“Diagnosis and Management of Acute Appendicitis in Adults” – Letter to the Editor & ACPMP Research Foundation Response

Please find below a Letter to the Editor written by Laura A. Lambert, MD, FACS, FSSO, on behalf of ACPMP’s Medical Advisory Board for the Appendix Cancer Pseudomyxoma Peritonei (ACPMP) Research Foundation. This letter was prompted by concerns raised to the organization by patients regarding the review article recently published in JAMA, titled “Diagnosis and Management of Acute Appendicitis in Adults”. Specifically, ACPMP patients expressed concern that the focus of the article on the potential for an “antibiotics first” approach in certain cases of acute appendicitis could result inadvertently in a delayed or perhaps even a missed diagnosis of appendix cancer. Although the article’s authors suggest consideration of an “antibiotics first” approach only in cases of uncomplicated appendicitis, the ACPMP Research Foundation felt it was important to respond. We are thankful to have had Dr. Lambert graciously respond on behalf of our organization.

To the Editor

We wish to complement Moris, Paulson and Pappas on an excellent review of the current management of acute appendicitis.¹ As the largest advocacy group for patients with appendiceal cancer, we want to emphasize that this review is specifically about patients with non-complex acute appendicitis only. This is an extremely important point because the incidence of appendiceal cancer has been repeatedly shown to rise in the presence of complex appendicitis, specifically for patients over the age of 40. Multiple studies have shown rates of neoplasm as high as 29% following interval appendectomy for complex appendicitis.²,³ A randomized clinical trial comparing interval appendectomy versus surveillance MRI for patients with complex appendicitis was stopped early due to an interval analysis that demonstrated a 17% incidence of appendiceal neoplasm in the interval appendectomy group (final overall incidence of 20%) with all of the neoplasms found in patients over 40 years old.

It is also notable, per the authors’ review, that approximately 30% of patients with non-complicated acute appendicitis fail treatment with antibiotics. We strongly encourage surgeons to consider appendectomy for all patients who fail antibiotic therapy, especially those over 40, to avoid missing the diagnosis of an appendiceal neoplasm. Due to the high incidence of peritoneal carcinomatosis and pseudomyxoma peritonei associated with the natural history of appendiceal cancer and neoplasm, we also strongly encourage all surgeons to consider each patient’s individual situation. If there is anything that raises a suspicion of something other than non-complex acute appendicitis, we encourage surgeons to perform a potentially curative appendectomy or either monitor the patient with imaging and/or arrange follow-up with a high volume appendiceal surgical oncologist. Because of its diminutive size and lack of essential function, serious concerns about the appendix are often dismissed. However, tumors and cancers that arise in the appendix are devastating and life-threatening, and once spread through the peritoneum, require major surgical and oncologic interventions. Because this is such a rare cancer, it is not often considered in the differential diagnosis, however the incidence of cancer of the appendix is clearly rising and our awareness of this potentially life-threatening condition needs to as well.⁴

Citation:

  1. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA. 2021;326(22):2299–2311. doi:10.1001/jama.2021.20502
  2. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review.
  3. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review.
  4. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review.