Journal Club January 2017: Appendicitis - Is it still an Operative disease?

smaller appendicitis image.jpg

At this journal club we looked at a number of studies examining the concept.  While they were of varied design, the premise of all was the same; namely with an antibiotic only approach, what is the success rate, recurrence rate, and cost savings / loss?

What we discussed was an initial "failure" rate that ranged anywhere from 12% to 24%, and a 1-2 failure rate of up to 30%.  It seems like failures (when they occurred) were mostly within the first week.  Late failures could often be treated with another course of antibiotics.

It was difficult to draw conclusions regarding cost savings given the design of the studies.

We concluded that this adds a possible treatment algorithm for patients where surgery is not possible / risky / etc.  We also concluded that none of the populations were exactly like ours nor were any of the studies designed to cause a seismic shift in the general surgical approach to the disease.

Two interesting factoids were also identified:

  • The lifetime risk of Clostridium Difficile infection goes WAY up after appendectomy (OR 0.3 for those keeping their appendix vs those who have it removed).  It is postulated that it is where the colon re-populates the gut with "good bacteria" after a diarrheal illnesses.
  • 2% of appendices removed have a cancer identified.  It is entirely unclear whether there would be an expected increase in adeno Ca if leaving the appendix in place became the norm.
     

Summary:  Appendicitis has traditionally been a purely operative disease.  Recently, however, there has been some literature supporting a non-operative approach with antibiotics, much like we treat other colonic diseases (eg diverticulitis, colitis).  While not the primary approach in the US, there is some world literature supporting the concept.

 

Written by Andrew Perron, MD, FACEP

Edited and Posted by Jeffrey A. Holmes, MD


ARTICLES REVIEWED

1.  Du Saveruio, S. et al. The NOTA Study (Non Operative Treatment for Acute Appendicitis):  prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long term follow-up of conservatively treated suspected appendicitis. Annals of Surgery, 2014 Jul; 260(1), 109-117. PMID: 24646528 DOI: 10.1097/SLA.000000000000056

2.  Ehlers, A. P., et al. Evidence for an Antibiotics-First Strategy for Uncomplicated Appendicitis in Adults: A Systematic Review and Gap Analysis. Journal of the American College of Surgeons. 2016 March; 222(3), 309-314. PMID: 26712246 DOI: 10.1016/j.jamcollsurg.2015.11.009

3.  Salminen, P., et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis. JAMA, 2015 Jun 16; 313(23), 2340. PMID: 26080338 DOI: 10.1001/jama.2015.6154

4.  Flum, D. (2015). Acute Appendicitis — Appendectomy or the “Antibiotics First” Strategy. N Engl J Med. 2015 May 14;372(20):1937-43. PMID: 25970051 DOI: 10.1056/NEJMcp1215006

 

DOWNLOAD ARTICLE SUMMARIES

  Du SaVuruio

Du SaVuruio

 Ehlers

Ehlers

 Salminen

Salminen

 

Extra Reading . Some interesting twists on the topic:

1.  An article attempting to assess the patient’s and family’s perspective, goals, and expectations with the management of appendicitis:

 2.  An article looking specifically at major complication rate between management of appendicitis with surgery vs antibiotic therapy.

  • Kirby, A., et al. Appendectomy for suspected uncomplicated appendicitis is associated with fewer complications than conservative antibiotic management: A meta-analysis of post-intervention complications. Journal of Infection, 70(2), 105-110. PMID: 25175926 DOI:10.1016/j.jinf.2014.08.009

3.  Here is meta-analysis looking at the possibility of using this strategy in kids

Libin Huan, et al.  Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children, A Meta-analysis.  JAMA Pediatr. Published online March 27, 2017. doi:10.1001/jamapediatrics.2017.0057

 

 

OTHER REVIEWS ON THE TOPIC

1.  EMLIT of note  by Ryan Radecki, MD - "The Era of the Appendectomy is Not Over"

2.  Life in the Fast Lane

3.  EMRAP Episode # 159 - Paper chase 3:  Antibiotics for Appendicitis

4.  Skeptics Guide to Emergency Medicine by Ken Milne, MD SGEM Episode #115