However, it might also be accurate to say: The Era of the Emergency Appendectomy is Over.
This is the Appendicitis Acuta trial, a multi-center trial from Finland, randomizing CT-diagnosed, suspected acute appendicitis to either antibiotics or immediate open appendectomy. Randomizing 530 patents, the trial failed to meet its pre-specified endpoint of non-inferiority, as measured by the outcome of need for appendectomy within 1 year of the initial episode.
And, by “non-inferior”, I’m a little uncertain regarding their clinical interpretation of such. Their statistical threshold, based on prior evidence, was a non-inferiority margin of 24%, and the actual rate of antibiotic treatment failure was 27%. However, frankly, I’m not certain how even meeting their non-inferiority margin would be considered clinically acceptable. I am all for innovating new, cost-effective approaches challenging classical dogma, but uncomplicated laproscopic appendectomies are just about the most-practiced, least harmful of surgical procedures.
The general argument in favor of antibiotics stems firstly from economic considerations – it’s far cheaper to use antibiotics – and secondly from avoidance of operative complications. Even here, in which patients uncharacteristically underwent open appendectomies, the overall complication rate of 20.5% is inflated by 19 of 273 patients with superficial wound infections. Minor, transient, treatable complications should not be included in such an analysis. The 23 patients with continued pain and bowel symptoms at 1-year follow-up, however, is concerning. But, again, whether such numbers from open appendectomies reflect the long-term symptom rate of laproscopic surgery is questionable.
This trial, at least, does seem to show an antibiotics-first strategy is not unreasonable. Even as this was a negative trial, 72.7% of patients did avoid recurrent appendicitis and surgery – and of those who did require surgery, only a handful crossed-over on the initial hospitalization. Additionally, the delay in definitive management was not specifically associated with increased complications. It would be interesting to someday see 5- and 10-year follow-up, and whether further patients ultimately fail non-operative management, as truly, the lifetime recurrence rate is the better measure of a successful delayed antibiotic strategy.
I would not fault adoption of a strategy of offering antibiotics and observation – but, without better long-term data, I personally would be opting for the appendectomy.
“Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis”
http://jama.jamanetwork.com/article.aspx?articleid=2320315
1- Wouldn't the appropriate comparison be :
– antibiotics, and if failed, surgery (within a to be defined time frame )
– vs surgery first
With as endpoints : meaningful (to be defined) complications, at 1 year (5 would be more interesting, but we want to see some results in our lifetime ! )
2- Ertapenem IV 3 days isn't a resonable option. We're trying to limit the use of fluoquinolons, ≥ 3d generation cephalosporins, let alone the penems !
3 Appies with appendicoliths were excluded, lets us not forget .