Antibiotic treatment for acute appendicitis: uncertain potential benefits

See Article on Page 192-197 Acute appendicitis is the most common indication for surgery in patients admitted to hospital due to an acute abdomen. Although most are uncomplicated, about 20% of all acute appendicitis cases are complicated, leading to local or diffuse peritonitis. An urgent appendectomy is the recommended treatment for both complicated and uncomplicated appendicitis. The appendectomy, which has been the first choice for the treatment of acute appendicitis for over 120 years, is a classic surgical procedure [1]. Nowadays, a laparoscopic appendectomy is widely practiced for its benefits, such as significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay [2]. Although an appendectomy is generally well tolerated, it is still considered a major surgical intervention and can be associated with postoperative morbidity in about 2%-23% of patients [3]. According to a study that followed patients for over a decade, 3% of the patients undergoing appendectomy were readmitted for intestinal obstruction related to postoperative adhesion [4,5]. Therefore, physicians are taking higher interest in noninvasive interventions, such as antibiotic therapy, as a primary treatment. Although the appendectomy remains the standard approach for treating appendicitis [6], several studies have already suggested that appendicitis can be treated with antibiotics [5]. Two well-studied appendicitis scoring systems based on clinical symptoms were used to diagnose appendicitis: the Alfredo Alvarado system for adults and the Madan Samuel system for children. The Alvarado score was developed in Philadelphia in the mid-1980s and has a sensitivity of 81% and a specificity of 74% [7]. The Pediatric Appendicitis Score was developed to diagnose appendicitis in children and has a high sensitivity of 100% and specificity of 92% [8]. Although these scoring systems were widely used to diagnose appendicitis in the past, they are no longer practically implicated. Recently, various diagnostic tools, such as computed tomography (CT) and ultrasound, have been developed to diagnose appendicitis. With the improvement of such radiologic tools, determining the severity of and diagnosing appendicitis have become more accurate. The development of radiologic tools has provided many advantages for diagnosing appendicitis and determining its severity. The increased use of CT has reduced the rate of negative (unnecessary) appendectomies [9]. A meta-analysis consisting of data from 31 studies revealed that both the sensitivity and the specificity of CT for appendicitis were as high as 94% [10]. The development of a precise scoring system based on CT to distinguish between complicated and uncomplicated appendicitis has led to an improvement in diagnostic accuracy [11]. This system provides the physician with the evidence needed to decide on a treatment strategy for appendicitis patients. A meta-analysis [12] of randomized controlled trials comparing antibiotics with appendectomies has shown that although antibiotic treatment alone can be successful in 77%-95% of the cases, patients should be made aware of the fact that the failure rate during the first year, with a need for readmission or surgery, is around 25%-30%. However, recently conducted research proposed the use of antibiotics as the single treatment for uncomplicated appendicitis. However, one should note that more accurate selection criteria, based on combinations of clinical risk scores and imaging, are required for patients or subgroups of patients in whom primary antibiotic treatment is more likely to succeed in the long-term, and CT could be of assistance in the process of selecting patients suitable for antibiotics therapy. Although the appendectomy is the best treatment for the appendicitis, studies on the use of antibiotics therapy to treat patients with uncomplicated appendicitis are still meaningful; thus, efforts for such research should be supported.

Demographic changes associated with the aging population mean that surgeons increasingly have contact and make decisions about treating patients from the oldest age groups. The aim of the study was to review the literature concerning the treatment of acute appendicitis in patients over the age of 60 years old. A review of the literature published in the years 2000-2015 has been carried out using the PubMed database. The initial number of results corresponding to the query in English, "appendicitis (MeSH) AND elderly (MeSH)" was 260. Selection based on the titles, abstracts, and eventually whole articles, ultimately resulted in 11 papers concerning the treatment of appendicitis in patients above 60 years of age. Nine papers were retrospective and 2 were prospective. In total, the studies included 82,852 patients. Laparoscopic appendectomy was associated with a lower mortality rate, a smaller number of postoperative complications and a shorter length of hospital stay, which led to it being recommended by most authors. Four of the ten papers demonstrated that the patients who were qualified for laparoscopic surgery had less comorbidity and were in a lower ASA (American Society of Anaesthesiology) category. Antibiotic therapy as an independent method was assessed in one study in a group of elderly people, on a selected group of 26 patients, and its effectiveness was shown to be 70%. Most studies, however, are highly heterogeneous which significantly hindered comparisons. Currently, laparoscopic appendectomy seems to be the treatment of choice in the elderly with acute appendicitis. Antibiotic therapy, as an independent method of treatment of acute appendicitis, cannot currently be recommended. However, further, prospective, and better-designed studies are needed, involving a larger number of patients, and primarily dedicated to the elderly.

Appendicitis

<p dir="ltr">Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.</p><p dir="ltr">Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.</p><p dir="ltr">Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.</p><p dir="ltr">Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.</p><p dir="ltr">Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged <18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.</p><p dir="ltr">Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.</p><p dir="ltr">In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.</p><p dir="ltr">In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value <0.0001.</p><p dir="ltr">Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Patkova B</b>, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. <a href="https://doi.org/10.1097/SLA.0000000000003646">https://doi.org/10.1097/SLA.0000000000003646</a></p><p dir="ltr">II. <b>Pátková B,</b> Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. <a href="https://doi.org/10.1001/jamasurg.2023.2756">https://doi.org/10.1001/jamasurg.2023.2756</a></p><p dir="ltr">III. <b>Patková B</b>, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]</p>

<p dir="ltr">Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.</p><p dir="ltr">Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.</p><p dir="ltr">Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.</p><p dir="ltr">Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.</p><p dir="ltr">Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged <18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.</p><p dir="ltr">Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.</p><p dir="ltr">In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.</p><p dir="ltr">In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value <0.0001.</p><p dir="ltr">Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Patkova B</b>, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. <a href="https://doi.org/10.1097/SLA.0000000000003646">https://doi.org/10.1097/SLA.0000000000003646</a></p><p dir="ltr">II. <b>Pátková B,</b> Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. <a href="https://doi.org/10.1001/jamasurg.2023.2756">https://doi.org/10.1001/jamasurg.2023.2756</a></p><p dir="ltr">III. <b>Patková B</b>, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]</p>

Acute appendicitis is a common surgical emergency. It is commonly caused by obstruction of the appendiceal lumen due to fecaliths, tumors, or lymphoid hyperplasia. For over a century, appendectomy has been the primary treatment for acute appendicitis. Abraham Groves performed the first open appendectomy in 1883. In 1983, Kurt Semm completed the first laparoscopic appendectomy, heralding a new era in appendectomy. However, appendectomy is associated with certain complications and a rate of negative appendectomies. Studies have suggested controversy over the impact of appendectomy on the development of inflammatory bowel disease and Parkinson's disease, but an increasing number of studies indicate a possible positive correlation between appendectomy and colorectal cancer, gallstones, and cardiovascular disease. With the recognition that the appendix is not a vestigial organ and the advancement of endoscopic te-chnology, Liu proposed the endoscopic retrograde appendicitis therapy. It is an effective minimally invasive alternative for treating uncomplicated acute appendicitis. Our team has developed an appendoscope with a disposable digital imaging system operated through the biopsy channel of a colonoscope and successfully applied it in the treatment of appendicitis. This article provides an overview of the progress in endoscopic treatment for acute appendicitis and offers a new perspective on the future direction of appendiceal disease treatment.

BackgroundCurrently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial.Methods/designThe study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4–15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery.DiscussionIn this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design.Trial registrationISRCTN15830435. Registered on 8 February 2017.

Acute appendicitis (AA) is cited as the leading cause of surgical acute abdomen in pediatrics and the most frequent urgent surgical pathology worldwide. For a long time, surgical appendectomy has been effectively used as the first-line treatment for AA. Other conservative management practices, such as the use of antibiotics, have been applied in the treatment of appendicitis. COVID-19 has had a significant impact on the surgical treatment strategies of AA in pediatrics, with many pediatric surgeons having to shift from upfront surgical appendectomy to conservative management involving the use of antibiotics as a treatment strategy. This meta-analysis compares the outcomes between appendectomy and conservative therapy in the management of AA during COVID-19 in pediatrics. Twenty-one articles fully met the inclusion criteria. Articles that were published more than five years ago were excluded from the analysis. Also, articles that included studies on the adult population were excluded. Results from various retrospective studies, prospective clinical controlled trials, correlational studies, and randomized clinical trials were analyzed. This study reveals that the use of antibiotics has been demonstrated to be safe and effective in the treatment of uncomplicated appendicitis. However, antibiotics have been shown to have some complications. Despite this being the case, the studies identified the potential of using antibiotics as a definitive treatment of uncomplicated AA in pediatrics. Further studies are required to evaluate the cost-effectiveness and recurrence of AA of this alternative treatment method.

Background:Interval appendectomy after acute appendicitis with lump formation (phlegmon) remains controversial. We conducted this study to determine the risk of recurrent appendicitis following initial non-operative treatment for appendicitis, and evaluate factors associated with recurrence. Secondarily, we evaluate the efficacy of interval appendectomy versus no appendectomy.Materials and Methods:Patients who received conservative treatment for appendicitis with lump formation were prospectively studied from June 2006 to June 2008. These patients were followed for recurrence of appendicitis.Results:Of 763 patients with acute appendicitis some 220 patients had lump formation (28.8%). Median age was 28 years. Conservative treatment was successful in 213 (96.8%) patients. The rate of recurrence was 13.1%, all occurring within six months after the index admission. Mean follow-up was 26±18 months.Conclusion:Conservative treatment of appendicitis with lump formation is efficient and the recurrence rate is low. Routine interval appendectomy after initial conservative treatment for lump formation is not a cost-effective intervention and not recommended.

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

The correct surgical approach in the treatment of acute appendicitis continues to be a source of debate and a ground for comparative studies, as physicians and surgeons seek to define the optimal management of this common and ‘‘simple’’ illness. Surely the place of laparoscopy in the treatment of appendicitis is still controversial, despite a major trend in this direction. Because this disease is so prevalent, it is possible to examine different subgroups separately, and this is what was done by Kirshtein et al. [1] in their report of elderly patients, 60 years old and older. Then, the question is twofold: Does the laparoscopic treatment of acute appendicitis differ between the young and the old? And how does the laparoscopic treatment in the elderly compare with the open approach? The authors address the first question, which has mainly academic interest because of the inherent differences between the young and the old. Discussion can only indirectly suggest whether laparoscopic appendectomy is justified in the older age group. The second question is more interesting clinically, and should be addressed separately, ideally in a prospective way, unlike this study. How does one decide whether the laparoscopic approach for a certain procedure is acceptable or even preferable? The potential for a laparoscopic procedure to be advantageous starts with the ratio between the access size and the magnitude of the task. If a large incision is required to remove a small and a simple organ (like the gallbladder), the advantages of minimizing abdominal wall trauma and the peritoneal exposure are obvious. If the incision is a relatively small part of a complicated task with many potential postoperative problems (like pancreaticoduodenectomy), then laparoscopy is much less appealing: Because it is time consuming and technically difficult, and it may lead to additional complications, the patient is less likely to benefit from the smaller access. At present, the role of laparoscopy remains to be established in smaller procedures (small incision/simple task), as the potential advantage of laparoscopy is less prominent, but may still exist. Appendectomy certainly belongs in this group of procedures. Evaluation may require larger series and optimal methodology to prove a small benefit—or perhaps disprove it or even demonstrate inferiority of the approach. Some early studies, for example, have claimed to find more pelvic abscesses in patients undergoing laparoscopic appendectomy, although many other studies have failed to support this claim. Furthermore, within the diverse group of patients with appendicitis, certain subgroups may differ in regard to the preferred surgical approach, because of different factors, such as stage of inflammation at presentation, or age. The present study, by Kirshtein et al., adds some information to our understanding of this question. Despite its admitted limitations, like incomparability of the groups (more complicated cases in the older age group, leading to more conversions), the two groups still had a similar rate of postoperative complications. Although this suggests that laparoscopic appendectomy in the elderly is acceptable, there is no way to infer from this kind of study whether an open approach would have been different in these patients—a direct comparison is mandatory. Should we offer laparoscopic appendectomy to our patients? Should a patient’s age have any influence on our decision? These questions cannot be answered from this study. It is probably okay; no major harm is done, but we D. Rosin (&) General Surgery & Transplantation, Sheba Medical Center, Tel Aviv University, Tel Hashomer 52621, Israel e-mail: drosin@mac.com

Acute appendicitis is one of the most common emergency abdominal disease, and recent studies have evaluated conservative treatment using antibiotics for uncomplicated appendicitis. Although the efficacy of conservative treatment for uncomplicated appendicitis is known, its efficacy for complicated appendicitis remains unknown, so are risk factors for the conservative treatment of appendicitis. In our institution, conservative treatment has long been the first choice for most appendicitis cases, except for perforation. Therefore, this novel study investigated the outcomes of conservative treatment for uncomplicated and complicated acute appendicitis and the risk factors associated with conservative treatment. To investigate the indication of conservative treatment by antibiotics for uncomplicated and complicated acute appendicitis. We investigated 270 patients who received conservative treatment for acute appendicitis at the Nishitokyo Central General Hospital, between April 2011 and February 2022. Twenty-eight (10.3%) patients were resistant to conservative treatment and underwent surgery. We retrospectively investigated the outcomes of conservative treatment for appendicitis and the risk factors for resistance to conservative treatment using the receiver operating characteristic curves and Cox hazard model. Two hundred and forty-two (89.7%) patients improved with conservative treatment. The significant and independent predictors of resistance to conservative treatment were body temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid visible on computed tomography (CT). The rate of resistance to conservative treatment was 66.7% (6/9) for patients with the above three factors, 22.9% (8/35) for patients with two factors (appendicolith and body temperature ≥ 37.3 °C), 16.7% (2/12) for patients with two factors (Douglas sinus fluid and appendicolith) and 11.1% (1/9) for patients with two factors (Douglas sinus fluid and body temperature ≥ 37.3 °C). A temperature ≥ 37.3 °C, appendicolith and Douglas sinus fluid on CT might be clinical risk factors of resistance to conservative treatment for acute appendicitis.

Over the last 10–15 years, the management of appendicitis in childhood has changed with regard to diagnosis and therapy. From the first report of conventional appendectomy in 1894 for decades, appendectomy through an incision as described by McBurney [1] has been the gold standard in surgical treatment of (suspected) acute appendicitis. The implementation of ultrasound, scoring systems to support the surgical indication, and minimal invasive techniques for surgery since the 1980s which nowadays range from conventional laparoscopy to single-site surgery have had major impact in the treatment of appendicitis. The aim is to propose practical clinical guidelines for the current gold standard of laparoscopic appendectomy.

To the Editor,We have read the article that is published by Kirkil et al. (1) with a great deal and interest. They have brought up nonoperative treatment of uncomplicated appendicitis versus appendectomy. Although nonsurgical treatment of acute appendicitis is an unsatisfied method for sur-geons we have analyzed the article particularly. We want to emphasize some subjects that must be explained.Appendicitis is one of the most common surgical dis-eases. The lifetime risk of the acute appendicitis is re-ported nearly 7% (2). Although nonoperative treatment of acute appendicitis looks like alternative to surgery it is not recognized by majority of surgeons. Nowadays laparoscopic appendectomy even single vs. multiple port is investigated.Apurva et al. reported the rate of diagnosis of appen-diceal adenocarcinoma who had previous diagnose as 3.1%. Although authors performed colonoscopy in suspected patients that must be in mind the success of colonoscopy with appendiceal malignancy is low. Also the criteria to perform colonoscopy are not well de-fined. As authors underlined; there is not enough data and study about this. In our opinion there must be cost analyze of operative versus nonoperative treatment of noncomplicated ap-pendicitis to support nonoperative treatment as an ef-fective method. Preoperative diagnosis, medical treat-ment, hospital charges during follow up period and in case of need unavoidable surgery compose the cumu-lative cost of nonoperative treatment of noncompli-cated appendicitis (3). Early noncomplicated acute ap-pendicitis has lower cost according to the complicated appendicitis. Effective surgery could prevent increase of hospital cost (4). However Kirkil et al. indicated that nonoperative treat-ment of noncomplicated acute appendicitis is an effec-tive treatment method we believe that a diagnostic al-gorithm must be used during diagnosis and treatment of acute appendicitis.

Use of antibiotics alone for treatment of uncomplicated acute appendicitis: A systematic review and meta-analysis