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Antibiotics versus Appendectomy for Uncomplicated Appendicitis: A Global Health Perspective

The following abstract was presented as part of London Health Research Day 2016.

Research Area: Endocrinology & Metabolism, Population Health, and Education
First Author: Rohin Krishnan
Supervisor(s): Dr. Janet Martin

Introduction:
Acute appendicitis is a common cause of abdominal pain. Traditionally, emergency appendectomy has been viewed as the treatment of choice. However, an appendectomy is not without risks, such as bowel injury, surgical site infection, and anesthetic-related complications. Additionally, surgical resources are not always accessible during patient presentation particularly in resource-limited and remote settings. Thus, interest has grown in exploring conservative management of acute appendicitis with antibiotics alone, instead of surgical appendectomy. The purpose of this study was to determine, through systematic review and meta-analysis of randomized trials, whether conservative management of uncomplicated appendicitis with antibiotics alone provides similar outcomes compared with appendectomy.

Hypothesis:
We hypothesize that patients treated with antibiotics will not experience higher rates of treatment failure compared to patients treated with appendectomy.

Materials and Methods:
We conducted a random-effects meta-analysis comparing appendectomy versus conservative treatment with antibiotics for suspected uncomplicated appendicitis. We searched Ovid MEDLINE, EMBASE, international clinical trials registries, and the Cochrane Library from 1950 to December 2015.  Studies were reviewed by two independent reviewers and any discrepancies resolved by consensus. In addition to the primary outcome of treatment failure (defined as the composite of recurrence, sepsis, death, or unnecessary surgery due to ‘negative’ findings), secondary outcomes included peritonitis or perforated appendix, complications, and mortality within 1 year of follow up.

Results:
Of 2348 citations screened, a total of 5 randomized trials and 1 quasi-randomized trial met the inclusion criteria (1451 patients). All studies were conducted in Scandinavia. Meta-analysis suggested that fewer patients undergoing surgery experienced treatment failure at 1 year compared to those receiving antibiotics alone (OR 0.09; 95% CI 0.04–0.18; p < 0.001; NNH=3). Reoccurrence was the main subcomponent that contributed to the significant difference in our primary outcome. Roughly, 33% of patients in the conservative management group experienced recurrent appendicitis, suggesting that only 2 in 5 patients will eventually require surgery in the first year.  No significant difference was detected for peritonitis/ perforation (OR 0.73; 95% CI 0.29-1.83; p = 0.50), total complications (OR 0.47; 95% CI 0.17-1.34; p=0.16), or mortality (OR 1.05; 95% CI 0.18-6.10; p=0.957) for immediate surgery versus antibiotics alone.

Discussion and Conclusions:
Existing evidence suggests that immediate surgery or conservative management with antibiotics alone may represent reasonable options for the management of acute uncomplicated appendicitis, and the choice may be best informed by patient preferences and local resources. While conservative treatment of acute appendicitis with antibiotics alone may prevent need for surgery in 2 in 5 patients, without significantly increasing risk of serious adverse events. At the very least, this study suggests that conservative management remains a viable alternative to surgery. The ability to ‘defer’ appendectomy may be especially important for low resource settings where access to hospitals and safe surgery may be scarce.