Letter to the Editor: Laparoscopic Surgery or Conservative Treatment for Appendiceal Abscess in Adults?

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To the Editor:
We read with great interest the randomized controlled trial by Mentula et al1 exploring the role of immediate laparoscopic surgical intervention and comparing this with conservative treatment for appendiceal abscesses.
The paper is a welcome addition to the acute care surgery literature, and further reinforces the clear feasibility of laparoscopic surgery in potentially complex acute surgical pathology. However, we are concerned regarding the applicability of the paper to the wider surgical community and to the individual, rather than the average, surgical patient.
The authors report on an enviable and unique patient cohort; the patients are relatively slim and have a very low rate of neoplastic disease underlying their appendiceal abscesses. The low average body mass index (and narrow interquartile range) makes the laparoscopic procedure more attractive, is likely to result in a reduced conversion rate,2 and is probably associated with improved overall success. These points also apply to low rate of neoplastic disease in this group of patients.
Apart from patient characteristics, the clinical environment and treatment system is also important in determining an appropriate management strategy. Laparoscopic appendicectomy, particularly in complex pathology, may be technically challenging. The authors acknowledge that the majority of patients in this study were operated on by a single surgeon, and at a single center; this single surgeon's excellent skill and workplace environment has determined this study's outcome.
To illustrate these concerns, let us consider 2 hypothetical cases. First: an 88-year-old patient with a 6 to 7 cm periappendiceal, a history of chronic obstructive pulmonary disease and cardiac disease, with multiple stents, presenting late at night, and, the on-call surgeon is junior, with limited laparoscopic experience, and even less experience in open surgery should a conversion be required, with the risk that this surgeon will persist in the laparoscopic approach for 2 to 3 hours, and struggle to perform the highly challenging appendicectomy. Second: a slim, 28-year-old patient with a 3 to 4 cm periappendiceal abscess, fit for surgery and anesthesia, presenting in the middle of the day, and, with a skilled laparoscopic specialist in charge of the case and primary operator. Notwithstanding the findings of the randomized controlled trial by Mentula et al,1 we suspect most experienced surgeons will treat the first case percutaneously, and the second case surgically.
We will continue to advocate for a clinical approach that is tailored to the individual patient's circumstance, and reflective of the situational realities of each case. For either treatment strategy, patient selection is key.

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