Treatment Of Uncomplicated Acute Appendicitis Research Articles

A randomized double-blind noninferiority clinical multicenter trial on oral moxifloxacin versus placebo in the outpatient treatment of uncomplicated acute appendicitis: APPAC IV study protocol.

Antibiotic therapy is currently considered a safe and effective treatment alternative for computed tomography (CT)-confirmed uncomplicated acute appendicitis with recent studies reporting good results on both oral antibiotics only and outpatient management. Furthermore, there are promising pilot results on uncomplicated acute appendicitis management with symptomatic treatment (placebo). This trial aims to assess whether both antibiotics and hospitalization can be safely omitted from the treatment of uncomplicated acute appendicitis. The APPAC IV (APPendicitis Acuta IV) trial is a randomized, double-blind, multicenter noninferiority clinical trial comparing oral moxifloxacin with oral placebo in an outpatient setting with a discharge directly from the emergency room (ER). Adult patients (18-60 years) with CT-confirmed uncomplicated acute appendicitis (absence of appendicolith, abscess, perforation, tumor, appendiceal diameter ⩾15 mm on CT, or body temperature >38 °C) will be enrolled in nine Finnish hospitals. Primary outcome is treatment success at 30 days, that is, the resolution of acute appendicitis resulting in discharge from the hospital without appendectomy during the 30-day follow-up evaluated using a noninferiority design with a noninferiority margin of 6 percentage points. Noninferiority will be evaluated using one-sided 95% confidence interval of proportion difference between groups. Secondary endpoints include postintervention complications, recurrent appendicitis after the 30-day follow-up, duration of hospital stay, admission to hospital and reason for admission, readmissions to emergency department or hospitalization, VAS pain scores, quality of life, sick leave, and treatment costs. The follow-up after discharge from the ER includes a phone call at day 1, and at 3-4 days, 30 days, and 1, 3, 5, 10, and 20 years. Those eligible patients, who decline to undergo randomization, will be invited to participate in a concurrent observational cohort study with follow-up at 30 days, and 1 and 5 years. To our knowledge, APPAC IV trial is the first large randomized, double-blind, noninferiority multicenter clinical trial aiming to compare oral antibiotics and placebo for CT-diagnosed uncomplicated acute appendicitis in an outpatient setting. The study aims to bridge the major knowledge gap on whether antibiotics and hospitalization or both can be omitted in the treatment of uncomplicated acute appendicitis. The study protocol has been approved by the Clinical Trials Information System (CTIS) of the European Medicines Agency (EMA), study number: 2023-506213-21-00 and the trial has been registered in ClinicalTrials.gov, NCT06210269.

Endoscopic retrograde appendicitis therapy formanagement ofchronic fecalith appendicitis.

Chronic appendicitis is a condition with chronic abdominal pain or mild attacks of appendicitis, seriously affecting the patient's quality of life. Endoscopic retrograde appendicitis therapy (ERAT) has emerged as a promising, non-invasive treatment for acute uncomplicated appendicitis. Here, we aim to assess the safety and efficacy of ERAT for chronic fecalith appendicitis. We retrospectively reviewed the medical records of consecutive patients who underwent ERAT for chronic fecalith appendicitis at Zhongshan Hospital, Fudan University, Shanghai, China between December 2017 and June 2023. Clinicopathological characteristics, procedure-related parameters, AEs, and follow-up outcomes were analyzed. A total of 60 patients were included. ERAT intubation was successfully performed in all patients (100%). The median procedure time was 15min (IQR, 12-25min). The postoperative abdominal pain scores were significantly reduced (P < 0.0001). Short-term adverse events included 5 cases of abdominal pain (8.3%) and 2 cases of fever (3.3%). Long-term adverse events included recurrent abdominal pain in 3 cases (5.0%) and recurrent appendicitis in 2 cases (3.3%). The median time to recurrence was 5months (IQR, 2-12months). Logistic regression analysis revealed appendiceal stenosis (OR 25.000, 95% CI 1.114-561.281, P = 0.043) and distorted appendix lumen (OR 12.500, 95% CI 1.373-113.806, P = 0.025) as significant risk factors for long-term adverse events. ERAT may be a safe, effective and minimally invasive alternative approach for chronic fecalith appendicitis. Appendix lumen stenosis and distortion are risk factors of recurrence. Further large-scale prospective studies are necessary to assess the efficacy and safety of ERAT compared with antibiotic therapy and surgery.

Clinical significance of peri-appendiceal abscess and phlegmon in acute complicated appendicitis patients undergoing emergency appendectomy.

Although antibiotic therapy has become the primary treatment for acute uncomplicated appendicitis, the management of acute complicated appendicitis necessitates careful consideration of various treatment options. To analyze the clinical data of patients who underwent emergency appendectomy for acute complicated appendicitis with peri-appendiceal abscess or phlegmon, identify factors influencing the postoperative length of hospital stay (LOS), and improve treatment strategies. The clinical data of acute complicated appendicitis patients with peri-appendiceal abscess or phlegmon who underwent emergency appendectomy at The Department of Emergency Surgery, Zhongshan Hospital, Fudan University from January 2016 to March 2023 were retrospectively analyzed. A total of 234 patients were included in our study. The duration of symptoms and the presence of an appendicolith were significantly correlated with the occurrence of peri-appendiceal abscess in patients with acute complicated appendicitis (P < 0.001 and P = 0.015, respectively). Patients with symptoms lasting longer than 72 h had a significantly longer postoperative LOS compared to those with symptoms lasting 72 h or less [hazard ratio (HR), 1.208; 95%CI: 1.107-1.319; P < 0.001]. Additionally, patients with peri-appendiceal abscesses had a significantly longer postoperative LOS compared to those with phlegmon (HR, 1.217; 95%CI: 1.095-1.352; P < 0.001). The patients with peri-appendiceal abscesses were divided into two groups based on the median size of the abscess: Those with abscesses smaller than 5.0 cm (n = 69) and those with abscesses 5.0 cm or larger (n = 82). Patients with peri-appendiceal abscesses measuring 5.0 cm or larger had a significantly longer postoperative LOS than those with abscesses smaller than 5.0 cm (P = 0.038). The duration of symptoms and the presence of an appendicolith are significant risk factors for the formation of peri-appendiceal abscesses in patients with acute complicated appendicitis. Patients with peri-appendiceal abscesses experience a significantly longer postoperative LOS compared to those with peri-appendiceal phlegmon.

ACUTE APPENDICITIS, PANORAMIC REVIEW

Introduction: appendicitis is distinguished by inflammation of the vermiform appendix and usually shows acutely within the first 24 hours. Acute appendicitis is the main source of abdominal surgery in children and the most common abdominal surgical emergency around the globe. Objective: to detail the current information related to acute appendicitis, etiology, epidemiology, pathophysiology, histopathology, anamnesis, physical examination, evaluation, treatment and complications of the disease. Methodology: a total of 37 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 25 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: acute appendicitis, abdominal pain, appendix, abdominal surgery, acute abdominal treatment. Results: appendectomy by open laparotomy or laparoscopy is the standard treatment for acute appendicitis, however, intravenous antibiotics are exceptionally considered as first line therapy in individuals. The incidence of acute appendicitis varies from 100 to 223 new cases per 100,000 people per year. This disease can occur at any age, however it is most commonly seen in the age range of 5 to 45 years. The lifetime incidence of acute appendicitis is 8.6% in men and 6.7% in women. The risk of appendiceal rupture may vary with 2% of cases being frequently perforated 36 hours after the onset of symptoms. Conclusions: It is of vital importance to recognize the etiology, epidemiology, pathophysiology, clinical picture and tests that support the diagnostic decision in any case of acute abdomen, especially in cases of acute appendicitis, because an accurate diagnosis will lead us to a rapid intervention, adequate treatment, reducing the risk of mortality and the risk of potential complications in the affected individual. Diagnostic tests and scales play an important role in the diagnosis. The efficacy of antibiotics as primary treatment for uncomplicated acute appendicitis has been extensively investigated, with conflicting and mixed results and conclusions. Comparing the results between individuals who underwent laparoscopic appendectomy and those who underwent open appendectomy, the former group showed a lower incidence of wound infection, a lower level of postoperative analgesic requirement and shorter postoperative hospital stays in the former group, with the main disadvantage being the longer operative time. KEY WORDS: appendicitis, pain, appendix, surgery.

Direct visualization endoscopic retrograde appendicitis therapy for treatment of acute uncomplicated appendicitis.

To investigate the diagnostic and therapeutic value of direct visualization (single-use eyeMax subscope) endoscopic management of acute uncomplicated appendicitis. Thirty-six patients diagnosed with acute uncomplicated appendicitis, confirmed by computed tomography or ultrasonography, from Jan 2023 to Feb 2024 were enrolled in this study. We collected demographics, colonoscopy findings, subscope findings, clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT), and adverse events associated with ERAT. Appendiceal intubation was successful for all 36 patients. Thirty-five patients (97.2%) were definitely confirmed as having acute uncomplicated appendicitis. One patient with negative appendicitis was diagnosed as having cecal diverticulitis with fecalith incarceration. The mean procedure time was 13.1 ± 13.6 min. One patient presented with worsening abdominal pain, and a computed tomography scan suggested a perforated appendix. The mean length of hospitalizations was 1.78 ± 2 days. The mean follow-up was 158 days; during this period, two patients (5.6%) experienced recurrent abdominal pain after 23 and 88 days and subsequently underwent laparoscopic appendectomy. Direct visualization ERAT may be effective for diagnosing and treating acute uncomplicated appendicitis and seems to have a low complication rate.

Outcomes Following Surgical and Nonsurgical Treatment for Uncomplicated Appendicitis in Older Adults

The optimal treatment of acute uncomplicated appendicitis in older adults with frailty is not defined. To examine outcomes associated with treatment strategies for acute uncomplicated appendicitis in older adults with or without frailty. This retrospective cohort study used National Inpatient Sample data from adults 65 years or older with a diagnosis of uncomplicated appendicitis from January 1, 2016, to December 31, 2018. Data were analyzed from July to November 2023. The National Inpatient Sample database approximates a 20% stratified sample of all inpatient hospital discharges in the US. Study patients were categorized into 3 groups: nonoperative management, immediate operation, and delayed operation. Clinical outcomes, including hospital complications and in-hospital mortality, were assessed among older adults with and without frailty, identified using an adapted claims-based frailty index. A total of 24 320 patients were identified (median [IQR] age, 72 [68-79] years; 50.9% female). Of those, 7290 (30.0%) were categorized as having frailty. Overall, in-hospital mortality was 1.4%, and the incidence of complications was 37.3%. In patients with frailty, multivariable analysis showed both nonoperative management (odds ratio [OR], 2.89; 95% CI, 1.40-5.98; P < .001) and delayed appendectomy (OR, 3.80; 95% CI, 1.72-8.43; P < .001) were associated with increased in-hospital mortality compared with immediate appendectomy. In patients without frailty, immediate appendectomy was associated with increased hospital complications compared with nonoperative management (OR, 0.77; 95% CI, 0.64-0.94; P = .009) and lower hospital complications compared with delayed appendectomy (OR, 2.05; 95% CI, 1.41-3.00; P < .001). In this cohort study of older adults with uncomplicated appendicitis, outcomes differed among management strategies based on frailty status. Routine frailty assessments incorporated in the care of older adult patients may help guide discussions for shared decision-making.

Surgical and Pre-surgical Factors Affecting Appendectomy Outcomes in Jeddah, Saudi Arabia: A Retrospective Record Review.

Appendectomy is the preferred treatment for acute uncomplicated appendicitis and the most common emergency abdominal surgery. While previous studies have investigated variables affecting post-appendectomy complications, local research is limited, and data on complication rates are scarce. Therefore, this study aimed to investigate appendectomy outcomes and the factors influencing them. This retrospective record review included all patients who underwent appendectomies at our center between 2013 and 2023, excluding those who underwent appendectomies as part of other procedures. Data were retrieved from the hospital database and recorded on predesigned Google Forms. A total of 556 patients were included. Complications occurred in 60 patients (10.8%); the most common included intra-abdominal collections (n=19, 3.4%), postoperative fever (n=13, 2.3%), and surgical site infections (n=11, 2.0%). The most frequently documented histopathological diagnoses included acute appendicitis (n=402, 72.3%), perforated appendicitis (n=109, 19.6%), and gangrenous appendicitis (n=19, 4.4%). Surgical site infection rates were higher after open appendectomies (6.0% vs. 0.9%, P=0.006), while intra-abdominal collections were more frequent after laparoscopic appendectomies (4.1% vs. 0.0%, P=0.095). Additionally, histopathology results showing complicated or chronic appendicitis were associated with higher complication rates (P<0.001, odds ratio=3.793, 95% confidence interval=1.957-7.350). To the best of our knowledge, this is the largest retrospective review of appendectomy cases in Saudi Arabia. However, this study was conducted in a tertiary care center, which may have caused the rates of complications to appear lower than those in primary centers. We recommend a multi-center study be conducted to establish more accurate results.

THE EFFICACY OF ANTIBIOTICS IN ACUTE APPENDICITIS TREATMENT : A COMPREHENSIVE SYSTEMATIC REVIEW

Background: Acute appendicitis has been the most common cause of lower abdominal pain leading to emergency visits worldwide. To avoid major complications, appendectomy has remained the standard treatment for uncomplicated acute appendicitis for over a century. The aim: The aim of this study to show about the efficacy of antibiotics in acute appendicitis treatment. Methods: By the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. This search approach, publications that came out between 2014 and 2024 were taken into account. Several different online reference sources, like Pubmed, SagePub, and Sciencedirect were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: Five publications were found to be directly related to our ongoing systematic examination after a rigorous three-level screening approach. Subsequently, a comprehensive analysis of the complete text was conducted, and additional scrutiny was given to these articles. Conclusion: The therapeutic effects of antibiotics and appendicectomy were comparable for the treatment of acute appendicitis.

Interval Appendectomy After Successful Antibiotic Treatment?

This Viewpoint discusses the pros and cons of performing interval appendectomy in patients who have recovered from successful antibiotic treatment of acute uncomplicated appendicitis.

Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis

Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking. To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up. This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298). Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days. The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design. After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave. This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis. ClinicalTrials.gov Identifier: NCT03236961.

Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study

BackgroundTo decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections. MethodsThe aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention. ResultsA total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups. ConclusionOur quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.

Conservative Versus Surgical Management of Acute Appendicitis: A Systematic Review.

Recent studies have discussed the role of antibiotic treatment in the conservative management of acute appendicitis and whether antibiotics are a safe option to replace appendicectomy, which has been the gold standard treatment of acute appendicitis for many years. The bibliographic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, Medline, and PubMed comparing conservative versus surgical treatment of acute appendicitis were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-one studies consisting of systematic reviews and meta-analyses involving 44,699 participants were identified. At least 17,865 participants were treated with antibiotics. Our studies compare antibiotic versus appendicectomy among acute appendicitis patients ranging from 7 to 94 years of age. In most studies, patients received parenteral antibiotics for a total of one to three days, and oral antibiotics such as oral cephalosporin plus metronidazole, oral amoxicillin/clavulanate, oral fluoroquinolones plus Tinidazole upon hospital discharge for a total of 7 to 10 days. The total course of antibiotics for both parenteral and oral regimes ranged from 2 to 16 days, with 10 days being the commonest duration. The recurrence rate following initial antibiotic treatment at one-year follow-up ranged from 13% to 38%, while the mean duration of recurrence ranged from three to eight months. The majority of the patients with recurrence underwent appendicectomy, while some patients were either given a repeat or different course of antibiotics due to the possible presence of antibiotic resistance; however, only 2.4% of the patients were successfully treated upon completion of the second course of antibiotics. Most of the studies concluded that appendicectomy remains the gold standard treatment for uncomplicated acute appendicitis, given its higher efficacy and lower complication rates. Although antibiotic treatment cannot be routinely recommended, it can be considered an appropriate alternative in selected patients with uncomplicated appendicitis who wish to avoid surgery and also acknowledge the risk of recurrence and the potential need for subsequent surgery at the same time.

Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis.

Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis. We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management. We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis scorewere found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis. From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.

Frequency of Appendectomy in Children after Conservative Treatment of Uncomplicated Acute Appendicitis

Background: Acute appendicitis, frequently seen in children, involves an inflamed appendix. Conventionally, surgical removal (appendectomy) has been the go-to treatment. Recently, interest in a conservative approach, utilizing antibiotics and close monitoring, has grown, particularly for uncomplicated cases. This shift aims to reduce surgical intervention, reflecting a changing understanding of the condition. Aim of the study: The aim of the study was to assess the frequency of appendectomy in children after conservative treatment of uncomplicated acute appendicitis. Methods: This prospective observational study spanned from July 2017 to March 2019, conducted at the Department of Paediatric Surgery, Dhaka Medical College Hospital, Bangladesh. It involved 62 children admitted for uncomplicated acute appendicitis. Data collection employed purposive sampling, and MS Office tools were used for data analysis. Results: In this study, the mean age of the total participants was 8.95±2.10 years within a range from 4 years to 12 years. The male-female ratio was 1.6:1. The frequency of appendectomy among the total participants was 4.9% (n=3). After taking conservative treatment, 95.1% (n=59) of patients were successfully discharged. Within six months, 13.0% (n=8) experienced recurrence, and the average hospital stay was 5.26±0.63 days. Conclusion: The frequency of appendectomy in children after conservative treatment of uncomplicated acute appendicitis. So, by using conservative treatment physicians can save a huge number of paediatric patients from the hassles and sufferings of surgery for uncomplicated acute appendicitis.

Outcomes of Conservative Treatment of Uncomplicated Acute Appendicitis in Children

Background: Pediatric healthcare is evolving, with acute appendicitis being a common issue. Traditionally, appendectomy has been the standard treatment. However, recent literature suggests that conservative antibiotic treatment could be a viable option, particularly for uncomplicated cases in children. Aim of the study: The aim of the study was to evaluate the outcomes of conservative treatment for uncomplicated acute appendicitis in children. Methods: From July 2017 to March 2019, a prospective observational study was conducted at Dhaka Medical College Hospital, Bangladesh, involving 62 children with uncomplicated acute appendicitis. They received conservative treatment, including supportive care, for five days. Patients who responded positively within 24 hours continued for at least five days before discharge and underwent a 6-month follow-up. Results: The study encompassed 62 patients, with a mean age of 8.95 years, and a slight male predominance (61.3% male, 38.7% female). Clinical findings revealed a notable decrease in pain intensity (9.42 to 0.77), temperature (101.02º to 98.90º), and inflammatory markers (CRP: 28.13 ± 11.56 mg/L to 9.78 ± 7.50 mg/L) from admission to day 5. The mean duration of hospital stay was 5.26 ± 0.63 days. Remarkably, 95.1% of patients successfully recovered with conservative treatment, while 4.9% required surgery as part of their treatment course. Conclusion: This study found some potential benefits of conservative treatment for uncomplicated acute appendicitis in children. Significant improvements in clinical parameters and a high success rate emphasize its potential as a viable alternative to surgery in select cases, warranting further exploration in pediatric healthcare practices.

Laparoscopic Appendectomy Combined with an "Antimicrobial-Free" Strategy for Acute Uncomplicated Appendicitis.

Objective: To explore the efficacy and safety of enhanced recovery protocol (ERP) combined with laparoscopic appendectomy (LA) in the treatment of acute uncomplicated appendicitis (AUA) without antibiotics. Methods: In this study, a total of 160 patients with AUA who underwent LA between January 2018 and December 2021 were included and divided into the antibiotic group (n = 80) or the no-antibiotic group (n = 80). The patients in the antibiotic group received the ERP combined with antimicrobials during the perioperative period, while those in the no-antibiotic group only received the ERP during the perioperative period. The clinical data of these patients were collected to compare the inflammation level and stress state before and after surgery. In addition, the incidence of postoperative complications and the recovery speed of the patients were compared between groups. Results: There were no significant differences in the inflammation level and stress state before or after surgery, the incidence of postoperative complications or the recovery speed between the antibiotic group and the no-antibiotic group (P > .05). Conclusion: The use of ERP combined with LA as an antimicrobial-free treatment scheme in the perioperative period was found to be safe and effective for patients with AUA. Therefore, this approach is clinically valuable.

Risk of appendiceal malignancy in conservatively treated acute appendicitis.

Appendectomy has historically been the standard treatment of acute appendicitis, but lately, conservative treatment of uncomplicated acute appendicitis with antibiotics has successfully been used in selected patients. Complicated acute appendicitis is often treated conservatively initially, but may benefit from interval appendectomy due to the higher risk of appendiceal malignancy and recurrence. Recommendations for follow-up after conservatively treated appendicitis vary. Furthermore, the risk of underlying malignancy and the necessity of routine interval appendectomy are unclear. This study aims to evaluate follow-up status, recurrence, and underlying appendiceal malignancy in conservatively treated uncomplicated and complicated acute appendicitis. This study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and data on follow-up, recurrence, number of appendectomies after initial conservative treatment, and underlying malignancy were retrieved from medical charts. The study cohort included 391 patients, 152 with uncomplicated and 239 with complicated acute appendicitis. Median time of study follow-up was 52 months. The recurrence risk was 23 (15.1%) after uncomplicated and 58 (24.3%) after complicated acute appendicitis (p = 0.030). During follow-up, 55 (23%) patients with complicated acute appendicitis underwent appendectomy. Appendiceal malignancies were found in 12 (5%) patients with previous complicated acute appendicitis versus no appendiceal malignancies after uncomplicated acute appendicitis (p = 0.002). The risk of appendiceal malignancy and recurrent appendicitis was significantly higher in patients with complicated acute appendicitis compared with uncomplicated acute appendicitis.

Comparison of the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis: a systematic review and meta-analysis

ObjectiveThis meta-analysis aimed to compare the efficacy and safety of antibiotic treatment and appendectomy for acute uncomplicated appendicitis.MethodsWe searched the randomized controlled studies (RCTs) comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis in the electronic database including Pubmed, Embase, Cochrane, Web of Science, CNKI, VIP, and WanFang. The primary outcomes included complication-free treatment success at 1 year, complications, surgical complications, and the complicated appendicitis rates. Secondary outcomes included negative appendicitis, length of hospital stay, the quality of life at 1 month, and the impact of an appendicolith on antibiotic therapy.ResultsTwelve randomized controlled studies were included. Compared with surgery group, the antibiotic group decreased the complication-free treatment success at 1 year (RR 0.81; 95% CI 0.73–0.91; z = 3.65; p = 0.000). Statistically significance was existed between antibiotic group and surgical group with both surgical types(open and laparoscopic) (RR 0.43; 95% CI 0.31–0.58; z = 5.36; p = 0.000), while no between the antibiotic treatment and laparoscopic surgery (RR 0.72; 95% CI 0.41–1.24; z = 1.19; p = 0.236). There was no statistically significant differences between two groups of surgical complications (RR 1.38; 95% CI 0.70–2.73; z = 0.93; p = 0.353), the complicated appendicitis rate (RR 0.71; 95% CI 0.36–1.42; z = 0.96; p = 0.338), negative appendectomy rate (RR 1.11; 95% CI 0.69–1.79; z = 0.43; p = 0.670), duration of hospital stay (SMD 0.08; 95%CI -0.11-0.27; z = 0.80; p = 0.422), and quality of life at 1 month (SMD 0.09; 95%CI -0.03-0.20; z = 1.53; p = 0.127). However, in the antibiotic treatment group, appendicolith rates were statistically higher in those whose symptoms did not improve (RR 2.94; 95% CI 1.28–6.74; z = 2.55; p = 0.011).ConclusionsAlthough the cure rate of antibiotics is lower than surgery, antibiotic treatment is still a reasonable option for patients with uncomplicated acute appendicitis who do not want surgery without having to worry about complications or complicating the original illness.

Invited Commentary: Low-Impact Laparoscopy Could Become the New Standard for Treatment of Uncomplicated Acute Appendicitis.

Invited Commentary: Low-Impact Laparoscopy Could Become the New Standard for Treatment of Uncomplicated Acute Appendicitis.

Assessing micro- vs macro-costing approaches for treating appendicitis in children with appendicectomy or non-operatively

ObjectivesWe conducted a health economic sub-study within a feasibility RCT comparing a non-operative treatment pathway as an alternative to appendicectomy for the treatment of uncomplicated acute appendicitis in children. The objectives were to understand and assess data collection tools and methods and to determine indicative costs and benefits assessing the feasibility of conducting a full economic evaluation within the definitive trial.MethodsWe compared different methods of estimating treatment costs including micro-costing, hospital administrative data (PLICS) and health system (NHS) reference costs. We compared two different HRQoL instruments (CHU-9D and EQ-5D-5L) in terms of data completeness and sensitivity to change over time, including potential ceiling effects. We also explored how the timing of data collection and duration of the analysis could affect QALYs (Quality Adjusted Life Years) and the results of the cost-utility analysis (CUA) within the future RCT.ResultsUsing a micro-costing approach, the total per treatment costs were in alignment with hospital administrative data (PLICS). Average health system reference cost data (macro-costing using NHS costs) could potentially underestimate these treatment costs, particularly for non-operative treatment. Costs incurred following hospital discharge in the primary care setting were minimal, and limited family borne costs were reported by parents/carers. While both HRQoL instruments performed relatively well, our results highlight the problem of ceiling effect and the importance of the timing of data collection and the duration of the analysis in any future assessment using QALYs and CUA.ConclusionsWe highlighted the importance of obtaining accurate individual-patient cost data when conducting economic evaluations. Our results suggest that timing of data collection and duration of the assessment are important considerations when evaluating cost-effectiveness and reporting cost per QALY.Clinical trial registrationCurrent Controlled Trials ISRCTN15830435.