The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm

Laparoscopic Appendectomy Combined with an "Antimicrobial-Free" Strategy for Acute Uncomplicated Appendicitis

Objective: To explore the efficacy and safety of enhanced recovery protocol (ERP) combined with laparoscopic appendectomy (LA) in the treatment of acute uncomplicated appendicitis (AUA) without antibiotics. Methods: In this study, a total of 160 patients with AUA who underwent LA between January 2018 and December 2021 were included and divided into the antibiotic group (n = 80) or the no-antibiotic group (n = 80). The patients in the antibiotic group received the ERP combined with antimicrobials during the perioperative period, while those in the no-antibiotic group only received the ERP during the perioperative period. The clinical data of these patients were collected to compare the inflammation level and stress state before and after surgery. In addition, the incidence of postoperative complications and the recovery speed of the patients were compared between groups. Results: There were no significant differences in the inflammation level and stress state before or after surgery, the incidence of postoperative complications or the recovery speed between the antibiotic group and the no-antibiotic group (P > .05). Conclusion: The use of ERP combined with LA as an antimicrobial-free treatment scheme in the perioperative period was found to be safe and effective for patients with AUA. Therefore, this approach is clinically valuable.

Diagnosis and treatment of appendicitis: systematic review and meta-analysis

BACKGROUND

The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children.

METHODS

Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively.

RESULTS

2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04).

CONCLUSIONS

This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.

Are Antibiotics the New Appendectomy?

Prior to the development of laparoscopic procedures, open appendectomy was the standard of care for the majority of appendicitis cases. Recently, studies have debated using antibiotics as a first-line treatment in uncomplicated appendicitis cases. The definition of uncomplicated appendicitis is not always clear-cut; however, with the large-scale accessibility of radiologic techniques, it is becoming increasingly easier to classify patient groups. As suggested by clinical and radiological patient data, this has raised the speculation of considering antibiotic therapy as the sole treatment modality in uncomplicated appendicitis cases. We aim to compare the options of surgery and antibiotics only in terms of efficacy, complications, and financial cost. A range of databases and search strategies were adopted, and various databases were used, including PubMed, ScienceDirect, Google Scholar, and JAMA. Collectively, 30 studies were reviewed, but only 18 were included. Efficacy rates were higher in the appendectomy group. Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up. Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin. Complications were more frequent and significant in the surgery group. These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism. Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. Given the high success rates post-appendectomy for acute appendicitis over the decades, the efficacy of conservatively treated acute appendicitis raises a strong argument when choosing one of the two options. The efficacy remained consistently higher across the literature in the surgery group than in the antibiotics-only group. However, it is still arguable that antibiotics may be a preferable option given an efficacy rate of more than 70% at one year and overall higher complications associated with surgery. The argument of missing a neoplasm by avoiding surgery is valid. However, most are carcinoid neuroendocrine neoplasms with a low probability of metastasis (<5%) and are usually considered benign. Given the current practice focused on conservative and minimally invasive treatments and recently the COVID-19 pandemic, with its restrictions and lessons learnt, antibiotics may be the future standard for treating uncomplicated acute appendicitis. Lastly, we noticed higher efficacy rates in articles published recently than those published at least five to ten years earlier. Antibiotics-only therapy for uncomplicated appendicitis is cost-effective with fewer complications than surgery. However, appendectomies have higher efficacy. Thus, surgical treatment prevails as the standard of care. Future literature should yield larger sample sizes and explore the numbers of emergency appendectomies mandated following antibiotics-only therapy.

Optimising the treatment for uncomplicated acute appendicitis (OPTIMA trial): a protocol for a multicentre, randomised, double-blinded placebo-controlled study

INTRODUCTION

Emerging evidence has shown that an antibiotic first strategy is a viable treatment option for uncomplicated acute appendicitis (AA). Although there has recently been an interest and increase in the use of antibiotics as the primary strategy for treating uncomplicated AA, there is no consensus regarding the optimum antibiotic regimen. In particular, the long-term outcomes of different antibiotic regimens, such as the recurrence rate, still lack evidence. Given that the flora of the appendix is mainly anaerobic bacteria, we hypothesised that antianaerobe regimens could decrease the recurrence rate compared with those that did not include antianaerobic antibiotics.

METHODS AND ANALYSIS

The OPTIMA(Optimising the treatment for uncomplicated acute appendicitis) trial is a multicentre, double-blinded placebo-controlled superiority randomised study aimed to evaluate the role of antianaerobic antibiotics in the resolution of uncomplicated AA. Patients (18-65 years) with uncomplicated AA (without gangrenous, perforated appendicitis, appendiceal abscess, or appendiceal fecaliths) are eligible for inclusion. The primary endpoint of this study is the success rate of the treatment, defined as the resolution of AA resulting in discharge from the hospital without surgical intervention and recurrent symptoms within one year. Secondary endpoints include mortality, postintervention complications, recurrent symptoms up to one year after treatment, hospital stay, sick leave, treatment cost, pain symptom scores and quality of life. Data are reported as the number of cases (%), median (range) and relative risk, which will be analysed using the Mann-Whitney U test or χ² test, as appropriate. P-value<0.05 will be considered significant.

ETHICS AND DISSEMINATION

The protocol has been approved by the Ethics Committee of Jinling Hospital on 13 November 2018 (2018NZKY-027-01). The trial findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR1800018896.

Paediatric appendicitis during the COVID-19 pandemic

AIM

The repercussions of the pandemic on patients without COVID-19 have been well documented. Although there is evidence that adult patients present later with complicated appendicitis, the impact on the paediatric population is unknown. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on the presentation and management of paediatric appendicitis.

METHODS

Data from consecutive paediatric patients admitted with right iliac fossa pain to a teaching hospital from 1 March 2020 until 30 June 2020 (COVID-19) were compared with patients admitted from 1 March 2019 until 30 June 2019 (control).

RESULTS

One hundred and seventy-two patients were admitted with right iliac fossa pain (control = 97, COVID-19 = 75). Seven patients had a normal diagnostic laparoscopy in the control group compared with none in the COVID-19 group. The proportion of patients diagnosed with appendicitis was significantly higher during the COVID-19 pandemic (24% vs. 10%, P = 0.03). They presented later (3 days vs. 1 day, P < 0.01) with higher inflammatory markers (white cell count 15.8 vs. 13.2 × 10⁹ cells per litre, P = 0.02; C-reactive protein 53 vs. 27 mg/L P = 0.04). The majority of patients underwent surgery within 1 day of admission (94% COVID-19 vs. 70% control, P = 0.13). Although there was a trend towards a greater proportion of complicated appendicitis (22% vs. 10%, P = 0.6) during COVID-19, this did not affect outcomes (no morbidity in both groups, length of hospital stay 4 vs. 2.5 days, P = 0.29).

CONCLUSION

Despite presenting later during COVID-19, paediatric patients with appendicitis were treated expediently with good outcomes.

Optimal initial antibiotic regimen for the treatment of acute appendicitis: a systematic review and network meta-analysis with surgical intervention as the common comparator

BACKGROUND

The optimal antibiotic regimen for the medical management of acute appendicitis remains unknown due to a lack of head-to-head comparisons between different antibiotic regimens.

METHODS

We systematically searched the PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases from their inception through to August 2020. We selected randomized controlled trials (RCTs) or observational studies comparing antibiotic therapy and appendectomy as the initial treatment for adult or paediatric patients with acute appendicitis. We performed a Bayesian network meta-analysis (NMA) to obtain the indirect comparison results between different antibiotic regimens by employing the group managed by surgery as a common comparator. Antibiotic regimens were classified into three categories: those including a carbapenem; those including a cephalosporin; and those including a β-lactam/β-lactamase inhibitor combination.

RESULTS

A total of 9 RCTs (adults, n = 8; paediatrics, n = 1) and 12 observational studies (adults, n = 3; paediatrics, n = 9) were included in the NMA, with a total of 4551 patients. The most commonly administered regimen was a β-lactam/β-lactamase inhibitor combination (9/21; 43%), followed by a cephalosporin (7/21; 33%) or a carbapenem (5/21; 24%). The NMA indicated that surgery significantly increased 1 year treatment success, compared with cephalosporins [OR: 16.79; 95% credible interval: 3.8-127.64] or β-lactam/β-lactamase inhibitor combinations (OR: 19.99; 95% credible interval: 4.87-187.57), but not carbapenems (OR: 3.50, 95% credible interval: 0.55-38.63). In contrast, carbapenems were associated with fewer treatment-related complications compared with surgery (OR: 0.12; 95% credible interval: 0.01-0.85).

CONCLUSIONS

Carbapenems might be recommended as the initial antibiotic regimen for the non-operative management of adult patients with acute appendicitis. Nevertheless, due to the imprecise estimates in our NMA, additional RCTs are needed to corroborate these findings, especially for paediatric patients.

Prediction Model for Failure of Nonoperative Management of Uncomplicated Appendicitis in Adults

BACKGROUND

Prediction of failure of nonoperative management (NOM) in uncomplicated appendicitis (UA) is difficult. This study aimed to establish a new prediction model for NOM failure in UA.

METHODS

We included 141 adults with UA who received NOM as initial treatment. NOM failure was defined as conversion to operation during hospitalization. Independent predictors of NOM failure were identified using logistic regression analysis. A prediction model was established based on these independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were used to assess the discrimination and calibration of the model, respectively, and risk stratification using the model was performed.

RESULTS

Among 141 patients, NOM was successful in 120 and unsuccessful in 21. Male sex, maximal diameter of the appendix, and the presence of fecalith were identified as independent predictors of NOM failure for UA. A prediction model with scores ranging from 0 to 3 was established using the three variables (male sex, maximal diameter of the appendix ≥ 15 mm, and the presence of fecalith). The area under the ROC curve for the new prediction model was 0.778, and the model had good calibration (P = 0.476). A score of 2 yielded a sensitivity of 71.4% and a specificity of 90.8%. Patients were stratified into low (0-1), moderate (2), and high (3) risk categories, which had NOM rates of 5.2%, 47.1%, and 77.8%, respectively.

CONCLUSIONS

Our prediction model may predict NOM failure in UA with good diagnostic accuracy and help surgeons select appropriate treatments.

Analysis of treatment success with new inclusion criteria for antibiotic therapy for uncomplicated appendicitis: A multicentre cohort study

BACKGROUND

Conservative antibiotic treatment for uncomplicated appendicitis is debated because of the unproven criteria for use and relatively high failure rate. We developed inclusion criteria to optimize antibiotic therapy use and compared the success rate to that seen in previous literature.

METHODS

Our antibiotic therapy inclusion criteria were developed based on clinical findings (symptom onset ≤48 hours and body temperature ≤38.3℃), laboratory parameters (white blood cell count ≤12000/mL) and radiologic findings (appendiceal diameter ≤12 mm and no appendicolith). Patients who met inclusion criteria were enrolled from three hospitals between 2016 and 2017. Treatment success was defined as a response to antibiotic therapy and no recurrent symptoms within 1 year. We compared our success rate with previous clinical trial success rates.

RESULTS

There were 240 patients enrolled (116 men and 124 women) with a mean age of 38.7 years. After initial antibiotic treatment, 233 patients (97.1%) responded to therapy and were discharged. There were no post-treatment complications with Clavien-Dindo grade ≥III. During the 1-year follow-up period, the treatment success rate was 88.8% (213/240) and the recurrence rate was 8.6% (20/233; 15 underwent surgery and 5 received antibiotics again). In contrast, the combined treatment success rate for six previous clinical trials was 76.5% (573/749) and the recurrence rate was 21.6% (157/727).

CONCLUSIONS

The group enrolled with the new inclusion criteria showed an improved treatment success rate compared to previous studies. These criteria will aid in determining optimal conservative treatment use in patients with uncomplicated appendicitis.

Did the COVID-19 Pandemic Cause a Delay in the Diagnosis of Acute Appendicitis?

BACKGROUND

Appendectomy for acute appendicitis remains one of the most common surgical procedures. This study aims to assess the clinical presentation and delays in diagnosing acute appendicitis during the COVID-19 pandemic.

METHODS

We evaluated data of all adult patients who underwent an appendectomy at our hospital between June 1, 2019 and June 1, 2020. Demographic data, admission type to the emergency room, radiological findings, pathological findings, and hospitalization time were noted. Patients were divided into four groups of 3-month periods, pre (Groups 5, 4, 3, 2) and during the pandemic (Group 1). Hospitalization time and perforation status of each group were compared. The hospital admission type and their effect on perforation were also evaluated.

RESULTS

Two hundred and fourteen patients were included; 135 patients were male, and 57 were female. The median age was 39 years. In Group 1 (pandemic period), 28.8% of patients were referred to us from pandemic hospitals. The median hospitalization time was 7.3 h before pandemics (Group 2-5), 5 h in the pandemic period (Group 1). Perforation rates were 27.8% in Group 1, 23.3% in Group 2, 16.3% in Group 3, 14.0% in Group 4, and 18.6% in Group 5 (0 = 0.58). There was no difference in the patients in Group 1 in the rate of perforated appendicitis in patients who were referred from other pandemic hospitals (29.4) and those admitted via our own emergency room (16.6%) (p = 0.27) during the pandemic period.

CONCLUSION

We did not observe any clear increase in the diagnosis of perforated appendicitis during the pandemic period, even in patients who were transferred from other hospitals.

Computed Tomography Findings Associated with Treatment Failure after Antibiotic Therapy for Acute Appendicitis

OBJECTIVE

To identify the CT findings associated with treatment failure after antibiotic therapy for acute appendicitis.

MATERIALS AND METHODS

Altogether, 198 patients who received antibiotic therapy for appendicitis were identified by searching the hospital's surgery database. Selection criteria for antibiotic therapy were uncomplicated appendicitis with an appendiceal diameter equal to or less than 11 mm. The 86 patients included in the study were divided into a treatment success group and a treatment failure group. Treatment failure was defined as a resistance to antibiotic therapy or recurrent appendicitis during a 1-year follow-up period. Two radiologists independently evaluated the following CT findings: appendix-location, involved extent, maximal diameter, thickness, wall enhancement, focal wall defect, periappendiceal fat infiltration, and so on. For the quantitative analysis, two readers independently measured the CT values at the least attenuated wall of the appendix by drawing a round region of interest on the enhanced CT (HU_post) and non-enhanced CT (HU_pre). The degree of appendiceal wall enhancement (HU_sub) was calculated as the subtracted value between HU_post and HU_pre. A logistic regression analysis was used to identify the CT findings associated with treatment failure.

RESULTS

Sixty-four of 86 (74.4%) patients were successfully treated with antibiotic therapy, with treatment failure occurring in the remaining 22 (25.5%). The treatment failure group showed a higher frequency of hypoenhancement of the appendiceal wall than the success group (31.8% vs. 7.8%; p = 0.005). Upon quantitative analysis, both HU_post (46.7 ± 21.3 HU vs. 58.9 ± 22.0 HU; p = 0.027) and HU_sub (26.9 ± 17.3 HU vs. 35.4 ± 16.6 HU; p = 0.042) values were significantly lower in the treatment failure group than in the success group.

CONCLUSION

Hypoenhancement of the appendiceal wall was significantly associated with treatment failure after antibiotic therapy for acute appendicitis.

[Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis]

La saturation intrahospitalière liée à l’arrivée massive de patients atteints du COVID-19 nécessitant une prise en charge urgente conduit à reconsidérer la prise en charge des autres patients. Différer au maximum les hospitalisations et les opérations chirurgicales non urgentes est un des objectifs des chirurgiens afin de désengorger autant que possible le système de soins. Alors que la majorité des opérations programmées sont annulées, la réduction de la chirurgie d’urgence est évidemment compliquée à proposer sans altérer la qualité de la prise en charge et conduire à une perte de chance pour le patient. Cependant, l’appendicite aiguë constitue une situation spécifique bien particulière et la fréquence de cette pathologie conduit à considérer ce cas particulier. En effet, tandis que le traitement recommandé de l’appendicite aiguë non compliquée est chirurgical, l’alternative non chirurgicale par antibiothérapie seule a été largement évaluée dans la littérature au cours de travaux de qualité. Dans la mesure où la limite principale du traitement médical exclusif de l’appendicite aiguë non compliquée est le risque de récidive à distance, cette option thérapeutique représente une alternative de choix pour réduire la surcharge intrahospitalière dans ce contexte de crise sanitaire. L’objectif de ce travail est donc de mettre à disposition des médecins et des chirurgiens un guide pratique issu d’une analyse de la littérature sur le traitement médical de l’appendicite aiguë non compliquée de l’adulte afin de pouvoir proposer ce traitement alternatif aux bons patients et dans des bonnes conditions, notamment lorsque l’accès au bloc opératoire est impossible.

Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis

The massive inflow of patients with COVID-19 requiring urgent care has overloaded hospitals in France and impacts the management of other patients. Deferring hospitalization and non-urgent surgeries has become a priority for surgeons today in order to relieve the health care system. It is obviously not simple to reduce emergency surgery without altering the quality of care or leading to a loss of chance for the patient. Acute appendicitis is a very specific situation and the prevalence of this disease leads us to reconsider this particular disease in the context of the COVID-19 crisis. Indeed, while the currently recommended treatment for uncomplicated acute appendicitis is surgical appendectomy, the non-surgical alternative of medical management by antibiotic therapy alone has been widely evaluated by high-quality studies in the literature. Insofar as the main limitation of exclusively medical treatment of uncomplicated acute appendicitis is the risk of recurrent appendicitis, this treatment option represents an alternative of choice to reduce the intra-hospital overload in this context of health crisis. The aim of this work is therefore to provide physicians and surgeons with a practical guide based on a review of the literature on the medical treatment of uncomplicated acute appendicitis in adults, to offer this alternative treatment to the right patients and under good conditions, especially when access to the operating room is limited or impossible.

Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review

BACKGROUND

Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist.

METHODS

PUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

RESULTS

Thirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success.

CONCLUSION

While further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management.

LEVEL OF EVIDENCE

Systematic review, level II.

Are antibiotics a safe and effective treatment for acute uncomplicated appendicitis?- First update

UPDATE

This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in January 2016.

INTRODUCTION

Appendicitis is a typical cause of acute abdominal pain and the most frequent cause of emergency abdominal surgery. In the last two decades, increasing evidence has been published about the use of antibiotics as an exclusive treatment for acute appendicitis.

METHODS

To answer this question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained through searches from multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, reanalyzed the data from the primary studies, performed a meta-analysis and prepared a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified 23 systematic reviews including 28 primary studies, of which eight were randomized trials. We concluded the exclusive use of antibiotics for the treatment of uncomplicated acute appendicitis could be less effective than appendectomy, but it might be associated with a lower rate of complications.

Antibiotics Versus Appendicectomy for the Treatment of Uncomplicated Acute Appendicitis: An Updated Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Uncomplicated acute appendicitis has been managed traditionally by early appendicectomy. However, recently, there has been increasing interest in the potential for primary treatment with antibiotics, with studies finding this to be associated with fewer complications than appendicectomy. The aim of this study was to compare outcomes of antibiotic therapy with appendicectomy for uncomplicated acute appendicitis.

METHOD

This meta-analysis of randomised controlled trials included adult patients presenting with uncomplicated acute appendicitis treated with antibiotics or appendicectomy. The primary outcome measure was complications. Secondary outcomes included treatment efficacy, hospital length of stay (LOS), readmission rate and incidence of complicated appendicitis.

RESULTS

Five randomised controlled trials with a total of 1430 participants (727 undergoing antibiotic therapy and 703 undergoing appendicectomy) were included. There was a 39 % risk reduction in overall complication rates in those treated with antibiotics compared with those undergoing appendicectomy (RR 0.61, 95 % CI 0.44-0.83, p = 0.002). There was no significant difference in hospital LOS (mean difference 0.25 days, 95 % CI -0.05 to 0.56, p = 0.10). In the antibiotic cohort, 123 of 587 patients initially treated successfully with antibiotics were readmitted with symptoms suspicious of recurrent appendicitis. The incidence of complicated appendicitis was not increased in patients who underwent appendicectomy after "failed" antibiotic treatment (10.8 %) versus those who underwent primary appendicectomy (17.9 %).

CONCLUSION

Increasing evidence supports the primary treatment of acute uncomplicated appendicitis with antibiotics, in terms of complications, hospital LOS and risk of complicated appendicitis. Antibiotics should be prescribed once a diagnosis of acute appendicitis is made or considered.

Comparative effectiveness of surgery versus antibiotics in acute appendicitis: a systematic review

AIM

To review outcomes of surgical and antibiotic management of acute appendicitis.

METHODS

11 prospective studies comparing surgical versus antibiotic management of acute appendicitis over a 21-year period were reviewed.

RESULTS

Antibiotic management is successful in most cases of uncomplicated acute appendicitis. The need for crossover in management and recurrent appendicitis were low among all studies. For those patients who ultimately required surgery, no increased complications were observed.

CONCLUSION

The decision to use antibiotics to treat acute appendicitis should be held to the same standards of diagnostic rigor as surgical management. Antibiotics may be safely recommended in patients with high surgical risk, such as the elderly or those with multiple comorbidities.

Outcomes of Nonoperative Management of Uncomplicated Appendicitis

BACKGROUND AND OBJECTIVES

Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization.

METHODS

Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up.

RESULTS

99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy.

CONCLUSIONS

A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy.

Lower Abdominal Pain

Although most frequently presenting with lower abdominal pain, appendicitis, colitis, and diverticulitis can cause pain throughout the abdomen and can cause peritoneal and retroperitoneal symptoms. Evaluation and management of lower intestinal disease requires a nuanced approach by the emergency physician, sometimes requiring computed tomography, ultrasonography, MRI, layered imaging, shared decision making, serial examination, and/or close follow-up. Once a presumed or confirmed diagnosis is made, appropriate treatment is initiated, and may include surgery, antibiotics, and/or steroids. Appendicitis patients should be admitted. Diverticulitis and inflammatory bowel disease can frequently be managed on an outpatient basis, but may require admission and surgical consultation.

Acute Appendicitis in the Adult Population: Modelled Decision Analysis Supports a Conservative Approach

INTRODUCTION

Acute appendicitis represents the commonest cause of acute intra-abdominal pathology. Appendectomy and antibiotics are the mainstay of therapy for appendicitis. Evidence is emerging that antibiotics alone may adequately treat most cases of appendicitis. Decision analysis is a quantitative method of examining alternate treatment strategies. This study describes a modelled decision analysis comparing operative and conservative management of appendicitis.

METHODS

The base case patient is a healthy, 23-year-old male presenting with migratory pain to the right iliac fossa (RIF) and elevated inflammatory markers. A decision tree was constructed comparing operative and conservative treatment. Rates of complications, failure of conservative therapy, recurrence and utilities were calculated via a systematic literature review. Variables were tested for sensitivity.

RESULTS

Overall, conservative management gives a significantly better outcome (51.51 vs 49.87 QALYs). Three variables proved sensitive. Once operative complication rates are lower than 11.5 %, surgical treatment becomes the optimal strategy. If rates of failure of conservative management exceed 12.9 %, surgery becomes optimal. If the utility assigned to a post-operative complication exceeds 0.44, surgery becomes optimal.

CONCLUSIONS

This decision analysis supports a conservative strategy, albeit with caveats. If operative complications are low or rates of failure of conservative management remain high, surgery is the preferable strategy.