Most patients treated with antibiotics for acute appendicitis do not experience recurrence
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Key takeaways:
- Initial antibiotic treatment was successful in 88% to 95% of patients.
- At 25 years, 60% treated with antibiotics had not undergone appendectomy and 71% discharged without appendectomy remained surgery-free.
More than half of patients treated with antibiotics for acute appendicitis avoided surgery for up to 25 years, with researchers reporting no evidence of long-term risks with nonoperative management other than recurrence.
“The longest outcomes reported of patients receiving nonoperative treatment for acute appendicitis have been at 5 years,” Barbora Pátková, MD, from Karolinska Institute and Uppsala University Hospital in Sweden, and colleagues wrote in JAMA Surgery.
To determine long-term outcomes at 19 to 26 years, researchers analyzed data from the Swedish National Registry of participants in two randomized clinical trials that compared appendectomy with nonoperative treatment for acute appendicitis. The first trial included 40 patients (33% women) assigned to appendectomy or antibiotics between May 1992 and March 1994, and the second included 252 male patients who were randomized to either treatment between March 1996 and June 1999.
Initial nonoperative treatment success was reported in 95% (19 of 20) of patients in the first trial and 88% (113 of 128) in the second, with 1-year recurrence rates of 36.8% and 14.4%, respectively.
Of the initial 292 participants, researchers were able to trace 259 in the registry, of whom 92.6% were in the nonoperative group and 84.7% underwent appendectomy. Twenty-one participants underwent appendectomy as a result of failure of initial nonoperative treatment, and 34 individuals had a subsequent appendectomy for acute appendicitis.
At the end of follow-up, 60% of patients had not undergone appendectomy and 71% who had been successfully discharged without appendectomy did not return for surgery.
“Although the rate of appendectomy was low after the first year, appendectomies continued to occur even up to 20 years later,” researchers wrote.
In addition to patients who had surgery due to failure of initial nonoperative treatment, 9.5% in the antibiotic group went to an outpatient clinic for abdominal pain compared with 0.01% from the surgical group.
“More than half of the patients treated nonoperatively did not experience recurrence and avoided surgery over approximately two decades,” researchers wrote. “There is no evidence for long-term risks of nonoperative management other than that of recurrence of appendicitis. The present data will further be beneficial to clinicians as well as patients with acute appendicitis in making a treatment decision.”
Perspective
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Diya Alaedeen, MD, FACS
While this is intriguing data regarding the long-term outcomes of nonoperative treatment of appendicitis, one must interpret the results with a bit more scrutiny. We should continue to look for predictors of nonoperative failures (patients who returned for an operation after antibiotic treatment).
Once we gather more data on this topic, through high-fidelity research protocols, we will be able to better council our patients regarding the treatment modality that guarantees the best long-term outcomes and lower chances for disease recurrence and complications.
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