanticipated Appendiceal Neoplasm

An unanticipated appendiceal neoplasm may be encountered at any elective or emergency