Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis

Monsell, Sarah E.; Voldal, Emily C; Davidson, Giana H.; Fischkoff, Katherine; Coleman, Natasha; Bizzell, Bonnie; Price, Thea P.; Narayan, Mayur; Siparsky, Nicole; Thompson, Callie M; Ayoung-Chee, Patricia; Odom, Stephen R.; Drake, Frederick Thurston; Johnson, Jeffrey; Cuschieri, Joseph; Evans, Heather L.; Liang, Mike K.; McGrane, Karen; Hatch, Quinton; Victory, Jesse; Wisler, Jon; Salzberg, Matthew; Ferrigno, Lisa; Kaji, Amy H.; DeUgarte, Daniel A.; Gibbons, Melinda M.; Alam, Hasan B.; Scott, John W.; Kao, Lillian S.; Self, Wesley H.; Winchell, Robert J.; Villegas, Cassandra; Talan, David A.; Kessler, Larry G.; Lavallee, Danielle C.; Krishnadasan, Anusha; Lawrence, Sarah O.; Comstock, Bryan A.; Fannon, Erin; Flum, David R.; Heagerty, Patrick J.

doi:10.1001/jamasurg.2021.6900

Cited by 24 publications

(13 citation statements)

References 44 publications

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“…The CODA trial 22 reported complications in 14 per cent of participants randomized to antibiotic therapy with an appendicolith compared with only 2 per cent of those without an appendicolith. Thus, it may be that this large trial (approximately of a size equal to all the other trials combined) and its inclusion of participants with appendicoliths has affected the analysis significantly, particularly as a secondary analysis of the trial found that presence of an appendicolith was associated with a nearly two-fold increased risk of participants undergoing an appendicectomy within 30 days of initiating antibiotic treatment 39 .…”

Section: Discussionmentioning

confidence: 99%

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

2022

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Background This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis. Methods A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented. Results Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. −0.05 to 0.35)). Conclusions Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.

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Section: Discussionmentioning

confidence: 99%

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

2022

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“…Appendectomy has been recognized as a standard treatment for appendicitis for a long time. Nevertheless, the successful management of patients without surgery is evident in several studies [ 24 , 25 ]. One of the most recent studies suggests that female sex, appendiceal diameter, and the presence of an appendicolith are factors that result in increased odds of having to undergo an appendectomy compared to using antibiotic treatments [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

“…The process of making a balanced judgement on whether to perform an appendectomy or not remains very challenging, mainly due to the variation in symptoms and signs in different patients, but also due to the lack of standardized care and organizational barriers [ 25 ]. That being said, there are several reasons why the insights derived from this study are of great importance.…”

Section: Discussionmentioning

confidence: 99%

Clinical Decision-Making for Appendectomy in Kosovo: A Conjoint Analysis

Hoxha

Duraj²,

Xharra³

et al. 2022

IJERPH

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Objective: The objective was to investigate the association of clinical attributes with decision making for performing appendectomy and making preoperative preparations for appendectomy. Method: A conjoint analysis with 17 clinical scenarios was executed with surgeons employed at public hospitals in Kosovo. Setting: The study was conducted at two public hospitals in Kosovo that have benefited from quality-improvement interventions. Participants: The participants included 22 surgeons. Outcome measures: The primary outcome was the overall effect of clinical attributes on the decision to perform appendectomy and make the preoperative preparations for appendectomy. Results: In the regression analyses, several attributes demonstrated statistically significant effects on the clinical decision to perform appendectomy and on the practice of preoperative preparation. Conclusions: We found that several factors influenced the decision to perform appendectomy and the practices for preoperative preparation. Nevertheless, the small sample size limited our efforts to interpret the results. These findings could assist Kosovo in the design and implementation of future similar studies and in fostering quality improvement measures that address clinical decision making and the lack of process standardization in the delivery of surgical care.

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“…Total serious morbidity-modified National Surgical Quality Improvement Program (NSQIP) events were documented in 3.5% of patients randomized to surgical intervention in the 2020 Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) Trial. In 2015, the overall (not just serious) complication rate was 20.5% in the Finnish Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis (APPAC) study [ 15 , 20 , 36 ]. An aggregated incidence of postoperative complications in a mixed population including uncomplicated and complicated appendicitis of 18.4% was derived from a meta-analysis of eleven trials assessing 1288 patients [ 37 ].…”

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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Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis

Cited by 24 publications

References 44 publications

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

Clinical Decision-Making for Appendectomy in Kosovo: A Conjoint Analysis

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

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