Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

V Sallinen, E A Akl, J J You, A Agarwal, S Shoucair, P O Vandvik, T Agoritsas, D Heels-Ansdell, G H Guyatt, K A O Tikkinen, V Sallinen, E A Akl, J J You, A Agarwal, S Shoucair, P O Vandvik, T Agoritsas, D Heels-Ansdell, G H Guyatt, K A O Tikkinen

Abstract

Background: For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non-perforated appendicitis.

Methods: A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non-perforated appendicitis. Key outcomes were analysed using random-effects meta-analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results: Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference -2·6 (95 per cent c.i. -6·3 to 1·1) per cent (low-quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference -7·2 (-18·1 to 3·8) per cent (very low-quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high-quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high-quality evidence). For every 100 patients with non-perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.

Conclusion: The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value- and preference-dependent, suggesting a change in practice towards shared decision-making is necessary.

© 2016 The Authors. BJS published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.

Figures

Figure 1
Figure 1
Flow chart showing selection of articles for review. WHO, World Health Organization; ICTRP, International Clinical Trials Registry Platform Search Portal
Figure 2
Figure 2
Forest plot showing absolute risk difference in major complications in antibiotic therapy versus appendicectomy group. Risk differences are shown with 95 per cent c.i.
Figure 3
Figure 3
Forest plot showing absolute risk difference in minor complications in antibiotic therapy versus appendicectomy group. Risk differences are shown with 95 per cent c.i.
Figure 4
Figure 4
Forest plot showing mean difference in length of hospital stay in antibiotic therapy versus appendicectomy group. Mean differences are shown with 95 per cent c.i. *Values are mean(s.d.)
Figure 5
Figure 5
Forest plot showing mean difference in length of sick leave in antibiotic therapy versus appendicectomy group. Mean differences are shown with 95 per cent c.i. *Values are mean(s.d.)

References

    1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132: 910–925.
    1. Masoomi H, Nguyen NT, Dolich MO, Mills S, Carmichael JC, Stamos MJ. Laparoscopic appendectomy trends and outcomes in the United States: data from the Nationwide Inpatient Sample (NIS), 2004–2011. Am Surg 2014; 80: 1074–1077.
    1. Fitz RH. Perforating inflammation of the vermiform appendix: with special reference to its early diagnosis and treatment. Am J Med Sci 1886; 92: 321–346.
    1. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J 1889; 50: 676–684.
    1. Coldrey E. Treatment of acute appendicitis. Br Med J 1956; 2: 1458–1461.
    1. Combined traditional Chinese and western medicine in acute appendicitis. Chin Med J (Engl) 1977; 3: 266–269.
    1. Adams ML. The medical management of acute appendicitis in a nonsurgical environment: a retrospective case review. Mil Med 1990; 155: 345–347.
    1. Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995; 82: 166–169.
    1. Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G et al Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicenter randomized controlled trial. World J Surg 2006; 30: 1033–1037.
    1. Hansson J, Körner U, Khorram‐Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 2009; 96: 473–481.
    1. Turhan AN, Kapan S, Kütükçü E, Yiğitbaş H, Hatipoğlu S, Aygün E. Comparison of operative and non operative management of acute appendicitis. Ulus Travma Acil Cerrahi Derg 2009; 15: 459–462.
    1. Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B et al Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open‐label, non‐inferiority, randomised controlled trial. Lancet 2011; 377: 1573–1579.
    1. Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T et al Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis. JAMA 2015; 313: 2340–2349.
    1. Svensson JF, Patkova B, Almström M, Naji H, Hall NJ, Eaton S et al Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children. Ann Surg 2015; 261: 67–71.
    1. Kirby A, Hobson RP, Burke D, Cleveland V, Ford G, West RM. Appendicectomy for suspected uncomplicated appendicitis is associated with fewer complications than conservative antibiotic management: a meta‐analysis of post‐intervention complications. J Infect 2015; 70: 105–110.
    1. Liu ZH, Li C, Zhang XW, Kang L, Wang JP. Meta‐analysis of the therapeutic effects of antibiotic versus appendicectomy for the treatment of acute appendicitis. Exp Ther Med 2014; 7: 1–6.
    1. Svensson J, Hall N, Eaton S, Pierro A, Wester T. A review of conservative treatment of acute appendicitis. Eur J Pediatr Surg 2012; 22: 185–194.
    1. Mason RJ, Moazzez A, Sohn H, Kathouda N. Meta‐analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis. Surg Infect (Larchmt) 2012; 13: 74–84.
    1. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta‐analysis of randomised controlled trials. BMJ 2012; 344: e2156.
    1. Fitzmaurice G. Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence. Can J Surg 2011; 54: 307–314.
    1. Liu K, Fogg L. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta‐analysis. Surgery 2011; 150: 673–683.
    1. Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev 2011; (11)CD008359.
    1. Ansaloni L, Catena F, Coccolini F, Ercolani, Gazzotti F , Pasqualini E et al Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta‐analysis of randomized controlled trials. Dig Surg 2011; 28: 210–221.
    1. Varadhan KK, Humes DJ, Neal KR, Lobo DN. Antibiotic therapy versus appendectomy for acute appendicitis: a meta‐analysis. World J Surg 2010; 34: 199–209.
    1. Liu KL, Fogg L. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta‐analysis. Surgery 2011; 150: 673–683.
    1. Karanicolas PJ, Montori VM, Devereaux PJ, Schünemann H, Guyatt GH. A new ‘mechanistic–practical’ framework for designing and interpreting randomized trials. J Clin Epidemiol 2009; 62: 479–484.
    1. Guyatt GH, Busse JW. Modification of Cochrane Tool to Assess Risk of Bias in Randomized Trials [accessed 6 September 2015].
    1. Akl EA, Johnston BC, Alonso‐Coello P, Neumann I, Ebrahim S, Briel M et al Addressing dichotomous data for participants excluded from trial analysis: a guide for systematic reviewers. PLoS ONE 2013; 8: e57132.
    1. Ebrahim S, Akl EA, Mustafa RA, Sun X, Walter SD, Heels‐Ansdell et al Addressing continuous data for participants excluded from trial analysis: a guide for systematic reviewers. J Clin Epidemiol 2013; 66: 1014–1021.e1.
    1. Ebrahim S, Johnston BC, Akl EA, Mustafa RA, Sun X, Walter SD et al Addressing continuous data measured with different instruments for participants excluded from trial analysis: a guide for systematic reviewers. J Clin Epidemiol 2014; 67: 560–570.
    1. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck‐Ytter Y, Schünemann HJ et al What is ‘quality of evidence’ and why is it important to clinicians? BMJ 2008; 336: 995–998.
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck‐Ytter Y, Alonso‐Coello P et al GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924–926.
    1. Malik AA, Bari SU. Conservative management of acute appendicitis. J Gastrointest Surg 2009; 13: 966–970.
    1. Leeuwenburgh MM, Wiezer MJ, Wiarda BM, Bouma WH, Phoa SS, Stockmann HB et al Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg 2014; 101: e147–e155.
    1. Atema JJ, van Rossem CC, Leeuwenburgh MM, Stoker J, Boermeester MA. Scoring system to distinguish uncomplicated from complicated acute appendicitis. Br J Surg 2015; 102: 979–990.
    1. Rao PM, Rhea JT, Rattner DW, Venus LG, Novelline RA. Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates. Ann Surg 1999; 229: 344–349.
    1. Mariadason JG, Wang WN, Wallack MK, Belmonte A, Matari H. Negative appendicectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendicectomy. Ann R Coll Surg Engl 2012; 94: 395–401.
    1. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010; (10)CD001546.
    1. Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, Hirakawa K. Meta‐analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis. J Gastrointest Surg 2012; 16: 1929–1939.
    1. Flynn D, Knoedler MA, Hess EP, Murad MH, Erwin PJ, Montori VM et al Engaging patients in health care decisions in the emergency department through shared decision‐making: a systematic review. Acad Emerg Med 2012; 19: 959–967.

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