Reply to Letter: “Laparoscopic Surgery or Conservative Treatment for Appendiceal Abscess in Adults?”

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We appreciate the comments presented by Weber and Di Saverio. As they pointed out, our study's outcome may not be generalized in every patient in every clinical setting. Laparoscopic surgery for appendiceal abscess requires experience and skills. With limited experience, complication rate and conversion rate are likely higher than the rates presented in our study. However, appendiceal abscess is hardly ever such surgical emergency that needs to be operated on out of regular working hours, when limited surgical experience is available. Therefore, we recommend that surgery for appendiceal abscess should be postponed until an experienced surgeon is available for the patient. In our institution we have utilized traffic-light coding system to organize emergency surgery. Using this system only the most urgent operations (red code) are allowed during the nighttime. Appendiceal abscesses are classified as orange code allowing maximum delay of 24 hours. These patients are operated on by surgeons dedicated to acute general surgery, mainly during daytime.
On the other hand, we believe that neither obesity nor advanced age should indicate conservative management. Nearly a quarter of patients in our study were obese [body mass index (BMI) > 30 kg/m2] and they recovered as well as nonobese patients. Nonoperative treatment with percutaneous drainage is still an option for patients unfit for surgery or when an experienced laparoscopic surgeon is not available. Unfortunately, the anatomical site of abscess may limit the use of percutaneous drainage. If abscess is not accessible for drainage, the risk for treatment failure is substantially high.

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