December 17, 2015

Non-Operative Treatment of Appendicitis May Have Unknown Long-Term Risks

CHICAGO -- December 17, 2015 -- It is too early to change the standard treatment of appendicitis in US adults to initial antibiotic therapy only, rather than surgical removal of the appendix, or appendectomy, according to a study published early online ahead of the print edition of the Journal of the American College of Surgeons.

Some research studies from Europe, including a study published this year, have concluded that some patients with acute uncomplicated appendicitis can cure their appendicitis by taking antibiotics alone. That study found that the 1 in 4 patients who later needed removal of their appendix did not have a higher rate of postoperative complications or a greater risk of a ruptured appendix.

“Despite the generally low rate of complications after appendectomy, some US physicians and the public are questioning whether we should change to non-operative treatment of appendicitis, as many surgeons in Europe already have done,” said lead investigator Anne P. Ehlers, MD, Department of Surgery, University of Washington, Seattle, Washington.

“What we found in our review is that antibiotics-first treatment of appendicitis is probably safe for adults and successful in 3 out of 4 patients,” she said. “However, there are many unanswered questions about outcomes of antibiotics-first treatment that patients have told us are important to them. These include their quality of life, long term residual symptoms, time to return to work and school and other financial considerations.”

Important differences exist between the US and European healthcare systems and surgical approaches, and the European studies potentially had limitations that might prevent their findings from being applied in general surgical practice.

Therefore, Dr. Ehlers and colleagues conducted a systematic review to summarise the best available research studies published on this topic, identify the studies’ limitations and the current gaps in knowledge about the new treatment approach, and guide physicians who may want to adopt an antibiotics-first strategy.

Their analysis, according to Dr. Ehlers, is the most up-to-date review of the best available evidence comparing results of antibiotics-first treatment and appendectomy for patients with uncomplicated appendicitis.

The researchers evaluated 6 randomised controlled clinical trials that compared antibiotics-first with appendectomy for treatment of acute appendicitis. Results of the clinical trials were published between 1995 and 2015 and included a total of 1,724 patients. All 6 studies were conducted in Europe in adults aged younger than 75 years, with 1 study also including children and 1 study excluding women, the investigators reported.

In all but 1 of these studies, 24% to 35% of the patients randomly assigned to the antibiotics-first group later required appendectomy because the medications did not cure the appendicitis, or due to recurrent disease or symptoms. Most studies reportedly had a follow-up period of 1 year.

A 1-year follow-up may be too short to detect the rate that appendicitis recurs in patients who kept their appendix, according to Dr. Ehlers. In addition, she said 1 year after non-operative treatment is likely not long enough to identify rare outcomes such as cancers of the appendix. This rare cancer, whose cause remains unknown, is likely found in less than 2% of all appendectomy specimens analysed under a microscope.

Major differences existed between the European studies’ measured outcomes and US standards of care, according to the researchers.

Typically, the non-operative approach involves a 10-day course of antibiotics, initially given intravenously in the hospital and followed at home by oral treatment. Among the 6 studies combined, the reported average length of hospital stay was approximately 3 days in both the surgically treated group and the antibiotics-first group.

“Three days in the hospital after a routine appendectomy is far longer than our practice in the United States,” said Dr. Ehlers. “Most patients here are discharged within 24 hours.”

Another difference in the United States is that the most common type of appendectomy is minimally invasive laparoscopy. Most of the European studies included in the review used open appendectomy, which usually requires a longer hospital stay and recovery and generally has more complications compared with laparoscopic appendectomy. Therefore, Dr. Ehlers said the difference in complication rates between appendectomy and antibiotics-first treatment (on average, 27% vs 9%) might not be as great if these 2 treatments were compared in the United States.

A final problem with all the studies is they did not track several patient-centred outcomes that Dr. Ehlers said would help patients with appendicitis decide which treatment to receive. These outcomes include quality of life, such as time needed away from work, pain severity and long-term symptoms, and fear of getting appendicitis again; the chances of regretting their decision; and whether out of pocket costs will be higher if they need appendectomy later compared with undergoing the operation right away.

Until future research answers these questions, Dr. Ehlers said it's likely some surgeons will offer patients with appendicitis the option of antibiotics-first therapy. This may only be a good idea if patients are aware of all the unknown elements and ideally this approach should only be part of a clinical trial or as part of a registry such as the Antibiotics-First Registry (available at http://www.becertain.org/appyregistry).

SOURCE: American College of Surgeons
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