Expert Commentary

Interval appendectomy in adults: A necessary evil?

Benjamin Quartey
Department of Surgery, National Naval Medical Center, Bethesda, MD 20889, USA

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

Key Words: Appendectomy, appendiceal mass, appendicectomy, interval appendectomy, phlegmon

INTRODUCTION of appendiceal mass has been a matter of major controversy

for decades. There are three schools of thought regarding the
Acute appendicitis is a clinical diagnosis. Its etiology is unknown correct management: (a) immediate appendicectomy prior to
but is believed to be multifactorial, with all of the following initial inflammatory mass resolution;[8–10] (b) initial conservative
playing a part: inadequate dietary fiber,[1] familial factors,[2] treatment followed by interval appendectomy;[11–13] and (c) an
and luminal obstruction from fecalith impaction or lymphoid entirely conservative approach, without any appendectomy. [14–16]
hyperplasia, and other processes[3,4] such as parasitic infestation. The initial conservative management of appendiceal mass entails
The lifetime risk for acute appendicitis is 8.6% and 6.7% for men hospital admission, bowel rest, broad-spectrum antibiotics,
and women, respectively, in US.[5] Appendectomy is the treatment hydration, and percutaneous drainage of the abscess until
of choice for acute appendicitis and remains the most commonly the resolution of the mass. Currently, the initial conservative,
performed abdominal emergency surgery. Epidemiologically, nonoperative management for appendiceal mass is favored
acute appendicitis accounts for over 1 million patient-days of by most surgeons. [13–16] However, for the past decade the
admission in the US.[5] Most patients present early in the disease million dollar question has been: what next after conservative
process; however, in 2%–6% of patients diagnosis is made when management of appendiceal mass? The classical or traditional
an appendiceal mass is discovered on preoperative imaging.[6,7] answer to this question is ‘interval appendectomy,’[11–13] but this
approach has been questioned in the literature.[7,15–22] Advocates
The appendiceal mass (tumor formation after appendicitis) of interval appendectomy believe recurrence of appendicitis is
is the end result of a walled-off appendiceal perforation. very high during the waiting period and, besides, appendectomy
Pathologically, it may range from phlegmon to abscess.[7] The will provide a definite diagnosis and also rule out any underlying
former is an inflammatory tumor consisting of the inflamed malignancy masquerading as a phlegmon or appendiceal
appendix, its adjacent viscera, and the greater omentum, whilst mass. [12,13,22,23] The antagonists of interval appendectomy argue
the later is a pus-containing appendiceal mass.[7] The management that the rate of recurrent acute appendicitis is low (6–20%) [24–26]
but that the complications of surgery for acute recurrent
appendicitis is not low, with reported rates ranging from 3.4–
Address for correspondence:
Dr. Benjamin Quartey, E-mail: benjamin.quartey@med.navy.mil 17%.[13,19,27] The present review revisits the above controversy,
evaluates the current literature, assesses the need for interval
Access this article online appendectomy, and provides recommendations.
Quick Response Code:
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www.onlinejets.org INTERVAL APPENDECTOMY: NECESSARY?

DOI:
Initial conservative management of an appendiceal mass, as
10.4103/0974-2700.99683 advocated by Ochsner,[28] is widely accepted among surgeons;
however, interval appendectomy is still practiced due to the
Journal of Emergencies, Trauma, and Shock I 5:3 I Jul - Sep 2012 213
Quartey: Interval appendectomy in adults

claimed risk of recurrent acute appendicitis and the need to However, it is noteworthy that in five (3.03%) patients the
establish a definite diagnosis and to rule out an underlying histological specimen revealed colon cancer.
malignancy.[12,29,30] In a retrospective review of 46 patients
who underwent interval appendectomy after initial successful A recent prospective nonrandomized study of 51 patients (mean
nonoperative management of appendiceal mass, 16% had a age: 31.75 years) who had initial successful conservative treatment
normal or obliterated appendix on final pathology.[31] However, of appendiceal mass revealed a recurrence rate of 17.6% (nine
44%, 15%, 4%, and 4% of these interval appendectomies patients) for acute appendicitis, with 44.4% (four patients) of
revealed acute appendicitis, chronic appendicitis, inflammatory these recurrences occurring within 6 weeks, 22.2% (two patients)
bowel disease, and mucinous cyst adenoma, respectively.[31] between 6–12 weeks, and 33.3% (three patients) after 12 weeks.[34]
Although only 9% (four patients) developed recurrent abdominal Interval appendectomy therefore prevents 10.6% and 6.7% of
pain after the initial successful nonoperative management, the cases of recurrent appendicitis if performed at 6 and 12 weeks,
authors recommended interval appendectomy as it would allow respectively; the 1 year recurrence rate was also low (1.9%).[34]
evaluation for a clinically significant disease process and help These data argue against interval appendectomy.
avoid recurrence.
Willemsem et al, based on their retrospective review of 233
In another retrospective series of 73 patients (mean age of appendectomies done after successful initial conservative
41 years), 5 patients underwent interval appendectomy 6–8 management of appendiceal mass, suggested that routine
weeks from initial presentation. There was one postoperative interval appendectomy was unnecessary.[19] Thirty percent of
complication of wound infection and one case showed the the appendectomies showed a normal appendix without signs of
presence of a mucocele on final pathology.[12] Although the previous inflammation. The recurrence rate was low (2%) but the
sample size was too small for any definitive conclusion, the complication rate due to interval appendectomy was high (18%).[19]
authors felt that interval appendectomy was beneficial. Besides, In a recent large retrospective cohort study involving 1012 patients
a recent survey (with a high response rate) of 90 practicing (58% men; 48% of subjects in the age range of 20–49 years)
general surgeons in England revealed that 53% still performed who presented with appendiceal mass and underwent initial
routine interval appendectomy at 6–12 weeks mainly due to fear successful conservative management, no interval appendectomy
of recurrent appendicitis[32] 13% of the surgeons did so because was performed in 864 (85%) patients.[28] The recurrence rate was
of concerns about presence of malignancy.[32] Yamini et al, have 5% (39 patients) after a mean follow-up of 4 years. The mean
reported that interval appendectomy is safe, with a complication length of hospital stay was 4 days for those who did not undergo
rate of only 10% and without need for prolonged hospitalization interval appendectomy as compared to 6 days for patients who
(mean length of hospital stay: 1.4 days).[33] underwent interval appendectomy. The authors concluded that
routine interval appendectomy was not justified.
INTERVAL APPENDECTOMY: EVIL?
The only randomized prospective study done in this decade
involved 60 patients with appendiceal mass, and the data from
Traditionally, after successful nonoperative management of an
that study showed that conservative management without interval
appendiceal mass, interval appendectomy is performed either
appendectomy is safe. The recurrence rate was low (10% after a
semi-electively or electively. This management approach is still
mean follow-up of 33.4 months) and, moreover, recurrent acute
preached today but has been questioned by a growing amount of
appendicitis could be successfully managed with appendectomy.[35]
evidence.[7,15–22,30] Tekin et al, prospectively followed 94 patients
(mean age 46.4 years) for 3 years after they were conservatively
managed for appendiceal mass.[21] The mean reported incidence DISCUSSION
of recurrent appendicitis was 14.6% (13-patients).[21] The majority
of the recurrences occurred in the first 6 months (9 patients; Although the surgical treatment of appendicitis is widely accepted,
10.1%) but the rate decreased to 2.2% at 1 year. The authors controversy still exists regarding the management of appendiceal
concluded that routine appendectomy after initial successful mass. Current literature supports an initial conservative approach
nonoperative management is not justified. but whether routine interval appendectomy should be done is
still a matter of debate. On the one hand, it is generally believed
Similarly, in a retrospective review of 165 patients (mean age: that recurrence of acute appendicitis is very high during the
53.6 years) managed conservatively after initial presentation waiting period but, on the other hand, appendectomy can provide
with appendiceal mass, the reported recurrence rate for acute a definite diagnosis and identify malignancy masquerading as a
appendicitis was 25.5%, with the risk of recurrence being phlegmon.[12,29,30]
highest during the first 6 months (83.3%).[22] However, if interval
appendectomy was performed 6 and 12 weeks after discharge, less The reported rate of recurrence of acute appendicitis ranges
than 16% and 10% of recurrent appendicitis could be prevented from 6–25.5%, with the majority of recurrences occurring
with this approach. Moreover, routine interval appendectomy during the first 6 months.[22,24–26] The 1-year recurrence rate is
benefited less than 20% of the patients in this study and therefore also low (1.9–2.2%).[19,21,32] The prospective series of Youseff
the authors did not recommend interval appendectomy. [22] et al, showed that interval appendectomy performed at 6
214 Journal of Emergencies, Trauma, and Shock I 5:3 I Jul - Sep 2012
 Quartey: Interval appendectomy in adults

weeks and 12 weeks will prevent 10.6% and 6.7% of recurrent As far as cost-effectiveness is concerned, interval appendectomy
appendicitis, respectively.[34] That means 89.4% and 93.3% of after conservative management of appendiceal mass was not
patients respectively had unnecessary appendectomy.[34] This is economical according to a large single-institution retrospective
similar to the less than 20% of patients benefiting from interval analysis involving 165 patients followed for 5-years.[37] According
appendectomy in the series reported by Lai et al,[22] Moreover, to the study, there is 38% cost reduction during follow-up if
there is no increased morbidity associated with appendectomy appendectomy is performed only after recurrence of acute
when done in recurrent cases.[34] However, even though current appendicitis as compared to routine interval appendectomy in
evidence does not support such practice, 53% of surgeons in all patients with appendiceal mass.[37] Kaminski et al, also showed
England still perform routine interval appendectomy at 6–12 that the median length of hospital stay for patients admitted due
weeks, mainly due to the fear of recurrent appendicitis.[32] to recurrent appendicitis was shorter than that for those admitted
for interval appendectomy and hence the former approach was
Another important reason for doing an interval appendectomy more cost-effective.[28] This is similar to the report by Kumar
after successful nonoperative management of appendiceal mass is et al., in which hospital stay was shorter and time spent away from
the need to make a definite diagnosis and to rule out malignancy. work less for patients managed entirely nonoperatively until they
Mucinous cystadenoma was noted in one out of five pathology developed recurrent appendicitis.[35]
specimens after interval appendectomy. [12] Similarly, one
adenocarcinoma was detected from 38 interval appendectomies CONCLUSION
in another series.[18] In a series of 46 interval appendectomies,
two patients had mucinous cystadenoma and another two had Appendiceal mass should be managed nonoperatively at the
inflammatory bowel disease on final pathology.[31] Recently, a initial presentation. Interval appendectomy is not indicated
retrospective study by Lai et al, reported 2% neoplasm and 8% after successful nonoperative management. The recurrence rate
mucinous changes among 70 interval appendectomies and 10% of acute appendicitis is low and appendectomy can be safely
neoplasm and 5% mucinous changes for those who underwent performed at that time. The risk of missing the diagnosis of an
appendectomies after recurrence (20 patients).[22] This greater underlying malignancy is also low but we recommend additional
incidence of new pathology on the final appendectomies is evaluation with colonoscopy or barium enema in patient over 40
not high enough to support the use of interval appendectomy
but, at the same time, it is also not low enough when one
takes into consideration the consequences of misdiagnosing Table 1: Studies with evidence against interval
an underlying malignancy. As expected, more than 50% of all appendectomy (1996–2010)
interval appendectomies showed chronic and acute appendicitis, Authors Year Patients treated Mean Morbidity Recurrence
which does not encourage routine interval appendectomy after without interval follow-up n (%) n (%)
appendectomy* (years)
successful nonsurgical treatment. Therefore, it would be prudent
Addalla et al.[15] 1996 30 1.3 NR 2 (7)
to do an evaluation of the colon with colonoscopy or barium Dixon et al.[38] 2003 237 NR NR 32 (13)
enema to detect any underlying disease in high-risk patients after Eryilmaz et al.[39] 2004 24 2.9 1(4) 3 (12)
Kumar et al.[35] 2004 20 2.8 N/A 2 (10)
a successful initial nonoperative approach.[20,22,30] Moreover, for Kaminski et al.[28] 2005 864 4 NR 39 (5)
extracolonic lesions and Crohn disease virtual colonoscopy, CT Lai et al.[22] 2006 94 2.75 2(10) 24 (25.5)
Tekin et al.[21] 2008 89 3 N/A 13 (14.6)
scan, and ultrasound are more useful investigational tools after Youseff et al.[34] 2010 51 NR 1(12.5) 9 (17.6)
conservative management of appendiceal mass.[20] In effect, *After successful initial conservative management. N/A: Not applicable; NR: Not recorded
colonoscopy augmented by CT scan is a good modality for
excluding cecal pathology in high-risk patients.[36]
Table 2: Studies that support interval appendectomy
Interval appendectomy is also not without morbidity. The (1996–2010)
reported complication rate ranges from 12% to 23%.[13,16,18,19,24] Authors Year Patients treated with New Morbidity
The complications include sepsis, bowel perforation, small interval appendectomy pathology n (%)
bowel ileus, fistulas, and various wound infections as reported Yamini et al.[33] 1998 41 3/41 4 (10)
Friedel et al.[12] 2000 5 1/5 1 (20)
by Willemsen et al. in their retrospective review of 233 interval Lugo et al.[31] 2010 46 5/46 1 (2)
appendectomies after successful initial conservative management
of appendiceal mass. [19] Eriksson et al, reported an 18%
complication rate for interval appendectomy in their series, Table 3: Studies evaluating the necessity of interval
which was similar to the rate in patients treated with immediate appendectomy
appendectomy for appendiceal mass[18] – ‘an outdated practice.’ Authors Year Patients Morbidity Conclusion Interval
The practice of interval appendectomy therefore need serious treated with n (%) appendectomy
interval recommended/not
reconsideration in view of the high complication rates and the appendectomy recommended
low probability of new findings on final pathology. Tables 1–3 Verwaal et al.[16] 1993 50 4 (8) Not recommended
summarize some of the key literature (since 1990) on the current Eriksson et al.[18] 1998 38 5 (13) Not recommended
Willemsen et al.[19] 2002 205 36 (17) Not recommended
controversy about the necessity for interval appendectomy.
Journal of Emergencies, Trauma, and Shock I 5:3 I Jul - Sep 2012 215
Quartey: Interval appendectomy in adults

years. In addition, nonoperative management has a cost advantage 20. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal
over routine interval appendectomy after initial successful abscess or phlegmon: A systematic review and meta-analysis. Ann Surg
2007;246:741-8.
conservative management.
21. Tekin A, Kurtoglu HC, Can I, Oztan S. Routine interval appendectomy is
unnecessary after conservative treatment of appendiceal mass. Colorectal
Disclaimer
Dis 2008:10:465-8.
The views expressed in this review article are those of the
22. Lai HW, Loong CC, Chiu JH, Chau GY, Wu CW, Lui WY. Interval
author and do not reflect the official policy of the Department appendectomy after conservative treatment of appendiceal mass. World
of the Navy (DON), Department of Defense (DOD), or US J Surg 2006;30:352-7.
Government. 23. Paul DL, Bloom GP. Appendiceal abscess. Arch Surg 1982;117:1017-9.
24. Mosegaard A, Nielsen OS. Interval appendectomy: A restrospective sudy.
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Surg 2002;19:216-20. Source of Support: Nil. Conflict of Interest: None declared.

216 Journal of Emergencies, Trauma, and Shock I 5:3 I Jul - Sep 2012
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