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Non-Operative Management of Appendicitis: Evolution, not Revolution
1Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA.
Surgical Infections
|September 21, 2021
Summary
Non-operative management (NOM) for acute appendicitis (AA) shows promise, but laparoscopic appendectomy remains the preferred treatment, especially with fecaliths. Patient preference is key for informed consent regarding NOM
Area of Science:
- Gastroenterology and Hepatology
- Surgical Innovation
- Evidence-Based Medicine
Background:
- The management of acute appendicitis (AA) has evolved significantly since the 15th century.
- Early surgical interventions for appendiceal inflammation date back to 1735, but widespread acceptance of appendectomy took 150 years.
- Modern understanding of AA was shaped by Reginald Fitz's 1886 study, establishing surgical diagnosis and treatment.
Purpose of the Study:
- To review the historical progression of acute appendicitis (AA) management.
- To analyze recent randomized clinical trials (RCTs) on non-operative management (NOM) of AA.
- To assess the current best interests of patients regarding AA treatment options.
Main Methods:
- A comprehensive review and synthesis of historical and contemporary literature in English, French, German, and Italian.
- Inclusion of expert opinion to supplement literary review.
- Analysis of data from randomized controlled trials (RCTs) published since 1995.
Main Results:
- Non-operative management (NOM) for acute appendicitis (AA) has seen increased investigation via RCTs since 1995.
- Recent trials indicate non-inferiority of NOM compared to laparoscopic appendectomy (LA), but with high one-year failure rates (around 30%).
- Laparoscopic appendectomy (LA) is curative and cost-effective, particularly when a fecalith is present.
Conclusions:
- Laparoscopic appendectomy (LA) remains the treatment of choice for acute appendicitis (AA) due to its curative nature and low morbidity.
- Non-operative management (NOM) offers a chance to avoid surgery (60%-70%) and should be considered in patient preferences for informed consent.
- Outpatient NOM and adherence to antibiotic stewardship principles are recommended when NOM is pursued.
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