Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. Laparoscopy in children with complicated appendicitis. Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prospective Multicenter Randomized Controlled Trial Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. A prospective randomized trial of laparoscopic versus open appendectomy. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial Open Versus Laparoscopic Appendectomy A Prospective Randomized Comparison Laparoscopic versus open appendectomy in children: a prospective randomised study. Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial) Improving Outcomes After Laparoscopic Appendectomy: A Population-Based, 12-year Trend Analysis of 7446 Patients Laparoscopic versus open appendectomy: prospective randomized trial. 
Open and laparoscopic appendectomy are equally safe and acceptable in children
 Long-Term Results Following Antibiotic Treatment of Acute Appendicitis in Adults Laparoscopic appendectomy-is it worthwhile? : A prospective, randomized study in young women. Ultrasound-based decision making in the treatment of acute appendicitis in children. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. [Does laparoscopy increase the bacteriological risk of appendectomy? Results of a randomized prospective study]. Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible Laparoscopic vs open appendectomy. Prospective randomized study of outcomes. Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study.
IMPORTANCE An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis . OBJECTIVE To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography ( CT ) . DESIGN , SETTING , AND PARTICIPANTS The Appendicitis Acuta ( APPAC ) multicenter , open-label , noninferiority r and omized clinical trial was conducted from November 2009 until June 2012 in Finl and . The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan . Patients were r and omly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period . INTERVENTIONS Patients r and omized to antibiotic therapy received intravenous ertapenem ( 1 g/d ) for 3 days followed by 7 days of oral levofloxacin ( 500 mg once daily ) and metronidazole ( 500 mg 3 times per day ) . Patients r and omized to the surgical treatment group were assigned to undergo st and ard open appendectomy . MAIN OUTCOMES AND MEASURES The primary end point for the surgical intervention was the successful completion of an appendectomy . The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period . RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group . Of 273 patients in the surgical group , all but 1 underwent successful appendectomy , result ing in a success rate of 99.6 % ( 95 % CI , 98.0 % to 100.0 % ) . In the antibiotic group , 70 patients ( 27.3 % ; 95 % CI , 22.0 % to 33.2 % ) underwent appendectomy within 1 year of initial presentation for appendicitis . Of the 256 patients available for follow-up in the antibiotic group , 186 ( 72.7 % ; 95 % CI , 66.8 % to 78.0 % ) did not require surgery . The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0 % ( 95 % CI , -31.6 % to ∞ ) ( P = .89 ) . Given the prespecified noninferiority margin of 24 % , we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery . Of the 70 patients r and omized to antibiotic treatment who subsequently underwent appendectomy , 58 ( 82.9 % ; 95 % CI , 72.0 % to 90.8 % ) had uncomplicated appendicitis , 7 ( 10.0 % ; 95 % CI , 4.1 % to 19.5 % ) had complicated acute appendicitis , and 5 ( 7.1 % ; 95 % CI , 2.4 % to 15.9 % ) did not have appendicitis but received appendectomy for suspected recurrence . There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients r and omized to antibiotic treatment . CONCLUSIONS AND RELEVANCE Among patients with CT-proven , uncomplicated appendicitis , antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy . Most patients r and omized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period , and those who required appendectomy did not experience significant complications . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01022567 BACKGROUND / PURPOSE Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children . The role of laparoscopy in complicated acute appendicitis is more controversial . The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis . METHODS A total of 102 children with suspected acute appendicitis were selected r and omly to undergo either a laparoscopic or an open appendectomy . The outcomes of 25 children with complicated appendicitis , 13 in the laparoscopic group and 12 in the open appendectomy group , were analyzed . Children , their parents , and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation . All 25 children completed a 30-day follow-up . RESULTS There were no differences in terms of patients ' age , sex , weight , height , and appendiceal histology between the 2 groups . All laparoscopic procedures were completed without conversion . The mean ( + /-SD ) operating time was 63 ( + /-31 ) minutes in the laparoscopic group and 37 ( + /-18 ) minutes in the open appendectomy group ( mean difference 26 minutes , 95 % CI 5 to 47 minutes , P = .02 ) . There were 2 major complications in the laparoscopic group in children with appendiceal masses . One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation . Another child had a pelvic abscess that resolved with antibiotic treatment . Superficial wound infections were encountered in 2 patients in the open appendectomy group . CONCLUSIONS Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis . Good surgical judgement is necessary in patients with an established appendiceal abscess Background Appendectomy has been the treatment for acute appendicitis for over 120 years . Antibiotic treatment has occasionally been used in small uncontrolled studies , instead of operation , but this alternative has never before been tried in a multicenter r and omized trial . Patients and Methods Male patients , 18–50 years of age , admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study . No women were enrolled by decision of the local ethics committee . If appendectomy was planned , patients were asked to participate , and those who agreed were r and omized either to surgery or to antibiotic therapy . Patients r and omized to surgery were operated on with open surgery or laparoscopically . Those r and omized to antibiotic therapy were treated intravenously for 2 days , followed by oral treatment for 10 days . If symptoms did not resolve within 24 hours , an appendectomy was performed . Participants were monitored at the end of 1 week , 6 weeks , and 1 year . Results During the study period 252 men participated , 124 in the surgery group and 128 in the antibiotic group .  The frequency of appendicitis was 97 % in the surgery group and 5 % had a perforated appendix . The complication rate was 14 % in the surgery group . In the antibiotic group 86 % improved without surgery ; 18 patients were operated on within 24 hours , and the diagnosis of acute appendicitis was confirmed in all but one patient , and he was suffering from terminal ileitis . There were seven patients ( 5 % ) with a perforated appendix in this group . The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14 % during the 1-year follow-up . Conclusions Acute nonperforated appendicitis can be treated successfully with antibiotics . However , there is a risk of recurrence in cases of acute appendicitis , and this risk should be compared with the risk of complications after appendectomy OBJECTIVE The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children . METHODS A pilot r and omized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children . Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were r and omized either to treatment with antibiotics or to surgery . Follow-up was for 1 year . RESULTS Fifty patients were enrolled ; 26 were r and omized to surgery and 24 to nonoperative treatment with  antibiotics . All children in the surgery group had histopathologically confirmed acute appendicitis , and there were no significant complications in this group . Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis . Another 6 patients have had an appendectomy due to recurrent abdominal pain ( n = 5 ) or parental wish ( n = 1 ) during the follow-up period ; none of these 6 patients had evidence of appendicitis on histopathological examination . CONCLUSIONS Twenty-two of 24 patients ( 92 % ) treated with antibiotics had initial resolution of symptoms . Of these 22 , only 1 patient ( 5 % ) had recurrence of acute appendicitis during follow-up . Overall , 62 % of patients have not had an appendectomy during the follow-up period . This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted BACKGROUND Laparoscopic appendectomy is feasible , but whether it confers any advantage to patients with acute appendicitis is not known . We performed a r and omized controlled trial to compare results of laparoscopic and open appendectomy in patients with signs and symptoms suggesting acute appendicitis who were seen by one surgical team . METHODS Sixty-two consecutive patients were r and omized , 30 to laparoscopy and 32 to a classical open appendectomy .  Postoperative recovery , complications , and return to normal activities were compared in the two groups . RESULTS The laparoscopy group were discharged earlier ( 2.5 vs 3.8 days , p less than 0.01 ) . Postoperative complications were more frequent after open appendectomy . Follow-up showed less pain , shorter bed stay at home , and faster return to work and sport after laparoscopic appendectomy . CONCLUSIONS This prospect i ve r and omized study shows that laparoscopic appendectomy is superior to open appendectomy in terms of hospital stay , postoperative complications , and return to normal activities and is recommended as the approach of choice in the management of acute appendicitis Importance Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis , but long-term outcomes are not known . Objective To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis . Design , Setting , and Participants Five-year observational follow-up of patients in the Appendicitis Acuta ( APPAC ) multicenter r and omized clinical trial comparing appendectomy with antibiotic therapy , in which 530 patients aged 18 to 60 years with computed tomography – confirmed uncomplicated acute appendicitis were r and omized to undergo an appendectomy ( n = 273 ) or receive antibiotic therapy ( n = 257 ) . The initial trial was conducted from November 2009 to June 2012 in Finl and ; last follow-up was September 6 , 2017 . This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone . Interventions Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole . Main Outcomes and Measures In this analysis , prespecified secondary end points reported at 5-year follow-up included late ( after 1 year ) appendicitis recurrence after antibiotic treatment , complications , length of hospital stay , and sick leave . Results Of the 530 patients ( 201 women ; 329 men ) enrolled in the trial , 273 patients ( median age , 35 years [ IQR , 27 - 46 ] ) were r and omized to undergo appendectomy , and 257 ( median age , 33 years , [ IQR , 26 - 47 ] ) were r and omized to receive antibiotic therapy . In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year ( 27.3 % [ 95 % CI , 22.0%-33.2 % ] ; 70/256 ) , 30 additional antibiotic-treated patients ( 16.1 % [ 95 % CI , 11.2%-22.2 % ] ; 30/186 ) underwent appendectomy between 1 and 5 years . The cumulative incidence of appendicitis recurrence was 34.0 % ( 95 % CI , 28.2%-40.1 % ; 87/256 ) at 2 years , 35.2 % ( 95 % CI , 29.3%-41.4 % ; 90/256 ) at 3 years , 37.1 % ( 95 % CI , 31.2%-43.3 % ; 95/256 ) at 4 years , and 39.1 % ( 95 % CI , 33.1%-45.3 % ; 100/256 ) at 5 years . Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis , 76 had uncomplicated appendicitis , 2 had complicated appendicitis , and 7 did not have appendicitis . At 5 years , the overall complication rate ( surgical site infections , incisional hernias , abdominal pain , and obstructive symptoms ) was 24.4 % ( 95 % CI , 19.2%-30.3 % ) ( n = 60/246 ) in the appendectomy group and 6.5 % ( 95 % CI , 3.8%-10.4 % ) ( n = 16/246 ) in antibiotic group ( P < .001 ) , which calculates to 17.9 percentage points ( 95 % CI , 11.7 - 24.1 ) higher after surgery . There was no difference between groups for length of hospital stay , but there was a significant difference in sick leave ( 11 days more for the appendectomy group ) . Conclusions and Relevance Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis , the likelihood of late recurrence within 5 years was 39.1 % . This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis . Trial Registration Clinical Trials.gov Identifier : Objective The authors compare open and laparoscopic appendectomy  in a r and omized fashion with regard to length of operation , complications , hospital stay , and recovery time . Methods Adult patients ( older than 14 years of age ) with the diagnosis of acute appendicitis were r and omized to either open or laparoscopic appendectomy over a 9-month period . All patients received preoperative  antibiotics . The operative time was calculated as beginning with the incision and ending when the wound was fully closed . Patients that were converted from laparoscopic to open appendectomy were considered a separate group . Return to normal activity and work were determined by question ing during postoperative clinic , telephone , or mailed question naire . Results There was a total of 169 patients r and omized , 88 to the open and 81 to the laparoscopic group . The groups were similar demographically . Of the 81 laparoscopic patients , 13 ( 16 % ) were converted to open . In the open group , 70 patients ( 79.5 % ) had acute appendicitis and 21 ( 23.9 % ) had perforative appendicitis . In the laparoscopic group , 62 patients ( 76.5 % ) had acute appendicitis and 10 ( 12.3 % ) had perforative appendicitis . There was no statistical difference in the return to activity or work between the laparoscopic and open groups . The operative time was significantly longer in the laparoscopic group ( 102.2 minutes vs. 81.7 minutes , p < 0.01 ) . The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically different ( p = 0.007 ) . There was no difference in the hospital stay for those with acute appendicitis ( 1.89 days vs. 2.61 days , p = 0.067 ) compared with those with a normal appendix but with pelvic inflammatory disease ( 1.1 days vs. 2.3 days , p = 0.11 ) . There was a significant difference in patients with perforative appendicitis ( 1.5 days vs. 9.5 days , p < 0.01 ) . The hospital cost for patients having laparoscopic appendectomy was $ 6077 and for an open appendectomy $ 7227 ( p = 0.164 ) . There were no increased complications associated with the laparoscopic technique . Conclusion Laparoscopic appendectomy is comparable to open appendectomy with regard to complications , hospital stay , cost , return to activity , and return to work . There was a greater operative time involved with the laparoscopic technique . Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis 43 children between the ages of 7 and 15 years with clinical symptoms of acute appendicitis were r and omised to an open appendectomy ( OA ) or a laparoscopic appendectomy ( LA ) . There were 15 acute cases of appendicitis and 5 perforated appendices in the OA group and 17 acute appendicitis , 3 cases of perforated appendices and 3 other diagnoses in the LA group . The operative time was a little shorter in the OA group . There were no differences in hospital stay or the postoperative course of the patients . In the LA group , there were two minor complications , no other complications were seen . When comparing the two surgical methods in the consistent group of patients with non-perforated acute appendicitis no statistical differences were seen in the operative time , hospital stay or in the recovery of the patients between the OA and the LA groups . We conclude that LA has no significant benefit over OA in routine use . In paediatric patients we recommend an open approach for clinical ly typical acute appendicitis , but there should be no hesitation to choose laparoscopic approach when the clinical diagnosis is unclear BACKGROUND Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial . We studied the results of initial conservative treatment ( antibiotics and percutaneous drainage if necessary , with or without interval appendectomy ) compared with immediate surgery . METHODS We undertook an observational , retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon , treated in our hospital between January 1997 and March 2009 . Patients younger than 14 , with severe sepsis or with diffuse peritonitis were excluded . A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment . A control group was composed of the other patients , who all underwent  urgent appendectomy  , matched for age and later r and omized 1:1 . The infectious risk stratification was established with the National Nosocomial Infections Surveillance System ( NNIS ) index . Dependent variables were hospital stay and surgical site infection . Analysis was with SPSS , with p < 0.05 considered significant . RESULTS Interval appendectomy  was performed in 7 study group patients . Surgical site infection episodes were more frequent in the control group ( 6 vs. 0 , p < 0.001 ) . A greater percentage of high risk patients ( NNIS ≥ 2 ) was identified in the control group ( 80 vs. 28.7 % , p < 0.03 ) , mostly related with contaminated or dirty procedures in this group ( p < 0.001 ) . No significant difference between groups was found in hospital stay . CONCLUSION Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options BACKGROUND Initial antibiotic treatment for acute appendicitis has been shown to be safe in adults ; so far , not much is known about the safety and efficacy of this treatment in children . The aims of this study were to investigate the feasibility of a r and omized controlled trial ( RCT ) evaluating initial antibiotic treatment for acute appendectomy in children with acute simple appendicitis and to evaluate the safety of this approach . METHODS In a multicenter , prospect i ve cohort study patients aged 7 - 17 years with a radiologically confirmed simple appendicitis were eligible .  Intravenous antibiotics ( amoxicillin/clavulanic acid 250/25 mg/kg 4 times daily ; maximum 6,000/600 mg/d and gentamicin 7 mg/kg once daily ) were administered for 48 - 72 hours . Clinical reevaluation every 6 hours , daily blood sample s , and  ultrasound follow-up  after 48 hours was performed . In case of improvement after 48 hours , oral antibiotics were given for a total of 7 days . At any time , in case of clinical deterioration or non-improvement after 72 hours , an appendectomy could be performed . Follow-up continued until 8 weeks after discharge . Adverse events were defined as major complications of antibiotic treatment , such as allergic reactions , perforated appendicitis , and recurrent appendicitis . RESULTS Of 44 eligible patients , 25 participated ( inclusion rate , 57 % ; 95 % CI , 42%-70 % ) . Delayed appendectomy was performed in 2 , and the other 23 were without symptoms at the 8 weeks follow-up . Minor complications occurred in three patients . None of the patients suffered from an adverse event or a recurrent appendicitis . CONCLUSION Our study shows that an RCT comparing initial antibiotic treatment strategy with urgent appendectomy is feasible in children ; the intervention seems to be safe Background Although the st and ard treatment of acute appendicitis ( AA ) consists of an early appendectomy , there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA . However , the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial . Methods / design The APPAC trial is a r and omized prospect i ve controlled , open label , non-inferiority multicenter trial design ed to compare antibiotic therapy ( ertapenem ) with emergency appendectomy in the treatment of uncomplicated AA . The primary endpoint of the study is the success of the r and omized treatment . In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year ( treatment efficacy ) . Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100 % . Secondary endpoints are post-intervention complications , overall morbidity and mortality , the length of hospital stay and sick leave , treatment costs and pain scores ( VAS , visual analoque scale ) . A maximum of 610 adult patients ( aged 18–60 years ) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and r and omized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem ( 1 g per day ) for three days continued by oral levofloxacin ( 500 mg per day ) plus metronidazole ( 1.5 g per day ) for seven days . Follow-up by a telephone interview will be at 1 week , 2 months and 1 , 3 , 5 and 10 years ; the primary and secondary endpoints of the trial will be evaluated at each time point . Discussion The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75–85 % of patients with uncomplicated AA can be treated with effective antibiotic  therapy avoiding unnecessary appendectomies and the related operative morbidity , also result ing in major cost savings . Trial registration Clinical OBJECTIVE Laparoscopic appendectomy for acute appendicitis has become increasingly used over the past decade . The objective of this trend analysis is to assess whether clinical outcomes after laparoscopic appendectomy have improved over the past 12 years . METHODS This analysis is based on the prospect i ve data base of the Swiss Association of Laparoscopic and Thoracoscopic Surgery . All patients undergoing emergency laparoscopic appendectomy for acute appendicitis from 1995 to 2006 were included . The following outcomes were assessed for each of the 12 years : conversion rates , intraoperative complications , surgical postoperative complications , general postoperative complications , rate of reoperations , and length of hospital stay . Unadjusted and risk-adjusted multivariable analyses were performed . Statistical significance was set at a level of P < 0.05 . All statistical tests were 2-sided . RESULTS Data from 7446 patients undergoing laparoscopic appendectomy for acute appendicitis were prospect ively collected . Over the period of observation , the conversion rate decreased significantly from 2.2 % to 1.2 % ( P(trend ) < 0.001 ) , as did intraoperative complications ( from 3.1 % to 0.7 % ; P(trend ) < 0.001 ) , surgical postoperative complications ( from 6.1 % to 1.9 % ; P(trend ) < 0.001 ) , general postoperative complications ( from 4.9 % to 1.5 % ; P(trend ) < 0.001 ) , and rates of reoperations ( from 3.4 % to 0.7 % ; P(trend ) < 0.001 ) . Average postoperative length of hospital stay also significantly decreased from 4.9 to 3.5 days ( P(trend ) < 0.001 ) . CONCLUSIONS Our investigation provides compelling evidence that intraoperative complications , surgical and general postoperative complications , conversion rates , rates of reoperations , and average length of hospital stay have significantly decreased over the past decade in patients undergoing surgery for acute appendicitis . The present trend analysis is the first one in the literature encompassing more than a decade and reporting clinical outcomes after laparoscopic appendectomy for acute appendicitis , which represents an important quality control Although classic open surgery is simple , expeditious , and effective , it has some drawbacks , including wound sepsis , delayed recovery , operative difficulties , and possibility of unnecessary appendectomies for false appendicitis . The aim of this study was to assess the applicability and safety of laparoscopic appendectomy ( LA ) in a prospect ively r and omized trial . Seventy nonselective patients with suspected appendicitis were r and omized to laparoscopic ( n = 35 , 17 male ) or open appendectomy ( n = 35 , 15 male ) and operated on an emergency basis . Operative findings , operating time , postoperative complications , and length of hospital stay were compared . We found that LA is associated with a shorter hospital stay , fewer postoperative complications , and better diagnostic accuracy , and it is recommended as the procedure of choice for the diagnosis and management of acute appendicitis Background : The aim of this study was to evaluate prospect ively whether laparoscopic ( LA ) and open appendectomy ( OA ) are equally safe and feasible in the treatment of pediatric appendicitis . Methods : A total of 517 children with acute appendicitis were r and omly assigned to undergo LA or OA appendectomy , based on the schedule of the attending surgeon on call . Patient age , sex , postoperative diagnosis , operating time , level of training of surgical resident , length of postoperative hospitalization , and minor and major postoperative complications were recorded . Chi-square analysis and the Student t-test were used for statistical analysis . Results : In all , 376 OA and 141 LA were performed . The two groups were comparable in terms of patient demographics and the incidence of perforated appendicitis . The operative time was also similar ( 47.3 ± 19.7 vs 49.9 ± 12.9 min ) . The overall incidence of minor or major complications was 11.2 % in the OA group and 9.9 % in the LA group . Conclusion : Pediatric patients with appendicitis can safely be offered laparoscopic appendectomy without incurring a greater risk for complications . Nevertheless , a higher ( but not significantly higher ) abscess rate was found in patients with perforated appendicitis who underwent laparoscopy Background Antibiotic treatment of acute appendicitis has gained interest and inquiries . Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis , but information on long-term results is required . Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis . Methods Patients with favourable response to antibiotics in earlier r and omized ( RCT , n = 97 ) and population -based ( PBT , n = 342 ) studies as well as subsequently treated non-r and omized ( Non-R , n = 271 ) patients are evaluated for long-term risk to relapse dem and ing surgical appendectomy ; altogether 710 patients . Results Clinical characteristics among r and omized and non-r and omized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation ( CRP , WCC ) when antibiotic treatment started . Females and males showed the same results . The median follow-up time was 2162 days ( 5.92 years ) , and the range across highest and lowest follow-up was 3495 days ( range 2–3497 ) for the entire group , without significant differences among subgroups ( RCT , PBT , Non-R ) . The cumulative probability for relapse of appendicitis dem and ing appendectomy was : 0.09 , 0.12 , 0.12 and 0.13 at 1- , 2- , 3- and 5-year follow-up , with a probability of 0.86 ± 0.013 without appendectomy after 8 years . This may imply an overall benefit of 60–70 % by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10–23 % in our published reports . Conclusion Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15 % for long-term relapse following favourable initial treatment response BACKGROUND Clinical diagnosis of acute appendicitis is most difficult in fertile-age women . In this patient group up to 50 % of open appendectomies are negative for appendicitis . We conducted a r and omized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis . METHODS Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were r and omized , 25 to laparoscopy and 25 to an open appendectomy .  Diagnostic accuracy , rate of negative appendectomies , safety , and final outcome were compared in the two groups . RESULTS Diagnosis was established in 96 % of patients in the laparoscopic group and in 72 % in the open group . There were 11 ( 44 % ) unnecessary appendectomies in the open group , but only one ( 4 % ) in the laparoscopic group ( p < 0.0005 ) . CONCLUSIONS In young women with right lower abdominal pain , laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies BACKGROUND / PURPOSE Imaging techniques are used widely to diagnose appendicitis . However , the negative appendectomy rate remains at about 15 % . The authors assessed ultrasound-based decision making in the treatment of acute appendicitis in children . METHODS The authors prospect ively studied 165 consecutive children ( 3 to 15 years old ) evaluated for appendicitis . Diagnosis and treatment were based solely on ultrasound scan findings . Criterion for appendicitis was a diameter exceeding 6 mm . Severity was classified into 4 grade s based on the appearance of intramural appendiceal structure . Patients with grade s I or II received antibiotic therapy . Patients with grade s III or IV underwent appendectomy . RESULTS Ultrasound scan diagnosed appendicitis in 93 children ( grade I , 7 ; grade II , 17 ; grade III , 41 ; and grade IV , 28 ) . All but 2 patients with grade s I or II underwent  antibiotic therapy  without complication . All grade s III or IV patients underwent appendectomy . There was no negative appendectomy among 76 appendectomies during this period . Ultrasound-based prediction of severity was correct in 67 cases ( 88 % ) . Ultrasonography identified other pathology in 39 . CONCLUSIONS Ultrasonography in children can not only visualize all inflamed appendices but also predict severity of disease . Treatment based entirely on ultrasound scan identified patients who required surgery for severe appendicitis and permitted successful conservative treatment for mild appendicitis IMPORTANCE Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe , but overall effectiveness is determined by combining medical outcomes with the patient 's and family 's perspective , goals , and expectations . OBJECTIVE To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1 , 2012 , through March 6 , 2013 . Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy . INTERVENTIONS Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and , on demonstrating improvement of symptoms , completion of 10 days of treatment with oral antibiotics . MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year success rate of nonoperative management . Successful nonoperative management was defined as not undergoing an appendectomy . Secondary outcomes included comparisons of the rates of complicated appendicitis , disability days , and health care costs between nonoperative management and surgery . RESULTS A total of 102 patients were enrolled ; 65 patients /families chose appendectomy ( median age , 12 years ; interquartile range [ IQR ] , 9 - 13 years ; 45 male [ 69.2 % ] ) and 37 patients /families chose nonoperative management ( median age , 11 years ; IQR , 10 - 14 years ; 24 male [ 64.9 % ] ) . Baseline characteristics were similar between the groups . The success rate of nonoperative management was 89.2 % ( 95 % CI , 74.6%-97.0 % ) at 30 days ( 33 of 37 children ) and 75.7 % ( 95 % CI , 58.9%-88.2 % ) at 1 year ( 28 of 37 children ) . The incidence of complicated appendicitis was 2.7 % in the nonoperative group ( 1 of 37 children ) and 12.3 % in the surgery group ( 8 of 65 children ) ( P = .15 ) . After 1 year , children managed nonoperatively compared with the surgery group had fewer disability days ( median [ IQR ] , 8 [ 5 - 18 ] vs 21 [ 15 - 25 ] days , respectively ; P < .001 ) and lower appendicitis-related health care costs ( median [ IQR ] , $ 4219 [ $ 2514-$7795 ] vs $ 5029 [ $ 4596-$5482 ] , respectively ; P = .01 ) . CONCLUSIONS AND RELEVANCE When chosen by the family , nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis , incurring less morbidity and lower costs than surgery . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01718275 OBJECTIVE The authors compare the risk of bacteraemia in  open  and  laparoscopic appendectomy  in a prospect i ve r and omized study . METHODS 35 patients with a presumptive diagnosis of acute appendicitis were r and omized to have conventional open or laparoscopic surgical procedures . Before r and omization , patients signed a consent form to participate in the study . Patients who were converted from laparoscopic to open appendectomy ( 3 cases ) , HIV+ , allergic to Augmentin or who had contraindications to laparoscopic surgery were excluded from the study . A total of 32 patients were r and omized : 17 to open ( group I ) and 15 to laparoscopic surgery ( group II ) . There were no significant differences with regard to age , ASA score , symptoms or macroscopic aspect of the appendix . Two patients had a normal appendix , 12 had acute appendicitis , 14 gangrenous appendicitis and 4 ruptured or abscessed appendicitis . All patients received preoperative antibiotic prophylaxis ( Augmentin ) after blood cultures ( H1 ) were drawn . Five other blood cultures were performed in st and ard medium and medium neutralizing Augmentin : at the time of opening the peritoneum ( H2 ) , after appendectomy ( H3 ) , after closure of the abdomen ( H4 ) , and at 6 ( H5 ) and 12 hours ( H6 ) after the operation . Bacterial cultures from the appendix site were performed before ( P1 ) and after ( P2 ) appendectomy . RESULTS The operative mortality rate after conventional or laparoscopic appendectomy was nil . The incidence of post-operative morbidity was 4 cases in group I and 2 cases in group II . No positive bacterial culture was obtained in 17 patients . The distribution of these patients was similar in groups I and II . Sample s P1 and P2 were positive in 5 cases . Nine of 27 cases with negative P1 became positive in P2 ( 33 % ) . There was no significant difference between the two groups with regard to the appearance of the appendix . Only two patients had positive blood cultures at H1 . One of them had blood cultures at H3 , H4 positive for a second germ . CONCLUSION A low risk of bacteraemia exists for both open and laparoscopic appendectomy . This risk did not appear to increase for laparoscopy . Conventional and laparoscopic surgical procedures led to positive peritoneal bacterial cultures after appendectomy in 33 % of cases Purpose Appendectomy versus conservative antibiotic treatment ( CAT ) for children with acute uncomplicated appendicitis ( AUA ) remains unresolved , with concerns regarding the practicality of CAT . We analyzed our center ’s experience with CAT for AUA , using a protocol with strict inclusion , exclusion and treatment criteria . Methods Non-r and omized , prospect i ve cohort study included all children admitted betwee 2014 and 2016 , with clinical and laboratory tests suspicious for AUA . Data collected included clinical signs and symptoms ; laboratory , ultrasound and pathology results . Follow-up was conducted through clinic visits , telephone conversations and national registry analysis . Results Included in CAT : 362 children , 19 underwent appendectomy within 1–2 days . Overall , 75 were readmitted for recurrent acute appendicitis during 22 months ( 6–43 ) follow-up . Thirty were treated successfully with antibiotics a second time . The remaining 45 had appendectomy . Overall , 86.8 % underwent CAT with no surgery . Histology of all recurrent AUA revealed no perforations . Conclusion We confirm the feasibility of conservative management of AUA in children . A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile . CAT does not compete with surgery or render appendectomy unnecessary . It is a safe alternative to surgery in selected cases OBJECTIVE To compare open appendectomy ( OA ) with laparoscopic appendectomy ( LA ) for length of the operation , complications , postoperative pain control , length of hospitalization , postdischarge recovery time , and hospital charges . DESIGN Prospect i ve r and omized clinical trial of patients with acute appendicitis . SETTING Tertiary care , urban teaching hospital . PATIENTS A population -based sample of patients ( aged > or = 12 years ; weight , > 49.7 kg ) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis . Patients were prospect ively r and omized to either OA or LA during a 20-month period ( from April 1 , 1994 , to December 31 , 1995 ) . Fifty-seven patients were initially enrolled in the study ; 7 did not complete the study because of a protocol violation . All remaining patients completed the study , including postdischarge follow-up . INTERVENTIONS Two ( 7.4 % ) of the 27 patients in the LA group required conversion to OA because of technical difficulties . One patient ( in the OA group ) underwent a second surgical procedure for drainage of a pelvic abscess . Three patients ( in the LA group ) required second surgical procedures . For analysis , no crossovers were allowed and all patients remained in their originally r and omized group . MAIN OUTCOME MEASURES Length of the operation , intraoperative and postoperative complications , postoperative pain control , length of hospitalization , postdischarge recovery time , and hospital charges . RESULTS Fifty patients ( 19 women and 31 men ) were examined . Twenty-seven patients underwent LA , 2 requiring conversion to an OA . Twenty-three patients underwent an OA . Patient demographics were similar between groups . Statistical differences between the 2 groups were found for ( 1 ) length of the operation ( median , 81.7 vs 66.8 minutes , LA vs OA groups : P < .002 ) , ( 2 ) operating room charges ( median , $ 3191 vs $ 1514 , LA vs OA group ; P < .001 ) , and ( 3 ) total hospital charges ( median , $ 5430 vs $ 3673 , LA vs OA group ; P < .001 ) . No statistical differences between the 2 groups were found for ( 1 ) length of hospitalization ( median , 1.1 vs 1.2 days , LA vs OA group ) , ( 2 ) pain control ( mean , 4 vs 3.7 of 10 [ 0 indicates least pain ; 10 , most pain ] , LA vs OA group ) , ( 3 ) recovery time ( time necessary before returning to work or school ) ( median , 14.0 days for both groups ) , and ( 4 ) complications ( 5 vs 1 , LA vs OA group ) . CONCLUSIONS Laparoscopic appendectomies and OAs are comparable for complications , postoperative pain control , length of hospitalization , and recovery time . Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges .  Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis BACKGROUND The management of an appendiceal mass remains controversial with 2 schools of thought ; early surgical intervention vs nonoperative management with or without interval appendectomy . The aim is to determine the role and safety of early laparoscopic appendectomy ( LA ) in children with acute appendicitis presenting with an appendiceal mass . METHODS This is a prospect i ve study of 88 consecutive pediatric patients who underwent attempted LA for suspected acute appendicitis at KK Women 's and Children 's Hospital , Singapore , between May and October 2003 . RESULTS A total of 88 patients with a mean age of 10 + /- 3 years ( range , 3 - 16 years ) underwent LA for an appendiceal mass ( n = 22 ) , simple appendicitis ( n = 36 ) , other complicated ( gangrenous or perforated ) appendicitis ( n = 23 ) , and a normal appendix ( n = 7 ) . There were 7 conversions to  open appendicectomy  , 3 of which occurred in patients with an appendiceal mass . There were no perioperative or postoperative mortalities . Morbidity occurred in only one patient who underwent LA for perforated appendicitis . He had prolonged sepsis that resolved after 2 weeks of intravenous antibiotics . None of the patients with an appendiceal mass developed complications . Patients who underwent early LA for an appendiceal mass had a statistically significant ( P < .05 ) longer operating time ( median , 103 minutes ; interquartile range , 90 - 151 minutes , vs median , 87 minutes ; interquartile range , 71 - 112 minutes ) , prolonged time to ambulation ( median , 2.0 days ; interquartile range , 2 - 2.5 days , vs median , 1.0 days ; interquartile , 1 - 2 days ) , increased time to resumption of diet ( median , 4 days ; interquartile , 3 - 5 days , vs median , 2 days ; interquartile , 2 - 3 days ) , and longer postoperative stay ( median , 6.0 days ; interquartile , 5.5 - 6.5 days , vs median , 4.0 days ; interquartile , 3 - 5.5 days ) compared with patients presenting with appendicitis without mass formation . However , there was no statistical difference in these parameters when LA for an appendiceal mass was compared with LA for other complicated appendicitis ( perforated and gangrenous ) . CONCLUSION Although early LA for an appendiceal mass is a technically dem and ing procedure , it can be performed safely in children with minimal morbidity and mortality . In an era where patients ' dem and for " key-hole " surgery is rising , early LA is a safe and viable option in the management of children with an appendiceal mass . It also offers the advantage of avoiding misdiagnoses and the need for a second hospitalization
Therefore we conclude that appendectomy remains the st and ard treatment for acute appendicitis .
BACKGROUND Acute appendicitis is one of the most common causes of acute abdominal pain .
Present day treatment of choice for acute appendicitis is appendectomy , however complications are inherent to operative treatment .
Though surgical appendectomy remains the st and ard treatment , several investigators have investigated conservative antibiotic treatment of acute appendicitis and reported good results .
OBJECTIVES Is antibiotic treatment as effective as surgical appendectomy ( laparoscopic or open ) in patients with acute appendicitis on recovery within two weeks , without major complications ( including recurrence ) within one year ?