Laparoscopic management of small bowel perforations was reported [122] but there was no comparative study with open surgery. Acute Appendicitis Acute appendicitis is the most common intra-abdominal

condition requiring emergency surgery. The Surgical Infection BIX 1294 Society and the Infectious Diseases Society of America have generated guidelines for the management and treatment of complicated intra-abdominal infections on 2010 [1]. Operative intervention for acute, non-perforated appendicitis is the treatment of choice. Non-operative management of patients with acute, non-perforated appendicitis can be considered if there is a marked improvement in the patient’s condition prior to operation (Recommendation 1 A). Antibiotic treatment has been shown to be effective in treating selected patients with acute appendicitis. Three randomized controlled trials (RCTs) have compared the efficacy of antibiotic therapy alone with that of surgery for acute appendicitis [123–125]. selleck inhibitor A meta-analysis of these RCTs concluded that while antibiotics may be useful as primary treatment for selected patients, antibiotics are unlikely to replace appendectomy at present [126]. Selection bias and crossover to surgery in the RCTs suggest that appendectomy is still the gold standard therapy for acute appendicitis.

A support for a less emergent approach comes from clinical trials analyzing time to perforation, which indicate this to be an unusual early event [127, 128]. Both open and laparoscopic approaches to appendectomy are appropriate (Recommendation 1 A). A systematic review that included

45 randomized trials compared the selleckchem diagnostic and therapeutic effects of laparoscopic and conventional open appendectomy Farnesyltransferase in the treatment of suspected acute appendicitis [129]. The most consistent findings were an approximately 50% reduction in wound infections but a threefold increase in intra-abdominal abscesses in the laparoscopic appendectomy group. However, subsequently, two large studies have shown that patients undergoing a laparoscopic technique were more likely to be readmitted within 28 days of surgery [130] and that the risk for a complication was higher in the laparoscopic appendectomy group with uncomplicated appendicitis [131]. Taken together, open appendectomy may be preferred, although laparoscopic appendectomy is useful in selected subgroups of patients. Use of either approach should be decided by the surgeon’s expertise. The laparoscopic approach is useful for obese patients, elderly patients and patients whose diagnosis is uncertain, especially women of childbearing age. Patients with perforated appendicitis should undergo urgent intervention (Recommendation 1 C). Patients with a periappendiceal abscess can be managed with percutaneous image-guided drainage. Appendectomy is generally deferred in such patients (Recommendation 1 A).