FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Despite a growing movement toward the antibiotics-first approach instead of surgical intervention for uncomplicated appendicitis, a new review of existing literature shows that the jury is still out on how to advise patients about their choices, according to Dr. Anne P. Ehlers and her colleagues who undertook the study.
The findings show that surgical intervention should continue to be considered a viable option and that appendectomy is not necessarily any better or worse in terms of long-term complication rates and length of hospital stay ( J Am Coll Surg. 2015. doi:10.1016/j.jamcollsurg.2015.11.009 ).
“What we found is that treatment of acute, uncomplicated appendicitis with antibiotics first is probably a safe approach, but that there are many questions that need to be answered before we can fully inform our patients about the long-term outcomes of this treatment strategy,” Dr. Ehlers of the department of surgery at the University of Washington, Seattle, said in an interview.
Dr. Ehlers and her coinvestigators combed the PubMed and EMBASE databases for all English-language randomized controlled trials involving comparisons of antibiotic and appendectomy-based treatments for acute appendicitis. Studies were excluded if they lacked adult population investigation.
“Our study is a critical review of the literature [available] on this topic to understand the current state of evidence,” explained Dr. Ehlers, adding that the study’s main goal was to answer the most common questions she and her coauthors encountered when talking to physicians and patients about the benefits and risks of antibiotics-first over appendectomy; namely, “Is my appendicitis going to come back?” “Am I going to have a lot of extra trips to the hospital?” and “What’s my quality of life going to be?”
Ultimately, six trials, comprising 1,720 patients, were selected for inclusion. These studies were led by Dr. S. Eriksson (40 subjects), Dr. J. Styrud (252 subjects), Dr. A.N. Turhan (290 subjects), Dr. J. Hansson (369 subjects), Dr. C. Vons (239 subjects), and Dr. P. Salminen (530 subjects). The Styrud study did not enroll any women, and no study enrolled subjects older than 75 years of age, but the average age of each study’s patients ranged from 26 to 38 years.
Length-of-stay comparisons between appendectomy and antibiotics-first cohorts varied among the studies, but most showed the same or longer LOS for antibiotics-first subjects. Mean LOS was 3.3 for surgical patients vs. 3.1 for antibiotics (Eriksson), 2.6 surgical vs. 3.0 antibiotics (Styrud), 2.4 surgical vs. 3.14 antibiotics (Turhan), 3.0 for both (Hansson), 3.04 surgical vs. 3.96 antibiotics (Vons), and 3.0 for both (Salminen).
Rates of appendectomy among patients treated with an antibiotics-first approach varied as well, with a 35% rate in the Eriksson study (7 out of the 20 subjects treated with antibiotics-first) and a 24% rate in the Styrud and Turhan studies. The Hansson trial reported an unusually high crossover between cohorts of 60%, the investigators noted.
Two studies – those led by Turhan and Vons – noted higher rates of complications in antibiotics-first patients versus those who received surgical intervention: 4.7% vs. 4.4%, and 2.5% vs. less than 1%, respectively. All other studies had high rates of complications in the surgical cohorts, with the Eriksson study reporting no complications whatsoever among antibiotics-first subjects.
These findings, Dr. Ehlers stressed, are just a first step. This review’s relatively low sample size and limiting factors require that further studies be done to more firmly ascertain which option for appendicitis treatment is the most beneficial. To that end, Dr. Ehlers said that she and her coinvestigators are working on that next step.
“Our group is currently working on a study called the CODA [Comparing Outcomes of Drugs in Appendectomy] Study,” she said, with the goal of answering “questions about long-term patient-centered outcomes related to the antibiotics-first approach.” These questions include patients’ quality of life, whether patients have decisional regret about choosing one treatment strategy over another, if they develop long-term anxiety any time they experience even a small abdominal pain, how much time they miss from school or work by choosing one treatment option over another, and so on.
The goal of this study is that physicians “will be able to give [patients] a more informed view of what each treatment entails,” she said. Funded by the Patient-Centered Outcomes Research Institute , the study has no firm date of publication.
Dr. Ehlers disclosed receiving support via a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. No other conflicts of interest were reported.