Efficacy and Safety of Non‐Operative Management of Uncomplicated Acute Appendicitis Compared to Appendectomy: An Umbrella Review of Systematic Reviews and Meta‐Analyses

Emile, Sameh Hany; Sakr, Ahmad; Shalaby, Mostafa; Elfeki, Hossam

doi:10.1007/s00268-022-06446-8

Cited by 15 publications

(17 citation statements)

References 46 publications

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“…Indeed, several recent prospective randomized control trials both in Europe and the USA have demonstrated non-inferiority of antimicrobial-based pharmacologic management of early-stage acute appendicitis compared with appendectomy [15][16][17][18][19]. While these results have been met with great interest, and have provided therapeutic alternatives in the appropriate patient, the incidence of recurrent acute appendicitis, principally in patients with an appendicolith, ranging from 24 to 31%, is seen by some as a failure of non-operative management [20,21]. Thus, outcomes related to surgical removal of the appendix remain of great importance for surgeons, Emergency Medicine clinicians, Primary Care physicians, as well as patients and their families.…”

Section: Discussionmentioning

confidence: 99%

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Bass

Kaplan

Forssten

et al. 2023

Eur J Trauma Emerg Surg

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Introduction Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. Material and methods We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). Results Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41–0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11–0.96), p = 0.045] complications could be detected when using energy devices. Conclusions Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

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Section: Discussionmentioning

confidence: 99%

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Bass

Kaplan

Forssten

et al. 2023

Eur J Trauma Emerg Surg

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“…Por otra parte, el presente estudio mostró como en los pacientes tratados con apendicectomía se reportó una menor estancia hospitalaria y un mayor éxito terapéutico. Sobre este tema, Emile et al 25 realizaron una revisión "umbrela" en el año 2022, que incluyo 18 revisiones sistemáticas, concluyendo que la evidencia existente muestra como el manejo no quirúrgico se asoció con un mayor fracaso terapéutico y una estancia más corta comparada con la apendicectomía, estos resultados muestran como el manejo con terapia antibiótica requiere una selección y observación cuidadosa de los pacientes.…”

Section: Discussionunclassified

Comparación de la seguridad y la eficacia del uso de antibióticos frente a la apendicectomía en el tratamiento de la apendicitis no complicada en adultos. Revisión sistemática y metaanálisis

et al. 2023

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Introducción. La apendicitis aguda es una emergencia quirúrgica frecuente, en la cual el tratamiento de tipo conservador basado en antibióticos se ha identificado como una opción terapéutica que necesita seguir siendo estudiada. El objetivo de este estudio fue determinar las diferencias en seguridad y eficacia del uso de antibióticos en comparación con la apendicectomía en adultos con apendicitis no complicada. Métodos. Revisión sistemática y metaanálisis. Se encontraron 452 estudios; después de una selección, 45 se evaluaron en texto completo y 15 para calidad metodológica; 11 estudios fueron seleccionados y 9 incluidos en el metaanálisis. Resultados. Se contó con 3186 participantes, de los cuales 1512 fueron tratados con terapia antibiótica y 1674 sometidos a apendicectomía. Se identificó estancia hospitalaria más corta en los pacientes sometidos a apendicectomía (SMD: 0,28; IC95%: 0,14 a 0,41). Para los pacientes tratados con terapia antibiótica, se evidenció puntajes de riesgo menores en las escalas de diagnóstico de apendicitis (SMD: -0,13; IC95%: -0,22 a -0,04), menor éxito terapéutico en un 16 % (RR: 0,84; IC95%: 0,77 a 0,92) y reducción del riesgo de complicaciones del 63 % (RR: 0,37; IC95%: 0,25 a 0,53). Se encontró alta heterogeneidad y riesgo de sesgo de publicación. Conclusiones. La terapia antibiótica necesita mayor evidencia para desenlaces como calidad de vida, satisfacción, dolor, o complicaciones específicas, entre otros, que permitan hacer comparaciones más contundentes. Los pacientes que consideren el manejo conservador necesitan ser adecuadamente asesorados y monitorizados para optimizar sus posibilidades de resultados favorables y la oportuna identificación de complicaciones que necesiten de otros abordajes.

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“…Decisionmaking regarding elective IA is often left to the discretion of children's caregivers' preferences in North America, as both management approaches have similar rates of low complications. 12 Parents facing the decision of whether or not to have their child undergo elective IA may face decisional conflict. For example, at our institution there are many instances where parents express decisional conflict regarding this elective procedure.…”

Section: Background and Rationalementioning

confidence: 99%

“…In cases where there are multiple viable treatments, decision-making can be difficult, especially among pediatric patients. Decision-making regarding elective IA is often left to the discretion of children’s caregivers’ preferences in North America, as both management approaches have similar rates of low complications 12…”

Section: Background and Rationalementioning

confidence: 99%

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Needs assessment of parents for a patient decision aid in pediatric interval appendectomy via the qualitative interview method

Grandpierre

Duba

April

et al. 2022

World Jnl Ped Surgery

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ObjectivesAppendicitis is one of the most commonly encountered pediatric surgical diagnoses, with non-operative management of perforated appendicitis leading to two treatment options: an interval appendectomy (IA) or expectant management. The primary objective of this study was to assess parents’ need for a patient decision aid (PDA) among parents considering IA or expectant management. A secondary objective was to determine parent preferences for the format and distribution plan of a drafted patient decision aid.MethodsCoulter’s systematic development process for PDA was used to guide the assessment interviews for parents. Participants included caregivers of a patient who experienced perforated appendicitis, and admission between 2019 and 2020. Semi-structured individual interviews were conducted to collect information about decision-making needs of parents of children who experienced perforated appendicitis.ResultsA total of 12 different parents participated in the interviews. Results indicate decisional conflict associated with the lack of evidence for optimal treatment, supporting the need for the development of a patient decision aid to assist in clarifying information and parent values with practitioners. Parents clearly identified a need for evidence to support decision-making in various formats (eg, pamphlet or electronic). Timing of when to deliver the PDA varied (ie, during hospital admission, at discharge, or at follow-up appointment).ConclusionResults indicated various factors contributing to parental decisional conflict, including the lack of evidence showing the optimal treatment, the need for more information, and guidance from practitioners. Overall, findings indicate a strong need for a patient decision aid.

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Efficacy and Safety of Non‐Operative Management of Uncomplicated Acute Appendicitis Compared to Appendectomy: An Umbrella Review of Systematic Reviews and Meta‐Analyses

Cited by 15 publications

References 46 publications

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Comparación de la seguridad y la eficacia del uso de antibióticos frente a la apendicectomía en el tratamiento de la apendicitis no complicada en adultos. Revisión sistemática y metaanálisis

Needs assessment of parents for a patient decision aid in pediatric interval appendectomy via the qualitative interview method

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