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Surgery for appendicitis: is it necessary?
1Division of Emergency Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California and Los Angeles County and USC Medical Center, Los Angeles, California, USA. rmason@surgery.usc.edu
Background:
Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored.
Methods:
Systematic review of published literature and derived expert opinion.
Results:
Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management.
Conclusions:
Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for.
Insights
Appendectomy may not be necessary for all acute appendicitis cases. Many patients experience spontaneous resolution or can be treated with antibiotics alone, suggesting a need for further research into non-operative management.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Infectious Disease
Background:
- Appendectomy is a standard procedure for acute appendicitis, with over 300,000 performed annually in the US.
- Appendicitis is typically viewed as a progressive condition requiring surgical intervention for source control.
- Non-operative management is established for other conditions but largely unexplored for appendicitis.
Purpose of the Study:
- To explore the potential for non-operative management of acute uncomplicated appendicitis.
- To review evidence supporting spontaneous resolution and antibiotic treatment for appendicitis.
- To evaluate the current understanding of appendicitis pathogenesis.
Main Methods:
- Systematic review of existing medical literature.
- Expert opinion synthesis.
Main Results:
- Clinical, epidemiological, radiological, and pathological evidence suggests spontaneous resolution of uncomplicated acute appendicitis.
- The pathogenesis of appendicitis, including the role of bacterial infection, was reviewed.
- Evidence indicates potential clinical success for non-operative management strategies.
Conclusions:
- Appendectomy might not be essential for most patients with acute uncomplicated appendicitis.
- Spontaneous resolution or antibiotic therapy may be viable alternatives.
- High-quality randomized trials comparing non-operative management with appendectomy are warranted.
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