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Analysis

Appendicectomy remains treatment of choice for patients with acute appendicitis

BMJ 2023; 382 doi: https://doi.org/10.1136/bmj-2022-074652 (Published 21 August 2023) Cite this as: BMJ 2023;382:e074652

Rapid Response:

Re: Appendicectomy remains treatment of choice for patients with acute appendicitis

Dear Editor,

We read with interest the recent ‘Analysis’ piece regarding the role of non-operative management in patients with acute appendicitis. In this, the authors argue that the risks associated with non-operative management mean that surgery is the ‘best’ approach. We believe that in selected cases, surgery is not the ‘best’ option and that for shared decision making, non-operative management needs to be offered to the patient.

The authors base their conclusion on several aspects - the comparative complication rate, the risk of recurrence or missing a malignancy, cost effectiveness and patient satisfaction. A recent meta-analysis did not show a significant difference in post-treatment complication rate between patients treated with surgery or antibiotics.[1] The authors criticise studies for not including recurrence as a complication in patients treated non-operatively and cite a selection of articles to justify their arguments. There is, however, a wealth of literature that disagrees with this view. We would argue that just as cancer recurrence is not considered a complication, appendicitis recurrence should not be considered a complication. Patients opting for antibiotics who are appropriately informed as part of shared decision making, will be acknowledging and accepting this foreseeable risk of long term failure of medical management.

The authors cite organ failure as a complication of antibiotic usage in the CODA trial, however a review of the CODA paper contains no mention of organ failure.[2] Importantly the CODA trial clearly attributes the higher rate of complications in the antibiotic arm of the trial to patients with an appendicolith, rather than those without.[2] This has confirmed, as previously thought, that appendicitis with an appendicolith should be treated as a different pathology and not be managed non-operatively.[3]

Appendiceal malignancy remains a rarity (occurring in approximately 1.5% of cases).[4] It occurs most commonly in patients aged >40 and has been strongly associated with CT proven complicated appendicitis.[4] It is therefore imperative to disentangle the considerations for varied patient populations and ensure that decisions are made contextually, accepting the evidence base for antibiotic management in the younger, uncomplicated group, where the malignancy risk is notably low.

Despite claiming a lack of robust cost analysis studies, the authors cited a comprehensive cost-effectiveness study, which considers the cost of repeat presentations.[5] Cost-effectiveness analysis that include wider societal costs are available from the APPAC teams, which favoured antibiotic therapy.[6] CODA and APPAC found operative patients had significantly longer time away from work or caregiving, which formed the majority of the societal cost.[2, 6]

Other aspects which we feel the authors may have omitted include patient choice, healthcare system and paediatric patients. Patient choice is fundamental within the shared decision making model. Several studies have shown that when presented with balanced and comprehensive information regarding both treatment choices, there remains a substantial percentage of patients who would prefer a trial of antibiotic management.[7, 8] The presumption that surgery is best risks surgeons not disclosing the alternative of antibiotics treatment to their patients, therefore denying them of choice (as well as being a clear breach of GMC guidance regarding consent). The authors do not consider global access to safe anaesthesia and surgery worldwide; the risk profile may alter considerably in low-income versus middle or high-income countries. Finally, the authors make no mention of children in their article despite a wealth of paediatric literature on the topic and ongoing research. Thus ensues a risk that children, as well as adults, may be denied the option of antibiotic treatment for uncomplicated appendicitis despite evidence of efficacy and safety.

References
Herrod PJJ, Kwok AT, Lobo DN. Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis. BJS Open [Internet]. 2022 Jul 7 [cited 2023 Sep 29]; 6(4): zrac100. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9379374/.

CODA Collaborative, Flum DR, Davidson GH, Monsell SE, Shapiro NI, Odom SR et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020;383:1907–1919.

Di Saverio S, PoddaM, De Simone B, Ceresoli M, Augustin G, Gori A et al. Diagnosis and treatment of acute appendicitis: 2020 update of theWSES Jerusalem guidelines. World J Emerg Surg 2020;15:27.

Naar L, Kim P, Byerly S, Vasileiou G, Zhang H, Yeh DD, Kaafarani HMA; EAST Appendicitis Study Group. Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study. Surgery. 2020 Oct;168(4):701-706.

Javanmard Emamghissi H, Hollyman M, Boyd-Carson H, Doleman B, Adiamah A, Lund JN et al. Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study. Br J Surg. November 2021; 108 (11): 1351–1359.

Sippola S , Grönroos J, Tuominen R, Paajanen H, Rautio T, Nordström P et al. Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 2017;104:1355–1361.

Bom WJ, Scheijmans JCG, Gans SL, Van Geloven AAW, Boermeester MA. Population preference for treatment of uncomplicated appendicitis [internet]. BJS Open, July 2021; 5(4): zrab058. Available from: https://doi.org/10.1093/bjsopen/zrab058.

Hanson AL, Crosby RD, Basson MD. Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis. JAMA Surg. 2018 May 1;153(5):471-478.

Competing interests: No competing interests

10 October 2023
Hannah M Javanmard-Emamghissi
Surgeon
N Hall, D MacAfee, S Moug, GM Tierney
University of Nottingham
University of Nottingham at Graduate Entry Medicine and Health, Royal Derby Hospital, Derby, United Kingdom, DE22 3NE