Perforated appendicitis: is it truly a surgical urgency?

Advanced perforated appendicitis with localized findings has classically been treated with either operative therapy or with percutaneous drainage. The role of nonoperative therapy followed by interval appendectomy (IA) remains controversial. We assessed the safety and efficacy of conservative management for perforated appendicitis in a 5-year review of patients treated conservatively for perforated appendicitis with localized abscess or phlegmon. Patients were treated initially with intravenous antibiotics, and CT-guided drainage was used only if the patient failed to improve after 48 to 72 hours. Patients still not improving underwent appendectomy. Patients responding to conservative therapy were recommended IA in 6 to 12 weeks. Sixty-six patients with 54 abscesses and 10 phlegmons were treated. Fifty-one patients (92%) improved without surgery. Only 58 per cent of the abscesses required percutaneous drainage. The mean length of stay for conservative therapy was 7.6 days. Forty-one patients underwent IA with a 10 per cent morbidity and a mean length of stay of 1.4 days. Conservative management of appendicitis with localized perforation or phlegmon is safe and effective. Percutaneous drainage is frequently not required. IA is associated with low morbidity without prolonged hospitalization.