Antibiotics may substitute appendectomy for uncomplicated acute appendicitis

A 10-day course of antibiotic treatment may be a suitable alternative to appendectomy in people with uncomplicated acute appendicitis, with a low complication rate following post-antibiotic treatment, 5 years according to a study by APPAC *.

APPAC participants were 530 individuals aged 18–60 years with confirmed and randomized CT scans with appendectomy (n = 273, middle age 35) or antibiotic treatment (intravenous Ertapenem [1 g / day] for 3 days followed by oral levofloxacin [500 mg QD] and Metronidazole [500 mg TID] for 7 days; n = 257, mean age 33).

The rate of appendicitis recurrence among those initially taking antibiotics increased in the subsequent period (cumulative rates, 27.3, 34.0, 35.2, 37.1, and 39.1% at 1, 2, 3, 4 and 5 years respectively). [JAMA 2018; 320: 1259-1265]

A total of 100 patients receiving the antibiotic underwent subsequent appendectomy, the majority of which (n = 70) during the first year of treatment, with the remaining 30 patients experiencing one to five years after treatment. treatment with antibiotics. Seven of the patients who subsequently underwent appendectomy turned out to be free from appendicitis.

Overall complications after 5 years, identified in this study as surgical infection, incision hernia, symptoms of intestinal obstruction and abdominal pain or wound pain, occurred more frequently in people undergoing surgical appendiceal removal compared to antibiotic users (24.4% vs. 6.5%, difference, 17.9 percentage points; p <0.001). Two patients who had undergone appendectomy experienced serious complications that required re-surgery with general anesthesia. There was no significant difference in the overall complication rate between patients randomized for appendectomy and those randomized to receive antibiotics who had subsequently undergone appendectomy (difference, 6, 6 percentage points; p = 0.20).

After treatment, patients who underwent appendectomy had more sick days than those receiving antibiotics (mean, 22 vs. 11 days; p <0.001), while the length of admission was comparable. Group comparison (mean, 3 days per group).

“These findings demonstrate the feasibility of treating appendicitis with antibiotics and without surgery. Nearly two-thirds of patients initially treated for uncomplicated appendicitis were successfully treated with antibiotics, and those who eventually developed the disease relapsed did not experience any adverse outcomes related to delay appendectomy ”, the researchers said. effects of different antibiotic regimens on uncomplicated appendicitis.

They show that the higher complication rate in the appendectomy group is mainly due to infection, which can be reduced if appendectomy is performed endoscopically. In countries where laparoscopic surgery may not be feasible due to a lack of resources, antibiotic therapy may be an appropriate initial treatment for appendicitis.

“For most of the 132 years since appendicitis was first described, the disease is considered a surgical emergency because it is believed that untreated appendicitis eventually progressed to perforation. and pelvic infections ”, said Dr. Edward Livingston, associate editor at JAMA. [JAMA 2018; 320: 1245-1246]

"The findings from the APPAC trial dispel the notion that uncomplicated acute appendicitis is a surgical emergency," he said. “In the new era of appendicitis treatment, in which the diagnosis can be made almost exactly with CT imaging, most cases of uncomplicated appendicitis can be successfully treated with resistance. born."

Considering the "overactive" antibiotic regimen used in APPAC, research on alternative regimens and their respective lengths of treatment is assured, Livingston said.

Translation: Dr. Hoang Hoa Hai

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