Operative Versus Non-Operative Management for Appendicitis With Abscess or Phlegmon

Complicated appendicitis with abscess or phlegmon represents a challenging problem to emergency general surgeons, and the preferred treatment remains controversial. A variety of therapies have been recommended including early operative intervention, delayed operative intervention, and non-operative management. Recently, a prospective randomized controlled trial from a single center was conducted in Finland comparing operative and non-operative management of appendiceal abscess. Patients managed in the operative arm were found to have a shorter length of stay, fewer re-admissions, and fewer additional interventions than those managed in the non-operative group, but there is no high-quality randomized control trial conducted in the United States to support this. The investigators, therefore plan to carry out a multi-center, patient choice study comparing operative and non-operative management of complicated appendicitis with abscess or phlegmon in the United States.

Inclusion criteria

• Complicated appendicitis with presumed perforation on (computer tomography) CT scan AND phlegmon or abscess greater than 2 centimeter (cm).

Exclusion criteria

• Antibiotic therapy greater than 24 hours prior to considering for enrollment.
• Attempted drainage before randomization
• Pregnancy
• Antibiotic allergy requiring the use of something other than a beta-lactam or quinolone based therapy.
• Previous major intra-abdominal surgery by laparotomy
• Hospitalization within 2 weeks of randomization
• Presence of septic shock on admission.
• Mechanical ventilation
• Acute renal failure requiring dialysis