The Appendix Bryan Richmond ‘Anatomy and Embryology ‘Appendicitis ‘Treatment of Appendicitis Appendicitis in Special Populations Neoplasms of the Appendix © Peace acess ExperConsulcom wo view he correspond Ing videos fortis cape, Appendicitis remains one of the most common diseases faced by the surgeon in practice. isthe most common urgent or emergent general surgical operation performed in the United States and is responsible for as many a8 300,000 hospitalizations annually. Although appendectomy is often the first “major” case performed by the young surgeon in craining, few other oper ill be learned that will have such a dramatic impact on the patient being, treated, is estimated that as much as 6% to 7% of the general popula- tion will develop appendicitis during ther lifetime, with the inc dence peaking in the second decade of life.’ Despite its prevalence in Western countries, the diagnosis of acute append citi can be challenging and requires a high index of suspicion on the part of the examining surgeon to facilitate prompt treatment of this condition, thereby avoiding the substantial morbidity (and cven mortality) associated with perforation. Appendicitis is much less common in underdeveloped countries, suggesting that ele ‘ments of the Western dit, specifically alow-fiber, high-fat intake, ay play a role inthe development of the disease process.” h ANATOMY AND EMBRYOLOGY ‘The appendix is a midgut organ and is fist identified at 8 weeks of gestation 2s 2 small outpouching of the cecum, As gestation progresses, the appendix becomes more elongated and tubular as the cecum rotates medially and becomes fixed in the right lower quadrant of the abdomen. ‘The appendiceal mucosa is of the colonic «ype, with columnar epithelia, neuroendocrine cel and mucin-producing goblet cells lining its cubular structure. Lymphoid tissue is found in che submucosa of the appendix, leading some to hypothesize that the appendix may play a role in the immune system. In addition, evidence suggests that the appendix may serve as a reservoir of “good” intestinal bacteria and ‘ay aid in recolonization and maintenance ofthe normal colonic flora." Consensus about this has not been achieved, however. Suc- 1296 cessful removal of the appendix has not been definitively demon- strated to have any known adverse sequelae ‘Asa midgut organ, the blood supply ofthe appendix is derived from the superior mesenteric artery. The ileocolic artery, one of the major named branches of the superior mesenteric artery, gives rise to the appendiceal artery, which courses through the meioap- pendix. The mesoappendix aso contains lymphatics ofthe appen- dix, which drain co the ileocecal nodes, along the blood supply from the superior mesenteric artery." “The appendix is of variable size (5 to 35 em in length) but averages 9 em in length in adults. Its base can be reliably identified by defining the area of convergence of the taeniae a che tip of the ‘cecum and then elevating the appendiceal base to define the se and position of the tip of the appendix, whichis variable in location. ‘The appendiceal tip may be found in a varity of locations, with the most common being retrocecal (but intraperi- oneal) in approximately 60% of individuals, pelvic in 30%, and retroperitoneal in 7% to 10%. Agenesis ofthe appendix has been reported, as has duplication and even triplcation.”” Knowledge ‘of these anatomic variations is important to the surgeon because the variable position of the appendiceal tip may account for dif- ferences in clinical presentation and in the location of the associ- ated abdominal discomfort. For example, patents with a retroperitoneal appendix may presene with back or flank pain, just as patients with the appendiceal tip in the midline pelvis may present with suprapubic pain, Both of chese presentations may result in a delayed diagnosis asthe symptoms are distinctly differ- cent from the classically described anterior right lawer quadrant abdominal pain asociated with appendiceal disease. APPENDICITIS History The frst appendectomy was reported in 1735 bya French Surgeon, ‘Claudius Amyand, who identified and successfully removed the appendix of an L1-year-old boy that was found within an inguinal hernia sac and chat had been perforated by a pin. Although autopsy findings consistent with perforated appendicitis appeared, sporadically thereafter inthe literature, the first formal description,VIDEOS Video 50-1: Laparascopic Appendectomy Video 50-2: Laparascopie Appendectomy in Pregnant Patient Video 50-3: S1LS Appendectomy Across a Spectrum of Disease Severity CHAPTER 50_ The Appendix aCHAPTER 50_ The Appendix 1297 ‘of the disease process, including the common clinical features and. a recommendation for prompt surgical removal, was in 1886 by Reginald Heber Ficz of Harvard Universi” Notable advances in surgery for appendicitis include McBur- ney’ description of his classic muscle-splitting incision and tech- nique for removal ofthe appendix in 1894 and the description of | the frst laparoscopic appendectomy by Kurt Semm in. 1982.’ Laparoscopic appendectomy has become the preferred method for management of acute appendicitis among surgeons in che United States and may be accomplished using several ypically chrce) Uwocar sites or through single-incision laparoscopic surgical tech- niques. Finally, but of no less significance, was the development ‘of broad-spectrum antibiotics, interventional radiologic. tech- ‘niques, and better surgeal critical cae strategies, all of which have resulted in substantial improvements in the care of patients wich appendiceal perforation and its subsequent complications. Pathophysiology and Bacteriology Appendicitis is caused by luminal obstruction.” The appendix is ‘vulnerable to this phenomenon because of its small luminal diam- eer relation co its length. Obstruction ofthe proximal lumen of the appendix eads to clevated pressure in the distal portion because ‘of ongoing mucus secretion and production of gas by bacteria, within the lumen, With progeessive distention ofthe appendix, che ‘venous drainage becomes impaired, resulting in mucosal ischemia. ‘Wich continued obseruction, full-thickness ischemia ensues, which ultimately leads to perforation. Bacterial overgroweh within the appendix results from bacterial stasis distal othe obstruction,” This is signifcanc because this overgrowth resulsin the release ofalarger bacterial inoculum in case of perforated appendicitis (able 50-1. “The time from onset of obstruction to perforation is variable and, ‘may range anywhere from a few hours toa few days. The presenta- tion alter perforation is also variable. The most common sequela is the formation of an abscess in the periappendiceal region or pelvis, On oceasion, however, fte perforation occurs that results in diffuse peritonitis.” Because the appendix isan outpouching ofthe cecum, che flora within the appendix is similar to that found within the colon, Infections associated with appendicitis should be considered poly microbial, and antibiotic coverage should include agents that address the presence of both gram-negative bacteria and anact~ obes. Common isolates include Escherichia col, Bacteroides frail, enterococci, Preudomonas aeruginosa, and others. "The choice and Cl ee Cork nee) eae TYPE OF BACTERIA ‘Anaerobie Batoroides fags a Bastoraidesthotaotamicton 6 Bioghia wadswortia 56 PATIENTS (%) Poptostoptcoccus sp. 4% Aorol Escherichia co 7 Vides streptococcus 8 Group 9 streptooccut 2 Preusomonas aesinesa 8 ‘Adegted fom Bennion AS, Thomason JE: Aapendists. In Fry DE, ‘citar Surgical infections, Boston, 1995, Lit, Brown, pp 241-250. uration of antibiotic coverage and the controversies surrounding the need for cultures ate discussed later in the chapter “The causes of the luminal obstruction are many and vatied. ‘These most commonly include fecal stasis and fecaliths but may. also include lymphoid hyperplasia, noplasms, fruit and vegetable material, ingested barium, and parasites such as ascarids, Pain of| appendicicishas both visceral and somatic components. Distention of the appendix is responsible for the initial vague abdominal pain (wiscerl) often experienced by the affected patient. The pain typi- cally does not localize to the right lower quadrant until the tip becomes inflamed and irvtates the adjacent parietal peritoneum (Gomatie) or perforation occurs, resulting in localized peritonitis.” Differential Diagnosis Appendicitis must be considered in every patient who has not had an appendectomy) who presents with acute abdominal pain, Knowledge of disease processes chat may have similar preseneing symptoms and signs is essential to avoid an unnecessary or incor rect operation. Consideration of the patients age and gender may help nartow the list of possible diagnoses. In children, other con- siderations include but are not limited to mesenteric adenitis (ofien seen after a recent vial illness), acute gastroenteritis, intus- susception, Meckels diverticulitis, inflammatory bowel disease and (in males) testicular cosion. Nephrolithiass and urinary act infection may be manifested with tight lower quadrant pain in cither gender” In women of childbearing age, the differential diagnosis is expanded even further. Gynecologic problems may be mistaken for appendicitis and rsulc in a higher negative appendectomy rate than in mal patients of comparable age. These include rupcured ovarian cysts, mitielichmere (mideyele pain occurring with ovula- tion), endometriosis, ovarian torsion, ectopic pregoancy, and pelvic inflammatory disease.” “Two other patient populations deserve mention. In the elderly, consideration must be given to acute diverticulitis and malignant disease as posible causes of lower abdominal pain. In the neutro- penic patient, gphliis (also known as neutropenic enterocolitis) should aso be considered within the differential diagnosis. Appen- dicits in these special populations is discussed later inthe chapter. Presentation History Patients presenting with acute appendicitis rypially complain of vague abdominal pain that is most commonly periumbilical in in and reflects the stimulation of visceral afferent pathways through the progressive distention of the appendix, Anorexia is fen present, as is nausea with or without associated vomiting. Either diashea or constipation may be present as well. As the con dition progresses and the appendieeal tip becomes inflamed, result ing in peritoneal itstaton, the pain localizes co its classic location in the right lower quadrant. This phenomenon remains a tliable symptom of appendicitis” and should serve to Further increase the clinician's index of suspicion for appendicitis (Fig. 50-1). ‘Whereas these symptoms represent the “lassie” presentation of appendicitis, the clinician must be awate tha the disease may be manifested in an atypical fashion. For example, patents with a retroperitoneal appendix may present in a more subacute ‘mannet, with flank or back pain, whereas patients with an appen- diceal Up in the pelvis may have suprapubic pain suggestive of tuinary tract infection.”’ We have on occasion encountered patients presenting wich symptoms of small bowel obstruction ‘who were found to be obstructed by multiple interloop abscessesa SECTION X_Abdomen GENERAL APPROACH TO THE PATIENT WITH SUSPECTED APPENDICITIS. Aopendicis suspected clinically Symptoms for <48 6 Diagnostic laparoscopy ‘Symptoms for 48h 1 FIGURE 50-1 Suggested algorithm for the approach to the patient with possible appendicitis as 2 consequence of unrecognized appendiceal perforation. Although cases such as these ate less common than the typical presentation, knowledge ofthese variations is essential co maintain the necessary index of suspicion to permit a prompt and accurate dliagnosis. Physical Examination Pacients with appendicitis ypically appear ill. They frequently lie sill because of the presence of localized peritonitis. which makes any movement painful. Tachycardia and mild debydration are often present to varying degrees. Fever is frequently present,CHAPTER 50_ The Appendix ranging fom low-grade temperature clevations (<38.5" C) 10 rote impressive elevations of body temperature, depending on the status of the disease process and the severity of the patients inflammatory response. Absence of fever does not exclude a diag- nosis of appendicitis"? ‘Abdominal examination typically eveals a quiet abdomen with tenderness and guarding on palpation ofthe right lower quadrant, “The location of the tendernes is casially over McBurney point, which is located one-third the distance between the anterior supe” rior iliae spine and the umbilicus. The pain and cenderness are ‘ypically accompanied by localized peritonitis as evidenced by the presence of rebound tenderness. Diffuse peritonitis or abdominal wal igiey due ‘wall musculature is strongly suggestive of perforation.” ‘A number of signs have been described to aid in the diagnosis of appendicitis. These include che Rovsing sign (the presence of right lower quadrant pain on palpation of che left lower quadrans), the obturator sign (right lower quadrant pain on internal rotation of the hip), and the psoas sign (pain with extension of the ipsi- lateral hip). among others. Although these are of historical intes- ‘st i is important to realize chat they are simply indicators of localized peritonitis rather than a diagnostic of a specific disease process. Still, they ate useful maneuvers to perform in examining. 4 patient with suspected appendicitis and are supportive of the diagnosis if cis suspected clinically. Rectal examination findings ate typically normal. However, a palpable mass or tenderness may be present if the appendiceal tip is located within the pelvis or if a pelvic abscess is present. In female patients, pelvic examination is important to exclude pelvic disease. However, cervical motion tenderness, a finding typically associated with pelvic inflammatory disease, may be present in appendicitis because of irvtation of the pelvic organs Irom the adjacent inflammatory process.” Laboratory Studies Laboratory studies should be interpreted with caution in eases of| suspected appendicitis and should be used to suppor the clinial picture rather than definitively co prove orto exclude the diagno- sis. A leukocytosis, often with a "left shift’ (a predominance of neutrophils and sometimes an increase in bands), is present in 50% of cases. A normal white blood cell count is found in 10% of eases, however, and it should not be used as an isolated tet 0 exclude’ the presence of appendicieis" Urinalysis is ypically normal aswell although the finding of trace leukocyte esterase or pyusia is not unusual and is presumably due to che proximity of the inflamed appendix to the bladder or uecer. Ifthe presentation is strongly suggestive of appendicitis, a “positive” urinalysis should not be used a5 an isolated test co refute the diagnosis, Pregnancy testing is mandatory in women of childbearing age. C-reactive protein has been demonstrated to be neither sensitive nor specific in diagnosing (or excluding) appendicitis." No symprom or sign has been demonstrated to be discrimi- ratory and predictive of appendicitis." ‘The same may be said of Laboratory tests, which ate also weakly predictive when con- sidered in isolation. Rathes, i is the assessment of the collective body of information that allows more precise diagnosis." Imaging Studies A variety of radiographic studies may be used to diagnose appen- dicitis. These consist of phin radiographs, compuced tomography (C1) scanning, ultrasound (US), and magnetic resonance imaging (MRD. Plain radiographs are frequently obtained in the emergency ddepartmene setting for the evaluation of acute abdominal pain but lack both sensitivity and specificity for the diagnosis of appendi citis and are rarely helpfl. Findings char may support che diag- nosis include the presence of a calcified fecaith in the right lower quadrant, although this finding must be placed into the appropri- ace clinical context and is ypically presene in only 5% of case.” Paeumoperisoneum, if present, should alere the clinician co other causes of a perforated viscus (such as a perforated ulcer or diver- Ciculits) as this is not typically observed in cases of appendicitis, ‘even with perforation, CT scanning is the most common imaging seudy to diagnose appendicitis and is highly effective and accurate” Modern helical CT seans have the advantage of being operator independent and ‘easy to interpret. CT has been shown to have a sensitivity of 90% 0 100%, a specificity of 91% to 99%, a positive predictive value of 92% to 98%, and a negative predictive value of 95% to 100%.” ‘the recommended imaging protocol from the Infec- ‘ious Diseases Soviey of America (IDSA) and the Surgical Infec- tion Society includes the intravenous administtation of contrast material only. Oral and rectal administration of contrast material is not recommended.” “The diagnosis of appendicitis on CT is based on the appearance of a thickened, inflamed appendix with surrounding “sanding” indicative of inflammation. The appendix is ypially more than 7 mm in diameter with a thickened, inflamed wall and mural enhancement or “target sgn’ (Fig, 50-2). Periappendiceal fluid or air is also highly suggestive of appendicitis and suggests perfora- tion, In cases in which the appendix is not visualized, the absence of inflammatory findings on CT suggests that appendicitis is not present.” Alchough we do not recommend CT in cass in which appendicitis is suongly suspected on clinical grounds based on supportive history and physical and laboratory findings, published, data do suggest chat use of CT in equivocal eases does indeed reduce the negative appendectomy rate.” US has been used for diagnosis of appendicitis since the 1980s ‘As US technology has become more advanced, so has its ability, «0 visualize the appendix, The US probe is applied to the area of pain in the ight lower quadrant, and graded compresion is used (o collapse normal surrounding bowel and co diminish the inter- ference encountered with overlying bowel gas. The inflamed appendix is typically enlarged, immobile, and noncompresible (Pig. 50-3). IF che appendix cannot be visualized, the study is inconclusive and cannot be relied on to guide treatment. Although US provides the advantage of avoiding ionizing radiation, the technology is highly operator dependent. The sensitivity is reported to range from 78% 0 83%, whereas the specificity ranges from 839% to 93%. Its greatest utility appeats to bein the ‘evaluation of the pediatric of pregnant patient, in whom the associated radiation exposure fiom CT is undesirable” MBI is cpically reserved for use in the pregnant patient; the scudy is performed withoue conerast agents. If tis obtained in a pregnant woman, the study should be noncontrasted. MRI offers ‘acellent resolution and is accurate in diagnosing appendicitis Criteria for MRI diagnosis include appendiceal enlargement G7 mm), thickening (2 mm), and the presence of in‘lamma- tion.’ The sensitivity of MRI is reported to be 100%, the specifc- ity 98%, the positive predictive value 98%, and the negative predictive value 100%. MRI is also operator independent and offers highly reproducible results. Drawbacks associated with the tue of MRI inckude is higher cost, motion artifact, greater diff- culty in interpretation by nonsadiologists who may have limitedSECTION X_ Abdomen FIGURE 50-2 CT scan ofthe abdomen demonstrating classi findings of acute appendicitis. A, Sa \witn arrow demonstrating & thickened, farmed, and fldiled appendix target sign. B, Coronal view of same pationt The arow points to the thikenee, elongates aaperdic wi FIGURE 50-3 Ultrasound image of » normal appendix (to) ilustrating the thin wall in coronal (left and longitudinal fight planes. In append cis, there is distention ard wall thekening /bottam, right, and blood flow is increased, leading to the so-called rng of five appearance. A, Apend experience with he technology, and limited availabilty (especially in the after-hours emergency sting) TREATMENT OF APPENDICITIS: Acute Uncomplicated Appendicitis ‘The appropriate «reatment of acute uncomplicated appendicitis is prompt appendectomy. The pationt should undergo fluid resus citation as indicated, and the intravenous administration of broad-spectrum antibiotics direcced against gram-negative and anaerobic organisms should be initiated immediately. should proceed without undue delay. peraopenciceal fat sanding and For open appendectomy, the patient is placed in the supine positon, The choice of incision is a matter of the surgeon's preference, whether it is an oblique muscle-spliting incision (MeArthur-McBurney: ), a transverse incision (Rockey- Davis), or a conservative midline incision. The cecum is grasped by the taeniae and delivered into the wound, allowing visualiza- tion of the base of the appendix and delivery ofthe appendiceal tip. The mesoappendix is divided, and the appendix is crushed just above the base, ligated with an absorbable ligature, and divided, The stump is then either cauterized or inverted by a pursestring or Z. suture technique, Finally, the abdomen is thor- ‘oughly irigated and the wound closed in layers. For laparoscopic appendectomy, the patient is placed in the supine position. The bladder is emptied by a straight cathecer or by having the patient void immediately before the procedure, The abdomen is entered at che umbilicus, and the diagnosis is con- firmed by inserting the laparoscope ( ). Two additional working ports are then placed, typically inthe left lower quadrant and in cither the suprapubic area or supraumbilical midline, based fon the surgeon’ preference. We have found i ro be advantageous for both the surgeon and assistant co stand to the left side of the patient with the left arm tucked. This allows optimum trisngula- ion of the camera and working instruments, Ateaumatic graspets are used to elevate the appendix, and the mesoappendix is care- fully divided using the harmonic scalpel. The base is then secured with endoloops and the appendix divided. Alternatively, the appendix may be divided with an endoscopic stapler. We prefer this technique in cases in which che entize appendix is friable because it allows che staple line to be placed slightly more proxi- ‘mally, on the edge ofthe healthy cecum, thereby reducing the risk of leakage fiom breakdown of a tenuous appendiceal stump, Rectieval of the appendix is accomplished by the use of a plastic retrieval bag, The pelvis is itrigated, the trocars are removed, and the wounds are closed. Laparoscopic appendectomy may also be performed with single-site laparoscopic surgical techniques as wel, although this technique temains les commonly performed than the traditional multictocar approach. ‘Ancibiotic administration is not continued beyond a single ‘Oral alimentation is begun immediately and preoperative dose.CHAPTER 50_ The Appendix ‘Supetiorleocecal Division of appendiceal artery in the mosoappend FIGURE 50-4 A, Loft Location of possile incisions for an open appendectomy. Right, Division of the esoappendix. B, Lgaton of the base and division of the appendix. Placement of purse-stng suture FZ stitch D Inversion of the appendiceal stump. (From Ortega JM, Ricardo AE: Surgory of the apooncbx and colon, In Moody FS, editor Atlas oF ambulatory surgery, Philedelph a, 1989, Wa Saunders}SECTION X_ Abdomen FIGURE 50:5 Laparoscopic appendectomy. A, Visualization and upward re ‘of mesoappendix using harman sealbel.€, Appleation of endlaops te anpensix secure the base: a third laop is applied distally 20 ‘we looas are used to 4 spilage ofthe luminal contents, The specimen is thon divided berweon the endoloaps. D, View of completed appendectomy after romoval of the specimen. |Wote: Depending on the surgeon's preverence, an endascope stapling davice ray be used v0 avide te advanced as tolerated. Discharge is usually possible the day after ‘operation Perforated Appendicitis The operative strategy for perforated appendicitis is similar to that for uncomplicated appendicitis with a few notable exceptions Fics of all the patient may require a more aggressive resuscitation before proceeding to the operating theater. As with uncomplicated appendicitis, antibiotic therapy should be initiated immediately on diagnosis.” Both the open and laparoscopic approaches are acceptable for the teatment of perforated appendicitis. Although the technique of appendectomy for perforation isthe same a for simple appen is, the level of difficulty encouncered in removing a friable, gangrenous, perforated appendix can be a challenge to the most experienced surgeon and requires gentle meticulous handling of the friable appendix and inflamed periappendiceal tissues to avoid tissue injury, Cultutes are not mandatory unless the patient as had exposure to a health care environment or has had recent exposure to antibiotic therapy because these factors increase the likelihood of encountering resistant bacteria. However, we r0U- ‘inely obtain them because they sometimes yield resistant bacteria and are helpfal in tailoring the switch co oral cherapy on dis- charge. ' Once the appendix i successfully removed, careful arten- tion should be given to the clearance of infectious material, including spilled fecal material or fealiths, ftom the abdomen. This cask may be accomplished by large-volume itrigation, with special attention given to the right lower quadrant and pelvis, Drains ate not routinely placed unless a discrete abscess cavity is present. If an abscess cavity is present, a single closed suetion Jackson-Pratt drain is placed within its base and left for several, days. Ifan open technique was used, the skin and subcutancous tissues are lefe open for 3 or 4 days to prevent developm wound infeetion, at which time the wound may be closed mesoazpendx and appendix instead of tne harmanie scalpel ané endaloons.) bedside with sututes, clips, or Ster-Strips, depending on the sur- goons preference Postoperatively, broad-spectrum antibiotics are continued for 4 to 7 days in accordance with IDSA. guidelines.” If culture specimens were obtained, antibiotic therapy should be modified in accordance with th results. Nasogastric suction is noc employed routinely but may be necessary if postoperative ileus develops Oral alimentation is begun after return of bowel sounds and passage of flaus and advanced as tolerated. Once the patient is tolerating a det, i afebrile, and has a normal white blood cell count, the patient may be discharged home Ifthe patient develops fever, leukocytosis, pain, and delayed secutn of bowel function, the possibilty of a postoperative abscess aust be entertained. Abscess complicates perforated appendicitis in 10% to 20% of cases and represents the major source of morbidity related to perforation.'” A CT scan with intravenous administration of a contrast agent is diagnostic and also allows simultaneous placement of percutaneous drain within the abscess cavity.” If CT drainage is not technically possible because of the locaton of the abscess, laparoscopic, eanstectal, or trans vaginal drainage isan alternative Laparoscopic versus Open Appendectomy The dehate about the choice of open versus lapatoscopic appen- dlectomy forthe teatment of appendicitis remains a major point of contzovetsy among surgeons. Although no level I data exist to support one approach over anocher, a study published in 2010 txamined this sue in detail. Ingraham and colleagues" analyzed results from 222 hospitals comparing laparoscopic vernis open appendectomy wing the Ametican College of Surgeons National Susi Quality Improvement Program. In all, 24,969 laparo scopic and 7714 open procedures were included in the analysis: Alchough the daca were limited by the retrospective nature, the investigators observed that laparoscopic appendectomy wasCHAPTER 50_ The Appendix associated with lower risk of wound complications and deep surgi- ‘al ste infection in uncomplicated appendicitis. In complicated appendicitis, laparoscopic appendectomy was associated. with fewer wound complications bur a slighty higher incidence of intra-abdominal abscess. ‘The overall conclusion, however, was that the laparoscopic approach was associated with an overall lower incidence of complications chan the open procedure, The conclusions evident from a number of scuies indicate chat both approaches are acceptable and that the advantages with laparos- copy, although small, were a lower overall morbidity, reduced, ‘wound complications, reduced postoperative pain, and pethaps a slightly shorter recovery time. ‘The slightly higher risk of inta- abdominal abscess formation ater laparoscopic appendectomy in ‘eases of complicated appendicitis was a negative aspect of laparo- scopic appendectomy. although the authors acknowledged that this has noc been observed in all studs.” ‘We prefer the laparoscopic approach for several reasons. Lapa- roscopy allows examination ofthe entre peritoneal space, making ic exceptionally useful co exclude other intra-abdominal disease that may be manifested in a similar fashion, such as diverticulitis or cubo-ovarian absces, whereas visualization of these structures ‘would not be possible chrough a right lower quadrant incision. We find it to be technically simpler in most patients, particularly the obese, and have been impressed with ous ability o discharge patents within several hours of the operation. “The debate about the superiority of laparoscopic versus open appendectomy will likely continue asa clearly superior choice has rot been conclusively demonstrated. What does appear clear, however is that regardless of che surgeons preferred approach, the most important aspect of appendectomy is that it be done promptly and safely. Delayed Presentation of Appendicitis Pasients may occasionally present several days to even weeks after the onset of appendicitis. In these cass, the treatment should be individualized on the basis ofthe nature of the presentation (Fig, 50-6). Although raze, a patient may present with diffuse perito- nitis, More commonly. however, patients present with localized right lower quadrant pain and fever, wich a history chat is compat- ible with appendicitis. A mass may be palpable in children or thin patents. Immediate exploration and attempted appendectomy in these patients may result in substantial motbidigy, including failure to idencify the appendix, postoperative abscess or fistula, and unnecessary extension of the operation to include ileocecee- tomy, all due to the exxreme induration and ftiability of the involved tissues, For this reason, in general, teatment for these patients is iniially accomplished nonoperaively Fluid resus- citation is initiated, and broad-spectrum antibiotic therapy is initiated. A CT sean is obtained, and perforated appendicitis with 4 localized abscess or phlegmon is confirmed (Fig. 50-7). Ifa localized abscess is identified, CT-guided percucancous drainage is performed for source control. The drainage catheter is typically left in place for 4 to 7 days, during which the patient is treated with anuibiosie therapy and after which time ic is removed. If ‘CT-guided drainage is not technically feasible, operative drainage may be accomplished through transrectal or ransvaginal approaches. Laparoscopic drainage is another option that we have found to be exceptionally useful. This technique is performed by visualizing the inflammatory mass with the laparoscope and then centering the abscess with a laparoscopic suction tip, evacuating, the purulent material, and placing a drain within the residual abscess cavity: Postoperative management is identical co that of patients who ate successfully drained percutaneous. Ifa periap- ppendiceal phlegmon is present or if the amount of uid present is not sufficient to drain, the pavient may be weated with ancibiot icsalone, eypicaly for 4'0 7 days also, as recommended by IDSA {guidelines for treatment of intrx-abdominal infection." “Traditionally, after suecessful nonoperative teatment of com plicated appendicitis, patients were advised co undergo semoval of the appendix, a procedure known as interval appendectomy, several weeks to months late. This practice has been reexamined. ‘The rationale for interval appendectomy is based on the potential for development of recurrent appendicitis and the subsequent risks assoctared with emergent femoval or reperforation of the appendix. However, the actual risk of recurrent appendicitis appears to be small, 8% at 8 years in one study of 6400 pediatric patient" The findings in this study as well as similar results feported by others have led shem to conclude thac interval appen dectomy should be reserved only for patients who present with symptoms of recurrent appendicitis" In addition, the presence of an appendicolith on CT has also been shown to be prediesive of a higher risk of recurrent appendicitis and has been used as a justification to proceed with interval appendectomy in that sub- ‘poup of patients. This selective approach to interval appendec- omy has also been demonstrated to be more cost-effective than its routine performance in all affecced patients.” A systematic review published by Hall and colleagues” exam ining che role of interval appendectomy found that che overal isk of recurrent appendicitis was 20.5%. All recurrences were seen within 3 years, and 80% of these occurred within 6 months. In addition, the morbidity of interval appendectomy was significant, ‘with complications reported in 23 of the seudes, for an overall rate of 3.496. Other authors have reported significant associated sosbidiy with interval appendectomy a wel, with rates a high as 18%." One argument favoring interval appendectomy in adults has been the observation by some investigators of a higher incidence ‘of appendiceal neoplasms found in interval appendectomy spec- mens." Also, perforated tumors of the cecum may be mani- fested in a similar fashion as perforated appendicitis.” For this reason, colonoscopy is recommended in all adult patients as routine follow-up after nonoperative management of complicated appendicitis." To date, no large-scale randomized controlled rials examining the outcomes of patients who do or do not undergo interval appendectomy afeer successful nonoperative treatment have been conducted. For this eason, this issue is likely to remain controversial for some time ‘The Normal-Appearing Appendix at Operation In cases of “negative appendectomy,” in which a normal appendix is identifed at operation, there is conteoverzy as to whether the appendix should be removed." Belore that particular issue is examined, i is important to emphasize the need ro thoroughly evaluate the abdomen for other causes of pain severe enough to ‘warrant an operation. The abdominal and pelvic organ should bye ascesed for any abnozmalties. In our expeticnce, this is most easily done through the laparoscopic approach, which we chink i a major advantage of laparoscopy over an open approach, Note Should be made of any fice Bud ar sach a finding may saggest perforation. Tae terminal 60 cm of eum should be examined for 4 Meckel’ diverticulum and the serosa ofthe small bowel for any sigmata of Crohn's disease, suchas inlamamation, sticcure forma tion, or the characterise “creeping ft" appearance ofthe meseh- tery lnspection of the ileal mesentery may reveal enlarged lymphSECTION X_ Abdomen APPROACH TO THE PRESENTATION OF Sl (CT drainage, antbiotes Colonoscopy after discharge Consider intwval appendectomy Diffuse peritonitis present PATIENT WITH DELAYED {USPECTED APPENDICITIS: Laparoscopic drainage, antibiotics Consider intrval appendectomy Follow algorthm for appendiceal neoplasm FIGURE 50-6 Suggested algorithm for managing the pallent with delayed presentation of appencicits, nodes suggestive of mesenteric adenitis. The uterine adnexa should bbe examined for any evidence of wubo-ovarian or salpingeal disease, such as ovarian torsion, tubo-ovarian absces, endomettio- sis, or ruptured ovarian cysts. The sigmoid colon should be exam- ined for evidence of acute diverticulitis, especially in cases in which a redundant sigmoid colon is found in the right lower quadrant. If these ate all normal, attention should be turned © the upper abdomen for examination of the gallbladder and duo- denam. Inability to perform an adequate evaluation of the ineea- abdominal organs oF demonstration of disease of other organs requiring intervention may require conversion to a midline lapse rotomy if necessary ‘We routinely remove the normal appendix for several reasons First, many causes of right lower quadrant pain discussed before may be recurtent, such as pain from ruptured ovarian cysts of mesenteric adenitis. Appendectomy is also advisable in cases of Crohns disease when suggested by findings at operation, unless the base of che appendix and cecum are involved. In this scenario, appendectomy is deferred to avoid breakdown of che intlamed stump and subsequent fistula formation. In these cliniealCHAPTER 50_ The Appendix FIGURE 50-7 Sagittal {A) and coronal {B) CT images demonstrate an appendiceal abscess ina paliont who presented with @ Zaveek history of endominal pain end was found to havea pslpable mass on exemiation, Tho arrows point to a perappendiceal abscess cavity. Sho was s Atsinage ana antbiote therapy. citcumstances, appendectomy is advisable because it removes appendicitis from the differential diagnosis when the patienc pre rectrrent right lower quadrant pain. In addition, abnor- ralitice of the appendix not apparent on gross inspection at che time of operation ate sometimes identified on pathologic Nonoperative Treatment of Uncomplicated Appendicitis Although prompt appendectomy isthe standatd of care, a number of studies have challenged this concept and have supported anti biotic cherapy alone as a definitive weatment for acute uncompli- cated appendicitis. Two metz-analyses analyzing the results of randomized contolled tals examining this issue concluded that nonoperative ceatment was associated with a lower risk of com plications (12% in the nonoperative group versus 18% in che appendectomy group; P = .001).”"” Appendectomy, however, outperformed the nonoperative group in overall treatment failure rate (40% nonoperative versus 9% in the appendectomy group: P<.001), The authors concluded that antibiotic therapy was safe asa treatment for uncomplicaced appendicitis but was associated with a significantly, peshaps prohibitively high failure rate com- pared with appendectomy." ”” For this reason, our practice is to reserve nonoperative therapy only for acute uncomplicated appen dicits for those patients in whom the operative risk is prohibitive Failures of nonoperative therapy in these high-risk patients are chen managed with adjunctive treatment measures, such as CT-guided drainage of periappendiceal abscesses. “Chronic” Appendicitis as a Cause of Abdominal Pain On oceasion, patents will present with a history of recurrent right lower quadant pain, and a surgical opinion will be sought as to the beneficof elective appendectomy for treatment of this condi tion, Modest epidemiologic data exist to suggest that appendicitis may spontancously resolve, so itis conceivable that appendicitis may wax and wane in some patints.' In addition, some patients with pain are found to have a thickened appendix or an appen dicolith on CT but have no evidence af a systemic illness of acute periappendiceal inflammation. In some eases, appendectomy will produce relief of symptoms, and in these eases, examination of sstully managed with percutaneous the appendix will sometimes reveal Bindings consistent with chronic inflammation." We will consider on a case by case bass, lective appendectomy in cates in which the history i con- sistent with appendiceal disease and there is radiographic (CT) evidence of appendicea disease More toubling, however, is the patient with pain in the absence of radiographic evidence of appendiceal disease. We typi cally pursue a mulidsciplinary workup in these patients involv ing input from specialists in gastroenterology and gynecology as well as swigery: Appendectomy is ypicaly not offered usess disease is demonstated radiographically; however, if diagnostic laparoscopy is pe (eypcaly by a gynecolog tomy, an approach advocated by others.” We sve found that as with the management of any chronic pain syndrome, manage- ment of expectations is critical in caring for this very dificule group of patients Incidental Appendectomy Incidental appendectomy is the cerm applied when a grossly normal appendix is removed at the time of an unrelated proce- dute, such as a hysterectomy, cholecystectomy, or sigmoid colec- omy, Once commonly performed, incidental appendectomy has become a controversial procedure, The theoretical benefi is that of eliminating the patients risk for development of appendicitis in che future, a concept that is thought to be most beneficial in patients younger than 35 yeats because of their greater lifetime fis fr development ofthe disease compared with older patents." ‘Dara suggesting that incidental appendectomy may be performed ‘with no additional morbidity have been criticized for not having. been properly risk adjusted. When these data were serutinized further, Wen and coworkers actually demonstrated that incidental appendectomy was associated with an increase in both morbidity and mortality * Other investigators have demonstrated that inci- dental appendectomy does not appear to be costeffective as a preventive measure.” Finally, che recent finding that che appendix, may actually have a role in the maintenance of healthy colonic flora makes the practice of incidental appendectomy even more controversial“ For these reasons, we advocate careful inspectionSECTION X_ Abdomen of the appendix for abnormalitiee during abdominal operations as part of a thorough exploration but do not advocate appendec- tomy unless an abnormality is detected APPENDICITIS IN SPECIAL POPULATIONS Appendicitis in the Pregnant Patient [Appendicitis remains the most common nonobsteric emergency in pregnaney and is consequently the most frequent reason for general surgical intervention inthis group of paticnts.” The diag- nosis of appendicitis in pregnancy presents a special challenge 0 the surgeon, As with all conditions in pregnancy, the surgeon ust consider the welfare of two patients, che mother and fetus, when considering possible diagnoses, workup, and treatment ig. 50-8). Tn pregnancy, appendicitis has a typical clinical presentation in only 5096 to 608 of cases." The common symptoms of early appendicitis, such as nausea and vomiting, are nonspecific and ae also ofien associated with normal pregnancy. The normal febrile response to illness may be blunted in pregnancy. Also, the physical examination of the pregnant patient is difficule and is altered because ofthe efect of the gravid uterus and its displace- ment of the appendix (© a more cephalad location within the abdomen, Lowet quadrant pain in the second trimester produced by traction on the suspensory ligaments ofthe uterus, a phenom enon known as round ligament pain, is a common occurtence and further complicates the clinical picture Further because 50% of cases of appendicitis occur in the second trimester. Finally biochemical and laboratory indicators used to support the diag- nosis of appendicitis in the nonpregnant patient are unscliable in pregnancy. For example, a mild physiologic leukocytosis of preg- nancy is a normal finding. C-reactive protein levels may also be physiologically clevated in pregnancy. In addition, the surgeon rust be concerned about the possibilty of obstetric emergencies as a cause of abdominal pain, such as preterm labor, placental abruption, or urerine rupture.” All of these factors have con- tributed to the high rate of negative appendectomy in pregoant patients, as high as 259% co 50%, when it is based on clinial presentation alone.” “The impact of appendicitis on the pregnant patient is severe “The risk of preterm labor has been shown to be 119% and fetal loss 696 with complicated appendicitis" These data would appear to favor an aggressive, erly approach to appendicitis in the preg- nant patient. Complicating this approach, however, was the finding in che same series that negative appendectomy was aso associated with preterm labor and feral los (10% and 4%, respec- tively). The lowest rates of preterm labor and fetal loss (6% and 2%, respectively) were seen in cases of uncomplicated APPROACH TO THE PREGNANT PATIENT WITH SUSPECTED APPENDICITIS Dittuse peritonits present ‘Appendectomy MRI (~) for appends Diagnoste laparoscopy i FIGURE 50-8 Suggostod algorthn for managing tho prograntpationt with possible appendicitisCHAPTER 50_ The Appendix 1307 appendicitis: For chese reasons, preoperative accuracy of diagno- sis is crucial in the pregnant patient with suspected appendicitis Routine imaging is ecommended in pregnant patients. The initial seudy of choice is US with graded compression. Ie has the advantage of being safe, inexpensive, and readily available. In addition, US may provide information as to fetal well-being and obstetric causes of abdominal pain, such as placental abruption, Scanning patients in a left posterior ablique or left lateral decu- bitus position rather than in the eraditional supine position has been advocated to increase the chances of visualizing the appen- dix. The criteria for US diagnosis ae the same a in the nonpreg. rant patient and have been discussed previously. Unforcunacly, the sensitiviey (78%) and speciiiey (83%) of US appear to be reduced in pregnancy because of the presence of the gravid con findings ate equivocal, MRI without gado- linium contrat, with its excellent soft este contrast resolution and lack of ionizing radiation, remains a safe alternative for con- frmation or exclusion of appendicitis inthe pregnant patient. In audition, the excellent sensitivity and specificity ate preserved in the pregnane patient (Tig. 50-9). A patient in whom MRI findings ae normal likely does noc require appendectomy. Routine use of MBI in pregnant patients has been demonstrated to reduce the negative appendectomy rate by 47% without a sgnifican inctease inthe perforation rate, and ic has been shown 0 be a costffective seudy." For these reasons, we encourage liberal use of MRI in pregnant patients suspected to have acute appendicitis without frank peritonitis. However, MRI may aot be available in some institutions and may be available only ona limited bass or during limited times in other instiutions. ‘The decision about any delay in appendectomy to obtain an MRI study is a complex one and should be made using all availabe clinical and imaging data aval able because there ate potentially severe consequences associated ith both negative appendectomy and appendiceal perforation. If US is inconelusive and MRI scanning is noc immediately available, CT scanning for diagnosis of appendicitis in pregnancy has been reported. A study published in 2008 demonstrated that the use of CT was associated with an 89% negative appendectomy rate, compared with 54% by clinical assessment alone and 3286 by clinical assessment combined with US. The authors concluded that CT should be used if US examination findings are equivocal FIGURE 50-3 MRI scan ina grave Petks NA, Schroepoel Tu: Upaate on imaging for ecute appendicitis ‘Surg Gin North Amn 91:14 1-186, 2071.) and argued that che amount of radiation delivered during a limited CCT examination is below the threshold required to induce fetal malformations and that most cases of appendicitis in pregnancy occur in the second or third erimester, when organogenesis in already complet." Although protocols vary, if CT is used during pregnancy for equivocal cases, care should be taken to perform as limited a study as possible with avoidance of intravenous admin. istration of contrast material. Further study is required before the routine use of CT can be accepted in this clinical seenaio. “The choice of laparoscopic versus open technique for appen- dectomy in pregnancy also merits discussion, Current Society of American Gasttoincestinal and Endoscopic Surgeons guidelines seate tha laparoscopic appendectomy is safe in pregnancy and is the standard of eare in pregnant patients.” Two studies, both small and retrospective, have shown no incteased fetal los with laparoscopic appendectomy compared with open appendectomy. Another seudy reported higher preterm labor and overall compli- cation rates in the open group compared with the laparoscopic group.” Others have reporced higher fetal loss rates with laparo- scopic appendectomy (5.6% versus 3.1%) compased with open appendectomy." Ie is apparent that this debate would be best resolved through randomized controlled wials, which to date have rot been performed (Our insticutional experience with laparoscopic appendectomy in pregoancy has been positive, making ic our preferred approach co the pregnant patient. In our hands, we believe it allows an easier identification of the highly variable location of the appendix, a more expeditious removal, and an opportunity for more thorough evaluation of the abdomen for any associated pathologic process ‘We do routinely use an open access approach (Hasson technique) for intial trocar placement to avoid any chance of injury co the gravid uterus. ‘Appendicitis in the Elderly Although itis not the peak age for its occurrence, appendicitis i not infrequently seen in elderly patients and should remain in the Ailferencal diagnoses of any elderly patient presenting with acure abdominal pain who has not had an appendectomy. The most important aspect is to realize the expanded differential diagnosis that must be considered in the elderly. Other possible diagnoses include but are not limited co acuce diverticulitis (uncomplicated or complicated), malignant disease, intestinal ischemia, ischemic colitis, complicated utinary tract infection, and perforated ulcer. ‘Appendicitis may alzo be manifested in an atypical manner, s0 a high index of suspicion must be maintained. A careful history and physical examination may aid in diagnosis, but chs may have lide value in cereain circumstances, such a in patients with dementia, an altered mental satus. The higher perforation rate in the elderly population, as high as 409 to 70%, combined with the fiequent coexistence of comorbidities resulting in higher morbid ity makes the diagnosis and treatment of appendicitis in the elderly a challenge, to say the least.” ‘When faced with an elderly patient with diffuse peritonitis, immediate laparotomy should be performed without unnecessary delay. When the pain is localized and peritonitis is absent, CT scanning of the abdomen should be performed to confirm the diagnosis and to evaluate for other pathologie changes. Laparo- scopic appendectomy is safe in the elderly and is our procedure of choice in this group of patients. Exceptions include patients with severe cardiomyopathy, in whom we prefer the open approach to avoid che deleterious effects of pneumoperitoncum in patents with marginal cardiae function.” We haveSECTION X_ Abdomen also successfully performed open appendectomy under spinal anesthesia in patients who are “pulmonary cripples” and in wh the risk of general surgery is prohibitive and likely co resul ventilator dependence Appendicitis in the Immunocompromised Patient Appendicitis in the immunocompromised patient is manage the same manner as in the immunocompetent patient, with prompt appendectomy. ‘The key in the evaluation of this popula- tion lies in maintenance of a high index of suspicion because the lack of the ability to mount an immune response may result in absence of fever, leukocytosis, and peritonitis. For this reason, carly use of CT imaging is advisable. This allows confirmation of the diagnosis of appendicitis aswell s the exclusion of diagnoses, such as neutropenic enterocolitis (typhlii), that may be amenable to nonoperative crearment. NEOPLASMS OF THE APPENI Neoplasms of the appendix, although rare, require appropriate treatment. An unanticipated appendiceal neoplasm may be encountered at any elective or emergency operation. Iti estimated that 50% of appendiceal neoplasms present as appendicitis and ae diagnosed on pathologic examination ofthe surgical specimen, bbue variable presentations have been reported. Ie is reported that I neoplasms ae identified in 0.7% to 1.796 of pathology In addition, an appendiceal mass is sometimes noted cidental finding on abdominal CT (Fig. 50-10). The pathologie classification and biologie behavior of appendiceal neo- plasms are diverse, which serves © make the classification, termic nology, and treatment recommendations even more confusing | Overall, appendiceal neoplasms ate thought co account for 0.4% to 1% ofall gastrointestinal malignant neoplasms. Aer appendeccomy for presumed appendi of unexpected findings in the surgical specimen is low. Stil, if identified, appropriate counseling and wcatment are cssential Carcinoid camors ae che most common tumor primary identified in the appendix.” These neoplasms arise from neuroendocrine cells from within the appendix and are detected in 0.3% to 0.5% of appendectomy specimens.’ These ate typically small, the incidence FIGURE 50-10 CT scan of the abdomen in a patient with a benign 0.cm mucccele. The axial image shows a distended fuidiled mass, redial to the appendix farowi, without associated inflammation ©, Cecum; Ti, terminal leur, well-citcumscribed lesions that ate located within the more distal aspect ofthe appendix. “The biologic bchavior of carcinoid tumors is highly variable Size appeats to be the best predictor of malignant behavior and metastatic potential, more so than histologie features, including Iymphovascular invasion, Carcinoids smaller than 1 em ate ypi cally thought t0 behave in a benign manner and are cuted with appendectomy. Carcinoids larger than 2 em are treated more aggressively, however. Other considerations include whether the carcinoid involves the base of the appendix o extends into the rmesoappendix, Patients with carcinoids larger than 2 om, with involvement of che base, or with extension fo the mesoappendix should undergo right hemicolectomy with regional lymphadenec- tomy. For lesions beeween 1 and 2 em in ste, recommendations should be made after cateful consideration of the individual tumor characteristics as metastases have been reported." ‘Adenocarcinoma af the appendix is rare and occurs at a fee~ quency of 0.08% to 0.19 of ll appendectomies.” Treatment is identical to that of cecal adenocarcinoma and consists of right hemicolectomy with regional lymphadenectomy. Chemotherapy is also identical to that of adenocarcinoma of the colon, with adjuvant administration of 5-Buorourail, leucovorin, and oxalic platin (FOLFOX) to selected patients. FOLFOX has also been ‘used in che neoadjuvant seting in patients with mucinous adeno- carcinoma before eytoreductive (debulking) surgery." ‘Mucinous cumors ofthe appendix are appendiceal tumors that are not frankly malignant but, ifruptured, can result in intaperi- toneal spread and the development of pseudomyxoma peritonci (PMP), Classification and nomenclatute of these lesions ate con- fusing and not universally agreed on.” Because PMP results as a consequence of perforation and direct peritoneal seeding from the appendieeal contents, the surgeon should use great caution +0 avoid rupturing an intact appendix if mucocele or mucinous neoplasm is suspected on preoperative imaging or diagnosed intraoperatively. IF PMP occurs, treatment by extensive eytoreduc- tive surgery involving removal of any involved organs combined with heated intraperitoneal chemotherapy is typically employed” and is associated with long-term survival ‘Although many appendiceal neoplasms are diagnosed on final pathologic examination, the mass will occasionally be visible at the time of appendectomy. An excellent algorithm for the man- agement of the incidentally identified appendiceal mass was pro- posed by Wray and colleagues, and a modified version is provided for eview (Fig. 50-11).' This algorithm is useful both in cases of| appendicitis and in cases in which an appendiceal mor i identi fied incidencally. The availability of frozen-section diagnosis may provide additional help with intraoperative decision making. ‘SELECTED REFERENCES Ingraham AM, Cohen ME, Bilimoria KY, etal: Comparison of ‘outcomes after laparoscopic versus open appendectomy for acuee appendicitis at 222 ACS NSQIP hospitals. Surgery 148:625-635, discussion 635-637, 2010. The authors provide ane of the largest series to date, nearly 32,000 patients, comparing outcomes of laparoscopic versus, ‘pen appendectomy using the ACS NSQIP database. ‘McGory ML, Zingmond DS, Tillou A, et al: Negative appendec- tomy in pregnane women is astociated with a substantial risk of fetal loss. J Am Coll Surg 205:534-540, 2007,CHAPTER 50_ The Appendix APPROACH TO PATIENT WITH APPENDICEAL NEOPLASM Tet Note: All patients with appendiceal neoplasm should undergo routine colonoscopy FIGURE 50-11 Suggested algorithm for managing the patient with an appendicesl neoplasm,SECTION X_ Abdomen This article, which demonstrates that fetal loss is not only. highest with appendiceal rupture but also increased with negative appendectomy, highlights the need for accurate diagnosis in the pregnant patient. Parks NA, Schroeppet TT: Updace on imaging for acute appendi- itis, Surg Clin North Am 91:141-154, 2011 The authors present a thorough, evidence-based review of the current available imaging studies used to diagnose appendiceal disease along with the clinical crcumstances in Which they are most useful, Silen W: Cope early diagnois of the acute abdomen, ed 22, New York, 2010, Oxford University Press This classic text, now in its 22nd edition, provides a master- fal overview of the differential diagnoses and subtle histor cal findings of appendicitis and related disease, It is a timeless source of wisdom and is considered a “must read” by many surgeons. Solomkin JS, Manuski JE, Bradley JS, et al: Diagnosis and man- agement of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 50:133— 164, 2010. This consensus statement from the IDSA and SIS provides evidence-based guidelines for the treatment of complicated intra-zbdominal infections, including appendicitis Wray CI, Kao LS, Millas SG, ec al: Acute appendicitis: Contro- versies in diagnosis and management. Curr Probl Surg 50:54-86, 2013. This timely and weilwritten review article details some of the controversial issues relating to surgery of the append ‘and includes an excellent overview of the treatment of appendiceal neoplasms, REFERENCES 1, Wray CI, Kao LS, Millas SG, etal: Acute appendicitis: Con- trovesies in diagnosis and management. Curr Probl Surg 50:54-86, 2013. 2, Addiss DG, Shaffer N, Fowler BS, etal: ‘The epidemiology of appendicitis and appendectomy in the Unived States. Amt J Epidemiol 132:910-825, 1990. 3. Prystowsky 1B, Pugh CM, Nagle AP: Current problems in. surgery. Appendicitis. Gurr Probl Surg 42:688-742, 2005. 4, Randal Bollinger R, Barbas AS, Bush EL, etal: Biofilms in the large bowel suggese an apparent function of the human vermiform appendix. J Theor Bol 249:826-831, 2007. 5. Deshmukh S, Verde E Johnson PT, et al: Anatomical variants and pathologies of the vermix. Emerg Radiol 21:543-552, 2014. 6. Chen CY, Chen YC, Pu HN, et ak Bacteriology of acute appendicitis and its implication for the use of prophylactic antibiotics. Surg nfet (Larchms) 13:383-390, 2012 2 3, 4 15 16, 19, 20. 2 2. 25, 26. Silen W: Capes early diagnosis of the acute abdomen, ed 22, Now York, 2010, Oxford University Press Andersson RE: Meta-analysis of the clinical and laboratory dliagnosis of appendicitis. Br J Surg 91:28-37, 2004, Parks NA, Schroeppel T}: Update on imaging for acute appendicitis. Surg Clin North Am 91:141-154, 2011. Birnbaum BA, Wilson SR: Appendicitis a che millennium, Radiology 215:337-348, 2000 Solomkin JS, Mazuski JE, Bradley JS, etal: Diagnosis and ‘management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infeeion Society and the Infectious Diseases Society of America, Clin Infect Dis 50:133-164, 2010. Brown MA: Imaging acute appendi CT MR 29:293-307, 2008 Drake FT, Florence MG, Johnson MG, eta: Progress in the diagnosis of appendicitis: A report from Washington States Surgical Care and Outcomes Assessment Program. Ann Surg 256 586-594, 2012. Ingraham AM, Cohen ME, Bilimoria KY, etal: Comparison of outcomes aftr laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQUP hospitals. Surgery 148:625-635, discussion 635-637, 2010. Fleming FJ, Kim MT, Messing S, et ak: Balancing the risk of postoperative surgical infections: A mulevariae analysis of factors associated with laparoscopic appendectomy from the NSQUP database. énn Surg 252:895-900, 2010 Teincira PG, Demetiades D: Appendicitis: Changing per- spectives, Adv Surg 47:119-140, 2013, Deelder JD, Richir MC, Schoorl T; eal: How to treat an appendiceal infammatory mass: Operatively or nonopera- tively? J Gastrointest Surg 18:641—645, 2014. Lugo JZ, Avgerinos DV, Lefkowitz AT, etal: Can interval appendeceomy be justified following conservative treatment of perforated acute appendicitis? J Surg Res 164:91-94, 2010. Fawley J, Gollin G: Expanded utilization of nonoperative management for complicated appendicitis in children, Lan- gembecks Arch Sarg 398:463~466, 2013. Zhang HL, Bai YZ, Zhou X. et al: Nonoperative manage- ‘ment of appendiceal phlegmon or abscess with an appendl- colith in children, J Gastrointest Surg 17:766-770, 2013, Puapong D. 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Carpenter SG, Chapital AB, Merritt MV, et al: Increased risk of neoplasm in appendicitis created with interval Semin UltrasoundCHAPTER 50_ The Appendix 2. 28. 29, 30, 31 32, 33, 35, 36 37, appendectomy: Singleinstcucion experience and literature review. Amn Surg 78:339-343, 2012. Furman MJ, Cahan M, Coben P. et al: Increased tisk of mucinous neoplasm of the appendix in adults undergoing interval appendectomy. JAMA Surg 148:703~706, 2013. Gactke-Uidager K, Maturen KE, Hammer SG: Beyond acute appendicitis: Imaging and pathologic spectrum of appendi- cezal pathology. Emerg Radiol 21:535-542, 2014, Lai HW, Loong CC, Chi JH, et al: Interval appendectomy. after conservative treatment of an appendiceal mass. World J Surg 30:352-357, 2006. Gatlipp B, Arle G: [Laparoscopy for suspected appendi Should an appendix that appears normal be removed? Chivarg 80:615-621, 2009. 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Clin North Am 31:1005-1022, 2013, Komdorfier JR. Jr, Felinger E, Reed W: SAGES guideline for laparoscopic appendectomy. Surg Endowe 24:757-761, 2010, ‘Walsh CA, Tang T, Walsh SR: Laparoscopic versus open appendicectomy in pregnancy: A systematic review. Ine J Surg 6339-344, 2008. Richmond BK, Thalheimer L: Laparoscopy associated mes- enteric vascular complications. Am Surg 76:1177-1184, 2010. Hernandes-Ocasio F Palermo-Garofalo CA, Colon M, et al: Right lower quadrant abdominal pain in an immunocompro- mised patient: Importance for an urgent diagnosis and teat ment. Bol Asoe Med P R 103:51-53, 2011 Boudreaux JP Klimstra DS, Hassan MM, etal: The NANETS, consensus guideline for the diagnosis and management of neutoendocrine tumors: Welllifferentiated neuroendoctine cumots of che jejunum ileum, appendix, and cecum. Panerear 39:753-766, 2010. Sugarbaker PH, Bijeic L, Chang D, ct al: Neoadjuvant FOLFOX chemotherapy in 34 consecutive patients with ‘mucinous peritoneal carcinomatosis of appendiceal origin I Surg Oncol 102:576-581, 2010. ‘Wagner PL, Austin FE Maduckwe U, etal: Extensive cytore- ductive surgery for appendiceal carcinomatosis: Morbidity, morality, and survival. Ann Surg Oncol 20:1056-1062, 2013.