Royal College Ireland: Surgery best for acute uncomplicated appendicitis

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A Royal College of Surgeons in Ireland study conducted in Beaumont Hospital in Dublin has found that surgery, rather than antibiotics-only, should remain as the mainstay of treatment for acute uncomplicated appendicitis.

Led by researchers from the RCSI University of Medicine and Health Sciences, the COMMA trial (Conservative versus Open Management of Acute uncomplicated Appendicitis) examined the efficacy and quality of life associated with antibiotic-only treatment of acute uncomplicated appendicitis versus surgical intervention. The results revealed that antibiotic-only treatment resulted in high recurrence rates and an inferior quality of life for patients.

Acute uncomplicated appendicitis is a commonly encountered acute surgical condition. Traditional management of the condition has involved surgery to remove the appendix (appendectomy). Antibiotic-only treatment has emerged as a potential alternative option that could offer benefits to patients and hospitals, such as a faster recovery, less scaring, less pain, a better quality of life for patients and reduced demand on operating theatres. There has been a reluctance to adopt antibiotic-only treatment due to previous research that has shown wide variability in failure rates and a lack of evidence regarding the impact on quality of life for patients.

In this research, 186 patients with radiological evidence of acute, uncomplicated appendicitis were randomised to two groups. One group received antibiotic-only treatment and patients in the other group were treated with surgery. Patients in the surgery group underwent a laparoscopic appendectomy. In those treated with antibiotics-only, intravenous (IV) antibiotics were administered until there was an improvement in a patient's signs and symptoms and this was followed by five days of oral antibiotics.

In the weeks and months following treatment, patients were followed up with questionnaires including a quality of life questionnaire at 1 week, 1 month, 3 months and 12 months. At these points, the patient's pain score, need for additional sick leave, surgical site infections and the development of recurrent appendicitis were recorded.
The results from the antibiotic-only group demonstrated that 23 patients (25%) experienced a recurrence of acute appendicitis within one year. In the quality of life questionnaires, it was found that patients in the surgery group experienced a significantly better quality of life score compared with the antibiotic-only group.

Professor Arnold Hill, head of School of Medicine and professor of surgery, RCSI, said: “Antibiotic-only treatment of acute uncomplicated appendicitis has been proposed as an alternative less-invasive treatment option for patients. The COMMA Trial set out to establish if antibiotic-only treatment could replace surgery in some cases, which could offer many benefits for patients and hospitals alike. The results indicate that the treatment protocols should not change. Surgery will deliver the best outcomes for patients in terms of quality of life and recurrence and therefore should remain as the mainstay of treatment for acute uncomplicated appendicitis.”

The study was carried out by researchers from RCSI and Beaumont Hospital Dublin. The research was supported by RCSI.

 

Study details
A Randomised Clinical Trial Evaluating the Efficacy and Quality of Life of Antibiotic Only Treatment of Acute Uncomplicated Appendicitis

Donal Peter O’Leary, Siun M Walsh, Jarlath Bolger, Chwanrow Baban, Hilary Humphreys, Sorcha O’Grady, Aisling Hegarty, Aoife M Lee, Mark Sheehan, Jack Alderson, Ruth Dunne, Martina M. Morrin, Michael J Lee, Colm Power, Deborah McNamara, Niamh McCawley, Will Robb, John Burke, Jan Sorensen, Arnold D Hill

Published in Annals of Surgery on 1 February 2021

Abstract
Objective
Evaluate the efficacy and quality of life associated with conservative treatment of acute uncomplicated appendicitis.
Summary background data
Conservative management with antibiotics only has emerged as a potential treatment option for acute uncomplicated appendicitis. However the reported failure rates are highly variable and there is a paucity of data in relation to quality of life.
Methods
Symptomatic patients with radiological evidence of acute, uncomplicated appendicitis were randomised to either intravenous antibiotics only or undergo appendectomy.
Results
186 patients underwent randomisation. In the antibiotic only group, 23 patients (25.3%) experienced a recurrence within one year following randomisation. There was a significantly better EQ-VAS quality of life score in the surgery group compared to the antibiotic only group at 3 months (94.3 v 91.0, p < 0.001) and 12 months post intervention (94.5 v 90.4, p < 0.001). The EQ-5D-3L quality of life score was significantly higher in the surgery group indicating a better quality of life (0.976 v 0.888, p < 0.001). The accumulated 12-month sickness days was 3.6 days shorter for the antibiotics only group (5.3 vs 8.9 days; p < 0.01). The mean length of stay in both groups was not significantly different (2.3 v 2.8 days, p = 0.13). The mean total cost in the surgery group was significantly higher than antibiotics only group (€4,816 v €3,077, p < 0.001).
Conclusions
Patients with acute, uncomplicated appendicitis treated with antibiotics only experience high recurrence rates and an inferior quality of life. Surgery should remain the mainstay of treatment for this commonly encountered acute surgical condition.

 

RCSI material

 

Annals of Surgery study (Restricted access)

 

 

See also MedicalBrief archives:

Antibiotics compared to surgery in treating appendicitis — Randomised trial

 

Antibiotics alone an alternative to surgery for appendicitis in children

 

Antibiotics an alternative to surgery for appendicitis

 

Antibiotic treatment of acute appendicitis mostly safe for children

 

Surgical removal still recommended for appendicitis

 

Treating child appendicitis

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