We’ve seen dogma challenged regarding diverticulitis and the necessity of antibiotics. This isn’t the first post regarding a change in initial strategy for appendicitis, however, it’s certainly reasonable to revisit again as the evidence accumulates.
This study is simply a prospective, observational case series of 159 patients with acute, uncomplicated appendicitis. In 2010, this institution in Italy made surgical appendectomy the exception, rather than the rule. Patients without serious illness or complicated appendicitis were admitted for short term observation and started on amoxicillin-clavulanate. Patients who failed to improve or worsened went to the OR. Others were discharged and re-examined at 5-7 days as an outpatient, and, again, those without significant improvement went to the OR. Over a 2 year follow-up period patients were assessed by phone.
Within 7 days, there were 19 (12%) treatment failures; 17 of 19 were acute appendicitis, 2 were tubo-ovarian abscess with secondary appendiceal inflammation. Over the 2 year follow-up, 22 (13.8%) patients had recurrent appendicitis – 14 of which were managed with antibiotics without complication. 8 went to the OR, 6 of which were confirmed as acute appendicitis.
I don’t think we’d have the same issue with misdiagnosed TOAs in our population – 73% of their diagnoses were by ultrasound, and only 17% underwent CT. 12% short-term treatment failure is also nothing to scoff at – and this number is consistent with other studies. Routine surgery, however, is much costlier, resource-intensive, and carries with it a similar or greater risk of major complications. It seems to me this is absolutely a viable strategy.
Is it time surgery added “Consider a trial of antibiotic therapy prior to surgery for acute, uncomplicated appendicitis” to their Choosing Wisely list?
“The NOTA Study (Non Operative Treatment for Acute Appendicitis)”