Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence

Interhospital variation in the non-operative management of uncomplicated appendicitis in adults

Background

Recent randomized trials have suggested non-operative management to be a safe alternative to appendectomy for acute uncomplicated appendicitis. Yet, there remains significant variability in treatment approach. This study sought to characterize center-level variation in non-operative management within a national cohort of adults presenting with appendicitis.

Methods

The 2016-2020 Nationwide Readmissions Database was queried to identify all adult (≥18 years) hospitalizations for acute uncomplicated appendicitis. Hierarchical, mixed-effects models were developed to ascertain factors linked with non-operative management. Bayesian methodology was applied to predict random effects, which were then used to rank centers by increasing hospital-attributed rate of non-operative management. Institutions with high center-specific rates of non-operative management (>90th percentile) were considered low-operating hospitals (LOH).

Results

Of an estimated 447,500 patients, 52,523 (11.7 %) were managed non-operatively. Compared to those undergoing appendectomy, the non-operative cohort was older, more commonly male, and of a higher comorbidity burden. Approximately 30 % in the variability of non-operative management was attributable to hospital effects, with absolute, risk-adjusted rates ranging from 0.5 to 22.5 %. Centers with non-operative management rates ≥90th percentile were considered LOH.Following risk adjustment, among patients undergoing appendectomy, care at LOH was linked with greater odds of postoperative infection, resource utilization, and non-elective readmission.

Conclusions

We identified significant interhospital variation in the utilization of non-operative management for acute uncomplicated appendicitis. Further, we found LOH to be associated with inferior outcomes following surgical management. Future work is needed to assess the care pathways that contribute to increased utilization of non-operative strategies, and disseminate best practices across institutions.

Systemic inflammatory markers for distinguishing uncomplicated and complicated acute appendicitis in adult patients

OBJECTIVE

This study aimed to investigate the predictive power of serum systemic inflammatory markers including neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-eosinophil ratio (MER), and C-reactive protein (CRP) levels for distinguishing uncomplicated and complicated acute appendicitis in adult patients admitted to the emergency department (ED).

METHODS

This retrospective, cross-sectional, observational, and single-center study enrolled 212 consecutive adult patients with acute appendicitis who were admitted to the ED of our tertiary care university hospital between January 1, 2019 and December 31 2021. Patients were divided into two groups (Group I, uncomplicated acute appendicitis; Group II, complicated appendicitis) according to their surgical findings and histopathological examination. Systemic inflammatory markers measured on admission were compared among patients to identify factors associated with complicated acute appendicitis.

RESULTS

A total of 132 patients, 83 male (62.9%) and 49 female (37.1%), were included in the study. The mean age was 34.7±13.40 years. Based on the histopathological examination, the number of patients in Group I was 103 (78.03%) and 29 (21.96%) in Group II. Laboratory findings on admission revealed no significant differences between Groups I and II patients in terms of mean serum NLR, MER, and CRP values (p=0.096, p=0.248, and p=0.297, respectively). However, the mean serum PLR in Group II patients was statistically significantly higher than those in Group I (p=0.032). The mean serum monocyte and monocyte fraction (%) values were significantly lower, and the mean serum neutrophil fraction (%) value was higher in Group II patients compared to those with Group I. Receiving operator characteristic (ROC) analysis identified a serum PLR cutoff value of ≥133.73 for distinguishing uncomplicated and complicated acute appendicitis in adult patients, with 60% sensitivity and 58.4% specificity. In addition, ROC analysis revealed a cutoff monocyte fraction (%) level of ≤6, with 72% sensitivity and 64% specificity, for distinguishing uncomplicated and complicated acute appendicitis in adult patients.

CONCLUSION

Our findings indicate that the mean serum NLR, MER, and CRP values measured on admission to ED in adult patients with acute appendicitis could not predict complicated acute appendicitis. However, mean serum PLR and neutrophil and monocyte counts can be useful in distinguishing complicated cases.

Operative Management of Acute Appendicitis Was Safe During the COVID-19 Pandemic Shutdown

INTRODUCTION

In the spring of 2020, New York City was one of the first epicenters of the COVID outbreak. In this study, we evaluate the incidence and treatment of appendicitis in two New York City community hospitals during the COVID pandemic.

METHODS

This retrospective study focused on the incidence and outcome of acute appendicitis in the adult population (>18 y old) during peak-COVID periods (March 16, 2020,-June 15, 2020) compared to pre-COVID and post-COVID periods. We compared the number of patients who underwent operative versus nonoperative management, patient demographics, length of stay (LOS), complications, and readmission rates within these time periods. Data are presented as mean ± standard deviation (analysis of variance).

RESULTS

From January 1, 2020 to December 31, 2020, 393 patients presented with acute appendicitis and 321 (81.7%) were treated operatively, compared to 441 total and 366 treated operatively (83%) in 2019 (P = 0.88). During the COVID outbreak, fewer patients presented with appendicitis (mean 6.9 ± 1 pre-COVID case/week, 4.4 ± 2.4 peak-COVID cases/week and 7.6 ± 0.65 post-COVID cases/week, P = 0.018) with no significant difference in the pre-COVID and post-COVID period. There was no difference in LOS between the pre-, peak-, and post-COVID periods with a median of 1 for all the three, (interquartile range (IQR): 0.8-2, 0.6-2, 0.6-2, respectively, P = 0.43). Additionally, there was no difference in 30-day readmission rates (4.2%, 0%, 3.9%, P = 0.99) and postoperative complications (4.2%, 0%, 2.9%, P = 0.98).

CONCLUSIONS

During peak-COVID, there was a significant reduction in the number of patients who presented with acute appendicitis without a post rebound increase in presentation. Those who presented during peak-COVID were able to undergo operative management safely, without affecting LOS or postoperative complications.

A rare case of appendiceal tip complete attachment to a sigmoid diverticulum: An appendiceal phlegmon case report

INTRODUCTION

Appendiceal phlegmon is defined as an inflammatory mass, consisting of the inflamed appendix, enclosed by adjacent viscera and the greater omentum in 2 % to 10 % of patients with acute appendicitis.

CASE PRESENTATION

A 24-year-old female presented to the hospital with chief complaints of fever, nausea, vomiting, and pain over the right lower quadrant of the abdomen for two days. In the local examination, tenderness and rebound tenderness were detected. Ultrasonography and abdominal CT scan indicated appendiceal phlegmon. After seven weeks of receiving a course of antibiotics with complete resolution of her symptoms, she underwent elective laparoscopic appendectomy. During surgery, the appendiceal tip was completely attached and fused to a sigmoid diverticulum, which has not been reported elsewhere. The appendix was completely removed, and the patient was discharged from the hospital in a good general condition after two days.

DISCUSSION

Acute appendicitis can cause serious complications, such as ruptured appendix, abscess, or phlegmon. In most cases, inflammation and infection resolve by antibiotic administration. In some cases perforation of the inflamed appendix and local abscess or diffuse peritonitis formation, which requires immediate percutaneous drainage or surgery as indicated. Theoretically, the inflamed appendix can cause adhesive damage to the adjacent organs; however, there is no particular report on this type of damage.

CONCLUSION

This rare case suggests that during phlegmon formation and related inflammation, other complications such as fistula formation, are theoretically expected.

Trichophagia as a cause of acute appendicitis in a patient with bipolar disorder

Acute appendicitis is one of the most common abdominal surgical emergencies worldwide. Clinical diagnosis is possible in most of the cases although imaging modalities may become necessary if the diagnosis is uncertain. Appendectomy, preferably the laparoscopic ap-proach, still remains the gold standard treatment to date. The pathophysiology usually includes luminal obstruction by an appendicolith or lymphoid hyperplasia and rarely parasitic infections. In this report, we present an extremely rare case of a patient with diagnosis of bipolar disorder and a history of trichophagia resulting in trichobezoar formation within the appendiceal lümen leading to acute appendicitis.

Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis

Importance

Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery.

Objective

To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis.

Design, Setting, and Participants

Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children's hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study.

Interventions

Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698).

Main Outcomes and Measures

The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments.

Results

Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor's degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, -4.3 days (99% CI, -6.17 to -2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference.

Conclusion and Relevance

Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met.

Trial Registration

ClinicalTrials.gov Identifier: NCT02271932.

Medical Treatment: An Emerging Standard in Acute Appendicitis?

Appendicectomy has been accepted as the gold standard for the management of appendicitis over the years, but there has been an increasing evidence and trend toward the conservative approach to the management of appendicitis. The aim of this review is to search existing literature and to evaluate and compare the conservative and operative approaches to the management of appendicitis. An electronic search of published literature was conducted through Pubmed, Google Scholar, Embase, and Medline using a variety of search items to find relevant observational studies, randomized clinical trials, systematic reviews, and meta-analyses. Bibliographies of selected articles were also analyzed for publications of interest relevant to the scope of the topic. The articles that reported primary outcomes after the management of appendicitis, complications, economic implications, and duration of follow-up were reviewed in detail. The major primary outcomes show a high recurrence rate and failed treatment associated with the conservative management of appendicitis. The other outcomes obtained show that there is an increased incidence of complications associated with operative management. Economic implications and cost-effectiveness analysis show that conservative treatment may be preferred. The length of hospital stay was significantly higher in conservative approach to management; however, shorter time off activities was observed. In general, the conservative management of appendicitis is still regarded as safe, effective, and efficacious, and further research with well-constructed study design, and larger sample size is required.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

A protocol for non-operative management of uncomplicated appendicitis

BACKGROUND

We developed a protocol to identify candidates for non-operative management (NOM) of uncomplicated appendicitis. Our objective was to evaluate protocol efficacy with the null hypothesis that clinical outcomes, hospital readmission rates, and hospital charges would be unchanged after protocol implementation.

METHODS

We performed a single-center 4-year propensity score matched retrospective cohort analysis of 406 patients with acute uncomplicated appendicitis. The protocol recommended NOM for patients with modified Alvarado score ≤6 and no appendicolith. Patients admitted before (n = 203) and after (n = 203) protocol implementation were matched by Charlson comorbidity index, duration of symptoms, and modified Alvarado score. Outcomes included operative management, days on antibiotic therapy, length of stay, and hospital charges, as well as readmissions, complications, and mortality within 180 days.

RESULTS

Baseline characteristics were similar between groups (age 31 years, ASA class 2.0, Charlson comorbidity index 0.0). Protocol compliance was higher when the protocol recommended appendectomy (97%) rather than NOM (73%, p < 0.001). The incidence of operative management decreased from 99% to 82% after protocol implementation (p < 0.001). In the protocol group, there was a lower incidence of open surgery (4% vs. 10%, p = 0.044) despite a longer interval between admission and surgery (8.6 vs. 7.1 hours, p < 0.001). After protocol implementation, 51 patients had NOM: 18 failed NOM during admission and 6 failed NOM after discharge. Compared to the pre-protocol group, the protocol group had similar length of stay, antibiotic days, and overall complication rates, but more readmissions (6% vs. 1%, p = 0.019) and lower hospital charges for the index admission ($5,630 vs. $6,878, p < 0.001).

CONCLUSIONS

Implementation of a protocol to identify candidates for NOM of acute uncomplicated appendicitis was associated with lower rates of open surgery, fewer appendectomies, decreased hospital charges, and no difference in overall complications despite high rates of readmission and failure of NOM.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Luminal obstruction in uncomplicated appendicitis: Detection with sonography and potential clinical implications

PURPOSE

To determine the frequency of luminal obstruction on appendiceal graded compression sonography (US) in patients with uncomplicated appendicitis and test the hypothesis that this frequency is similar to the failure rates of primary antibiotic therapy for uncomplicated appendicitis when treatment selection is based on CT findings.

METHODS

Sonograms of 150 consecutive patients with appendicitis diagnosed on ultrasound (US) and proven histopathologically were retrospectively evaluated; 114 (76.0%) had uncomplicated appendicitis, that is, appendicitis without gangrene or perforation, and were evaluated for appendicolithiasis and lymphoid hyperplasia using previously published sonographic criteria, and for luminal obstruction.

RESULTS

Of the 114 patients with uncomplicated appendicitis, US demonstrated no luminal obstruction in 74 (64.9%) and luminal obstruction in 40 (35.1%, P = .018), the latter including 16 (40.0%) with lymphoid hyperplasia and 24 (60.0%, P = .074) with appendicolithiasis.

CONCLUSIONS

US demonstrated luminal obstruction in 35.1% of patients with uncomplicated appendicitis, similar to the published failure rates of antibiotic therapy when treatment selection is based on CT. This confirms the hypothesis, supporting the possibility that undiagnosed luminal obstruction may account for treatment failures when patients are selected by CT for primary antibiotic therapy, and suggests a role for US in selecting patients without luminal obstruction for antibiotic therapy.

Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules

PURPOSE

Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test.

METHODS

A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA.

RESULTS

Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate.

CONCLUSIONS

Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.

Conservative treatment of acute appendicitis

Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.

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.

Outcomes of appendectomy in elderly veteran patients

BACKGROUND

Some studies indicate that noncomplicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy. This study was undertaken to assess outcomes in elderly veterans and to determine if operative intervention would lead to substantial complications such that a nonoperative strategy should be investigated.

METHODS

A retrospective, single-institution analysis was conducted of patients who underwent an appendectomy at the VA North Texas Health Care System over a period of 12 years (from July 2005 to June 2017). Patients who underwent an appendectomy for cancer, interval appendectomy, exploratory laparotomy for perforated appendicitis, or appendectomy as part of another major operation were excluded from the study. Patients were then grouped as elderly (≥60 years old) and young (<60 years old), and differences in outcome were assessed. Univariate and multivariate analyses were also performed to determine if age and comorbid conditions were independent predictors of complications in both cohorts.

RESULTS

Of patients who underwent an appendectomy for acute appendicitis (n = 257, male = 90.7%, age = 45.4 ± standard deviation 15.6 years, body mass index = 30.3 ± 6.3 kg/m²), 195 were young (38.7 ± 11.2 years old) and 62 elderly (66 ± 5 years old). More patients were male in the elderly cohort (98.4% vs 88%; P = .01). The incidence of gangrenous and perforated appendicitis was greater in elderly patients (11.3% and 14.4% vs 24 % and 40%, P < .01 each). Diabetes and hypertension, as well as a history of cardiac, pulmonary, and renal diseases, were more than 2-fold greater in older patients. Complications and 30-day readmission rates were similar in both groups (young vs elderly: 7.2% and 9% vs 9.7% and 11%, P > .5 each). Logistic regression analysis showed that age and American Society of Anesthesia level were not independent predictors of complications. A history of cardiac disease and open operation independently predicted complications regardless of age. Unexpected malignancy was 3% in the elderly and 1.5% in the young cohort (P = .6) CONCLUSION: Complicated appendicitis is more common in elderly patients. Appendectomy in elderly veteran patients has a low rate of complications similar to younger patients and the private sector. Operative intervention in this group of patients is not prohibitive. Further studies are needed to determine if nonoperative intervention is noninferior to an appendectomy in this high-risk patient population.

Antibiotics for appendicitis! Not so fast

BACKGROUND

Emerging literature in acute appendicitis favors the nonoperative management of acute appendicitis. However, the actual use of this practice on a national level is not assessed. The aim of this study was to assess the changing trends in nonoperative management of acute appendicitis and its effects on patient outcomes.

METHODS

We did an 8-year (2004-2011) retrospective analysis of the National Inpatient Sample database. We included all inpatients with the diagnosis of acute appendicitis. Patients with a diagnosis of appendiceal abscess or patients who underwent surgery for any other pathology were excluded from the analysis. Jonckheere-Terpstra trend analysis was performed for operative versus nonoperative management and outcomes.

RESULTS

A total of 436,400 cases of acute appendicitis were identified. Mean age of the population was 33 ± 19.5 years, and 54.5% were male. There was no significant change in the number of acute appendicitis diagnosed over the study period (p = 0.2). During the study period, nonoperative management of acute appendicitis increased significantly from 4.5% in 2004 to 6% in 2011 (p < 0.001). When compared with operatively managed patients, conservatively managed patients had a significantly longer hospital length of stay (3 [2-6] vs. 2 [1-3] days, p < 0.001), and in-hospital complications (27.8% vs. 7%, p < 0.001). On comparison of open and laparoscopic appendectomy, both had shorter hospital length of stay and rate of in-hospital complications. Overall hospital charges were lower in patients managed conservatively (15,441 [8,070-31,688] vs. 20,062 [13,672-29,928] USD, p < 0.001).

CONCLUSIONS

Nonoperative management of appendicitis has increased over time; however, outcomes of nonoperative management did not improve over the study period. A more in-depth analysis of patient and system demographics may reveal this disparity in trends.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Diabetes increases the risk of an appendectomy in patients with antibiotic treatment of noncomplicated appendicitis

BACKGROUND

This retrospective cohort study examined whether diabetic patients have a higher risk for recurrent appendicitis during a 1-year follow-up period after successful antibiotic treatment for patients with acute uncomplicated appendicitis than nondiabetic patients using a population-based database.

METHODS

We included 541 appendicitis patients who received antibiotic treatment for acute appendicitis. We individually tracked each patient for a 1-year period to identify those who subsequently underwent an appendectomy during the follow-up period.

RESULTS

Cox proportional hazard regressions suggested that the adjusted hazard ratio of an appendectomy during the 1-year follow-up period was 1.75 for appendicitis patients with diabetes than appendicitis patients without diabetes. We found that among females, the adjusted hazard ratio of an appendectomy was 2.18 for acute appendicitis patients with diabetes than their counterparts without diabetes. However, we failed to observe this relationship in males.

CONCLUSIONS

We demonstrated a relationship between diabetes and a subsequent appendectomy in females who underwent antibiotic treatment for noncomplicated appendicitis.

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

Background

For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis.

Methods

A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.

Conclusion

The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary.

Limitations of each evolving

Neutrophil-to-lymphocyte ratio has a close association with gangrenous appendicitis in patients undergoing appendectomy

The purpose of this study was to clarify the clinical features most closely associated with gangrenous appendicitis. From among 314 patients who had undergone open appendectomy in our collected database, 222 for whom sufficient data were evaluable were enrolled. The results of univariate analysis revealed that age (≤40/>40 years), sex (female/male), fever (≤37°/>37°C), the serum levels of C-reactive protein and albumin, the Glasgow prognostic score (0, 1/2), and the neutrophil-to-lymphocyte ratio (NLR) (≤8/>8) were associated with gangrenous appendicitis. Among these 7 clinical features, multivariate analysis disclosed that age (≤40/>40 years) (odds ratio, 3.435; 95% confidence interval 1.744-6.766; P < 0.001) and NLR (≤8/>8) (odds ratio, 3.016; 95% confidence interval 1.535-5.926; P = 0.001) were associated with gangrenous appendicitis. The sensitivity and specificity of these two clinical features were 65% and 27%, and 73% and 39%, respectively. NLR (>8) shows a significant association with gangrenous appendicitis in patients undergoing appendectomy.

The Systemic Inflammatory Response in Patients with Appendicitis: a Progressive Phenomenon

The systemic inflammatory response has been described in patients with appendicitis. However, its progression from onset of symptoms to diagnosis has not been characterized. The specific purpose of this study was to describe and characterize the systemic inflammatory response to appendicitis. A descriptive cross-sectional study was conducted. One hundred eighty-three patients were studied, divided into four groups from onset of symptoms to diagnosis. The primary outcome measure was to determine the systemic inflammatory response to appendicitis according to the established groups of time intervals. The secondary outcome measure was the analysis of C-reactive protein for the same purpose. The variables of the systemic inflammatory response, according to diagnostic intervals, showed non-significant differences in white blood cell count. The temperature rose constantly after 48 h, reaching its peak after 72 h (p = 0.001), and the respiratory rate rose after 73 h (p < 0.0001). After 73 h, most patients had three or four systemic inflammatory response criteria (p < 0.0001). C-reactive protein levels rose progressively, showing higher levels after 48 h (p = 0.005). The inflammatory response to appendicitis is progressive, being more marked along the timeline from onset of symptoms to diagnosis.

Non-operative management of early, acute appendicitis in children: is it safe and effective?

PURPOSE

The purpose of this study was to determine if early, acute appendicitis in children can be safely and effectively managed with antibiotics alone.

METHODS

A retrospective review was performed of children (<18 yrs) treated non-operatively (NOM) for early, acute appendicitis since May 2012. These were compared to patients treated with appendectomy between January 2011 and October 2011 (OM). Inclusion criteria included: (a) symptoms <48 h, (b) localized peritonitis, and (c) ultrasound findings consistent with early, acute appendicitis.

RESULTS

Twelve patients (66% female, mean age 12.2,SD=4.2 yrs) were treated non-operatively, while 12 (50% female, mean age 12.5,SD=3.2 yrs) were treated operatively. Two NOM children (16.7%) required initial appendectomy. One patient developed recurrent appendicitis requiring appendectomy 7 months post-discharge. Four other NOM patients returned with symptoms but did not require admission or surgery. Two OM patients (8.3%) had hospital visits and admissions related to surgical site infections. Mean length of stay (LOS) for the first visit was 1.5 days (SD=1.0d) (NOM) vs. 1.3 days (SD=0.5d) (OM) (p=0.61). Including first and subsequent admissions, mean LOS was 1.8 days (SD=1.1d) (NOM) vs. 1.7 days (SD=1.5d) (OM) (p=0.97).

CONCLUSION

Early acute appendicitis in appropriately selected children can be successfully treated non-operatively. Randomized trials with longer follow-up are required.

Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis

BACKGROUND

Emerging literature has supported the safety of nonoperative management of uncomplicated appendicitis.

STUDY DESIGN

Patients with emergent, uncomplicated appendicitis were identified by appropriate ICD-9 diagnosis codes in the California Office of Statewide Health Planning and Development database from 1997 to 2008. Rates of treatment failure, recurrence, and perforation after nonsurgical management were calculated. Factors associated with treatment failure, recurrence, and perforation were identified using multivariable logistic regression. Mortality, length of stay, and total charges were compared between treatment cohorts using matched propensity score analysis.

RESULTS

Of 231,678 patients with uncomplicated appendicitis, the majority (98.5%) were managed operatively. Of the 3,236 nonsurgically managed patients who survived to discharge without an interval appendectomy, 5.9% and 4.4% experienced treatment failure or recurrence, respectively, during a median follow-up of more than 7 years. There were no mortalities associated with treatment failure or recurrence. The risk of perforation after discharge was approximately 3%. Using multivariable analysis, race and age were significantly associated with the odds of treatment failure. Sex, age, and hospital teaching status were significantly associated with the odds of recurrence. Age and hospital teaching status were significantly associated with the odds of perforation. Matched propensity score analysis indicated that after risk adjustment, mortality rates (0.1% vs 0.3%; p = 0.65) and total charges ($23,243 vs $24,793; p = 0.70) were not statistically different between operative and nonoperative patients; however, length of stay was significantly longer in the nonoperative treatment group (2.1 days vs 3.2 days; p < 0.001).

CONCLUSIONS

This study suggests that nonoperative management of uncomplicated appendicitis can be safe and prompts additional investigations. Comparative effectiveness research using prospective randomized studies can be particularly useful.

Evaluation of acute abdominal pain

Abdominal pain is a common complaint encountered in primary care and in the ED. Varying levels of pain dictate the immediacy of the intervention. Time is vital when making the decision to initiate therapeutic interventions. A comprehensive assessment with physical exam and diagnostic studies is required.

Management of Complicated Appendicitis in the Pediatric Population: When Surgery Doesn't Cut It

The management of complicated appendicitis in children has evolved significantly over the last century. What initially was a surgeon's dilemma is becoming the interventional radiologist's task because image-guided percutaneous drainage of abscesses from a ruptured appendix obviates the need for urgent surgery and allows for selective interval appendectomy at the surgeon's discretion (versus conservative nonoperative management in selected cases). This paradigm shift places the onus on the interventional radiologist to recognize when the procedure is emergently indicated and to be cognizant of the special needs of a pediatric patient.

Treatment options of inflammatory appendiceal masses in adults

At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn’s disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Examining a common disease with unknown etiology: trends in epidemiology and surgical management of appendicitis in California, 1995-2009

BACKGROUND

The study was designed to examine the epidemiology of appendicitis and risk factors of perforation and appendectomy.

METHODS

Retrospective analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995 to 2009. Patients with appendicitis were identified by ICD-9 diagnosis code. Population statistics from the RAND Corporation were used to calculate incidence rates. Risk factors of perforation and appendectomy were also calculated.

RESULTS

A total of 608,116 patients with appendicitis (70% non-perforated) were included. The incidence increased at an average rate of 0.5 cases/100,000 population/year (p<0.001), with annual incidence peaking during the third quarter. Children age 10-14 had the highest rates of appendicitis (169.6 cases/100,000). The lifetime cumulative incidence rate is 9.0%. Appendicitis is most common in whites and Hispanics and less common in African Americans and Asians. Risks of perforation include Hispanic or Asian race, young or old age, and non-private insurance. The adjusted odds of appendectomy increased since 1995 in patients with non-perforated appendicitis (OR 1.5, 95% CI (1.3-1.7); p<0.001), but it decreased in patients with perforated appendicitis (OR 0.4, 95% CI (0.4-0.5); p<0.001).

CONCLUSIONS

This is the largest epidemiological study of appendicitis to our knowledge in recent years. Incidence has increased over time and is higher in the summer months. Whites and Hispanics have higher rates of appendicitis, but Hispanics and Asians and patients with non-private insurance, have higher odds of perforation. Surgical management of perforated appendicitis has decreased over time. It is unknown why the incidence has increased, displays seasonality, and varies by race.

Antibiotics as first-line therapy for acute appendicitis: evidence for a change in clinical practice

BACKGROUND

Randomized studies have indicated that acute appendicitis may be treated by antibiotics without the need of surgery. However, concerns have been raised about selection bias of patients in such studies. Therefore, the present study was aimed to validate previous findings in randomized studies by a full-scale population-based application.

METHODS

All patients with acute appendicitis at Sahlgrenska University Hospital (May 2009 and February 2010) were offered intravenous piperacillin plus tazobactam according to our previous experience, followed by 9 days out-hospital oral ciprofloxacin plus metronidazole. Endpoints were treatment efficacy and complications. Efficient antibiotic treatment was defined as recovery without the need of surgery beyond 1 year of follow-up.

RESULTS

A total of 558 consecutive patients were hospitalized and treated due to acute appendicitis. Seventy-nine percent (n = 442) received antibiotics as first-line therapy and 20 % (n = 111) had primary surgery as the second-line therapy. Seventy-seven percent of patients on primary antibiotics recovered while 23 % (n = 100) had subsequent appendectomy due to failed initial treatment on antibiotics. Thirty-eight patients (11 %) of the 342 had experienced recurrent appendicitis at 1-year follow-up. Primary antibiotic treatment had fewer complications compared to primary surgery.

CONCLUSIONS

This population-based study confirms previous results of randomized studies. Antibiotic treatment can be offered as the first-line therapy to a majority of unselected patients with acute appendicitis without medical drawbacks other than the unknown risk for long-term relapse, which must be weighed against the unpredicted but well-known risk for serious major complications following surgical intervention.

Changing bacteriology of abdominal and surgical sepsis

PURPOSE OF REVIEW

This review focuses on recent changes in epidemiological aspects of bacteria-induced intra-abdominal infections (IAIs), including the dominant pathogens, antimicrobial susceptibility profiles, and emerging resistance phenotypes.

RECENT FINDINGS

Enterobacteriaceae species, including Escherichia coli and Klebsiella pneumoniae, remain the major pathogens contributing to abdominal sepsis, although Pseudomonas aeruginosa and Acinetobacter baumannii have recently become common causes of hospital-acquired IAIs. The prevalence of multidrug-resistant Gram-negative bacilli, especially those that produce extended-spectrum β-lactamases (ESBLs), has increased worldwide, although the distribution of those organisms varies from region to region. Furthermore, recent changes in interpretive breakpoints for antimicrobial susceptibility testing recommended by the Clinical Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) have resulted in a marked increase in the reported rates of resistance among Gram-negative bacilli to carbapenems, extended-spectrum cephalosporins, and fluoroquinolones. Besides, routine detection and reporting of ESBL phenotypes for clinical isolates have not been recommended after following new interpretive breakpoints. More studies are needed to investigate the impacts of these changes on therapeutic strategies and epidemiological surveillance. In addition, pathogens carrying New Delhi metallo-β-lactamases (NDMs), K. pneumoniae carbapenemases (KPCs), and other carbapenemases show extended resistance to currently available antibiotics and rapid transfer between species and countries. Although some of these pathogens are still susceptible to tigecycline and colistin, rates of resistance to these two agents are rising.

SUMMARY

Abdominal sepsis due to multidrug-resistant bacteria, especially ESBL producers, and international and interspecies spreading of metallo-β-lactamase raise key therapeutic problems.

Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

OBJECTIVE

To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis.

DESIGN

Meta-analysis of randomised controlled trials.

POPULATION

Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations.

INTERVENTIONS

Antibiotic treatment versus appendicectomy.

OUTCOME MEASURES

The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions.

RESULTS

Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I(2)=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I(2)=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis.

CONCLUSION

Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.