Short Appendiceal Stump on CT Predicts Complex Resection and Open Conversion

The management of acute complicated appendicitis remains a point of clinical contention, particularly regarding the choice between immediate operative intervention and initial nonoperative management with antibiotics or percutaneous drainage [1, 2, 3]. While laparoscopic appendectomy is the established standard for uncomplicated cases, the presence of a phlegmon (an inflammatory mass involving the appendix and adjacent viscera) or abscess significantly increases the technical difficulty of the procedure [4, 2]. Surgeons must frequently navigate decisions regarding the optimal method for appendiceal stump closure, weighing the use of endoloops, clips, or staplers to prevent postoperative leaks and abscesses [5, 6, 7]. Despite advancements in energy devices (surgical instruments that use ultrasonic or electrical current to seal and transect tissue), the risk of conversion to open surgery or the need for extended bowel resection remains a concern in severe inflammatory presentations [8, 9]. A multicenter retrospective review of 152 patients now indicates that an appendiceal stump length of less than 2 cm on preoperative computed tomography (CT) is associated with a significantly increased risk of extended resection (OR 20.2, 95% CI: 4.43 to 92.15, p < 0.001) and a higher likelihood of conversion to open surgery (OR 5.9, 95% CI: 1.97 to 17.63, p < 0.001) [10, 11]. These findings suggest that preoperative imaging markers can help clinicians anticipate intraoperative challenges and tailor their surgical approach to reduce the mean length of hospital stay, which was significantly longer in patients with shorter stumps (4.6 days versus 3.0 days, p = 0.01) [10].