Abstract
Purpose
Appendectomy has been the gold standard for every form of appendicitis. In recent years, though, it has repeatedly been claimed that for acute uncomplicated appendicitis, antibiotic therapy can be an equivalent treatment. The aim of this meta-analysis was to determine if antibiotic therapy is a safe and effective alternative to appendectomy for acute uncomplicated appendicitis.
Methods
In a systematic literature review, relevant databases were searched for randomized studies comparing appendectomy with antibiotic treatment for uncomplicated acute appendicitis. Two independent reviewers performed study selection and data extraction. The primary endpoint was the successful treatment of appendicitis. Secondary endpoints were pain intensity, duration of hospitalization, absence from work, and the incidence of complications.
Results
Five randomized controlled studies (n = 1430 patients) fulfilled the inclusion criteria. Of the 727 patients treated initially with antibiotics, 272 (37.4%) underwent secondary appendectomy within 1 year (treatment effectiveness: 62.6% compared to 96.3% in the surgical group, RR 0.65, 95% CI 0.55–0.76, p < 0.00001). Neither duration of hospital stay (MD 0.11 days, 95% CI: − 0.22–0.43, p = 0.53) nor the probability of complication-free treatment (RR 1.08, 95% CI: 0.97–1.22, p = 0.16) were significantly different between the two treatments. Absence from work was significantly shorter in the antibiotic group (MD − 2.49 days, 95% CI: − 4.59–− 0.40, p = 0.02).
Conclusions
This meta-analysis shows that appendectomy is more effective than antibiotic therapy for definitive cure of acute uncomplicated appendicitis. However, since the incidence of complications does not differ between the two treatments, antibiotic therapy might be a reasonable alternative for selected patients.
Similar content being viewed by others
References
Addiss DG, Shaffer N, Fowler BS, Tauxe RV (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132(5):910–925
Fagerstrom A, Paajanen P, Saarelainen H, Ahonen-Siirtola M, Ukkonen M, Miettinen P, Paajanen H (2017) Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit. Scand J Gastroenterol 52(10):1072–1077. https://doi.org/10.1080/00365521.2017.1342140
Cervellin G, Mora R, Ticinesi A, Meschi T, Comelli I, Catena F, Lippi G (2016) Epidemiology and outcomes of acute abdominal pain in a large urban emergency department: retrospective analysis of 5,340 cases. Ann Transl Med 4(19):362. https://doi.org/10.21037/atm.2016.09.10
Sakorafas GH, Mastoraki A, Lappas C, Sampanis D, Danias N, Smyrniotis V (2011) Conservative treatment of acute appendicitis: heresy or an effective and acceptable alternative to surgery? Eur J Gastroenterol Hepatol 23(2):121–127. https://doi.org/10.1097/MEG.0b013e32834233b6
Harrison PW (1953) Appendicitis and the antibiotics. Am J Surg 85(2):160–163
Coldrey EJJICS (1959) Five years of conservative treatment of acute appendicitis. J Int Coll Surg 32(3):255–261
Kapischke M, Friedrich F, Hedderich J, Schulz T, Caliebe A (2011) Laparoscopic versus open appendectomy--quality of life 7 years after surgery. Langenbeck's Arch Surg 396(1):69–75. https://doi.org/10.1007/s00423-010-0715-1
Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Grönroos JM (2015) Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. Jama 313(23):2340–2348. https://doi.org/10.1001/jama.2015.6154
Elder DP, Kuentz M, Holm R (2016) Antibiotic resistance: the need for a global strategy. J Pharm Sci 105(8):2278–2287. https://doi.org/10.1016/j.xphs.2016.06.002
Hansson J, Korner U, Khorram-Manesh A, Solberg A, Lundholm K (2009) Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 96(5):473–481. https://doi.org/10.1002/bjs.6482
Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, Rex L, Badume I, Granström L (2006) Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicenter randomized controlled trial. World J Surg 30(6):1033–1037. https://doi.org/10.1007/s00268-005-0304-6
Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, Karoui M, Alves A, Dousset B, Valleur P, Falissard B, Franco D (2011) Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 377(9777):1573–1579. https://doi.org/10.1016/s0140-6736(11)60410-8
Eriksson S, Granstrom L (1995) Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 82(2):166–169
Wilms IM, de Hoog DE, de Visser DC, Janzing HM (2011) Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev (11):Cd008359. https://doi.org/10.1002/14651858.CD008359.pub2
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700. https://doi.org/10.1136/bmj.b2700
Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA (2011) The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. Bmj 343:d5928. https://doi.org/10.1136/bmj.d5928
Ryan R (2016) Cochrane Consumers and Communication Review Group. ‘Heterogeneity and subgroup analyses in Cochrane Consumers and Communication Group reviews: planning the analysis at protocol stage. http://cccrg.cochrane.org/sites/cccrg.cochrane.org/files/public/uploads/heterogeneity_subgroup_analyses_revising_december_1st_2016.pdf. Accessed 28 Jan 2019
Roberts KE, Starker LF, Duffy AJ, Bell RL, Bokhari J (2011) Stump appendicitis: a surgeon's dilemma. Jsls 15(3):373–378. https://doi.org/10.4293/108680811x13125733356954
Zhanel GG, Johanson C, Embil JM, Noreddin A, Gin A, Vercaigne L, Hoban DJ (2005) Ertapenem: review of a new carbapenem. Expert Rev Anti-Infect Ther 3(1):23–39
Paajanen H, Gronroos JM, Rautio T, Nordstrom P, Aarnio M, Rantanen T, Hurme S, Dean K, Jartti A, Mecklin J-P, Sand J, Salminen P (2013) A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial). BMC Surg 13:3 1471–2482 (Electronic)
Sippola S, Gronroos J, Tuominen R, Paajanen H, Rautio T, Nordstrom P, Aarnio M, Rantanen T, Hurme S, Salminen P (2017) Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 104(10):1355–1361. https://doi.org/10.1002/bjs.10575
Shaib WL, Assi R, Shamseddine A, Alese OB, Staley C 3rd, Memis B, Adsay V, Bekaii-Saab T, El-Rayes BF (2017) Appendiceal mucinous neoplasms: diagnosis and management. Oncologist 22(9):1107–1116. https://doi.org/10.1634/theoncologist.2017-0081
Lietzen E, Gronroos JM, Mecklin JP, Leppaniemi A, Nordstrom P, Rautio T, Rantanen T, Sand J, Paajanen H, Kaljonen A, Salminen P (2019) Appendiceal neoplasm risk associated with complicated acute appendicitis-a population based study. Int J Color Dis 34(1):39–46. https://doi.org/10.1007/s00384-018-3156-x
Hanson AL, Crosby RD, Basson MD (2018) Patient preferences for surgery or antibiotics for the treatment of acute appendicitis. JAMA Surg 153(5):471–478. https://doi.org/10.1001/jamasurg.2017.5310
Kadera SP, Mower WR, Krishnadasan A, Talan DA (2016) Patient perspectives on antibiotics for appendicitis at one hospital. J Surg Res 201(2):253–257. https://doi.org/10.1016/j.jss.2015.11.016
Harnoss JC, Zelienka I, Probst P, Grummich K, Muller-Lantzsch C, Harnoss JM, Ulrich A, Buchler MW, Diener MK (2017) Antibiotics versus surgical therapy for uncomplicated appendicitis: systematic review and meta-analysis of controlled trials (PROSPERO 2015: CRD42015016882). Ann Surg 265(5):889–900. https://doi.org/10.1097/sla.0000000000002039
Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, Pietrobon R (2004) Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 239(1):43–52. https://doi.org/10.1097/01.sla.0000103071.35986.c1
Ubbink DT, Hageman MG, Legemate DA (2015) Shared decision-making in surgery. Surg Technol Int 26:31–36
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Prechal, D., Damirov, F., Grilli, M. et al. Antibiotic therapy for acute uncomplicated appendicitis: a systematic review and meta-analysis. Int J Colorectal Dis 34, 963–971 (2019). https://doi.org/10.1007/s00384-019-03296-0
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-019-03296-0