Long term outcomes are important when trying to understand the usefulness of a non-surgical approach to appendicitis. If all the patients eventually fail and have an appendicectomy, then what is the point?
The Appendicitis
Acuta (APPAC) trial out of Finland randomized 530 patients with CT proven
uncomplicated acute appendicitis to antibiotics vs. open appendicectomy. Now
we have some 5-year data.
The cumulative
incidence of appendicitis was 27% at year one, 34% year two, 35% year
three, 37% year four and finally 39% by 5 years.
The five
year overall surgical complication rate (SBO, surgical infection,
incisional hernias, and abdominal pain) was 24%.
These are
good statistics to consider when considering shared decision-making.
But there
are a few things to remember.
- All patients
got CT prior to randomization
to ensure uncomplicated illness. (i.e no perforation, abscess, appendicolith or
suspicion of tumor.)
- They excluded children and adults over the age of 60
- They used
some crazy C diff inducing doses of antibiotics including an IV
carbapenem for 3 days followed by an oral fluoroquinolone and metronidazole. (But
Augmentin has been used in other studies.)
- Patients had open appendicectomies. Laparoscopic surgery would be expected to have a lower surgical complication rate.
What’s the take
home?
There is now
more and more literature consistently demonstrating the decent efficacy of
antibiotic therapy for uncomplicated appendicitis. Decades of surgical tradition
is hard to change. But it is getting to the point where patients will need to participate in discussions regarding treatment options.
Covering:
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;320:1259-65. [link to article]
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