Article PDF: 2. antibiotics versus appendicectomy

Meta‐analysis of antibiotics versus appendicectomy for non‐perforated acute appendicitis

Although appendectomy is generally well tolerated, it is a major surgical intervention and can be associated with postoperative morbidity. Recently, an increasing amount of evidence has been reported showing that the majority of patients with uncomplicated acute appendicitis may be treated with antibiotics alone instead of surgery. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis.

A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis.

This review demonstrated both advantages and disadvantages to an initial management strategy of antibiotics with appendicectomy.

Advantages of the antibiotic regimen include:

• a potentially lower rate of major complications (primarily appendiceal perforations)
• a potentially lower rate of minor complications
• potentially shorter sick leave
• a lower rate of appendicectomies in the first month after presentation

Disadvantages of the antibiotic regimen include:

• a 22.6% incidence of recurrence of appendicitis at 1 year (high‐quality evidence)
• potentially longer hospital stay (by 0·4 days, moderate‐quality evidence)

In conclusion, this review provides valuable evidence regarding the outcomes of antibiotic first versus immediate surgery for acute non-perforated appendicitis. The trade-off between the antibiotic-first approach-potentially 3% fewer major complications, 7% fewer minor complications, 4 days’ shorter sick leave and 92% fewer appendicectomies in the first month – must be balanced against the disadvantages: a 23% recurrence rate within 1 year and slightly longer hospital stay (half a day). Patients averse to surgery are likely to choose an initial trial of antibiotics; those averse to the possibility of recurrence may prefer immediate appendicectomy. Ensuring that the decision is consistent with patients’ values and preferences requires shared decision‐making.