IMPORTANCE: Antibiotic therapy is effective and safe for uncomplicated acute appendicitis in adults, but randomized clinical trial results exceeding 5 years are missing.
OBJECTIVE: To determine the 10-year appendicitis recurrence and appendectomy rate in patients with uncomplicated appendicitis treated with antibiotics.
DESIGN, SETTING, AND PARTICIPANTS: Ten-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotics at 6 Finnish hospitals from November 2009 to June 2012, where 530 patients (aged 18-60 years) with uncomplicated acute appendicitis diagnosed by computed tomography were randomly assigned to appendectomy (n = 273) or antibiotics (n = 257). Last follow-up was April 29, 2024. This current analysis focused on assessing the 10-year appendicitis recurrence rate among patients assigned to antibiotics.
INTERVENTIONS: Open appendectomy vs antibiotics with intravenous ertapenem sodium (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times/d).
MAIN OUTCOMES AND MEASURES: Prespecified 10-year secondary end points included late (after 1 year) appendectomy and appendicitis recurrence rate after antibiotics and complications. Post hoc outcomes included the detection of possible appendiceal tumors among patients in the antibiotic group undergoing appendectomy or with an intact appendix using magnetic resonance imaging. Additional post hoc outcomes were quality of life and patient satisfaction.
RESULTS: At 10-year follow-up, 253/257 patients (98.4%) randomized to receive antibiotics (median age, 33 years; 102 [40.3%] female) were assessed for appendicitis recurrence, with a true appendicitis recurrence rate (appendicitis at histopathology) of 37.8% (95% CI, 31.6%-44.1% [87/230]) and a cumulative appendectomy rate of 44.3% (95% CI, 38.2%-50.4% [112/253]). Overall, the 10-year cumulative complication rate in the group randomized to appendectomy was 27.4% (95% CI, 21.6%-33.3% [62/226]) and 8.5% (95% CI, 4.8%-12.1% [19/224]) in the group randomized to receive antibiotics (P < .001). There was no observed significant difference in quality of life between antibiotics and appendectomy (387/530; median health index value, 1.0 [95% CI, 1.0-1.0] for both groups; P = .18).
CONCLUSIONS AND RELEVANCE: Among patients initially treated with antibiotics for uncomplicated acute appendicitis, the rate of recurrence and appendectomy at 10-year follow-up supports the use of antibiotics as an option for uncomplicated acute appendicitis in adult patients.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01022567.
| Discipline Area | Score |
|---|---|
| Surgery - General |  |
| Emergency Medicine |  |
| Surgery - Gastrointestinal |  |
| Infectious Disease | |
| Hospital Doctor/Hospitalists | Coming Soon... |
| Internal Medicine | Coming Soon... |
I do not think that any emergency medicine physician would select antibiotics rather than surgery without engaging a surgeon to evaluate the patient and engage in shared decision-making, so this topic is of peripheral relevance to EM physicians. However, EM physicians ought to be aware that the 10-year outcomes of patients with appendicitis treated with antibiotics rather than surgery are equivalent to the surgical option. Someday, this option should be part of EM clinical practice guidelines for appendicitis (http://pmid.us/37210169 and http://pmid.us/35543712).
Long-term outcomes (i.e., 10 years) showed similar quality of life between those who received an appendectomy vs antibiotics. Recurrent appendicitis requiring appendectomy was 44% in the 10-year follow up for those who initially received antibiotics, although the total complication rate was higher in the appendectomy group vs antibiotic group (27.4% vs 8.5%). Interestingly, more than half would not choose antibiotics who subsequently required an appendectomy, which is much higher compared with antibiotics only (and no subsequent appendectomy) or those randomized to appendectomy. It would be interesting to see the cost analysis of this. It does seem like shared decision making is needed as there is a high level of need for appendectomy for thoes initially treated with antibiotics. It would be interesting to see for those with recurrent appendicits if repeat antibiotics would also reduce the need for appendectomy.
This study extends the followup of patients with acute appendicitis who were treated with antibiotics from 5 to 10 years, and continues to show it as a reasonable alternative to immediate surgery
The conclusion of the study outcome is in the eyes of the beholder. If someone with uncomplicated acute appendicitis is told that treatment with antibiotics caries a success rate of 61.2% in preventing recurrence and a success rate of 55.7% in avoiding appendectomy over the next 10 years (the other coin of the results), I suspect many would elect earlier surgery, particularly if the 15- or 20-year outcome follows the same trend.
Interesting that the surgical group had more complications over 10 years - why? If antibiotics are now 'in' for appendicitis, this means that it will become yet another Medicine rather than Surgery problem.
Unhelpful study. Open appendectomy is an incorrect approach. Intravenous ertapenem is not a light treatment. A rate > 44% of appendectomy during follow-up after antibiotic is not a good result for the conservative arm.
Top-notch article. I very strongly recommend.