Conservative treatment of acute appendicitis.
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ABSTRACT:
SUBMITTER: Coccolini F
PROVIDER: S-EPMC6502196 | biostudies-literature | 2018 Dec
REPOSITORIES: biostudies-literature
Publications
Conservative treatment of acute appendicitis.
Coccolini Federico F Fugazzola Paola P Sartelli Massimo M Cicuttin Enrico E Sibilla Maria Grazia MG Leandro Gioacchino G De' Angelis Gian Luigi GL Gaiani Federica F Di Mario Francesco F Tomasoni Matteo M Catena Fausto F Ansaloni Luca L
Acta bio-medica : Atenei Parmensis 20181217 9-S
Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or ...[more]
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Project description:BACKGROUND:Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist. METHODS:PUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS:Thirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success. CONCLUSION:While further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management. LEVEL OF EVIDENCE:Systematic review, level II.
| S-EPMC6437084 | biostudies-literature
Project description:BackgroundAppendectomy is the gold standard for treatment of acute appendicitis. However, recent studies favor primary antibiotic therapy. The aim of this observational study was to explore changes in the numbers of operations for acute appendicitis in the period 2010-2017, paying special attention to disease severity.MethodsData from diagnosis-related group statistics were used to analyze the trends, mortality, and complication rates in the surgical treatment of appendicitis in Germany between 2010 and 2017. All cases of appendectomy after a diagnosis of appendicitis were included.ResultsAltogether, 865 688 inpatient cases were analyzed. The number of appendectomies went down by 9,8%, from 113 614 in 2010 to 102 464 in 2017, while the incidence fell from 139/100 000 in 2010 to 123/100 000 in 2017 (standardized by age group). This decrease is due to the lower number of operations for uncomplicated appendicitis (79 906 in 2017 versus 93 135 in 2010). Hospital mortality decreased both in patients who underwent surgical treatment of complicated appendicitis (0.62% in 2010 versus 0.42% in 2017) and in those with a complicated clinical course (5.4% in 2010 versus 3.4% in 2017).ConclusionDecisions on the treatment of acute appendicitis in German hospitals follow the current trend towards non-surgical management in selected patients. At the same time, the care of acute appendicitis has improved with regard to overall hospital morbidity and hospital mortality.
| S-EPMC8283679 | biostudies-literature
Project description: Not available
| S-EPMC9565953 | biostudies-literature
Project description:BackgroundCurrently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial.Methods/designThe study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery.DiscussionIn this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design.Trial registrationISRCTN15830435 . Registered on 8 February 2017.
| S-EPMC5833142 | biostudies-literature
Project description:Acute appendicitis manifests in two microbiome state types, with oral pathogens driving severity
| PRJEB49215 | ENA
Project description:Gene expression was evaluated in 9 appendix samples removed from patients who went to the operating room with the diagnosis of acute appendicitis and 4 samples removed for non-inflammatory reasons. A circumferential piece of tissue was obtained at the distal aspect of each specimen. The tissue was flash frozen at -80 degrees for later processing. Frozen specimens were homogenized into TriReagent and RNA was isolated according to the manufacturer's instruction. RNA was processed and hybridized to Affymetrix microarray. Keywords: Disease state analysis
2008-04-22 | GSE9579 | GEO
Project description:Antibiotic treatment of acute appendicitis has gained interest and inquiries. Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis, but information on long-term results is required. Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis.Patients with favourable response to antibiotics in earlier randomized (RCT, n = 97) and population-based (PBT, n = 342) studies as well as subsequently treated non-randomized (Non-R, n = 271) patients are evaluated for long-term risk to relapse demanding surgical appendectomy; altogether 710 patients.Clinical characteristics among randomized and non-randomized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation (CRP, WCC) when antibiotic treatment started. Females and males showed the same results. The median follow-up time was 2162 days (5.92 years), and the range across highest and lowest follow-up was 3495 days (range 2-3497) for the entire group, without significant differences among subgroups (RCT, PBT, Non-R). The cumulative probability for relapse of appendicitis demanding appendectomy was: 0.09, 0.12, 0.12 and 0.13 at 1-, 2-, 3- and 5-year follow-up, with a probability of 0.86 ± 0.013 without appendectomy after 8 years. This may imply an overall benefit of 60-70% by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10-23% in our published reports.Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15% for long-term relapse following favourable initial treatment response.
| S-EPMC5544800 | biostudies-other
Project description:Gene expression was evaluated in 9 appendix samples removed from patients who went to the operating room with the diagnosis of acute appendicitis and 4 samples removed for non-inflammatory reasons. A circumferential piece of tissue was obtained at the distal aspect of each specimen. The tissue was flash frozen at -80 degrees for later processing. Frozen specimens were homogenized into TriReagent and RNA was isolated according to the manufacturerâs instruction. RNA was processed and hybridized to Affymetrix microarray. Experiment Overall Design: 9 patients and 4 controls
2008-06-16 | E-GEOD-9579 | biostudies-arrayexpress
Project description:Importance:Studies have compared surgical with nonsurgical therapy for acute uncomplicated appendicitis, but none of these studies have a patient-centered perspective. Objectives:To evaluate how patients might choose between surgical and nonsurgical therapy for acute uncomplicated appendicitis and to identify targets to make antibiotic treatment more appealing. Design, Setting, and Participants:This study comprised an online survey and an in-person sensitivity analysis survey. For the web survey, a convenience sample of 1728 respondents were asked to imagine that they or their child had acute uncomplicated appendicitis, provided information about laparoscopic and open appendectomy and antibiotic treatment alone, and asked which treatment they might choose. The web survey was open from April 17, 2016, through June 16, 2016, and was disseminated via email link, a poster with a Quick Response code, and social media. For the sensitivity analysis, 220 respondents were given the same scenario and options. Those who chose surgery were asked whether certain factors influenced their decision; each factor was incrementally improved during questioning about whether respondents would consider switching to antibiotics. These participants were recruited at public venues from June 3, 2016, to July 31, 2016. Web survey data were analyzed from June 17, 2016, to September 21, 2017. Sensitivity analysis data were analyzed from August 1, 2016, to September 21, 2017. Main Outcomes and Measures:Treatment preferences. Results:Among the 1728 web survey respondents, 1225 (70.9%) were female and 500 (28.9%) were male (3 [0.2%] either did not answer or responded as "gender fluid" within the comments section of the survey), and most self-reported being between 50 and 59 years of age (391 [22.6%]) and being non-Hispanic white (1563 [90.5%]). For themselves, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84 (4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone. For their child, 1372 respondents (79.4%) chose laparoscopic appendectomy, 106 (6.1%) open appendectomy, and 250 (14.5%) antibiotics alone. Respondents were somewhat more likely to choose antibiotics for themselves if they had education beyond college (105 [12.6%]; P?<?.001), identified as other than non-Hispanic white (24 [14.9%]; P?<?.001), or did not know anyone who had previously been hospitalized (12 [15.8%]; P?=?.02), but they were less likely to choose antibiotics if they were surgeons (11 [5.4%]; P?=?.008). Of the 220 participants interviewed for the sensitivity analysis, 120 (54.5%) were female and 100 (45.5%) were male, and most self-reported being between 18 and 24 years of age (53 [24.1%]) and being non-Hispanic white (204 [92.7%]). Their responses suggested that improvements in the short- and long-term failure rate of antibiotic treatment-rather than reductions in the duration of hospitalization or antibiotic treatment-were more likely to increase the desirability of choosing antibiotics. Conclusions and Relevance:Most patients may choose surgical intervention over antibiotics alone in treatment of acute uncomplicated appendicitis, but a meaningful number may choose nonoperative management. Therefore, from a patient-centered perspective, this option should be discussed with patients, and future research could be directed at reducing the failure and recurrence rates of antibiotic treatment for appendicitis.
| S-EPMC5875347 | biostudies-literature