Operative versus non-operative therapy for acute phlegmon of the appendix: Is it safer? A case report and review of the literature

Abstract

HighlightsThis case report reviews complicated appendicitis that failed non-operative management, underwent appendectomy, and did well post-operatively.In the present case, the patient’s clinical picture was substantially worse on presentation four weeks post-diagnosis when compared to his prior hospitalizations, indicating failed non-operative treatment.This case report provides an opportunity to review the management of complicated perforated appendicitis.This case report could help to increase the awareness of medical professionals who manage similar cases and outline best treatment options such as early surgical intervention.

Is Emergency Appendicectomy Better Than Elective Appendicectomy for the Treatment of Appendiceal Phlegmon?: A Review

“…Reduces length of hospital stay in the initial admission [19] Operative difficulty [21] Safer with a lower risk of iatrogenic bowel injury [24] Failure of initial conservative management [18] Reduces financial burden [10] Increased risk of morbidity [27] Recurrent attacks are milder than the primary attack [27] Higher incidence of recurrent attacks of appendicitis [18,20] Comparatively lesser intraoperative adhesions [19] Higher risk of surgical site infections [24] Easier delineation of the intraoperative anatomy [25] Missed diagnosis of an underlying condition like colitis or malignancy [2,20] Lesser rate of re-admissions [1,2] Increased risk in organspace infections [24] The shorter length of hospital stay during both the admissions [24] Failure of this management can lead to surgical admission requiring bowel resection [21] Better health-related quality of life [10] Higher risk of occurrence of abdominal/pelvic abscess [25] Loss of patients to follow-up [2] Laparoscopic approach can reduce the risk of post-operative complications [20] The increased financial burden due to multiple admissions [1]…”

“…Acute appendicitis is the inflammation of the appendix which is caused by the obstruction of the appendiceal lumen by faecolith, foreign body, lymphoid hyperplasia, or malignancy. This causes increased intraluminal pressure eventually leading to appendiceal ischemia and necrosis [ 1 ].…”

“…However, the incidence of overall complications, abdominal/pelvic abscesses, and wound infections were higher in the patients who underwent emergency appendicectomy as compared to those who underwent conservative management with a p-value of 0.0002, 0.02 and <0.001, respectively [ 22 ]. A case report by Elkbuli et al showed how a 19-year-old patient managed conservatively required recurrent hospitalizations and increased the burden on healthcare [ 1 ]. In a randomized control trial by Blakely et.al, involving children, comparing early appendectomy with interval appendectomy, it was found that those treated with early appendectomy returned to normal activities an average of five days earlier (p < 0.001) [ 23 ].…”

“…But the abdomen is much more frequently left untouched than it should be, and that an operation is too often deferred until practically useless" -Sir William Osler Appendicitis is one of the most common surgical emergencies with a prevalence encountered in the emergency room. It occurs most commonly in the 2nd and 3rd decades of life and carries a higher risk in men as compared to women [1]. The typical symptoms are migration of pain from the periumbilical region to the right iliac fossa associated with nausea, vomiting, anorexia, fever, and usually leukocytosis.…”

Perforated appendicitis in the setting of a massive ventral hernia, morbid obesity, and multiple severe comorbidities: challenges in acute management

“…Despite the traditional viewpoint that complicated appendicitis warrants urgent surgical treatment,3 16 17 several groups have shown that complicated appendicitis can be safely managed conservatively. In a meta-analysis of complicated appendicitis, medical management produced fewer overall complications, wound infections, abdominal/pelvic abscesses, and ileus/bowel obstructions.…”