Appendicitis remains one of the most common and urgent surgical conditions worldwide, with a lifetime risk of 8.6% in men and 6.9% in women.[10] Prompting intervention is crucial for preventing complications and improving prognosis.[11] Traditionally, the standard treatment for acute appendicitis has been an appendectomy, performed either through open surgery or laparoscopically.[12] However, there is growing interest in nonsurgical management for patients with uncomplicated appendicitis. Several studies have demonstrated the efficacy of antibiotic therapy as a nonsurgical alternative for patients with acute uncomplicated appendicitis, reducing the immediate need for surgery.[3, 4] Despite its effectiveness, there remains a risk of recurrence, necessitating careful patient selection and diligent follow-up.[13, 14]
Complicated appendicitis presents additional challenges and often necessitates a more comprehensive treatment approach than uncomplicated appendicitis.[15] There have been significant advancements in the management of complicated appendicitis via both conservative and surgical methods.[16, 17] In conservative treatment, optimized antibiotic regimens and the use of broad-spectrum antibiotics have reduced the need for immediate surgery.[18] Additionally, imaging-guided percutaneous drainage techniques have improved the safety and effectiveness of managing abscesses.[19, 20] Enhanced patient monitoring protocols, along with the advent of telemedicine and home-based care, have improved follow-up and reduced hospital stays.[21] In surgical treatment, laparoscopic appendectomy and robotic-assisted surgery are revolutionary surgical procedures, that offer shorter recovery times and fewer complications compared to open surgery.[22, 23] The concepts of interval appendectomy, risk stratification methods, and enhanced recovery protocols, including multimodal analgesia and early mobilization, have further refined surgical approaches.[24, 25] Ongoing comparative studies, research on long-term outcomes, and evaluations of patient preferences and quality of life are essential for developing comprehensive and patient-centered care strategies for complicated appendicitis patients.
Despite advances in conservative management, some surgeons and patients still prefer surgical intervention for various reasons, such as resolving the patient's issue in a single procedure and avoiding the prolonged duration of conservative treatment.[7] Typically, surgical treatment is recommended for early-stage appendicitis (duration of symptoms ≤ 72 hours) with peri-appendiceal phlegmon due to the effectiveness of immediate intervention in preventing further complications. Conversely, for late-stage appendicitis (duration of symptoms > 72 hours) or cases with peri-appendiceal abscess formation, an initial conservative approach involving antibiotics and percutaneous drainage is often favored to manage the condition effectively.[6] For patients who refuse conservative treatment initially, surgery becomes the only viable option. However, is surgery the right option? In our study, patients with peri-appendiceal abscesses had a significantly longer LOS compared to those with phlegmon. Additionally, we divided the patients with peri-appendiceal abscesses into two groups based on the median size of the abscess: those with abscesses less than 5.0 cm and those with abscesses 5.0 cm or larger. Both groups with abscesses had a significantly longer LOS than patients with phlegmon, and patients with peri-appendiceal abscess measuring 5.0 cm or larger had a significantly longer LOS than those with abscess smaller than 5.0 cm. These data suggest that the presence of a peri-appendiceal abscess, especially a larger abscess, is associated with longer hospital stays compared to the presence of peri-appendiceal phlegmon.
When reviewing the treatment approach for patients with acute complicated appendicitis with peri-appendiceal abscess or phlegmon, different strategies are recommended based on the patient’s condition.[11] For patients with peri-appendiceal phlegmon, immediate surgical intervention is typically advised.[26] In contrast, for patients with peri-appendiceal abscesses, especially larger abscesses, an initial conservative treatment approach is recommended.[16, 17] This involves the use of antibiotics and percutaneous drainage to manage infection and inflammation.[27] The efficacy of conservative treatment for peri-appendiceal abscesses was highlighted in another clinical study (NCT06469086), which concluded that conservative treatment can effectively reduce the need for immediate surgery and minimize complications for selected patients.
The presence of an appendicolith, a calcified deposit within the appendix, significantly affects the progression and severity of acute appendicitis and the formation of peri-appendiceal abscesses.[28] An appendicolith can obstruct the appendix lumen, leading to increased pressure, bacterial overgrowth, and inflammation, often delaying symptom relief. This obstruction is also a major risk factor for localized perforation and abscess formation, necessitating more complex treatment approaches.[29] In this study, we found that the presence of an appendicolith is a risk factor for peri-appendiceal abscess formation in patients with acute complicated appendicitis. Our previous research demonstrated that identifying an appendicolith through imaging helps stratify patients by risk, guiding treatment decisions such as early surgical intervention to prevent severe complications or conservative management with antibiotics and drainage for abscess formation. Understanding the relationship between appendicoliths and these complications is crucial for improving patient outcomes, emphasizing the need for careful diagnosis, appropriate management strategies, and further research into effective treatment protocols.
This study has several limitations that should be considered. First, as a retrospective analysis, it is inherently prone to selection biases, despite utilizing data from a prospectively recruited database. The retrospective nature of the study limits the ability to control for all potential confounding variables, which might impact the generalizability of the findings. Second, the lack of long-term follow-up data restricts our ability to assess the long-term outcomes of the treatment strategies evaluated. This absence makes it challenging to determine the durability of the results and the potential for late complications, which are crucial for a comprehensive understanding of treatment efficacy. Third, the analysis did not incorporate various subjective factors, such as sociocultural influences, which can significantly affect treatment outcomes, particularly in the context of China.[30, 31] Moreover, the study's focus on clinical and demographic factors without considering the broader socioeconomic context may overlook important variables that influence health outcomes. Factors such as access to healthcare, economic constraints, and educational levels can also play a significant role in the success of treatment and patient adherence to medical advice.