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

Abstract

BackgroundFor 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.MethodsA 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.ResultsFive 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.ConclusionThe 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.

Acute appendicitis

“…[43][44][45][46] If primary antibiotic treatment is initiated, a fifth of patients can expect a readmission, with recurrent symptoms within a year; most will undergo an appendicectomy that is not more complicated. The data for use of antibiotics have short follow-up times, so the lifetime recurrence risk and the risk of missing a subclinical incidental neoplasm are unknown.…”

Acute appendicitis: Epidemiology, treatment and outcomes- analysis of 16544 consecutive cases

“…Several reports described spontaneous resolution of uncomplicated appendicitis without the need of an operation and, since the high rate of negative appendectomy and the significative complications rate, some authors proposed and advised conservative management for uncomplicated appendicitis[6,7]. Conservative management for appendicitis has been described in 1930 by the “Ochsen-Sherren delayed[8] treatment”, which consisted of resting and fasting followed by delayed elective appendectomy; nowadays, a conservative approach based on antibiotic therapy is gaining popularity, as documented by several randomized studies and meta-analyses that analyze this peculiar issue[9-17]. Conservative treatment has been shown to be safe and effective as primary treatment compared to surgical treatment with a significative reduction in morbidity, even with a considerable one year recurrence rate of 23%[17].…”

“…Conservative management for appendicitis has been described in 1930 by the “Ochsen-Sherren delayed[8] treatment”, which consisted of resting and fasting followed by delayed elective appendectomy; nowadays, a conservative approach based on antibiotic therapy is gaining popularity, as documented by several randomized studies and meta-analyses that analyze this peculiar issue[9-17]. Conservative treatment has been shown to be safe and effective as primary treatment compared to surgical treatment with a significative reduction in morbidity, even with a considerable one year recurrence rate of 23%[17]. …”

Trends in the Management of Acute Appendicitis in a Single-Center Quality Register Cohort of 5,614 Patients

“…The standard treatment for acute appendicitis in the past century has been surgical removal of the appendix, but there is still some debate whether open appendectomy (OA) or laparoscopic appendectomy (LA) is the preferable surgical approach. More recently, some data suggest that medical treatment can suffice in uncomplicated cases [2].…”