Antibiotics or Appendectomy for Acute Non-Perforated Appendicitis—How to Interpret the Evidence?

2016, Vol. 105(1) 3 –4 © The Finnish Surgical Society 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1457496916632188 sjs.sagepub.com All surgeons during their residency perform appendectomy as it is the most common emergency surgery procedure worldwide. It has been taught for decades that appendicitis is a surgical emergency requiring prompt appendectomy to prevent inevitable perforation and subsequent peritonitis. However, the evidence for such dogma is weak. Over 20 years ago, a small randomized controlled trial (RCT) already suggested that uncomplicated appendicitis can be successfully treated with antibiotics, at least in selected cases, and that perforation is not an inevitable consequence of acute appendicitis (1). Although larger RCTs have later confirmed these findings (2–6), clinical practice has changed little. After the publication of the biggest RCT on this topic, the Finnish Appendicectomy Versus Antibiotics in the Treatment of Acute Uncomplicated Appendicitis (APPAC) trial (5), it is time to assess the benefits and drawbacks of antibiotic therapy compared to appendectomy in patients with uncomplicated appendicitis. A recent systematic review and meta-analysis (7) summarized data from five RCTs including 1116 patients (1, 2, 4–6). Pooled data demonstrated that only 8% of patients with acute non-perforated appendicitis initially treated with antibiotics required appendectomy within 1 month (7). However, a further 23% of patients initially treated with antibiotics had a recurrence (or suspicion) of appendicitis leading to surgery within the first year of follow-up. Both findings were based on high-quality evidence, and it is therefore unlikely that further research will substantially change these estimates. Obviously, an 8% failure rate is low, but should a 23% recurrence rate be considered high or low? In other words, 7 out of 10 patients avoid surgery, but every fourth patient suffers a recurrence of appendicitis within a year, including re-hospitalization causing substantial inconvenience and costs. Indeed, it is a preference sensitive decision how to balance this trade-off. Although these randomized trials raise the quality of evidence regarding surgical versus medical treatment of appendicitis to a new level, many questions remain. First, these RCTs had follow-up up to 1 year only, and little is known about recurrence rates with longer follow-up. Furthermore, whether patients recruited in these trials represent the real world is also unknown. Only 16% of the eligible patients with uncomplicated appendicitis were recruited in the Antibiotics or Appendectomy for Acute non-perforAted Appendicitis—How to interpret tHe evidence?