‘Antibiotics only’ effective alternative to appendectomy for uncomplicated appendicitis
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Nonoperative management of patients with acute, uncomplicated appendicitis is comparable to surgical treatment in safety and efficacy, although longer hospital stays and recurrence are possible, according to a meta-analysis in JAMA Surgery.
“Antibiotic-only treatment may be an attractive option to patients, as it may be associated with avoidance of surgical scars, reduction of postoperative pain and faster recovery,” Rodrigo Moises de Almeida Leite, MD, of the colon and rectal surgery department at Massachusetts General Hospital, and colleagues wrote. “It may also provide potential benefits to health care systems by reducing the burden on operating rooms, sparing the use of personal protective gear and reducing overall costs.
“However, the wide range of treatment failure rates (7% to 39%) have led to confusion about overall effectiveness of nonoperative treatment and rendered these analyses difficult to interpret.”
To help determine which form of treatment might be best for a patient, researchers conducted a systematic review of Embase and PubMed databases for clinical trials comparing nonoperative management and appendectomy in adults with acute, uncomplicated appendicitis. Of 1,504 studies identified for screening, eight met their inclusion criteria.
Treatment success at 30 days — including abdominal pain resolution, no complications and inflammatory marker improvement — served as the primary outcome. Secondary outcomes included risks for major complications and length of hospital stay.
Using the Cochrane risk of bias 2 tool for their analysis, researchers found that surgical and nonsurgical management had similar treatment success at 30 days (RR = 0.85; 95% CI, 0.66-1.11), with a similar percentage of major adverse events reported (RR = 0.72; 95% CI, 0.29-1.79).
Researchers did, however, note differences between the two forms of management: Patients who received nonsurgical treatment had significantly longer length of hospital stay (RR = 1.48; 95% CI, 1.26-1.7) and an 18% median cumulative incidence of recurrent appendicitis.
“A nonsignificant trend toward better outcomes was observed in the nonoperative group compared with the surgical group, specifically a higher incidence of treatment success with longer periods of follow-up,” de Almeida Leite and colleagues wrote. “This may be because of the higher incidence of long-term complications in the surgical group, such as incisional hernias or adhesions.”
The researchers noted that: “A patient-centered discussion considering the substantial rate of recurrent appendicitis with antibiotics only must be prioritized. Patients should be informed that despite promising outcomes with nonoperative management of acute appendicitis, nearly 1 of 5 patients treated nonoperatively in this review eventually experienced recurrent appendicitis symptoms.”
Perspective
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Today’s complex medical environment mandates new solutions to old problems. High fidelity clinical data are ushering a paradigm shift in the treatment of acute uncomplicated appendicitis. Taking all aspects into consideration, informed patients can now choose an option other than surgery to remedy their disease.
This highlights, yet again, the prerequisite for any clinical encounter between the patient and the clinician to be built on trust, clear communication and evidence-based medicine.
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