Expert Health Articles

Acute Appendicitis: Urgent Surgery, Emergent Surgery or Not at All

Mohamed Salem MD, FACSMohamed Salem MD, FACS


Traditionally, immediate appendectomy has been the standard of care for the treatment of acute appendicitis. However, this management paradigm is being challenged and much work has occurred over the last several decades. The general consensus currently is that delayed surgery within 24 hours does not adversely affect the outcome of the patient, in contrast to previously held belief. This finding has been confirmed for both adults and children.

This undeniable shift in paradigm from an emergent to an urgent intervention allows for more efficient allocation of physician and hospital recourses. In all recent case studies, no differences were shown in the length of stay, operative time or rates of complication from those whose operations were performed between 12 and 24 hours. 

Either laparoscopic or open appendectomy is the treatment of choice for uncomplicated appendicitis as recommended by the American College of Surgeons. However, non-operative management of acute appendicitis with antibiotic only has been an evolving debate. The rate of recurrence of appendicitis treated with antibiotics alone is up to 7% to 14% at 1 year from the original episode of appendicitis.

If the patient presents to the emergency department with perforated appendicitis, the treatment will depend on the general condition of the patient. If the patient is very ill and shows signs of sepsis, an immediate operation is needed. In other patients presenting with abscess or contained perforation, antibiotic therapy and drainage of the abscess by a catheter or a drain placed under CT guidance through the skin with no surgical intervention is the treatment of choice, and no further surgery, because immediate surgical intervention can be associated with a more than threefold increase in complications compared with nonoperative management. Unlike adults, interval appendectomy in 8-12 weeks is proposed in children with complicated appendicitis. The main reason for this is a higher risk of recurrent appendicitis.