A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues? RETRACTED ARTICLE: Conservative Management of Acute Appendicitis Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. Comparative trial of four antibiotic combinations for perforated appendicitis in children. Retraction Note to: Conservative Management of Acute Appendicitis A role for conservative antibiotic treatment in early appendicitis in children. Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis Acute appendicitis—a clear-cut case in men, a guessing game in young women
 Comparison of operative and non operative management of acute appendicitis. Laparoscopic versus open appendicectomy for complicated appendicitis: A prospective study Laparoscopic versus open surgical exploration in premenopausal women with suspected acute appendicitis. Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis Can oral metronidazole substitute parenteral drug therapy in acute appendicitis? A new policy in the management of simple or complicated appendicitis with localized peritonitis: a randomized controlled clinical trial. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. Laparoscopic versus open appendicectomy: prospective randomised trial Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study. Leucocyte count and neutrophil percentage in appendicectomy for suspected appendicitis. Randomized study of the value of laparoscopy before appendicectomy [Appendicitis in the last decade of the 20th century--Analysis of two prospective multicenter clinical observational studies]. It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis.
Introduction : The management approach for acute appendicitis has been challenged in recent years , with numerous r and omized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment , with lower complication rates . Methods : A national survey of all consultant general surgeons evaluating their practice s was performed . Reasons for changed practice s , choice of antibiotics and follow-up investigations were evaluated . In addition , the role of interval appendicectomy and conservative management in the pediatric population was also assessed . Results : The response rate for this survey was 74.7 % ( n = 74/99 ) . Over one-fifth ( n = 17 , 22.9 % ) routinely treat acute appendicitis conservatively , while another 14.8 % ( n = 11 ) consider this approach in selected cases . Main reasons for modified practice s included the presence of inflammatory phlegmon ( 75 % ) , delayed presentation ( 64 % ) , and recent evidence -based medicine developments ( 46 % ) . Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management ( 53 % ) . Alternatively , combinations of antibiotics were also utilized . One-third felt interval appendicectomy was warranted , while one-fifth supported conservative management in the paediatric setting . The overwhelming majority ( > 95 % ) advocate follow-up colonoscopy ± computed tomography in any patient aged > 40 years managed conservatively . Conclusion : Considerable variation in management of uncomplicated appendicitis  remains in Irel and despite growing evidence suggesting that the non-operative approach is safe . Reasons for adopting a conservative management practice have been identified and reflect the exp and ing literature on this subject Background The acute appendicitis is the most common abdominal emergency , and the primary treatment has been appendicectomy . Antibiotics are started preoperatively and continued postoperatively as needed . Methods This prospect i ve study was carried out at Sher-i-Kashmir Institute of Medical Sciences , Soura , Srinagar , Kashmir , India to determine the role of antibiotics as the only treatment in acute appendicitis and the analgesic consumption needed . Total of 80 patients were included in the study with a duration of abdominal pain less than 72 h. Out of 80 patients , 40 patients received antibiotics intravenously for 2 days followed by oral treatment for 7 days , while another 40 patients considered as controls were r and omized to surgery . Results Patients managed conservatively were discharged within 3 days except for two— patients who required surgery after 12 and 24 h , respectively , because of peritonitis due to perforated appendicitis . Four patients were readmitted within 1 year as a result of recurrent appendicitis and had to undergo surgery when appendicitis was confirmed . The diagnostic accuracy within the operated group was 90 % . Two patients had perforated appendicitis at operation . Conclusion Our conclusion is that antibiotic treatment in the patients with acute appendicitis is quite effective , and these patients may not need surgery . The patients managed conservatively with antibiotics alone experience less pain and require less analgesia but have high recurrent rate In a prospect i ve controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated . Of 40 patients admitted with a duration of abdominal pain of less than 72 h , 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were r and omized to surgery . All patients treated conservatively were discharged within 2 days , except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis . Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery , when appendicitis was confirmed . The diagnostic accuracy within the operated group was 85 per cent . One patient had perforated appendicitis at operation .  Antibiotic treatment  in patients with  acute appendicitis was as effective as surgery . The patients had less pain and required less analgesia , but the recurrence rate was high 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 OBJECTIVE To compare the therapeutic efficacy of four antibiotic regimens : penicillin , tobramycin , and clindamycin ; penicillin , tobramycin , and ornidazole ; piperacillin alone ; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis . DESIGN Prospect i ve r and omised study . SETTING Teaching hospital , Turkey . SUBJECTS 200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were r and omly assigned to one of four groups each consisting of 50 patients . INTERVENTIONS Preoperative antibiotics given intravenously , peritoneal drainage by Penrose drains without irrigation , appendicectomy with the inversion of the stump by a purse string , taking peritoneal swabs , and primary skin closure . MAIN OUTCOME MEASURES Comparability of the groups , duration of fever , leucocytosis , antibiotic treatment , stay in hospital , nasogastric intubation , and drainage , as well as results of cultures and complications . RESULTS There were no significant differences between the groups for any variable studied . The predominant bacterial species were Escherichia coli , Klebsiella spp , Pseudomonas spp , Fusobacteria , and Peptostreptococci which were appropriately covered by all the antibiotic regimens . Fourteen patients had complications including wound infections ( n = 10 ) , prolonged ileus ( n = 2 ) and intra-abdominal abscess ( n = 2 ) all of which were treated conservatively . There was no mortality and no major complications . All regimens had the same clinical and bacteriological efficacy . CONCLUSION There is no gold st and ard for antimicrobial chemotherapy in perforated appendicitis . Different antibiotic combinations or a single broad spectrum antibiotic , which include both aerobic and anaerobic coverage , can safely be used in children with perforated appendicitis The editors of the Journal of Gastrointestinal Surgery as well as the SSAT Board of Directors have retracted the article Malik , A.A. & Bari , S.U. Conservative management of  acute appendicitis . J Gastrointest . Surg 13 , 966–970 ( 2009 ) since significant portions of the article were published earlier in the following articles : Eriksson , S. & Granstrom , L. R and omized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis . Br J Surg 82 , 166–169 ( 1995 ) . Horton , M.D. , Counter , S.F. , Florence , M.G. & Hart , M.J. A prospect i ve trial of computed tomography and ultrasonography for diagnosing  appendicitis in the atypical patient . Am J Surg 179 , 379–381 ( 2000 ) PURPOSE To evaluate whether antibiotics without surgery is sufficient treatment for children with clinical ly and ultrasonographically suspected acute appendicitis ( AA ) . METHOD Children with clinical , laboratory and radiological findings suspicious for AA were evaluated prospect ively . Patients with mild clinical signs , without peritonitis were considered for IV followed by oral antibiotics without surgery . RESULTS From 1 November 2013 through 30 June 2014 , 45 children were diagnosed with early , acute appendicitis . Ages ranged from 4 to 15 years ( mean 9.3 ) and 32 ( 75 % ) were boys . All had routine , clinical laboratory and ultrasound workup . Forty-two improved with antibiotic treatment and were discharged home within 3 - 5 days , without surgery . Three of them were operated on within 24 hours , another two underwent appendectomy for recurrent appendicitis : one at 2 weeks and the other 2 months after discharge . There was no more recurrent appendicitis in 6 - 14-month follow-up . CONCLUSION Our series of patients with AA treated with antibiotics only are a product of the observation that some children improve with antibiotics alone at a stage in which surgery is still debatable . These results ( 89 % success rate ) support the conservative approach in cases of early appendicitis , without increased morbidity in failed cases Uncomplicated appendicitis may resolve spontaneously or require treatment with antibiotics or appendicectomy . The aim of this r and omized trial was to compare the outcome of a non‐antibiotic management strategy with that of antibiotic therapy in uncomplicated appendicitis Abstract Background : The aggressive surgical approach to patients suspected of having acute appendicitis for fear of perforation , and the inaccuracy of available diagnostic methods lead to an unacceptably high negative appendicectomy rate , especially in young women , in whom gynecological disorders frequently mimic appendicitis . Our objectives were to determine the value of diagnostic laparoscopy in women of child-bearing age to reduce the number of negative laparotomies and establish the correct diagnosis to allow prompt and appropriate treatment . Methods : 161 consecutive adult female patients under 50 years of age with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy  prior to the planned appendicectomy .  If an inflamed appendix was found , appendicectomy was usually done through a muscle-splitting McBurney incision . Other diagnoses were treated accordingly . A normal appendix was not removed . Results were compared to a group of 42 similar patients in whom the laparoscopy was omitted for various reasons , to 23 postmenopausal women , and to all 137 male adults , directly operated by the McBurney approach .  Results : After laparoscopy , 55 % of the patients required  appendicectomy  for appendicitis while in 23 % a gynecological diagnosis was made in spite of previous examination by a gynecologist . Fourteen percent had a negative laparoscopy . There were no false-negative results . The negative appendicectomy rate after laparoscopy was 5 % due to two false positives and eight laparoscopy failures . In the group of fertile females who escaped laparoscopy the negative appendicectomy rate was 38 % . The respective rates for postmenopausal women and men were 4 % and 8 % . Conclusions : All women of child-bearing age suspected of having acute appendicitis should undergo diagnostic laparoscopy prior to the planned appendicectomy , regardless of the certainty of the preoperative diagnosis . This is currently the only way to reduce the negative appendicectomy rate and establish a correct diagnosis allowing prompt and appropriate treatment . In male patients and postmenopausal women one may proceed directly to emergency appendicectomy BACKGROUND In this prospect i ve study , operative and nonoperative management of acute appendicitis were evaluated regarding their safety and cost effectiveness . METHODS Two hundred ninety patients presenting to our Emergency Department between March 2005 and March 2006 with acute appendicitis were included in this prospect i ve study . Nonoperative medical therapy was performed in 107 patients ( Group 1 ) , and 183 patients were treated surgically ( Group 2 ) . Routine follow-up controls were done on the 10th day , at the 3rd and 6th months and at the first year after discharge in Group 1 . Both groups were compared regarding age , gender , mean hospital stay , modified Alvarado score , morbidity , mortality , and cost effectiveness . RESULTS The male/female ratio of Groups 1 and 2 were 65/42 ( mean age : 30.98+/-1.30 ) and 125/58 ( mean age : 26.25+/-0.79 ) , respectively . In Group 1 , 19 patients were operated . Operation indications were resistance to therapy , patient 's request , and operation in another hospital . Although the mean hospital stay of Group 1 was statistically significantly longer than Group 2 , the mean cost of the therapy was $ 559 in Group 2 and $ 433 in Group 1 . Morbidity rates were similar , with no mortality in either group . CONCLUSION With its high success rate and cost effectiveness , medical treatment seems to be a good alternative to the gold st and ard therapy of surgery in management of acute appendicitis Aims : The purpose of this study was to compare open versus laparoscopic appendicectomy ( LA ) in complicated appendicitis . Material s and Methods : We prospect ively analyzed all children over a 2-year period who underwent appendicectomy in a single institution and found 30 cases of complicated appendicitis diagnosed on the table and confirmed by histopathology . These children were allocated r and omly into Group 1 if they had LA and Group 2 if they had open appendicectomy ( OA ) , solely based on surgeon assessment . The parameters assessed were duration of symptoms before surgery , use of postoperative parenteral analgesia , timing of initiation of feeds after surgery , postoperative complications and duration of postoperative stay . Results : Of the 30 patients with complicated appendicitis , 12 patients in Group 1 underwent LA and 18 patients in Group 2 underwent OA . The two groups were comparable for age and sex . Children in Group 1 were found to need less parenteral analgesia ( two out of 12 versus six out of 18 ) . Postoperatively , feeds were started earlier in Group 1 than in Group 2 ( 2.5 days versus 3.7 days ) . The average postoperative hospital stay was 5 days in Group 1 and 7.5 days in Group 2 . There were only minor wound infections in Group1 as against two major complications in Group 2 . There was no mortality in either group . Conclusions : In complicated appendicitis , laparoscopic approach carries definite advantages with less postoperative morbidity and hospital stay . It is a feasible and better alternative than the open approach in complicated appendicitis OBJECTIVES To assess the utility of laparoscopic versus conventional surgical exploration in premenopausal women with suspected acute appendicitis . METHOD Female patients aged 15 - 45 years in whom an independent decision to undertake surgical exploration had been made , were r and omised to laparoscopic or open procedures .  Comparison of patient groups was conducted on an intention-to-treat basis . RESULTS Eighteen patients underwent laparoscopic exploration  , with 1 procedure requiring conversion to lower midline laparotomy . Open surgical exploration was performed primarily in 16 patients .  Postoperative complications ( 3 patients versus 1 patient ) and diagnostic errors ( 5 patients versus 1 patient ) were more frequent in patients undergoing open surgical procedures . Laparoscopic procedures tended to be of longer duration than open operations , but were generally associated with slightly more favourable indices of postoperative recovery ( analgesic requirement , postoperative hospitalisation , return to normal activity , return to work ) . In patients found not to have acute appendicitis , the difference in mean postoperative hospitalisation following laparoscopic intervention ( 2.6 days ) and conventional surgery ( 3.4 days ) approached statistical significance ( p < 0.1 ) . CONCLUSIONS Laparoscopy may carry some diagnostic advantage over open surgery in premenopausal women with suspected acute appendicitis . Patients found not to have acute appendicitis have a marginally shorter period of hospitalisation after laparoscopic intervention . The outcome following laparoscopic appendicectomy for confirmed acute appendicitis is at least equivalent to that achieved with conventional appendicectomy . Laparoscopic exploration is an acceptable option in premonopausal women requiring surgery for suspected acute appendicitis BACKGROUND In 2012 , a protocol for routine  outpatient laparoscopic appendectomy for uncomplicated appendicitis was published reflecting high success , low morbidity , and significant cost savings . Despite this , national data reflect that the majority of laparoscopic appendectomies are performed with overnight admission . This study up date s our experience with outpatient appendectomy  since our initial report , confirming the efficacy of this approach . METHODS In July 2010 , a prospect i ve protocol for outpatient  laparoscopic appendectomy  was adopted at our institution . Patients were dismissed from the postanesthesia recovery room or day surgery if they met predefined criteria for dismissal . Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management . An institutional review board – approved retrospective review of patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2012 was performed to analyze success of outpatient management , postoperative morbidity and mortality , as well as readmission rates . RESULTS Three hundred forty-five patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame . There were 166 men and 179 women , with a mean age of 35 years . Three hundred five patients were managed as out patients , with a success rate of 88 % . Forty patients ( 12 % ) were admitted for preexisting comorbidities ( 15 patients ) , postoperative morbidity ( 6 patients ) , or lack of transportation or home support ( 19 patients ) . Twenty-three patients ( 6.6 % ) experienced postoperative morbidity . There were no mortalities . Four patients ( 1 % ) were readmitted for transient fever , nausea/vomiting , partial small bowel obstruction , and deep venous thrombosis . CONCLUSION Outpatient laparoscopic appendectomy can be performed with a high rate of success , a low morbidity , and a low readmission rate . This study reaffirms our original pilot study and should serve as the basis for a change in the st and ard of care for appendicitis . LEVEL OF EVIDENCE Therapeutic study , level To demonstrate the efficacy of oral metronidazole ( OM ) in simple or complicated appendicitis with localized peritonitis , a r and omized prospect i ve study was carried out in 1083 patients , ranging in age from 4 to 50 years ( mean age , 21.38 ) . The patients were r and omly divided into two groups . The study group ( SG ) ( 524 patients ) received OM ( 500 mg for adults , 7 - 10 mg/kg if less than 15 years ) 2 - 3 hours before operation . The drug was continued 4 to 5 hours after operation , every 8 hours , for three doses if the appendix was mild to severely inflamed . In the case of complicated appendicitis ( 114 patients ) , the same dose was given for 3 to 6 days , depending on the absence or presence of pus . Ceftizoxime was administered to the control group ( CG ) ( 559 patients ) 2 to 3 hours before operation and then postoperatively every 6 hours for three doses if the appendix was mild to severely inflamed . The complicated cases in the CG ( 120 patients ) received a combination of penicillin , chloramphenicol , and gentamicin for 3 to 6 days , depending on the absence or presence of pus . The serum concentration of metronidazole  measured in 43 patients was at bactericidal level in 40 ( mean + /- SD st and ard deviation , 10.65 + /- 4.89 microg/mL ) . The rate of wound infection was not significantly different in the SG and the CG with the same degree of pathology ( 3.17 % vs 2.96 % if uncomplicated ; 15.78 % vs 14.16 % if complicated , respectively ) . Pelvic collection occurred in four adults and one child in the CG with perforated appendicitis ( 4.16 % ) . The same complication developed in two adults and two children in the SG with perforated appendicitis ( 3.5 % ) . All six adults and one of the children in the SG had to be re-explored , whereas the remaining two children responded to conservative management  ( OM and gentamicin ) . In uncomplicated cases , hospital stay and hospital charge were both almost the same in both groups . However , length of hospitalization was nearly 1 day shorter and hospital cost per day was about 30 per cent less in complicated cases in the SG as compared with the CG . Conclusively , OM may not only substitute parenteral antibiotics in acute appendicitis as a prophylactic agent , but it may also be used as a cost-effective drug and is more convenient to the patient INTRODUCTION Appendicitis is the most common emergency condition in children . Historically , a 3-drug regimen consisting of ampicillin , gentamicin , and clindamycin ( AGC ) has been used postoperatively for perforated appendicitis . A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole ( CM ) to be a more simple and cost-effective antibiotic strategy . Therefore , we performed a prospect i ve , r and omized trial to compare efficacy and cost-effectiveness of these 2 regimens . METHODS After internal review board approval ( IRB no. 04 12 - 149 ) , children found to have perforated appendicitis at appendectomy were r and omized to either once daily dosing of CM ( 2 total doses per day ) or st and ard dosing of AGC ( 11 total doses per day ) . Perforation was defined as an identifiable hole in the appendix . The operative approach ( laparoscopic ) , length of antibiotic use , and criteria for discharge were st and ardized for the groups . Based on our retrospective analysis using length of postoperative hospitalization as a primary end point , a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82 . RESULTS One hundred patients underwent laparoscopic appendectomy for perforated appendicitis . On presentation , there were no differences in sex distribution , days of symptoms , temperature , or leukocyte count . There was no difference in abscess rate or wound infections between groups . The CM group result ed in significantly less antibiotic charges then the AGC group . CONCLUSIONS Once daily dosing with the 2-drug regimen ( CM ) offers a more efficient , cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen R and omised assessment of new laparoscopic surgical techniques is difficult . Surgeons need time to become experienced with the methods and tend , when they have experience , to favour one or other approach . We have carried out a prospect i ve r and omised comparison of laparoscopic and conventional appendicectomy done by surgeons of comparable experience in patients with suspected acute appendicitis . Postoperative management decisions were made by surgeons other than the operating surgeon . 140 patients were r and omly assigned to open ( OA ) or laparoscopic ( LA ) appendicectomy ( 70 each ) . The age , sex ratio , duration of symptoms , and proportion of patients with histologically confirmed appendicitis was similar in the two groups . Operating time was longer for LA than for OA ( mean 70.3 [ SD 21.9 ] vs 46.5 [ 25.9 ] min ; p < 0.001 ) . There were no major intraoperative complications in either group . 14 ( 20 % ) patients in the LA group required conversion to an open operation . No significant differences between the groups were found postoperatively for pain score , analgesic requirement , time to re introduction of diet , or hospital stay .  46 LA patients and 42 OA patients attended follow-up 3 weeks after surgery . Similar proportions had returned to work ( 36 [ 79 % ] vs 31 [ 74 % ] ) . The frequency of wound complications and wound pain after leaving hospital was lower after LA but not significantly so . We conclude that the postoperative course after LA and conventional OA does not differ significantly An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis . The objective of this study was to compare the costs of antibiotics alone  versus  appendicectomy  in treating uncomplicated acute appendicitis within the r and omized controlled APPAC ( APPendicitis ACuta ) trial INTRODUCTION Perforated appendicitis is a common condition in children , which , in a small number of patients , may be complicated by a well-formed abscess . Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy . Although this strategy has become well accepted , there are no published data comparing initial nonoperative management ( drainage/interval appendectomy ) to appendectomy upon presentation with an abscess . Therefore , we conducted a r and omized trial comparing these 2 management strategies . METHODS After internal review board approval ( # 06 11 - 164 ) , children who presented with a well-defined abdominal abscess by computed tomographic imaging were r and omized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess  ( when possible ) , followed by interval laparoscopic appendectomy approximately 10 weeks later . This was a pilot study with a sample size of 40 , which was based on our recent volume of patients presenting with appendicitis and abscess . RESULTS On presentation , there were no differences between the 2 groups regarding age , weight , body mass index , sex distribution , temperature , leukocyte count , number of abscesses , or greatest 2-dimensional area of abscess in the axial view . Regarding outcomes , there were no differences in length of total hospitalization , recurrent abscess rates , or overall charges . There was a trend toward a longer operating time in patients undergoing initial appendectomy ( 61 minutes versus 42 minutes mean , P = .06 ) . CONCLUSIONS Although initial laparoscopic appendectomy trends toward a requiring longer operative time , there seems to be no advantages between these strategies in terms of total hospitalization , recurrent abscess rate , or total charges 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 The total leucocyte count ( TLC ) and neutrophil percentage ( NP ) were studied prospect ively in 1032 patients who underwent appendicectomy for suspected acute appendicitis . On histopathological study of the resected appendices , 97 patients had normal appendices , and 935 patients had acutely inflamed , gangrenous or perforated appendicitis . Statistically more patients with appendicitis had either raised TLC or raised NP compared with patients with normal appendices ( P less than 0.001 ) , and also compared with 357 patients who were admitted with right lower quadrant abdominal pain but were not subjected to operation ( P less than 0.001 ) . The sensitivity and specificity of raised TLC in diagnosing appendicitis for patients who underwent appendicectomy  were 81.4 % and 77.3 % , respectively . Sensitivity increased when either raised TLC or raised NP were used , but specificity decreased . In contrast , sensitivity decreased when both raised TLC and raised NP were used together , but specificity increased . Raised TLC , preferably combined with raised NP , is a useful diagnostic aid in acute appendicitis . The TLC and NP , however , should only be interpreted in the light of physical findings in patients with suspected appendicitis because these blood tests have false positive and false negative results Two groups of 30 women with clinical signs of appendicitis were r and omized to immediate appendicectomy or diagnostic laparoscopy . In the latter group , appendicectomy was performed if a diagnosis of acute appendicitis was established or if the appendix could not be visualized . Eleven patients undergoing immediate operation had unnecessary appendicectomy  , compared with two having laparoscopy . This difference of 30 per cent ( 95 per cent confidence interval 11–49 per cent ) was significant ( P = 0.01 ) . There was no significant difference in postoperative morbidity rate in the two groups . Diagnostic laparoscopy is a useful preliminary investigation in women with clinical signs of acute appendicitis AIMS OF THE STUDY The authors present an accurate and comprehensive snapshot of appendicitis in the last decade of the 20 ( th ) century . The present study also aims to determine the influence of introduction of laparoscopic techniques on the quality of appendicitis therapy . PATIENTS AND METHODS All consecutive patients admitted for suspected appendicitis were recruited into this prospect i ve multicenter study . Two different periods of time were considered : from 1 . 7 . 1988 to 31 . 12 . 1989 , 6 266 patients from 18 hospitals were included , and from 1 . 6 . 1996 to 31 . 5 . 1997 , 7 398 patients from 34 institutions . RESULTS In the first period ( 1988/89 ) , 1 869 patients were treated conservatively ( 29.8 % ) , 4 397 ( 70.2 % ) were operated . Histopathological analysis of the appendix documented no acute inflammation in 28.8 % , the perforation rate was 8.3 % and the wound infection rate 9.6 % . In the second period ( 1996/97 ) , 2 430 patients were treated conservatively ( 32.8 % ) , in 24.9 % of all operated cases , the histopathological examination shows no acute inflammation of the appendix , the perforation rate was 5.9 % and the rate of wound infections 2.5 % . During this second period , 33.2 % of all appendectomies were performed using the laparoscope , the conversion rate was 7.2 % . CONCLUSIONS The introduction of laparoscopic techniques did not modify the operative indications for treatment of appendicitis . An increase in the number of normal appendices removed was not observed . The number of perforations and the incidence of wound infections was significantly reduced in the second period BACKGROUND / PURPOSE Appendicitis is the most common surgical emergency in children . However , management varies widely . The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis . METHODS Data were collected prospect ively for 3 successive cohorts : All patients operated for suspected appendicitis were included . The pathway was modified after interim analysis of group B data . P < .05 was significant . RESULTS Six hundred patients were included . When compared with group A , group C patients were more likely to receive  preoperative antibiotics  ( P < .0001 ) , undergo  formal pain assessment ( P < .0001 ) , and be operated before midnight ( P = .025 ) . There was a significant decrease in readmission rates from 10.0 % to 4.2 % ( P = .023 ) despite an increase in cases of gangrenous and perforated appendicitis ( P = .010 ) . CONCLUSIONS The introduction of a care pathway result ed in improved compliance with antibiotic regimens , more frequent pain assessment , and fewer post-midnight operations . Postappendicectomy readmission rates were reduced despite an increase in disease severity . This was achieved by critical reevaluation of outcomes and pathway re design where appropriate
The major primary outcomes show a high recurrence rate and failed treatment associated with the conservative management of appendicitis .
The other outcomes obtained show that there is an increased incidence of complications associated with operative management .
Economic implication s and cost-effectiveness analysis show that conservative treatment may be preferred .
The length of hospital stay was significantly higher in conservative approach to management ; however , shorter time off activities was observed .
Appendicectomy has been accepted as the gold st and ard for the management of appendicitis over the years , but there has been an increasing evidence and trend toward the conservative approach to the management of appendicitis .
The aim of this review is to search existing literature and to evaluate and compare the conservative and operative approaches to the management of appendicitis .