Current management of diverticulitis

Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis

BACKGROUND

The objective was to conduct a meta-analysis of randomized controlled trials evaluating the efficacy and morbidity of the management of acute uncomplicated (no abscess or phlegmon) appendicitis by antibiotics versus appendectomy.

METHODS

Appropriate trials were identified. The seven outcome variables were overall complication rate, treatment failure rate for index hospital admission, overall treatment failure rate, length of stay (LOS), utilization of pain medication, duration of pain, and sick leave. Both fixed and random effects meta-analyses were performed using odds ratios (ORs) and weighted or standardized mean differences (WMDs or SMDs, respectively).

RESULTS

Five trials totaling 980 patients (antibiotics=510, appendectomy=470) were analyzed. In three of the seven outcome analyses, the summary point estimates favored antibiotics over appendectomy, with a 46% reduction in the relative odds of complications (OR 0.54; 95% confidence interval [CI] 0.37, 0.78; p=0.001); a reduction in sick leave/disability (SMD -0.19; CI -0.33, -0.06; p=0.005), and decreased pain medication utilization (SMD -1.55; CI -1.96, -1.14; p<0.0001). For overall treatment failure, the summary point estimate favored appendectomy, with a 40.2% failure rate for antibiotics versus 8.5% for appendectomy (OR 6.72; CI 0.08, 12.99; p<0.001). Initial treatment failure, LOS, and pain duration were similar in the two groups.

CONCLUSIONS

Non-operative management of uncomplicated appendicitis with antibiotics was associated with significantly fewer complications, better pain control, and shorter sick leave, but overall had inferior efficacy because of the high rate of recurrence in comparison with appendectomy.

Surgery for appendicitis: is it necessary?

BACKGROUND

Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored.

METHODS

Systematic review of published literature and derived expert opinion.

RESULTS

Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management.

CONCLUSIONS

Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for.

Diagnosis and management of diverticulitis and appendicitis

Diverticulitis and appendicitis are common infections of the gastrointestinal tract that require urgent medical and surgical attention. Successful management of these conditions requires a multidisciplinary approach among primary care providers, gastroenterologists, surgeons, and radiologists. The diagnosis of appendicitis, in particular, can be difficult. Advances in radiographic imaging have improved the diagnostic accuracy in these infections. Minimally invasive surgical techniques have improved the patient's postoperative recovery when surgery is necessary in the management of these conditions.