In Appendicitis Acuta (APPAC), a multicenter randomized clinical trial in Finland, 530 patients with uncomplicated acute appendicitis (UAA) were randomly assigned to undergo an appendectomy (n=273) or to receive antibiotics (n=256). An observational follow-up study looked at outcomes in both groups at five years. In addition to the 70 patients who first received antibiotics but had appendectomy within a year, 30 additional patients in the antibiotic group (16.1%) had appendectomy between one and five years. Cumulative incidence of appendicitis recurrence was 34.0% at two years, 35.2% at three years, 37.1% at four years, and 39.1% at five years. At five years, the overall complication rate (surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms) was 24.4% in the appendectomy group and 6.5% in the antibiotic group (P<0.001).
The follow-up study was published Sept. 25, 2018, in JAMA. The following commentary by Markos Kalligeros, MD, and Eleftherios Mylonakis, MD, PhD, appeared in the ACP Journal Club section of the Jan. 15 Annals of Internal Medicine.
Salminen and colleagues compared broad-spectrum antibiotic therapy with open surgery for treating patients with UAA. Although noninferiority for the nonsurgical approach at 1 year was not proven, delay of surgery in these patients resulted in no major complications.
Possible candidates for nonoperative management must be chosen carefully because current guidelines counter such approaches for treating UAA. Patients 18 to 60 years of age presenting with CT-confirmed UAA without fecalith who either refuse or are unable to have appendectomy could be considered. Also, when surgery is not readily accessible or patients want to choose their surgeon, antibiotic coverage could be provided without the need for emergency procedures and fear of a major complication. Although there is substantial risk for recurrent appendicitis, such patients could also be given the chance to share in the decision making for their treatment. However, despite low complication risks with the nonoperative approach in the APPAC trial, we need more such trials with adequate follow-up periods to answer questions about long-term complications.
The broad-spectrum antibiotic regimen used in APPAC may not be appropriate for all patients, and this must be taken into consideration. A more targeted approach should be evaluated in future trials for patients at low risk for infection with multidrug-resistant organisms. Moreover, other supportive care, such as IV fluids, analgesics, and antipyretics, should be considered, evaluated, and optimized. Finally, increasing use of laparoscopic vs standard open surgical approaches could reduce hospital stays and such complications as pain and infection. Trials comparing nonsurgical management with laparoscopic treatment for UAA are needed to fully estimate any potential benefit.