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Second date appendectomy: Operating for failure of nonoperative treatment in perforated appendicitis
1Advanced Surgical Oncology Unit, Department of General Surgery 1, Papa Giovanni XXIII Hospital, Bergamo, Italy.
Background:
Nonoperative treatment of acute appendicitis is embraced by many surgical teams, driven by low to moderate quality randomized studies that support noninferiority of antibiotics versus appendectomy for treatment of acute uncomplicated appendicitis. Several flaws of these studies have emerged, especially in the recruitment strategy and in the diagnostic criteria that were used. The growing confidence given to antibiotics, together with the lack of reliable criteria to distinguish between uncomplicated and perforated appendicitis, exposes patients with perforated appendicitis to the likelihood to be treated with antibiotics instead of surgery. Among them, those patients who experience a temporary relief of symptoms due to antibiotics, followed by early recurrence of disease when antibiotics are discontinued, are likely to undergo appendectomy at their second date. Second date appendectomy, i.e. the removal of the appendix when acute inflammation relapses within the scar of a previously unhealed perforated appendicitis, is the unwanted child of the nonoperative treatment and a new challenge for both the surgeon and the patient.
Methods:
Between June and July 2016, two patients were readmitted and operated for failure of nonoperative treatment with antibiotics.
Results:
A video is presented, which focuses on the different anatomic presentation and technical challenges between prompt and second date laparoscopic appendectomy.
Conclusions:
When proposing nonoperative treatment for acute appendicitis, surgeons should be aware and inform their patients that if the appendix is perforated and an incomplete healing and early recurrence occur, a second date appendectomy could be a more challenging operation compared to a prompt appendectomy.
Insights
Nonoperative treatment for acute appendicitis may lead to a more complex "second date" appendectomy if the appendix is perforated and recurs. Surgeons must inform patients of this risk.
Area of Science:
- Surgical innovation
- Gastrointestinal surgery
- Clinical outcomes
Background:
- Nonoperative management of acute appendicitis using antibiotics is increasingly adopted, supported by studies suggesting noninferiority to appendectomy for uncomplicated cases.
- However, flaws in study design and diagnostic criteria raise concerns about accurately differentiating uncomplicated from perforated appendicitis.
- This diagnostic uncertainty may lead to inappropriate antibiotic treatment for perforated appendicitis.
Observation:
- Two patients treated with antibiotics for acute appendicitis experienced treatment failure and required subsequent surgery.
- These cases highlight the potential for temporary symptom relief followed by early recurrence upon antibiotic discontinuation.
- The study presents a video detailing the anatomical and technical challenges of "second date" appendectomy compared to immediate appendectomy.
Findings:
- "Second date" appendectomy, performed after initial nonoperative treatment failure for perforated appendicitis, presents unique surgical challenges.
- Recurrence of inflammation in a previously unhealed perforated appendix scar complicates the procedure.
- Laparoscopic appendectomy in these cases requires careful consideration of altered anatomy and potential adhesions.
Implications:
- Surgeons must counsel patients on the risks associated with nonoperative treatment for acute appendicitis, particularly the possibility of a more complex "second date" appendectomy.
- Accurate diagnostic tools are needed to reliably distinguish between uncomplicated and perforated appendicitis to guide appropriate treatment.
- Failure to identify perforated appendicitis initially can lead to delayed surgical intervention and increased patient morbidity.
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