Here are some landmark papers on acute appendicitis
Objective:
Evaluate the efficacy and quality of life
associated with conservative treatment of acute uncomplicated
appendicitis.
Summary background data:
Conservative management
with antibiotics only has emerged as a potential treatment option for
acute uncomplicated appendicitis. However, the reported failure rates
are highly variable and there is a paucity of data in relation to
quality of life.
Methods:
Symptomatic patients with radiological
evidence of acute, uncomplicated appendicitis were randomized to either
intravenous antibiotics only or undergo appendectomy.
Results:
One hundred eighty-six patients underwent
randomization. In the antibiotic-only group, 23 patients (25.3%)
experienced a recurrence within 1 year following randomization. There
was a significantly better EQ-VAS quality of life score in the surgery
group compared with the antibiotic-only group at 3 months (94.3 vs 91.0,
P < 0.001) and 12 months postintervention (94.5 vs 90.4, P < 0.001). The
EQ-5D-3L quality-of-life score was significantly higher in the surgery
group indicating a better quality of life (0.976 vs 0.888, P < 0.001).
The accumulated 12-month sickness days was 3.6 days shorter for the
antibiotics only group (5.3 vs 8.9 days; P < 0.01). The mean length of
stay in both groups was not significantly different (2.3 vs 2.8 days, P
= 0.13). The mean total cost in the surgery group was significantly
higher than antibiotics only group (€4,816 vs €3,077, P < 0.001).
Conclusions:
Patients
with acute, uncomplicated appendicitis treated with antibiotics only
experience high recurrence rates and an inferior quality of life.
Surgery should remain the mainstay of treatment for this commonly
encountered acute surgical condition.
Yeh D, Eid AI, Young KA, Wild J, Kaafarani HM,
Ray-Zach M, Kana'an T, Lawless R, Cralley AL, Crandall M. EAST
Appendicitis Study Group.
Objective:
We sought to describe contemporary presentation,
treatment, and outcomes of patients presenting with acute (A),
perforated (P), and gangrenous (G) appendicitis in the United States.
Summary background data:
Recent European trials have reported that medical
(antibiotics only) treatment of acute appendicitis is an acceptable
alternative to surgical appendectomy. However, the type of operation
(open appendectomy) and average duration of stay are not consistent with
current American practice and therefore their conclusions do not apply
to modern American surgeons.
Methods:
This multicenter prospective observational study
enrolled adults with appendicitis from January 2017 to June 2018.
Descriptive statistics were performed. P and G were combined into a
"complicated" outcome variable and risk factors were assessed using
multivariable logistic regression.
Results:
A total 3597 subjects were enrolled across 28
sites: median age was 37 (27-52) years, 1918 (53%) were male, 90%
underwent computed tomography (CT) imaging, 91% were initially treated
by appendectomy (98% laparoscopic), and median hospital stay was 1 (1-2)
day. The 30-day rates of Emergency Department (ED) visit and readmission
were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%)
required appendectomy during index hospitalization and 12 (5%) underwent
appendectomy within 30 days, for a cumulative failure rate of 21%.
Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%)
patients had P and G, respectively. On regression analysis, age,
symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith
were predictive of "complicated" appendicitis, whereas co-morbidities,
smoking, and ED triage to appendectomy >6 hours or >12 hours were not.
Conclusion:
In the United States, the majority of patients
presenting with appendicitis receive CT imaging, undergo laparoscopic
appendectomy, and stay in the hospital for 1 day. One in five patients
selected for initial non-operative management required appendectomy
within 30 days. In-hospital delay to appendectomy is not a risk factor
for "complicated" appendicitis.
Abstract
Purpose:
The aim of this prospective multicenter study was
to compare antibiotic therapy and appendectomy as treatment for patients
with uncomplicated appendicitis confirmed by ultrasound and/or computed
tomography.
Methods:
The study was conducted from January 2017 to
January 2018. Data regarding all patients discharged from the
participating centers with a diagnosis of uncomplicated appendicitis
were collected prospectively.
Results:
Of the 318 patients enrolled in the study, 27.4%
underwent antibiotic-first therapy, and 72.6% underwent appendectomy.
The matched group was composed of 87 patients in both study arms. Of the
87 patients available of 1-year follow-up in the antibiotic-first group,
64 (73.6%) did not require appendectomy. The complication-free treatment
success in the antibiotic-first group was 64.4%. A statistically
significant higher complication-free treatment success was found in the
appendectomy group: 81.8% in the pre-matching sample and 83.9% in the
post-matching sample. Patients in the antibiotic-first group reported
lower VAS scores compared to those treated with an appendectomy, both at
discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs
2.1 ± 1.7). The mean of the days of absence from work was higher in the
appendectomy group (β 0.63; 95% CI 0.08-1.18).
Conclusion:
Although laparoscopic appendectomy remains the gold
standard of treatment for uncomplicated appendicitis, conservative
treatment with antibiotics is a safe option in most cases. Approximately
65% of patients treated with antibiotics are symptom-free at 1 year,
without increased risk of adverse events should symptoms recur, and
better outcomes in terms of less pain and shorter period of absence from
work compared to patients undergoing an appendectomy.
Background: Antibiotic
therapy has been proposed as an alternative to surgery for the treatment
of appendicitis.
Methods:
We conducted a pragmatic, nonblinded,
noninferiority, randomized trial comparing antibiotic therapy (10-day
course) with appendectomy in patients with appendicitis at 25 U.S.
centers. The primary outcome was 30-day health status, as assessed with
the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores
range from 0 to 1, with higher scores indicating better health status;
noninferiority margin, 0.05 points). Secondary outcomes included
appendectomy in the antibiotics group and complications through 90 days;
analyses were prespecified in subgroups defined according to the
presence or absence of an appendicolith.
Results:
In total, 1552 adults (414 with an
appendicolith) underwent randomization; 776 were assigned to receive
antibiotics (47% of whom were not hospitalized for the index treatment)
and 776 to undergo appendectomy (96% of whom underwent a laparoscopic
procedure). Antibiotics were noninferior to appendectomy on the basis of
30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence
interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had
undergone appendectomy by 90 days, including 41% of those with an
appendicolith and 25% of those without an appendicolith. Complications
were more common in the antibiotics group than in the appendectomy group
(8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to
3.98); the higher rate in the antibiotics group could be attributed to
those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate
ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an
appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95%
CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100
participants in the antibiotics group and 3.0 per 100 participants in
the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50).
Conclusions:
For the
treatment of appendicitis, antibiotics were noninferior to appendectomy
on the basis of results of a standard health-status measure. In the
antibiotics group, nearly 3 in 10 participants had undergone
appendectomy by 90 days. Participants with an appendicolith were at a
higher risk for appendectomy and for complications than those without an
appendicolith. (Funded by the Patient-Centered Outcomes Research
Institute; CODA ClinicalTrials.gov number,
NCT02800785.).
Importance: Long-term
results support antibiotics for uncomplicated acute appendicitis as an
alternative to appendectomy. To our knowledge, treatment-related
long-term patient satisfaction and quality of life (QOL) are not known.
Objective:
To determine patient satisfaction and QOL
after antibiotic therapy and appendectomy for treating uncomplicated
acute appendicitis.
Interventions:
Open appendectomy vs antibiotics
with intravenous ertapenem, 1 g once daily, for 3 days followed by 7
days of oral levofloxacin, 500 mg once daily, and metronidazole, 500 mg
3 times per day.
Design, setting, and
participants: This
observational follow-up of the Appendicitis Acuta (APPAC) multicenter
randomized clinical trial comparing appendectomy with antibiotics
included 530 patients age 18 to 60 years with computed
tomography-confirmed uncomplicated acute appendicitis who were
randomized to undergo appendectomy (273 [52%]) or receive antibiotics
(257 [49%]). The trial was conducted from November 2009 to June 2012;
the last follow-up was May 9, 2018. The data were analyzed in February
2019.
Main outcomes and measures:
In this analysis, post
hoc secondary end points of postintervention QOL (EQ-5D-5L) and patient
satisfaction and treatment preference were evaluated.
Results:
Of the 530 patients enrolled in the trial
(appendectomy group: 273 [174 men (64%)] with a median age of 35 years;
(antibiotic group: 257 [155 men (60%)] with a median age of 33 years),
423 patients (80%) were available for phone interview at a median
follow-up of 7 years; 206 patients (80%) took antibiotics and 217 (79%)
underwent appendectomy. Of the 206 patients taking antibiotics, 81 (39%)
had undergone appendectomy. The QOL between appendectomy and antibiotic
group patients was similar (median health index value, 1.0 in both
groups; 95% CI, 0.86-1.0; P = .96). Patients who underwent appendectomy
were more satisfied in the treatment than patients taking antibiotics
(68% very satisfied, 21% satisfied, 6% indifferent, 4% unsatisfied, and
1% very unsatisfied in the appendectomy group and 53% very satisfied,
21% satisfied, 13% indifferent, 7% unsatisfied, and 6% very unsatisfied
in the antibiotic group; P < .001) and in a subgroup analysis this
difference was based on the antibiotic group patients undergoing
appendectomy. There was no difference in patient satisfaction after
successful antibiotic treatment compared with appendectomy (cumulative
odds ratio [COR], 7.8; 95% CI, 0.5-1.3; P < .36). Patients with
appendectomy or with successful antibiotic therapy were more satisfied
than antibiotic group patients who later underwent appendectomy (COR,
7.7; 95% CI, 4.6-12.9; P < .001; COR, 9.7; 95% CI, 5.4-15.3; P < .001,
respectively). Of the 81 patients taking antibiotics who underwent
appendectomy, 27 (33%) would again choose antibiotics as their primary
treatment.
Conclusions and relevance:
In this analysis, long-term QOL was similar
after appendectomy and antibiotic therapy for the treatment of
uncomplicated acute appendicitis. Patients taking antibiotics who later
underwent appendectomy were less satisfied than patients with successful
antibiotics or appendectomy.
Importance: Short-term
results support antibiotics as an alternative to surgery for treating
uncomplicated acute appendicitis, but long-term outcomes are not known.
Objective:
To determine the late recurrence rate of
appendicitis after antibiotic therapy for the treatment of uncomplicated
acute appendicitis.
Design, setting, and
participants: Five-year
observational follow-up of patients in the Appendicitis Acuta (APPAC)
multicenter randomized clinical trial comparing appendectomy with
antibiotic therapy, in which 530 patients aged 18 to 60 years with
computed tomography-confirmed uncomplicated acute appendicitis were
randomized to undergo an appendectomy (n = 273) or receive antibiotic
therapy (n = 257). The initial trial was conducted from November 2009 to
June 2012 in Finland; last follow-up was September 6, 2017. This current
analysis focused on assessing the 5-year outcomes for the group of
patients treated with antibiotics alone.
Interventions:
Open appendectomy vs antibiotic
therapy with intravenous ertapenem for 3 days followed by 7 days of oral
levofloxacin and metronidazole.
Main outcomes and measures:
In this analysis,
prespecified secondary end points reported at 5-year follow-up included
late (after 1 year) appendicitis recurrence after antibiotic treatment,
complications, length of hospital stay, and sick leave.
Results:
Of the 530 patients (201 women; 329 men)
enrolled in the trial, 273 patients (median age, 35 years [IQR, 27-46])
were randomized to undergo appendectomy, and 257 (median age, 33 years,
[IQR, 26-47]) were randomized to receive antibiotic therapy. In addition
to 70 patients who initially received antibiotics but underwent
appendectomy within the first year (27.3% [95% CI, 22.0%-33.2%];
70/256), 30 additional antibiotic-treated patients (16.1% [95% CI,
11.2%-22.2%]; 30/186) underwent appendectomy between 1 and 5 years. The
cumulative incidence of appendicitis recurrence was 34.0% (95% CI,
28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at
3 years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95%
CI, 33.1%-45.3%; 100/256) at 5 years. Of the 85 patients in the
antibiotic group who subsequently underwent appendectomy for recurrent
appendicitis, 76 had uncomplicated appendicitis, 2 had complicated
appendicitis, and 7 did not have appendicitis. At 5 years, the overall
complication rate (surgical site infections, incisional hernias,
abdominal pain, and obstructive symptoms) was 24.4% (95% CI,
19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5% (95% CI,
3.8%-10.4%) (n = 16/246) in antibiotic group (P < .001), which
calculates to 17.9 percentage points (95% CI, 11.7-24.1) higher after
surgery. There was no difference between groups for length of hospital
stay, but there was a significant difference in sick leave (11 days more
for the appendectomy group).
Conclusions and relevance:
Among patients who were initially treated with
antibiotics for uncomplicated acute appendicitis, the likelihood of late
recurrence within 5 years was 39.1%. This long-term follow-up supports
the feasibility of antibiotic treatment alone as an alternative to
surgery for uncomplicated acute appendicitis.
Abstract
Importance:
An increasing amount of evidence supports
the use of antibiotics instead of surgery for treating patients with
uncomplicated acute appendicitis.
Objective:
To compare antibiotic therapy with
appendectomy in the treatment of uncomplicated acute appendicitis
confirmed by computed tomography (CT).
Design, setting, and
participants: The
Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority
randomized clinical trial was conducted from November 2009 until June
2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years
with uncomplicated acute appendicitis confirmed by a CT scan. Patients
were randomly assigned to early appendectomy or antibiotic treatment
with a 1-year follow-up period.
Interventions:
Patients randomized to
antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days
followed by 7 days of oral levofloxacin (500 mg once daily) and
metronidazole (500 mg 3 times per day). Patients randomized to the
surgical treatment group were assigned to undergo standard open
appendectomy.
Main outcomes and measures:
The primary end point for
the surgical intervention was the successful completion of an
appendectomy. The primary end point for antibiotic-treated patients was
discharge from the hospital without the need for surgery and no
recurrent appendicitis during a 1-year follow-up period.
Results:
There were 273 patients in the surgical
group and 257 in the antibiotic group. Of 273 patients in the surgical
group, all but 1 underwent successful appendectomy, resulting in a
success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic
group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent
appendectomy within 1 year of initial presentation for appendicitis. Of
the 256 patients available for follow-up in the antibiotic group, 186
(72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The
intention-to-treat analysis yielded a difference in treatment efficacy
between groups of -27.0% (95% CI, -31.6% to ∞) (P = .89). Given the
prespecified noninferiority margin of 24%, we were unable to demonstrate
noninferiority of antibiotic treatment relative to surgery. Of the 70
patients randomized to antibiotic treatment who subsequently underwent
appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated
appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute
appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have
appendicitis but received appendectomy for suspected recurrence. There
were no intra-abdominal abscesses or other major complications
associated with delayed appendectomy in patients randomized to
antibiotic treatment.
Conclusions and relevance:
Among patients with CT-proven, uncomplicated
appendicitis, antibiotic treatment did not meet the prespecified
criterion for noninferiority compared with appendectomy. Most patients
randomized to antibiotic treatment for uncomplicated appendicitis did
not require appendectomy during the 1-year follow-up period, and those
who required appendectomy did not experience significant complications.