Antibiotic Treatment and Appendectomy for Uncomplicated Acute Appendicitis in Adults and Children

Abstract

Objective: The aim of this meta-analysis was to summarize the current available evidence on nonoperative management (NOM) with antibiotics for uncomplicated appendicitis, both in adults and children. Summary Background Data: Although earlier meta-analyses demonstrated that NOM with antibiotics may be an acceptable treatment strategy for patients with uncomplicated appendicitis, evidence is limited by conflicting results. Methods: Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases for randomized and nonrandomized studies comparing antibiotic therapy (AT) and surgical therapy-appendectomy (ST) for uncomplicated appendicitis. Literature search was completed in August 2018. Results: Twenty studies comparing AT and ST qualified for inclusion in the quantitative synthesis. In total, 3618 patients were allocated to AT (n = 1743) or ST (n = 1875). Higher complication-free treatment success rate (82.3% vs 67.2%; P < 0.00001) and treatment efficacy based on 1-year follow-up rate (93.1% vs 72.6%; P < 0.00001) were reported for ST. Index admission antibiotic treatment failure and rate of recurrence at 1-year follow-up were reported in 8.5% and 19.2% of patients treated with antibiotics, respectively. Rates of complicated appendicitis with peritonitis identified at the time of surgical operation (AT: 21.7% vs ST: 12.8%; P = 0.07) and surgical complications (AT: 12.8% vs ST: 13.6%; P = 0.66) were equivalent. Conclusions: Antibiotic therapy could represent a feasible treatment option for image-proven uncomplicated appendicitis, although complication-free treatment success rates are higher with ST. There is also evidence that NOM for uncomplicated appendicitis does not statistically increase the perforation rate in adult and pediatric patients receiving antibiotic treatment. NOM with antibiotics may fail during the primary hospitalization in about 8% of cases, and an additional 20% of patients might need a second hospitalization for recurrent appendicitis.

Laparoscopy versus open appendectomy for elderly patients, a meta-analysis and systematic review

“…Previous studies demonstrated that appendicitis in elderly are associated with higher risk of perforation and complications due to more comorbidities and more challenge of accurate diagnosis [4,5]. Therefore, precise diagnosis coupled with appropriate procedure are crucial for treating appendicitis in elderly population [6,7].…”

Serum bilirubin concentration as a marker of severity of acute appendicitis.

“…Evidence suggests that laparoscopic appendectomy appears to be a method of choice in most patients presenting with the symptoms of AA [6,16]. However, recent studies such as the APPAC randomized clinical trial published by Salminen et al [20] and a meta-analysis by Podda et al [16], which included more than 3500 patients with suspicion of AA, have shown that antibiotic therapy for image-proven uncomplicated appendicitis is a viable Ovarian cyst rupture 3…”

“…Other studies have attempted to evaluate the usefulness of hyperbilirubinemia in distinguishing AA from other conditions presenting with similar clinical symptoms, and the outcomes confirmed the hypothesis [2,15]. Moreover, in the face of growing evidence for non-surgical treatment of uncomplicated AA the search for a clinically useful marker to establish the severity of AA seems obligatory [16].…”

“…treatment option compared to surgery. Podda et al [16] reported antibiotic treatment to have a failure rate of 27.7% at 1-year follow-up along with lower complication-free treatment success (no postoperative complications, adverse events, or treatment failure occurring -67.2% for conservative vs. 82.3% for surgical management). Additionally, a decreased rate of postintervention complications (7.1% vs. 14.5%) and reduced cost were noted.…”

What is the main problem in the conservative management of complicated appendicitis? A meta-analysis

“…For uncomplicated appendicitis, recent meta-analyses 4 have reported that antibiotic therapy could represent a feasible treatment option. Although the success rates of complication-free treatment generally are higher than those with surgical treatment, some studies have suggested that non-operative management for uncomplicated appendicitis does not statistically increase the perforation rates in adults and in pediatric patients receiving antibiotic treatment 5,6 .…”