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Antibiotic Therapy Versus Appendectomy for Acute Appendicitis: A Meta-Analysis


World Journal of Surgery

World J Surg (2010) 34:199-209 DOI 10.1007/s00268-009-0343-5

ORIGINAL SCIENTIFIC REPORTS AND REVIEWS

Antibiotic Therapy Versus Appendectomy for Acute Appendicitis: A Meta-Analysis

Krishna K. Varadhan • David J. Humes • Keith R. Neal • Dileep N. Lobo

Published online: 30 December 2009

© Societe Internationale de Chirurgie 2009

Abstract

Background Antibiotic treatment has been shown to be effective in treating selected patients with acute appendi­citis, and three randomized controlled trials (RCTs) have compared the efficacy of antibiotic therapy alone with that of surgery for acute appendicitis. The purpose of this meta-analysis of RCTs was to assess the outcomes with these two therapeutic modalities.

Methods All RCTs comparing antibiotic therapy alone with surgery in patients over 18 years of age with sus­pected acute appendicitis were included. Patients with suspected perforated appendix or peritonitis, and those with an allergy to antibiotics had been excluded in the RCTs. The outcome measures studied were complications, length of hospital stay, and readmissions.

Results Meta-analysis of RCTs of antibiotic therapy versus surgery showed a trend toward a reduced risk of complications in the antibiotic-treated group [RR (95%CI): 0.43 (0.16, 1.18) p = 0.10], without prolonging the length of hospital stay [mean difference (inverse variance, ran­dom, 95% CI): 0.11 (-0.22, 0.43) p = 0.53]. Of the 350

This article was presented at the Annual Conference of the Society for Academic and Research Surgery, London, January 2010.

K. K. Varadhan • D. J. Humes • D. N. Lobo (&) Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen‘s Medical Centre, Nottingham NG7

2UH, United Kingdom

e-mail: dileep.lobo@nottingham.ac.uk

K. R. Neal

Department of Epidemiology and Public Health, and Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen‘s Medical Centre, Nottingham NG7 2UH, United Kingdom

patients randomized to the antibiotic group, 238 (68%) were treated successfully with antibiotics alone and 38 (15%) were readmitted. The remaining 112 (32%) patients randomized to antibiotic therapy crossed over to surgery for a variety of reasons. At 1 year, 200 patients in the antibiotic group remained asymptomatic. Conclusions This meta-analysis suggests that although antibiotics may be used as primary treatment for selected patients with suspected uncomplicated appendicitis, this is unlikely to supersede appendectomy at present. Selection bias and crossover to surgery in the RCTs suggest that appendectomy is still the gold standard therapy for acute appendicitis.

Introduction

Acute appendicitis is one of the commonest of surgical emergencies, and appendectomy has become established as the gold standard of therapy. However, as the diagnosis of appendicitis in most countries is mainly a clinical one, based on history and examination, diagnostic uncertainty in patients with suspected appendicitis may lead to a delay in treatment or negative surgical explorations, adding to the morbidity associated with the condition [1].

Traditionally, patients with no overt diagnostic signs such as right iliac fossa guarding or peritonism are moni­tored for changes in clinical signs with or without having been started on antibiotic therapy [2]. While antibiotics are indicated in patients with signs of peritonism, their role in the routine treatment of acute non-perforated appendicitis is still debatable [3, 4]. Some studies have reported that antibiotic therapy reduces wound and intra-abdominal septic complications following surgery [5, 6]. Although antibiotic therapy has been shown to be effective in treating

1 Springer

200 World J Surg (2010) 34:199-209

selected patients with suspected acute appendicitis, their role in the primary treatment of the disease has not yet been established clearly. Over the past two decades three ran­domized clinical trials (RCTs) [7-9] have compared the efficacy of antibiotic therapy alone with that of surgery for acute appendicitis. The purpose of the present study was to perform a meta-analysis of RCTs in order to assess the outcomes with the two therapeutic modalities.

Methods

All RCTs in which patients over 18 years of age with suspected acute appendicitis were randomized to antibiotic therapy alone or surgery (appendectomy) at initial pre­sentation were included. Patients with suspected perforated appendix or peritonitis, and those with allergy to antibiotics used in the protocols had been excluded in the RCTs.

The primary outcome measure of this meta-analysis was complications, as described in the individual RCTs [7-9] (major complications such as reoperation, abscess, small bowel obstruction, wound rupture, wound hernia, deep vein thrombosis, pulmonary embolism, postoperative cardiac problems, and need for ileocecal resection, as well as minor complications such as prolonged postoperative course, bladder dysfunction, anesthesia-related complications, diarrhea, Clostridium difficile infection, fungal infection, and wound infection among others). Secondary outcome measures included length of hospital stay and readmission rates.

Search strategy

The Medline, Embase and Cochrane Library databases were searched for RCTs comparing antibiotic therapy with sur­gery for suspected acute appendicitis, published between January 1966 and June 2009. The MESH terms, antibiotics, surgery, appendicectomy, appendectomy, randomized controlled trial, controlled clinical trial, randomized, pla­cebo, drug therapy, randomly, trial, and groups were used in combination with the Boolean operators AND, OR, and NOT. The ‘‘related article‘‘ function was used to identify other eligible studies for inclusion in the meta-analysis. The search included publications in all languages.

Data collection and analysis

Two review authors (K.K.V. and K.R.N.) inspected the citations identified from the search, and the retrieved arti­cles were assessed according to the previously defined criteria for inclusion in the meta-analysis. The data were extracted from the included RCTs by the authors (K

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