Uncomplicated Acute Appendicitis Research Articles

Use of the Alvarado Score in Elderly Patients with Complicated and Uncomplicated Appendicitis

The purpose of this study was to determine whether the Alvarado score is beneficial in identifying complicated versus uncomplicated acute appendicitis in elderly patients. A retrospective review was conducted of patients aged 65 years and older who underwent an appendectomy for pathologically confirmed appendicitis. A review of 310 operative reports and patient charts from October 2012 to December 2016 yielded 216 patients. Patients were grouped based on complicated versus uncomplicated appendicitis. One hundred ten patients had complicated appendicitis, whereas 106 patients were uncomplicated. Among the complicated appendicitis patients, 76.4 per cent were perforated, 38.2 per cent were gangrenous, and 34.5 per cent had an abscess. The complicated appendicitis group had a higher mean duration of symptoms (2.70 ± 3.41 days vs 2.09 ± 3.08 days, P = 0.011). Appendectomies that were open or converted to open were more likely to be associated with complicated appendicitis (75% vs 48%, P = 0.012). Mean hospital length of stay was greater in those with complicated appendicitis (5.34 ± 5.56 days vs 3.12 ± 2.86 days, P < 0.001). The two groups did not differ on mean Alvarado score (complicated = 6.96 ± 1.99 vs uncomplicated = 6.72 ± 1.85, P = 0.36). Only 62.5 per cent of patients had an Alvarado score that met the cutoff for acute appendicitis. The Alvarado score was not able to differentiate complicated from uncomplicated appendicitis in elderly patients.

Management of acute appendicitis in adults: A practice management guideline from the Eastern Association for the Surgery of Trauma

Acute appendicitis (AA) has been considered one of the most common acute surgical conditions in the world. Recent studies, however, have suggested that nonoperative management (NOM) with a course of antibiotics (ABX) may be as effective as surgery in treating appendicitis. As there are evolving perspectives regarding the optimal therapy for appendicitis, we sought to provide recommendations regarding the role of NOM with the administration of antibiotics (antibiotics-first approach) in uncomplicated AA as well as the need for routine interval appendectomy (RIA) in those presenting with appendiceal abscess or phlegmon (AAP) initially managed without appendectomy. A writing group from the Guidelines Committee of the Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analysis of the current literature regarding appendicitis in adult populations. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied and meta-analyses and evidence profiles generated. When comparing antibiotics-first therapy to surgery for uncomplicated AA in adult populations, we found that perforation and recurrence of disease were the only outcomes consistently represented in the literature. For perforation, we were unable to make a definitive conclusion based on the degree of heterogeneity among the six randomized controlled trials reviewed. The risk of recurrence at 1 year with antibiotics-first treatment was 15.8% (95% confidence interval, 12.05-118.63). Critical outcomes could not be evaluated with the current literature. In NOM patients for AAP, the risk of recurrence was 24.3% if RIA was not performed (95% confidence interval, 2.74-73.11). Based on the completed meta-analysis and Grading of Recommendations Assessment, Development and Evaluation profiles, we were unable to make a recommendation for or against the antibiotics-first approach as primary treatment for uncomplicated AA. For NOM with AAP, we conditionally recommend against RIA in an otherwise asymptomatic patient. This review reveals multiple limitations of the published literature, leaving ample opportunities for additional research on this topic. Systematic review, level II.

The contemporary appendectomy for acute uncomplicated appendicitis in children

BackgroundNational, procedure-specific clinical registries are increasingly available in surgery, although data about children have lagged behind. Data related to the surgical management of appendicitis in children have become available recently and can be used to inform patient and family expectations and to identify clinical areas in need of ongoing improvement. MethodsCases of acute, uncomplicated appendicitis in children (<18 years of age) were extracted from the 2017 pediatric appendectomy-targeted file of the American College of Surgeons National Surgical Quality Improvement Program. Epidemiologic data were generated across 5 domains: (1) patient characteristics/severity, (2) preoperative imaging patterns, (3) characteristics of the operation, (4) pathologic outcomes, and (5) postoperative morbidity and mortality. ResultsThe final sample included 9,507 appendectomies for acute, uncomplicated appendicitis performed at 106 hospitals. The population was predominantly male (60.6%), involving children 6 to 12 years of age (55.3%). Only 2.9% of patients did not have imaging before their appendectomy. Overall, 38.2% received a computed tomography; however, patients transferred with imaging received computed tomography at 3.8 times the rate of those with only local (ie, operating hospital) imaging. Laparoscopy was used in 94.6% of cases, with 1.1% converted to open. Negative appendectomy and complication rates were 3.3% and 2.1%, respectively. Children ≤5 years of age had 2.3 greater odds of negative appendectomy than children 6 to 17 years of age. ConclusionChildren undergoing operation for acute, uncomplicated appendicitis have excellent clinical outcomes, although children ≤5 years of age have an increased risk of negative appendectomy. Despite guidelines against their use, more than one-third of children received a computed tomography before operation, driven predominantly by transferring hospitals.

Expedited discharge in uncomplicated acute appendicitis: Decreasing the length of stay while maintaining quality

BackgroundAn expedited discharge protocol for uncomplicated appendicitis was developed at a Canadian academic hospital to determine if patients could be safely discharged home early without negatively impacting care and patient satisfaction. MethodsA non-randomized prospective quality improvement project was completed between February 01, 2017 and January 31, 2018. The project included patients between 16 and 65 years with uncomplicated appendicitis managed with laparoscopic appendectomy. The primary outcome was average length of stay post PACU. 30 day ED visit, cross-sectional imaging and readmission rate were balancing measures. The CTM-3 tool was used to measure patient satisfaction. Results450 patients had emergent laparoscopic appendectomy. 287 (63.8%) patients met the project inclusion criteria. The average length of stay decreased 41.0% to 13.1 h. The 30 day ED visit, cross-sectional imaging and readmission rate were 9.8%, 4.5% and 1.0% respectively compared with 8.1%, 4.5% and 2.5% at baseline. Patient satisfaction was 3.72/4 compared to 3.74/4. ConclusionAn expedited discharge after an uncomplicated laparoscopic appendectomy is safe and feasible without a negative impact on 30-day ED visit, diagnostic imaging or readmission.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis.

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis. A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis. Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4days vs. 8.9days, p = 0.02) and earlier resumption of solid food (2.7days vs. 3.7days, p = 0.03). These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Bundled Payments for Appendectomy: a Model of Financial Implications to Institutions

BackgroundBundled payments are increasingly becoming common in surgery, yet little is known regarding their potential impact on reimbursements for patients presenting with acute appendicitis. This study examines the financial impact of bundled payments for acute appendicitis. MethodsThis was a retrospective review of all open or laparoscopic appendectomies between July 2014 and June 2017. Patients that were not candidates for surgery were not included in this review. ResultsOf the total 741 patients, 42.1% were diagnosed with complicated acute appendicitis. The median length of stay was 1 day (range, 0 to 21 days). The median hospital cost was $4183 (range, $2075 to $71,023). The 90-day readmission rate was 3.2%, with a mean cost of $5025 per readmission (range, $1595 to $10,795). Length of stay, hospital costs, and 90-day readmissions were significantly higher for complicated versus uncomplicated acute appendicitis. In our current fee-for-service model, hospital reimbursements resulted in margins of − 4.0% to 24.6% depending on the severity of disease. If we assume that bundled payments do not reimburse for readmissions, we estimate that our hospital would incur losses of − 5.7% for patients with acute appendicitis with localized peritonitis and − 20.2% for patients with acute appendicitis with generalized peritonitis. ConclusionsAs bundled payments become more common, hospitals may incur significant losses for acute appendicitis under a model that does not reflect the heterogeneous nature of patients requiring appendectomies. These losses can range up to − 20.2% for complicated cases. Improving clinical outcomes by reducing readmissions may mitigate some of these anticipated losses.

Outcomes of extracorporeal, transumbilical versus intracorporeal laparoscopic appendectomy for acute uncomplicated appendicitis in children and adolescents: A retrospective observational cohort study

BackgroundAn extracorporeal (ECA), transumbilical appendectomy has been proposed as a treatment for appendicitis. This study assessed the 30-day perioperative outcomes and cost between ECA and traditional intracorporeal (ICA) techniques for acute uncomplicated appendicitis. MethodsIRB approval was obtained for this retrospective cohort study of acute uncomplicated appendicitis in children aged 4 to 17 between April 2014 and April 2017. Patients were grouped based on ICA versus ECA. Operative time, length of stay, and complication rates were recorded. ResultsA total of 289 patients were included, and of these 217 underwent ICA, and 72 underwent ECA. Median weight-for-age percentile was the only demographic characteristic different between groups (ECA 50 [0.1–100] vs. ICA 71 [0–100]; p < 0.01). Median operative time was significantly shorter in the ECA group (21.0 min [8.0–61.0] vs. 38.0 min [19.0–87.0]; p < 0.0001). Length of stay and complication rates were similar between groups. The median per case cost was significantly lower in the ECA group (CAD$ 593.05 range: 499.70–900.81 vs. CAD$ 858.78 range: 490.36–1106.29; p < 0.001). ConclusionsExtracorporeal transumbilical laparoscopic appendectomy is associated with shorter operative times and no increased risk of 30-day postoperative complications in children and adolescents. This offers a new operative approach that may reduce hospital cost and resources. Level of evidenceIII.

Looking back 2018--focused on surgical infection

The published clinical research in 2018 in surgical infection are changing current opinions in the management of acute appendicitis, antibiotics usage, resuscitation of septic shock, and choice of nutritional therapy in critically ill patients. In the management of uncomplicated acute appendicitis, antibiotic therapy can be successful in selected patients who wish to avoid surgery. Delayed primary wound closure can not reduce superficial surgical site infection rates compared to primary wound closure for complicated appendicitis. Infusion of antibiotics 30 minutes before the start of operation may influence their prophylactic effect on surgical site infection. After adequate source control, long-course antibiotic therapy in critically ill post-operative patients is not associated with any clinical benefit. Although susceptible in the test, piperacillin-tazobactam can not replace carbapenems in patients with Escherichia coli and Klebsiella pneumoniae bloodstream infection that produce extended-spectrum beta-lactamase for definitive treatment. Deresuscitation of critically ill patients is associated with reduced mortality. Hydrocortisone therapy has potential role in the patients with septic shock and worth further evidence. The use of an energy-dense formulation for enteral delivery of nutrition can not improve 90-day survival rate in patients undergoing mechanical ventilation. Compared with early isocaloric parenteral nutrition, early enteral nutrition did not reduce mortality or the risk of secondary infections, but was associated with a greater risk of digestive complications in critically ill adults with septic shock.

In uncomplicated acute appendicitis, 61% of patients initially treated with antibiotics had not had appendectomy at 5 years.

Source Citation Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320:1259...

Evaluation of conservative management of uncomplicated acute appendicitis in a rural medical college

Evaluation of conservative management of uncomplicated acute appendicitis in a rural medical college

Surgical outcome of cutting diathermy versus scalpel skin incisions in uncomplicated appendectomy: A comparative study.

It is traditionally believed that diathermy skin incisions produce a comparatively poorer surgical outcome despite recent evidences to the contrary. This study set out to compare diathermy and scalpel skin incisions with respect to immediate post-operative pain, surgical-site infection and surgical scar cosmesis. This was a randomised, double-blinded study comparing cutting diathermy and scalpel skin incisions in patients undergoing open appendectomies for uncomplicated appendicitis. The post-operative pain was rated with the Visual Analogue Pain Scale 6, 12 and 24 h postoperatively, and 30 day wound infection was rated with the Southampton score. Scar cosmesis was assessed at 3 months, by a plastic surgery trainee, using the Patient and Observer Scar Assessment Scale (POSAS). The patients also self-evaluated their scars using POSAS. A total of 64 patients were randomised to cutting diathermy (32) and scalpel (32) skin incision groups. The mean pain score was higher in the diathermy incised wounds, but this was not statistically significant (P = 0.094). There was one wound infection recorded in the scalpel incision group and none in the diathermy incision group (P = 0.524). At 3 months post-surgery, there was no difference between the diathermy and scalpel incised wounds in mean (±SD) objective POSAS scores (15.64 [±5.98] vs. 17.79 [±6.37], P = 0.228) or subjective POSAS scores (22.44 [±13.13] vs. 22.21 [±13.17], P = 0.951), respectively. The mean scar satisfaction score, as assessed by the patients, was better for the diathermy incised wounds, but this was not statistically significant (P = 0.406). In patients undergoing open appendectomy for uncomplicated acute appendicitis, skin incision with a cutting diathermy is not inferior to the scalpel in surgical outcome, with respect to post-operative pain, wound infection and surgical scar cosmesis.

Comparision of Laparoscopic Approach Over Conventional Appendicectomy in Emergency Uncomplicated Acute Appendicitis

Comparision of Laparoscopic Approach Over Conventional Appendicectomy in Emergency Uncomplicated Acute Appendicitis

Parental satisfaction with same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis.

Recent studies suggest that same-day discharge is safe for the paediatric population after various laparoscopic procedures. Same-day discharge is increasingly common after laparoscopic surgery for uncomplicated appendicitis although it is not standard practice. This prospective study aims to assess parental satisfaction with same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis. At our institution, 849 patients with uncomplicated acute appendicitis underwent laparoscopic appendectomy in 2016; of which, 382 were discharged on the same calendar day. Postdischarge surveys assessing parental satisfaction were administered by telephone at the 2-week follow-up. Approximately 65% of 185 total parental responses reported initial satisfaction with same-day discharge. About 30% were nervous at that time, and 5% did not feel ready to go home yet. Upon reflection, a higher proportion of parents (81.6%) felt same-day discharge was the appropriate course of action, 11.4% were unsure, and 7.0% would not do it again. Some parents cited concerns regarding pain control and incongruous expectations from conversations with staff or surgical experiences of their own. The majority of parents recalled being happy at discharge, with an increase to 82% retrospectively. Only 7% of parents would not elect to go home on the same day again. Opportunities for improvement include a unified plan from all providers with expectations of same-day discharge if appendicitis is intraoperatively confirmed to be uncomplicated and better analgesic instructions at discharge.

Never put equipoise in appendix! Final results of ASAA (antibiotics vs. surgery for uncomplicated acute appendicitis in adults) randomized controlled trial.

Acute appendicitis is the most common surgical emergency; however, its etiology and diagnosis are still discussed with a considerable proportion of wrong diagnosis resulting in appendectomies for non inflamed appendix. Moreover, the biologic function of the appendix is still unclear. For uncomplicated acute appendicitis the conservative treatment with antibiotics has been proposed with interesting results. The aim of this study was to compare surgical treatment vs. antibiotics in uncomplicated acute appendicitis. This is a monocentric randomized controlled trial comparing surgery with antibiotic therapy in adults with uncomplicated acute appendicitis. The primary outcome was the success rate (resolution of symptoms within 2weeks and no need for further treatments); secondary outcomes were complication rate; negative appendectomy rate (only in surgical arm); and long-term outcomes within a year as recurrence. The study was designed as a non-inferiority trial. From September 2011 to December 2014, 224 patients fulfilled the eligibility criteria and 45 patients were randomized. Twenty four patients (53.3%) were randomly assigned to surgery and 21 (46.6%) to antibiotic therapy. In surgical group primary outcome was reached for all the patients; secondary negative outcomes were recorded in five patients (22.7%): two cases of negative appendectomies, three wound infections. In antibiotics group treatment fails in 16.8% of cases; secondary negative outcomes were recorded in one patient who experienced relapse of AA at 30days No further events or complications were observed at 1-year follow-up. Due to the poor patients' accrual the study had no enough statistical power to demonstrate the non-inferiority of conservative treatment and results were inconclusive. Due to the poor patient's accrual rate the study failed to demonstrate the non-inferiority of conservative treatment in uncomplicated acute appendicitis. On the other hand the study demonstrates the difficulty in performing randomized trials in emergency surgery and focus on the ethical aspects.

Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review.

BACKGROUNDMeta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist.METHODSPUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.RESULTSThirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success.CONCLUSIONWhile further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management.LEVEL OF EVIDENCESystematic review, level II.

Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial)

BackgroundBased on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70–80%) or complicated (20–30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis.MethodsAPPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients.Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin.DiscussionTo our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis.Trial registrationClinicaltrials.gov, NCT03236961, retrospectively registered on the 2nd of August 2017.

A randomised placebo-controlled double-blind multicentre trial comparing antibiotic therapy with placebo in the treatment of uncomplicated acute appendicitis: APPAC III trial study protocol

IntroductionRecent studies show that antibiotic therapy is safe and feasible for CT-confirmed uncomplicated acute appendicitis. Spontaneous resolution of acute appendicitis has already been observed over a hundred years ago. In...

The contemporary appendectomy for acute uncomplicated appendicitis in adults

Epidemiologic data related to the surgical management of appendicitis are out of date. As we contemplate the role of nonoperative therapy in uncomplicated appendicitis, a contemporary profile of the risks and benefits of operative appendectomy is needed. This study merged the 2016 National Surgical Quality Improvement Program essential and appendectomy-targeted participant use files. The appendectomy-targeted file provides procedure-specific variables related to imaging, approach, and outcomes. Epidemiologic data were generated across five domains for adults with uncomplicated appendicitis: patient characteristics/severity, imaging patterns, operative characteristics, pathologic outcomes, and postoperative morbidity/mortality. The merged data file contained 12,376 adult appendectomies from 115 National Surgical Quality Improvement Program sites. After exclusions, 7,778 cases were analyzed. Almost all patients (96.1%) received preoperative imaging, with most (79.2%) receiving a computed tomography scan only. Only 2.6% of appendectomies were performed open, and the laparoscopic to open conversion rate was 0.5%. Most patients (87.3%) were discharged the day of or the day after their operation. The rate of finding an incidental tumor was 1.1%, with greater rates in the elderly (2.7% among patients aged ≥65 years). The overall rate of a negative appendectomy (NA) was 3.8%; the negative appendectomy rate was 1.7% for patients with any positive imaging study and 19.4% for patients with no imaging. The 30-day mortality was 0.04%; 30-day rates of any complication and serious complications were 3.0% and 2.2%, respectively. Preoperative imaging, a laparoscopic approach, and excellent clinical outcomes have become the norm for the surgical management of uncomplicated appendicitis. As surgeons contemplate the role of nonoperative therapy for uncomplicated appendicitis, the data presented here should be used to inform the ongoing debate.

Readmission after antibiotic management of uncomplicated acute appendicitis in adults: prospective study.

Acute appendicitis is the most common surgical cause of acute abdomen. Many randomized studies compare between antibiotic and surgery, and such studies indicated that antibiotics might treat acute appendicitis. However, there are concerns about selection bias in previous studies. Hence, to overcome this worry; we used in this study a full-scale population-based application. We identified 327 adult patients who were admitted to surgical ward with diagnosis of uncomplicated acute appendicitis between March 2013 and February 2016. All patients received antibiotic therapy after confirming the diagnosis by computed tomography. Endpoints were treatment efficacy, readmission, and complications in 1year of follow-up. Of the 327 patients include in this study, 8 (2.5%) patients failed initial non-operative (antibiotic) management and underwent operation during their initial hospitalization. Of 319 available for 1-year follow-up, 280 patients (87.8%) did not require appendectomy; while 39 patients (12.2%) need readmission within 1year. Antibiotics are a safe and visible option in acute appendicitis management. This approach needs careful assessment and evaluation for each individual patient before it is used as the first-line therapy.

Antibiotic treatment vs. appendectomy for non-perforated appendicitis in adults

For decades, the mandatory treatment for acute uncomplicated appendicitis was urgent appendicectomy. This dogma has now been questioned by several randomized controlled trials, which demonstrated the safety of antibiotic treatment of uncomplicated appendicitis without increased morbidity and mortality. The efficacy of this conservative treatment, however, is inferior to surgery: Within the first year after antibiotic treatment of acute appendicitis, approximately 30% of patients require appendicectomy. Within 5 years the rate of appendicectomy increases to 40% and the life-long risk of appendicectomy after conservative treatment can be expected to be even higher. The advantages of conservative treatment of appendicitis are faster recovery and the lack of postoperative wound pain; however, all currently available trials compared conservative treatment almost exclusively with conventional appendicectomy, trials comparing laparoscopic appendicectomy to antibiotics are currently not available. As laparoscopic appendicectomy is awell-established and safe treatment ubiquitously available in Germany, conservative treatment in patients with uncomplicated appendicitis cannot generally be recommended. As antibiotic treatment is a less effective but equally safe procedure, it can be offered to selected patients only.