Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient's factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon's skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.

To determine clinical and imaging predictors of recurrent appendicitis after non-operative management for children with perforated appendicitis presenting with an appendicular inflammatory mass.

A case-control study was carried out of children with clinical and ultrasonographic diagnosis of an appendicular inflammatory mass. Patients were divided into two groups according to the presence or not of recurrent appendicitis (or predisposing pathological findings during interval appendectomy). Several clinical and imaging factors were compared between both groups using an independent and progressive analysis to identify which were the most relevant predictors.

The persistence of symptoms after resolution of the appendicular inflammatory mass, as well as its time of resolution (p<0.001), were the most relevant factors during group classification. The identification of an ultrasonographic image of an appendicolith and the initial size of the mass were also identified as independent predictors (p<0.018 and p<0.01). The presence of the first two factors in a patient was strongly associated with recurrent appendicitis.

Persistent symptoms after the recovery of the initial episode, associated with a slow resolution of the appendicular inflammatory mass, are indications for an interval appendectomy. A previous history of appendicitis or detection of an ultrasonographic image of an appendicolith is the other indication for an interval appendectomy.

At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient's own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn's disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.

The management of appendiceal mass remains a matter of major controversy in the current literature. Currently, initial nonoperative management followed by interval appendectomy is favored over immediate appendicectomy. However, the necessity of doing an interval appendectomy has been questioned - is it a necessary evil? The present review revisits the above controversy, evaluates the current literature, assesses the need for interval appendectomy in adults, and provides recommendations.

Appropriate management of appendix mass is based on an accurate diagnosis of the underlying pathology. This is a report of a complex patient presenting with an appendix mass, whose surgery was deferred due to severe co-morbidities and who later died from severe metastatic disease. A 65-year-old lady presented with right iliac fossa pain and a mass. She was treated for an appendix mass initially and when the mass failed to resolve after four weeks, she was thoroughly investigated for the possibility of a tumour. Severe co-morbities had a significant impact on her management as definitive surgery was delayed. She represented 10 months after the initial admission with small bowel obstruction and died of metastatic caecal cancer. Management of appendix mass must entail a careful approach to investigating and treatment with emphasis on early intervention if the mass does not resolve promptly. This will avoid delayed diagnosis, treatment and a detrimental impact on prognosis.

No standardized approach is available for the management of complicated appendicitis defined as appendiceal abscess and phlegmon. This study used meta-analytic techniques to compare conservative treatment versus acute appendectomy.

Comparative studies were identified by a literature search. The end points evaluated were overall complications, need for reoperation, duration of hospital stay, and duration of intravenous antibiotics. Heterogeneity was assessed and a sensitivity analysis was performed to account for bias in patient selection.

Seventeen studies (16 nonrandomized retrospective and 1 nonrandomized prospective) reported on 1,572 patients: 847 patients received conservative treatment and 725 had acute appendectomy. Conservative treatment was associated with significantly less overall complications, wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations. No significant difference was found in the duration of first hospitalization, the overall duration of hospital stay, and the duration of intravenous antibiotics. Overall complications remained significantly less in the conservative treatment group during sensitivity analysis of studies including only pediatric patients, high-quality studies, more recent studies, and studies with a larger group of patients.

The conservative management of complicated appendicitis is associated with a decrease in complication and reoperation rate compared with acute appendectomy, and it has a similar duration of hospital stay. Because of significant heterogeneity between studies, additional studies should be undertaken to confirm these findings.

Although appendix mass occurs in 10% of patients with acute appendicitis, its surgical management is surrounded with controversy. This article reviews some of the controversial issues in the management of appendix mass.

A search of the English literature was conducted for "appendiceal mass," "interval appendicectomy," and "laparoscopic appendicectomy" and manual cross-referencing.

The majority of the studies were small and retrospective. Emergency appendicectomy for appendix mass is emerging as an alternative to conventional conservative treatment. It is feasible, safe, and cost-effective, allowing early diagnosis and treatment of unexpected pathology. However, the appropriate timing for emergency surgery is not clear. After successful conservative management, interval appendicectomy is not necessary and can safely be omitted, except in patients with recurrent symptoms. In patients over 40 years of age, other pathological causes of right iliac mass must be excluded by further investigations (colonoscopy and computerized tomography scan), and a close follow-up is needed. Laparoscopic appendicectomy whether in emergency or interval settings is feasible and safe and should replace the conventional open method. Large prospective, randomized controlled trials are lacking, and therefore, such trials are needed to scientifically compare emergency surgery vs conservative management without interval appendicectomy.

The management of adult inflammatory appendix mass is evolving. Traditional management has been shown to be initially conservative, with interval appendicectomy performed after the mass resolved. This remains the most common approach in UK surgical practice. Recently, an increasing number of studies have challenged this approach. This review looks at the management of the inflammatory appendix mass in the adult in light of these recent changes and suggests a management approach based on the current evidence.

A Medline, Pubmed and Cochrane database search was performed using key words including combinations of; appendix, appendiceal, interval, appendectomy, appendicectomy, mass, abscess, phlegmon, and appendicitis. All articles were cross-referenced.

A conservative management approach will be successful in the majority of patients presenting with an appendix mass. The incidence of recurrence of symptoms following successful conservative management is low.

After initial successful conservative management, routine use of interval appendicectomy is not justified in asymptomatic patients.

There is still much controversy surrounding whether interval appendicectomy is appropriate for adults with an appendiceal mass or abscess. The main debate centres on the recurrence rate, the complication rate of interval appendicectomy, and the potential for underlying malignancy. This review aims to assess current practice and to determine whether it is possible to define "best practice" for the asymptomatic patient who has had an appendiceal mass or abscess treated conservatively. I sent a postal questionnaire to 90 consultant general surgeons requesting information about their practice of interval appendicectomy. I also conducted a literature search confined to studies involving only adult patients. The 77.8% of questionnaires returned revealed that 53% of the surgeons perform routine interval appendicectomy, mainly because of concerns about recurrence. The preference was for open appendicectomy at 6 weeks to 3 months. The literature search revealed a recurrence rate of 10%-25%, with a complication rate of 23%. It was evident that the chances of missing malignancy are low and thorough investigation is better than interval appendicectomy in detecting colonic cancer. The practice of performing interval appendicectomy varies, with just over half of the surgeons surveyed performing this procedure routinely. The literature provides little evidence that interval appendicectomy is routinely indicated and would support the view that it is unnecessary in 75%-90% of cases. However, there is scope for further consideration of the use of laparoscopic interval appendicectomy and a randomised trial is needed to fully evaluate this issue.

Conservative management of advanced complicated appendicitis in children is becoming more common. Formation of an appendiceal mass or abscess may mitigate against urgent appendectomy during the acute stage, and conservative treatment followed by interval appendectomy has been advocated. We present our experience of interval laparoscopic appendectomy in our institution.

All children who were offered interval laparoscopic appendectomy between January 2000 and December 2004 were included. Retrospective case note analysis was performed and data collected included demographics, duration of symptoms, method of diagnosis, days of antibiotics, length of interval, operative time, length of hospital stay (conservative treatment and interval laparoscopic appendectomy), analgesia requirements, complications, and histology.

Thirty-six children, median age 8 years (range, 1-15 years) diagnosed with appendiceal mass or abscess were offered interval laparoscopic appendectomy by two surgeons in our institution: one patient declined interval laparoscopic appendectomy. Median antibiotic treatment was 10 days (range, 3-23 days). Median length of stay for conservative treatment was 6 days (range, 1-27 days). Five children required percutaneous drainage. For the 35 children who had interval laparoscopic appendectomy, the median interval was 93 days (range, 34-156 days) and median operative time was 55 minutes (range, 25-120 minutes). Median length of stay for interval laparoscopic appendectomy was 1 day (range, 1-3 days). There were no complications following interval laparoscopic appendectomy.

Interval laparoscopic appendectomy can be safely performed in children, is associated with a short hospital stay and minimal morbidity, analgesia, and scarring following conservative management of appendiceal mass or abscess. Interval laparoscopic appendectomy eliminates the risk of recurrent appendicitis and serves to excise undiagnosed carcinoid tumors. In future it may be possible to perform interval laparoscopic appendectomy as a day-case procedure in selected patients.

The purpose of this study was to study the clinical symptoms, laboratory data, and the characteristics of computed tomography (CT) imaging of nonoperated perforated appendicitis for predicting the recurrence of appendicitis.

Thirty-five patients with nonoperated perforated appendicitis were retrospectively reviewed for this study. During a median follow-up period of 1155 days, 7 patients had to receive an appendectomy owing to recurrent appendicitis. Accordingly, the patients were divided into 2 groups: the recurrence and the nonrecurrence group. The clinical characteristics between these 2 groups were compared.

Both of the 2 patients who had a past history of appendicitis suffered recurrent appendicitis (the recurrence versus the nonrecurrence group, P<.05). The only CT imaging relating to the recurrence of appendicitis is the presence of calcified appendicolith (the recurrence versus the nonrecurrence group, P<.001).

It is most likely that appendicitis will recur if a calcified appendicolith on CT imaging or a past history of appendicitis is presented. Interval appendectomy may be reserved only for those patients who possess one of these risk factors of recurrent appendicitis.

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 randomized trial.

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 randomized either to surgery or to antibiotic therapy. Patients randomized to surgery were operated on with open surgery or laparoscopically. Those randomized 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.

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.

Acute non-perforated 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.

The purpose of this study was to clarify the role of interval appendectomy after conservative treatment of an appendiceal mass.

From January 1998 to December 2003, patients with an appendiceal mass who received conservative treatment at the Taipei Veterans General Hospital were studied retrospectively. Data on demographics, rate of appendicitis recurrence, duration of hospital stay, and complication rate were collected and analyzed.

A total of 165 patients were included (89 males, 76 females). The mean age was 53.6 years (range 7-89 years). The rate of appendicitis recurrence after conservative treatment was 25.5%; most recurred within 6 months after discharge (83.3%). The benefit of preventing recurrence is less than 16% if interval appendectomy is performed 6 weeks after discharge and less than 10% if it is done 12 weeks later. The complication rate of appendectomy performed before or after recurrence was 10% in both groups. The duration of the second hospital stay for patients who underwent interval appendectomy before or after recurrence was 4.43 +/- 3.32 vs. 6.75 +/- 5.73 days (P = 0.023). Of the 165 patients, 17 (10.3%) had their diagnosis changed after survey or surgery, and 5 (3.03%) were found to have colon cancer upon follow-up.

Patients who recovered from conservative treatment of an appendiceal mass should undergo colonoscopy or barium enema to detect any underlying diseases and to rule out coexistent colorectal cancer. Routine interval appendectomy benefits less than 20% of patients.

A retrospective chart review of 32 patients who underwent laparoscopic interval appendectomy at the Children's Hospital of Eastern Ontario between May 1999 and December 2003 was performed. The age range was 0.5 to 18 years (mean, 11.8 years; median, 11.5 years). The interval time from the acute episode to the laparoscopic interval appendectomy ranged from 1 to 16 weeks (median, 6 weeks). The initial presentations were 11 patients with appendiceal abscess, 9 with appendiceal masses/phlegmons, and 12 patients with an acute but resolving clinical picture with ultrasonographic evidence of appendicitis. There were no wound infections or recurrent intra-abdominal abscesses. The average length of stay was 1.38 days, ranging from same-day discharge (1 patient) to a three-night stay (2 patients). There were no complications related to the laparoscopic technique, confirming reports that laparoscopic interval appendectomy is a technically safe procedure. Pathologic analysis of the appendices demonstrated acute or subacute changes in 14 patients (interval time = 7.9 weeks), chronic changes in 8 (interval time = 8.1 weeks), both acute and chronic changes in 5 (interval time = 8.2 weeks), and no pathologic diagnosis in 6 (interval time = 4.28 weeks). These findings support the need for interval appendectomy, and suggest that laparoscopy is a safe alternative to open appendectomy.

Interval appendectomy after conservative treatment of appendicitis with tumor formation remains controversial. The purpose of this study was to evaluate the efficacy of interval appendectomy based on a cost-effectiveness analysis.

This was a retrospective study including appendicitis patients with tumor formation who received conservative treatment at first admission to Taipei Veterans General Hospital between January 1998 and December 2003. Demographic data, rate of recurrent appendicitis, and medical costs were analyzed.

Of the 165 patients, 1 died after an acute myocardial infarction. The rate of recurrence of appendicitis after conservative treatment was 25.5%. The median cost of follow-up after conservative treatment was NT24,344 dollars. The median cost of interval appendectomy was NT47,746 dollars. The median cost of appendectomy after recurrent appendicitis was NT62,135 dollars. Routine interval appendectomy in all 164 patients would have cost NT7,830,344 dollars. The follow-up protocol with appendectomy after recurrence cost NT5,655,220 dollars. An additional NT2,175,124 dollars (38%) would have been needed for routine interval appendectomy compared with the follow-up policy, an extra NT13,263 dollars per person.

Routine interval appendectomy would increase the cost per patient by 38% compared with follow-up and appendectomy after recurrence. Routine interval appendectomy is not a cost-effective intervention.

This study examines the clinical characteristics of patients who developed recurrent appendicitis after previous nonoperative management of perforated appendicitis.

Retrospective chart review was performed, and data from the recurrent and initial episode of appendicitis were collected.

In all, 237 patients from 1989 to 2001 were managed nonoperatively for perforated appendicitis and 32 (14%) were readmitted for recurrent appendicitis. Median white blood cell count at recurrence was 9.5 (interquartile range [IQR]: 6.6 to 13.2] versus 13.1 [IQR: 10.8 to 16.1] at initial presentation (P = 0.002). Maximum temperature was 98.6 degrees F [IQR: 98.2 to 100.5] at recurrence versus 100.3 degrees F [IQR: 99.5 to 101.5] (P = 0.008). Median time for intravenous antibiotics use was 3 [IQR: 3 to 7] days at recurrence versus 6 [IQR: 4 to 8] days initially (P = 0.01). Inpatient stay was also shorter; median length was 6 [IQR: 3 to 8] days compared with 7 [IQR: 5 to 9] days at initial presentation (P = 0.02).

Patients managed nonoperatively for perforated appendicitis who later developed recurrent appendicitis exhibited a milder clinical course at recurrence. Elective interval appendectomy may be reserved until a recurrent episode.

The objective of this work was to conduct a truly rural-based study to evaluate, from our own rural data devoid of influence from urban-based studies, the management of appendiceal masses in a typical peripheral hospital in Nigeria. The study aimed to highlight the results of neglected appendicitis in our community and the occasional difficulty of making a correct preoperative diagnosis. It also sought to draw the attention of the health care practitioner in our community to the importance of continued enlightenment of the people regarding the need to seek medical treatment early. This was a retrospective study, with the setting at St. Victoria Specialist Hospital, Ekwulobia, Anambra State, Nigeria, a rural hospital serving its community. A series of 30 patients who were managed for an appendiceal mass between January 1, 1992 and December 31, 2001, a 10-year period, were included in the study. We identified the cases by reviewing the surgical register. The relevant case notes were retrieved from the Records Department. The following data were extracted for each patient: age and sex; how early the patient presented; the history and presentation of the patient; whether the diagnosis was made before or during surgery; the treatment modality; length of hospital stay; and outcome. The results showed that 13 patients (43.3%) presented more than 1 week after the onset of symptoms. The age range was 15 to 60 years (average 27 years); 13 patients (43.3%) were in the age range of 40-49 years. Twenty men and ten women were treated, giving a male/female ratio of 2:1. The main clinical features were fever, anorexia, pain, tenderness, and a palpable mass in the right iliac fossa. The problem was diagnosed before surgery in 23 patients (76.7%) and during surgery in 7 (23.3%). Treatment modalities were conservative + interval appendectomy in 18 patients (60%); open and close + conservative + interval appendectomy in 3 patients (10%); immediate appendectomy without burying the stump in 2 cases (6.7%); right hemicolectomy (in one 40-year-old woman and one 55-year-old man); and incision and drainage of an appendiceal abscess in 5 patients (16.7%). No deaths were recorded. The study showed that appendical masses are most prevalent during the fifth decade of life and are rare before age 10 and after age 60. More men are affected than women, and most cases can be diagnosed before surgery, although some patients must await more sophisticated diagnostic tools or surgical exploration for diagnosis.

Our current treatment of an appendiceal mass is initially conservative, followed by an interval appendectomy. The necessity of this routine interval appendectomy is debatable. A study was conducted to evaluate whether surgical factors and pathological features of the excised appendices support interval appendectomy.

We performed a retrospective study at the University Hospital Groningen and the Deventer Ziekenhuis. All patients diagnosed with an appendiceal mass in the period January 1991 to January 1997 were identified using the hospital database. The medical records of all these patients (n = 233, 108 M, 125 F) were reviewed. The clinical course of the appendiceal mass patients was split up into three distinct episodes: initial diagnosis and treatment of the appendiceal mass, the interval period and the interval appendectomy. Presenting symptoms, findings at clinical examination and additional imaging (ultrasound) were registered, as well as the course of the primary hospitalisation, the interval period, and the interval appendectomy. Results of histological examination of all resected specimens were reviewed.

It was found that clinical findings alone were not specific enough to diagnose an appendiceal mass; 47% had a palpable abdominal mass and the median temperature was 38.2 degrees C ranging from 36 to 40.5 degrees C. Ultrasound examination was done in 69% of patients and showed an appendiceal mass in 72%. During the interval period, 4 patients presented with an appendiceal mass needing drainage, and 3 with acute appendicitis requiring emergency appendectomy. At interval appendectomy, histological examination of resection specimen showed a normal appendix without signs of previous inflammation in 30% of cases. In addition, complications due to interval appendectomy were seen in 18% of patients, including sepsis, bowel perforation, small bowel ileus, and various wound abscesses.

We conclude that when causes for the appendiceal mass other than appendicitis are excluded, interval appendectomy seems unnecessary in patients who respond well to initial conservative treatment.

To evaluate the outcome of patients treated for appendiceal abscess, and managed either conservatively or surgically, and to describe the short and long-term outcome as well as incidence of interval appendicectomy in those treated conservatively.

Retrospective study.

University hospital, Sweden.

Ninety-three patients with the diagnosis of appendiceal abscess, 50 treated conservatively and 43 who were operated on, with a mean age of 46 (14-93) years. Mean (range) follow-up for patients operated on was 65 (11-135) and for those treated conservatively 66 (6-136) months.

Course of acute disease, recorded complications, recurrence of appendicitis and incidence of interval appendicectomy during follow-up.

The duration of pain before admission was 4 (0.5-82) days for those operated on and 7 (2-60) days for those treated conservatively. A palpable mass was more common in the conservatively managed group. Complications were common among patients who were operated on. No interval appendicectomies were done during the second half of the study period. 4 of the patients treated conservatively (8%) had an underlying tumour diagnosed at follow-up.

Operative management of patients with appendiceal masses seems to be associated with a high risk of postoperative complications and the risk of a more extensive surgical procedure. If possible, a conservative approach should be advocated. Because of inaccurate radiological imaging during the acute phase and the risk of an underlying malignancy, routine follow-up is necessary. Routine interval appendicectomy cannot be recommended.

Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess.

This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8-10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998.

Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections.

We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay.