RANDOMIZED CONTROLLED TRIAL

Laparoscopic Surgery or Conservative Treatment for

Appendiceal Abscess in Adults?
A Randomized Controlled Trial
Panu Mentula, MD, PhD, Henna Sammalkorpi, MD, and Ari Leppäniemi, MD, PhD

surgery and nonsurgical approach have been published. According

Objective: We hypothesized that immediate laparoscopic surgery for appen-
to 2 systematic reviews and meta-analysis, the nonsurgical approach
diceal abscess would result in faster recovery than conservative treatment.
is recommended, as it is associated with lower complication rate
Background: On the basis of the retrospective studies, conservative manage-
and lower morbidity rate.3,4 Studies included in these meta-analyses
ment of appendiceal abscess is recommended as a first line treatment, but
were done on both children and adults. Also, both of these analyses
some controversy exists.
combined patients with appendiceal abscess and appendiceal mass or
Methods: Sixty adult patients diagnosed with appendiceal abscess were ran-
phlegmon, with mixed diagnostic methods. Therefore, it is difficult to
domly assigned to either laparoscopic surgery (n = 30) or conservative treat-
draw conclusions for the management of adult patients with abscess
ment (n = 30). Hospital stay, recurrences, additional interventions, and com-
diagnosed with diagnostic imaging.
plications within 60 days from randomization were recorded.
A few authors have recommended acute surgery for appen-
Results: There was no difference in hospital stay: 4 days (interquartile range:
diceal mass including abscess because of high rate of recurrences
3–5 days) in the laparoscopy group versus 5 days (3–8) in the conservative
after nonoperative management and the relatively high rate of bowel
group, P = 0.105. Patients in the laparoscopy group had 10% risk for bowel
malignancy.5 In adult patients, no prospective studies comparing
resection and 13% risk for incomplete appendectomy. There were significantly
acute surgery and conservative management for appendiceal abscess
fewer patients with unplanned readmissions in the laparoscopy group: 1 (3%)
have been published to date. In children, one prospective nonran-
versus 8 (27%), P = 0.026. Additional interventions were required in 2 (7%)
domized study6 showed that early surgical intervention was benefi-
patients in the laparoscopy group (percutaneous drainage) and in 9 (30%)
cial over nonoperative management whereas the only published small
patients in the conservative group (surgery), P = 0.042. Recurrent abscesses
prospective randomized study7 did not found any significant differ-
and failure to respond to conservative treatment were the main reasons for
ences between the 2 approaches.
additional interventions. Open surgery was required in 3 (10%) patients in the
Immediate appendectomy for appendiceal abscess may be
laparoscopy group and in 4 (13%) patients in the conservative group. Post-
technically challenging, and surgical exploration may lead to ileo-
operative complications occurred in 3 patients in laparoscopic group versus 2
cecal resection or right-sided hemicolectomy. Surgical complications
patients in the conservative group. The rate of uneventful recovery was 90%
are the major concern when operating on patient with appendiceal
in the laparoscopy group versus 50% in the conservative group, P = 0.002.
abscess, and wound complications occur in up to 17% of patients
Conclusions: Laparoscopic surgery in experienced hands is safe and feasible
after open appendectomy.1,4 Laparoscopic surgery for acute appen-
first-line treatment for appendiceal abscess. It is associated with fewer read-
dicitis has now become a standard of care in many centers.8 It has
missions and fewer additional interventions than conservative treatment with
been used also in patients with appendiceal abscess.9 Because laparo-
comparable hospital stay.
scopic appendectomy is associated with reduced risk of surgical site
Keywords: abdominal abscess, appendicitis, drainage, laparoscopy, random- infections,10,11 it may provide a better alternative for acute manage-
ized controlled trial ment appendiceal abscess than open surgery. However, little data are
available for comparison of laparoscopic surgery versus conservative
(Ann Surg 2015;262:237–242)
management in these patients.
Before initiation of this study, authors’ personal experiences
of immediate laparoscopic surgery on patients with appendiceal ab-
A ppendiceal abscess is encountered in 7% of adult patients with
acute appendicitis.1 Nowadays, abscess is usually diagnosed pre-
operatively, because diagnostic imaging is frequently used in assess-
scess had been encouraging. Because the level of evidence for the
management of appendiceal abscess in adults was based only on
heterogenic retrospective studies recommending conservative man-
ment of patients with possible appendicitis.2 Although appendectomy
agement, a prospective randomized trial comparing immediate la-
is considered a gold standard for treatment of acute appendicitis,
paroscopic surgery to conservative management was justified.
the management of patients with appendiceal abscess is controver-
sial. Both operative and conservative treatments have been used with
variable success. Several retrospective studies comparing immediate METHODS
Study Design and Participants
This was a single-center randomized controlled trial comparing
From the Department of Abdominal Surgery, Helsinki University Central Hospital, laparoscopic surgery and conservative management in adult patients
Helsinki, Finland. with appendiceal abscess. The study with 2 parallel groups designed
Disclosure: The study was financially supported by Mary and Georg C. Ehrnrooth
foundation and by special state subsidy for health science research. The authors
to identify superiority was conducted in Finland. The study was ap-
declare no conflicts of interest. proved by The Ethics Committee, Department of Surgery, Helsinki
Reprints: Panu Mentula, MD, PhD, Department of Abdominal Surgery, Helsinki and Uusimaa Hospital District. The study conformed to good clinical
University Central Hospital, P.O. Box 340, 00029 HUS, Helsinki, Finland. practice guidelines and followed the recommendations of the Dec-
E-mail: panu.mentula@hus.fi.
Copyright C 2015 Wolters Kluwer Health, Inc. All rights reserved.
laration of Helsinki. The study was registered in Clinicaltrials.gov
ISSN: 0003-4932/15/26202-0237 database (NCT01283815) on January 20, 2011. The study was carried
DOI: 10.1097/SLA.0000000000001200 out between February 2011 and August 2014 in Helsinki University

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Mentula et al
Central Hospital, which serves as both secondary and tertiary referral
center. This is the only hospital in Helsinki providing acute general
surgery; thus, all patients living in Helsinki requiring hospitalization
or surgery for appendiceal abscess are treated there. Adult patients
with appendiceal abscess diagnosed by either computed tomography
or ultrasonography or both were assessed for eligibility. Decision to
perform diagnostic imaging was not based on protocol but frequently
used when there was a clinical suspicion of appendiceal abscess.
Eligible participants were adult patients presenting with appen-
diceal abscess with largest diameter of at least 2 cm in the imaging
study. Exclusion criteria included (1) antimicrobial therapy for more
than 24 hours before randomization; (2) attempted drainage before
randomization; (3) age more than 80 years or less than 18 years;
(4) pregnancy; (5) allergy to either cefuroxime or metronidazole;
(6) severe chronic disease, which substantially increased the risk
for operative mortality; (7) previous major intra-abdominal surgery,
which may have caused intra-abdominal adhesions; (8) carrier of a re-
sistant bacterial strain; and (9) being institutionalized or hospitalized
for at least 2 weeks before randomization. Although not described in
the original study protocol, we found that it was unethical to random-
ize patients with (10) suspicion of malignant disease in the imaging
study and patients with (11) clinically diffuse peritonitis, and these
patients were also excluded. Written informed consent was obtained
from all eligible patients before randomization.
Treatment and Follow-up
The both groups received the same antimicrobial therapy, with
combination of intravenous cefuroxime 1.5 g × 3 per day and metron-
idazole 500 mg × 3 per day. Antimicrobial therapy was initiated at the
time of randomization or no more than 24 hours before randomiza-
tion and continued until discharge. Intravenous antibiotics continued
until patient was afebrile (body temperature <37.5◦ C for 24 hours),
C-reactive protein (CRP) was declining and less than 150 mg/L. Af-
ter discharge, patients were given combination of oral cephalexin
500 mg × 3 per day and metronidazole 500 mg × 3 per day for
7 days.
In the conservative treatment group, ultrasound-guided percu-
taneous drainage of the abscess was attempted as soon as possible in
case the largest diameter of the abscess was 3 cm or more.12 If place-
ment of the drain was not feasible, needle aspiration of the abscess
was attempted. Bacterial culture was taken from pus.
In the laparoscopy group, laparoscopic appendectomy was
scheduled within next 8 hours. A standard laparoscopy instruments
with 3 trocars and 30 degree 10 mm optic was used. After estab-
lishing pneumoperitoneum and placement of trocars, the abscess was
entered using blunt dissection, and abscess was emptied with suc-
tion device and sample for bacterial culture was taken. After that
inflamed appendix was identified and dissected free from adhesion
and mesoappendix was divided. The base of the appendix was closed
either with endostapler or single Endoloop ligature. All specimens
were extracted inside disposable retrieval bag to avoid contamina-
tions of the wound. In case no appendix was found, only laparoscopic
drainage of abscess was considered as an adequate treatment. Con-
version to open surgery was done if bowel perforation occurred or
if closure of the stump of the appendix was not technically possi-
ble. Also, in case where malignancy was suspected during the course
of operation, the operation was converted to open surgery. Drainage
after surgery was not obligatory and was used selectively.
During hospital stay, daily blood tests were taken for plasma
CRP and leucocyte count measurement. Drains were removed as soon
as they did not show any purulent discharge.
Patients were discharged when they were able to tolerate nor-
mal diet, drain was removed, did not require opiates for pain man-
agement, and there was no need for intravenous antibiotics. After
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Annals of Surgery r Volume 262, Number 2, August 2015
discharge, patients were told to contact in case of high fever or wors-
ening of symptoms. At 30 to 36 days after randomization, outpatient
visit with measurement of plasma CRP and leucocyte count was done.
Repeat computed tomographic (CT) scan was performed if patient
was still in hospital 7 days after randomization. Also, in case patient
was readmitted after discharge or if patient had any signs of ongoing
infection during outpatient visit repeat CT scan was done. Patients
were advised to contact us in case of any worsening of symptoms
at home. Because this was the only hospital in the region providing
care for acute general surgical patients, all data of readmissions was
available for review. Interval appendectomy for conservatively treated
patients was not routinely offered during outpatient visit, but it was
scheduled later than 60 days from randomization if a patient insisted
it. To rule out malignancy, colonoscopy was scheduled for all patients
with age more than 40 years, who were treated nonsurgically at the
time of 30- to 36-day outpatient visit.
Outcomes
Primary Outcome
The main outcome measure was hospital stay within 60 days
from randomization. This included both primary hospitalization and
possible readmissions within 60 days. No elective surgery was done
during this time period.
Secondary Outcomes
Secondary outcome measures included the following: (1)
the need of additional interventions. These included percutaneous
drainage and operations after primary intervention. (2) Residual ab-
scess on day 7 after randomization. (3) Attempted procedure not
successfully performed. In the laparoscopy group, the rate of con-
version and the rate of failed appendectomies were registered. In the
conservative group, the number of patients in whom planned per-
cutaneous drainage was not possible. (4) Complications within 60
after randomization. Complications were classified according to the
Clavien-Dindo classification.13 (5) Number of recurrent abscesses
within 60 days after randomization.
Sample Size
Sample size calculation was based on primary outcome mea-
sure. According to one study,9 the median hospital stay after laparo-
scopic surgery for appendiceal abscess was 6 days. On another study,
the initial nonoperative management resulted in median of 9 days
hospital stay,1 but this included also hospitalization for interval ap-
pendectomy for the majority of the patients. We assumed that hospital
stay for laparoscopic group would be 6 days and the standard deviation
for hospital stay 2.5 days in both groups. To show 2-day difference
in hospital stay, 52 patients had to be randomized 1:1. Two-sample
t test with 80% power and 5% alpha level was used for sample size
calculation with G∗ Power 3 software.14 According to this calculation
and possible dropouts, a sample size of 60 patients was chosen for
randomization.
Randomization
A block randomization with 1:1 allocation with randomly var-
ied block size of 4 to 6 was done using Blockrand 1.1 package with R
Statistical Software.15 Randomization cards were enclosed in sequen-
tially numbered, opaque, sealed envelopes and opened sequentially.
Statistical Analysis
Statistical analysis was done using IBM SPSS Statistics 20
(IBM Corp, Armonk, NY). Continuous variables were compared
using 2-sample t test for normally distributed data and differences
of means with 95% confidence intervals (CI) were calculated. For

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Annals of Surgery r Volume 262, Number 2, August 2015 Laparoscopy for Appendiceal Abscess

non-normally distributed data, Mann-Whitney U test was used. Cat- Primary Outcome
egorical data were analyzed using the Fisher exact test. All statistical There was no significant difference in hospital stay during
tests were 2-tailed. P values of less than 0.05 were considered sig- the first 60 days from randomization: median 4 days [interquartile
nificant. All data were analyzed according to the intention-to-treat range (IQR): 3–5 days] in the laparoscopy group and 5 days (3–8)
principle. in the conservative group, P = 0.105, with mean difference of 1.16
days (95% CI: 2.56–0.25). The length of primary hospitalization was
RESULTS similar in the both groups, but a significantly more readmission was
detected in the conservative group Table 3.
As shown in the Table 1, the baseline characteristics of the pa-
tients were comparable. All randomized patients received allocated
first-line treatment as shown in Figure 1. In the laparoscopy group,
abscess was found in 27 (90%) patients during the surgery. Two Need of Additional Interventions
patients had appendiceal mass without abscess, and 1 patient had There were significantly more patients in the conservative
mesenterial lymphadenitis, and there were no signs of appendicitis group needing additional interventions (Table 3). Two patients in
or abscess during surgery. The median length of the operation was the laparoscopy group required drainage for postoperative abscess,
52 minutes (IQR: 41–77). Appendectomy was successfully performed but no reoperations were required. Nine patients in the conservative
in 26 (87%) patients. In 1 patient no appendix was found, and 3 pa- group had to be operated on at median of 9 days after randomiza-
tients underwent incomplete appendectomy. Postoperative drainage tion (range: 5–59 days). Reasons for these operations were failure
was used in 13 (43%) patients. Conversion to open surgery was re- to respond to conservative therapy during the first hospitalization in
quired in 3 (10%) patients in the laparoscopy group. Reasons for 2 patients, recurrent or residual abscess with aggravating symptoms
conversion were iatrogenic bowel perforation (ileum and caecum) in after discharge in 6 patients, and uncomplicated acute appendicitis
2 patients, and suspicion of malignancy in 1 patient. Ileocecal re- after discharge in 1 patient. Two patients with recurrent abscess had
section (for the 2) and right hemicolectomy were performed in these additional drainage 1 and 7 days before surgery. Five of 9 operations
patients, respectively. The suspected malignancy appeared to be an were successfully done laparoscopically, 3 were converted from la-
inflammatory lesion secondary to appendiceal abscess in patholog- paroscopy to open, and 1 patient had open appendectomy. In 1 patient
ical examination. One patient in the laparoscopy group had small operated on day 59 after randomization, a stage IIIC carcinoma of
grade I neuroendocrine tumor of the appendix in the pathological cecum infiltrating adjacent sigmoid colon was found during the op-
examination, and appendectomy was considered curable. A single eration and after conversion right hemicolectomy and resection of
surgeon (P.M.) performed 28 (93%) of the operations in the laparo- sigmoid colon was done.
scopic group with failing to do complete appendectomy in 2 (7%)
cases. Also the same surgeon performed a majority of operations in
the conservative group. Residual or Recurrent Abscess
In the conservative group, drainage of abscess was attempted in A residual or recurrent abscess (abscess found on repeated
28 patients with abscess size 3 cm or more. In 16 patients the abscess imaging study between day 7 and day 60 after randomization) was
was aspirated with puncture, and in 3 patients drain was left in place. found in 8 (27%) patients in the conservative group and in 3 (10%)
In 9 (30%) patients, drainage was not possible because of lack of in the laparoscopy group, P = 0.181. In the laparoscopy group, 2
safe puncture route due to anatomical position of the abscess. The residual abscesses were diagnosed after 8 and 7 days from laparo-
results of bacterial cultures obtained from the abscesses are shown in scopic appendectomy during first hospital stay and were managed
Table 2. with percutaneous drainage. The third recurrent abscess was diag-
nosed during readmission due to ileus 13 days after laparoscopy, and
this was managed conservatively without additional interventions. In
the conservative group, the median time to detect recurrent or residual
TABLE 1. Baseline Characteristics at the Time of abscess was 13 days (IQR: 8–2) after randomization. One residual
Randomization abscess was diagnosed with repeated CT scan on day 8 during the
first hospitalization and was managed without additional interven-
Laparoscopy Conservative tions. Another 7 abscesses were diagnosed (6 with CT scans and 1
Group Group with ultrasound) after discharge, because patient was readmitted or
No. randomized patients 30 30 after outpatient visit if patient showed ongoing signs of infection. Six
Age, median (IQR/range) 45 (34–61/24–80) 46 (33–61/18–73) out of these were managed surgically.
Sex female 11 (37%) 15 (50%)
Any comorbidity 11 (37%) 6 (20%)
Body mass index∗ 25.9 (23.7–29.4) 25.5 (23.0–28.9) Postoperative Complications
CT scan done 25 (83%) 27 (90%)
Ultrasound done 9 (30%) 7 (23%) Postoperative complications within 60 days occurred in 3
Size of abscess, cm 5.5 (3.2–8.0) 5.0 (4.3–7.0) (10%) patients in the laparoscopy group: In 2 patients postopera-
Multiple abscesses 4 (13.3%) 1 (3.3%) tive abscess required percutaneous drainage (Clavien-Dindo grade
Duration of symptoms, d 7 (5–12) 6.5 (4–7) IIIa), and in 1 patient postoperative abscess and ileus was managed
C-reactive protein, mg/L 147 (90–193) 171 (99–215) with nasogastric tube and antibiotics (Clavien-Dindo grade II). In the
White blood cell count 10.5 (8.5–14.9) 13.3 (11.0–15.5) conservative group, 2 patients had postoperative complications: mild
(×109 ) postoperative hemorrhage from trocar site, which was managed with
Duration of treatment with 11 (5–16) 10 (7–14) suturing bedside (Clavien-Dindo grade I) and iatrogenic perforation
antibiotics, hrs
of bladder identified and sutured during laparoscopy but required
Values are median (IQR) or number of patients (%).
∗
urinary catheter treatment postoperatively for 7 days (Clavien-Dindo
Missing body mass index in 4 and 2 patients in laparoscopic and conservative grade I). All the patients in the 2 groups recovered without postoper-
treatment groups.
ative wound infections.


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Mentula et al
Composite Outcome
When all adverse effects and complications were taken into
account such as additional interventions, readmission, recurrent ab-
scesses and the need for repeated CT scans, the overall rate of un-
eventful recovery within 60 days was 90% in the laparoscopy group
versus 50% in the conservative group, P = 0.002.
Risk for Failure of Treatment
A post hoc analysis was done to analyze the risk of failed
primary intervention for additional interventions and residual or re-
current abscesses during the follow-up. Failed primary intervention
included incomplete appendectomy (n = 4) in laparoscopy group and
failed attempt of percutaneous drainage in conservative group (n =
9). In the laparoscopy group, none of the patients with failed primary
intervention had additional interventions, but 1 patient (25%) had
postoperative abscess and ileus. On the contrary, in the conservative
group patients had 56% risk for additional interventions after failed
primary intervention compared with 19% risk after successful inter-
vention (n = 21), P = 0.082. In the conservative group, the risk for
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Annals of Surgery r Volume 262, Number 2, August 2015
FIGURE 1. Randomization flowchart.
residual or recurrent abscesses was 44% when drainage was attempted
but not possible whereas the risk was 19% after successful primary
intervention, P = 0.195. On pooled analysis with both groups, the
risk for residual or recurrent abscess after failed primary interven-
tion was significantly higher (46%) compared with the patients with
successful primary intervention (13%), P = 0.049, odds ratio = 4.3
(95% CI: 1.05–17.5).
Long-term Outcome
Long-term outcome was not included in the primary protocol,
but reviewing of patients’ medical records at median of 12 months
(range: 3–33) after randomization revealed some important findings.
In the laparoscopy group, one patient had to be reoperated after
4 months after randomization. The reason for operation was acute
stump appendicitis after primary partial appendectomy. Two patients
in the laparoscopic group with partial appendectomy and laparoscopic
drainage only, respectively, have been seen in the Emergency Depart-
ment later on because of right lower abdominal pain. However, no
diagnostic findings were found in the CT scan in either patient. In

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Annals of Surgery r Volume 262, Number 2, August 2015 Laparoscopy for Appendiceal Abscess

tive group. The complication rate after immediate laparoscopy (10%)

TABLE 2. Results of Bacterial Cultures
outperformed pooled complication rate of immediate surgery (35.6%
Laparoscopy Conservative and 39.7%) reported in the 2 meta-analyses.3,4 One explanation can
Group Group be that these meta-analyses report mainly results of open surgery,
Sample taken, n (%) 28 (93%) 21 (70%) which is associated with high rate of surgical site infections (16.4%)
Positive culture 26 (87%) 17 (57%) and ileus/bowel obstruction (8%).4
Multiple bacteria isolated, %∗ 23 (89%) 16 (94%) Success rate of conservative management reported in the ret-
Anaerobes isolated, %∗ 23 (89%) 14 (82%) rospective studies (7.6%)3 has been considerable better than in this
Isolated species, %∗ study. Only 1 recent study from Netherlands5 has been reported as
Escherichia coli 17 (65%) 11 (65%) poor nonoperative outcome as presented here. One explanation for
Bacteroides fragilis 20 (77%) 11 (65%) unfavorable outcome in the conservative group in this study can be a
Unspecified anaerobes 7 (27%) 6 (35%) high number of abscesses, which were inaccessible for percutaneous
Streptococcus anginosus 7 (27%) 7 (41%)
drainage. On the contrary, the rate of percutaneous drainage in this
Streptococcus viridans 7 (27%) 4 (24%)
Pseudomonas aeruginosa 2 (8%) 2 (12%) study (63%) was similar to other studies reporting the rate of 47%16
Streptococcus beta hemolyticus 1 (4%) 2 (12%) and 87%.17 Compared with earlier studies,4 the duration of intra-
Klebsiella pneumonia 1 (4%) 0 (0%) venous antibiotic treatment in the conservative group was shorter.
Citrobacter species 0 (0%) 1 (6%) One could speculate that a longer treatment with intravenous antibi-
Staphylococcus aureus 1 (4%) 0 (0%) otics could have resulted in fewer readmissions. However, we used
Numbers are number of patients the same criteria for discontinuation of intravenous antibiotics in the
∗
Percentage out of patients with positive culture. both treatment arms to reduce bias in primary outcome measure. If
intravenous antibiotics were given for longer time in the conserva-
tive treatment group, they would have had longer primary hospital
TABLE 3. Outcome Within 60 Days From Randomization stay and probably the primary outcome could have been significantly
different between the groups.
Laparoscopy Conservative Because of nature of the retrospective studies, patients that
Group Group P have initially been chosen for conservative treatment but were oper-
Attempted procedure failed,∗ n 4 (13%) 9 (30%) 0.209 ated on for some reason during the same hospital admission may have
Length of stay (primary), d 3 (3–5) 3 (2–4) 0.228 been excluded from the retrospective series. This can cause significant
Length of stay (60 day),† d 4 (3–5) 5 (3–8) 0.105 bias favoring nonoperative management. Also, selection of patients to
Readmission, n 1 (3%) 8 (27%) 0.026 conservative management in retrospective studies may be biased, as
Recurrent or residual abscess 3 (10%) 8 (27%) 0.181 patients in whom percutaneous drainage of abscess cannot be done,
between day 7–60 may have been operated on without trial of conservative treatment
Additional intervention, n 2 (7%) 9 (30%) 0.042
Unplanned operation 0 (0%) 9 (30%) 0.002
first. Selection bias may probably be the main reason for good re-
Repeated CT scan 3 (10%) 13 (43%) 0.007 sults in the retrospective series as shown by 2 publications from the
Uneventful recovery 27 (90%) 15 (50%) 0.002 same center.1,16 Dixon et al16 reported that 3% failed nonoperative
and recurrent appendicitis rate of 14% in patients with appendiceal
Bold values indicate statistically significant.
∗
Appendectomy failed (no appendectomy or subtotal appendectomy performed)
mass treated conservatively between 1989 and 2001. However, Oliak
in the laparoscopy group or attempted drainage of abscess failed in the conservative et al1 provided consecutive patients with appendiceal abscess from
group. the same institution between 1992 and 1998 showing that only 57%
†T test for normally distributed data used. of the patients were initially treated conservatively. In that study, pri-
marily operated patients did not have preoperative CT scan, and the
reasons were not clear why some patients were selected for imaging
the conservative group, 6 patients (20%) have had surgery related to study and others were not. Only prospective, either randomized or
appendiceal abscess later than 60 days: 2 patients due to recurrent ap- cohort, studies are able to show unbiased success rate of conservative
pendiceal abscess and 1 due to phlegmonous acute appendicitis. Two management.
patients have had elective appendectomy. Both of these patients had As the use of CT scan has become more popular,18 a number of
signs of acute inflammation of the appendix in the pathological ex- patients with appendiceal abscess do not have only 1 CT scan but sev-
amination. With 1 patient who primarily recovered without problems eral increasing the risks for excess radiation exposure. In this study, a
in the conservative treatment group, a diagnosis of mucinous carci- significantly higher number of patients in the conservative group had
noma of appendix and pseudomyxoma peritonei was done 8 months to undergo repeated CT examinations. Taken into account the risk of
after randomization, and the patient died of disseminated cancer later recurrences, the risk for additional CT scans may become even
28 months after randomization. bigger. Repeated CT examinations increase radiation dose, which es-
pecially in young patients is considered harmful because of increased
DISCUSSION life-time risk of cancer.19
This was the first randomized trial comparing immediate Total number of cancer cases related to appendiceal abscess in
surgery and conservative management in adults with appendiceal the study was 3 (5%). The rate of cancer cases was in line with
abscess. On contrary to the result of 2 meta-analyses comparing im- the study by Deelder et al,5 who reported frequency of neopla-
mediate surgery and conservative treatment,3,4 laparoscopic surgery sia in 5.9% of 119 patents with appendiceal inflammatory mass.
outperformed conservative treatment by requiring less additional However, Carpenter et al20 reported a substantially higher frequency
interventions. Although the primary outcome, hospital stay within of neoplasia (28%) in patients treated with interval appendectomy,
60 days from randomization, was not significantly different, the mean whereas the frequency of neoplasia in adults with appendiceal mass
hospital stay in the laparoscopic group was 1 day shorter than in the in the meta-analysis was only 1.4%.3 Because of the risk of neo-
conservative group. The rate of uneventful recovery was 90% in the plasia, colonoscopy is recommended in patients older than 40 years
laparoscopy group, which was markedly higher than in the conserva- after conservative management of appendiceal abscess.20 Although


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Mentula et al
colonoscopy can identify colonic neoplasia, appendiceal neoplasms
can be missed. In this trial, both of the patients with delayed cancer di-
agnosis had CT scan before randomization and there was not any sus-
picion of neoplasia in the radiology report. Neither of these patients
had colonoscopy, although colonoscopy was scheduled. Another pa-
tient was readmitted because of recurrent abscess and operated on be-
fore colonoscopy, whereas another patient did not attend to scheduled
endoscopy. Immediate surgery for patients with appendiceal abscess
confirms the diagnosis and, thus, makes later endoscopic examina-
tions unnecessary. Acute appendectomy would be the safest way to
avoid delayed cancer diagnosis in patients with appendiceal abscess.
Laparoscopic appendectomy in patients with appendiceal ab-
scess is technically challenging, resulting in higher rate of conversion
to open surgery than in case of simple acute appendicitis.11 Also,
10% risk for bowel resection in the laparoscopy group must be taken
into consideration, because bowel resection may predispose patients
to more severe postoperative complications. Also, normal organ (the
right colon and the terminal ileum) was sacrificed without a clear
preoperative indication and may have not been sacrificed with a con-
servative approach. However, in patients randomized to initial con-
servative management, the rate of open surgery was similar. If these
patients required surgery, it was done later during the course of the
disease. Longer duration of symptoms before surgery was associated
with severe inflammatory reaction and dense adhesions making safe
dissection even more challenging. Because of technical difficulties,
there appeared to be a significant risk for incomplete appendectomy.
However, those few patients with incomplete appendectomy had com-
parable postoperative recovery with those patients treated with percu-
taneous drainage. During laparoscopy, the drainage of the abscess was
simple, and always technically feasible, but appendectomy part was
challenging in some patients, and usually perioperative difficulties
were not preoperatively predictable.
The anatomical location of abscess does not always provide
safe route for percutaneous drainage, which limits its usage. In pa-
tients without access to the abscess, there was no possibility to get
bacterial culture. However, in this study, no resistant bacteria were en-
countered and most patients responded to empirical antibiotics. None
of the treatment failures could be attributed to antibiotic-resistant
bacteria. However, the situation can be different in places with higher
prevalence of intestinal bacteria resistant to antibiotics.
Although the study showed significantly higher rate of un-
eventful recovery within 60 days in patients with immediate surgery,
the long-term results may be even more favorable for the immediate
surgery group. We found that appendicitis or appendiceal abscess
recurred in some patients later than 60 days after successful con-
servative management, which is in line with previously estimated
recurrence risk between 5% and 14%.16,21 Although some authors do
not recommend routine interval appendectomy,3,21 some patients may
insist on interval appendectomy to avoid unexpected acute surgery or
to rule out possible appendiceal neoplasia. Possibility of appendiceal
neoplasia suggests that patients older than 40 years and patients with
radiologic evidence of a residual appendiceal stump should probably
have interval appendectomy after successful conservative treatment.
However, further studies in a larger population are needed to define
the risk of appendiceal neoplasia in patients with appendiceal abscess.
The limitation of this study was that it was a single-center
study and 1 surgeon operated on the majority of the patients. Thus,
these results may not be generalized to other centers and to surgeons
with limited experience in laparoscopic surgery. However, the study
shows that immediate laparoscopic surgery can outperform conser-
vative management, if done by experienced surgeon familiar with
acute surgical conditions. This can be done in other centers too, be-
cause surgery for appendiceal abscess can usually be done on regular
working hours, when experienced surgeons are available.
242 | www.annalsofsurgery.com
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Annals of Surgery r Volume 262, Number 2, August 2015
CONCLUSIONS
Laparoscopic surgery in experienced hands is a safe and fea-
sible first-line treatment in adult patients with appendiceal abscess.
Although laparoscopy was associated with 10% risk of bowel resec-
tion and 13% risk of incomplete appendectomy, it had significantly
higher rate of uneventful recovery than conservative management and
did not increase hospital stay. Several factors including preventing de-
layed cancer diagnosis support the use of immediate surgery.
REFERENCES
1. Oliak D, Yamini D, Udani VM, et al. Initial nonoperative management for
periappendiceal abscess. Dis Colon Rectum. 2001;44:936–941.
2. Rybkin AV, Thoeni RF. Current concepts in imaging of appendicitis. Radiol
Clin North Am. 2007;45:411–422.
3. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or
phlegmon: a systematic review and meta-analysis. Ann Surg. 2007;246:741–
748.
4. Simillis C, Symeonides P, Shorthouse AJ, et al. A meta-analysis comparing
conservative treatment versus acute appendectomy for complicated appendici-
tis (abscess or phlegmon). Surgery. 2010;147:818–829.
5. Deelder JD, Richir MC, Schoorl T, et al. How to treat an appendiceal inflamma-
tory mass: operatively or nonoperatively? J Gastrointest Surg. 2014;18:641–
645.
6. Samuel M, Hosie G, Holmes K. Prospective evaluation of nonsurgical ver-
sus surgical management of appendiceal mass. J Pediatr Surg. 2002;37:
882–886.
7. St Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy
versus initial nonoperative management and interval appendectomy for per-
forated appendicitis with abscess: a prospective, randomized trial. J Pediatr
Surg. 2010;45:236–240.
8. National Surgical Research Collaborative. Multicentre observational study of
performance variation in provision and outcome of emergency appendicec-
tomy. Br J Surg. 2013;100:1240–1252.
9. Yau KK, Siu WT, Tang CN, et al. Laparoscopic versus open appendectomy for
complicated appendicitis. J Am Coll Surg. 2007;205:60–65.
10. Markides G, Subar D, Riyad K. Laparoscopic versus open appendectomy in
adults with complicated appendicitis: systematic review and meta-analysis.
World J Surg. 2010;34:2026–2040.
11. Brügger L, Rosella L, Candinas D, et al. Improving outcomes after laparoscopic
appendectomy: a population-based, 12-year trend analysis of 7446 patients. Ann
Surg. 2011;253:309–313.
12. Zerem E, Salkic N, Imamovic G, et al. Comparison of therapeutic effective-
ness of percutaneous drainage with antibiotics versus antibiotics alone in the
treatment of periappendiceal abscess: is appendectomy always necessary after
perforation of appendix? Surg Endosc. 2007;21:461–466.
13. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications:
a new proposal with evaluation in a cohort of 6336 patients and results of a
survey. Ann Surg. 2004;240:205–213.
14. Faul F, Erdfelder E, Lang A-G, et al. G∗ Power 3: a flexible statistical power
analysis program for the social, behavioral, and biomedical sciences. Behav
Res Methods. 2007;39:175–191.
15. R Core Team. R: A Language and Environment for Statistical Computing
[computer program]. Vienna, Austria: R Foundation for Statistical Computing;
2010. Available at: http://www.R-project.org. Accessed January 25, 2011.
16. Dixon MR, Haukoos JS, Park IU, et al. An assessment of the severity of
recurrent appendicitis. Am J Surg. 2003;186:718–722.
17. Brown CVR, Abrishami M, Muller M, et al. Appendiceal abscess: immediate
operation or percutaneous drainage? Am Surg. 2003;69:829–832.
18. Rhea JT, Halpern EF, Ptak T, et al. The status of appendiceal CT in an urban
medical center 5 years after its introduction: experience with 753 patients. AJR
Am J Roentgenol. 2005;184:1802–1808.
19. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associ-
ated with common computed tomography examinations and the associ-
ated lifetime attributable risk of cancer. Arch Intern Med. 2009;169:2078–
2086.
20. Carpenter SG, Chapital AB, Merritt MV, et al. Increased risk of neoplasm in
appendicitis treated with interval appendectomy: single-institution experience
and literature review. Am Surg. 2012;78:339–343.
21. Kaminski A, Liu I-LA, Applebaum H, et al. Routine interval appendectomy
is not justified after initial nonoperative treatment of acute appendicitis. Arch
Surg. 2005;140:897–901.

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