Appendicitis --- Operate or Antibiotics?

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Presentation transcript:

Appendicitis --- Operate or Antibiotics? E. Patchen Dellinger, MD University of Washington

Operate of Course ! ! Duuhh

Ultrasound Findings after Antibiotic Rx of Appendicitis Ultrasound helpful to verify response and see failures 7/19 (37%) failures to O.R. in 1 year Eriksson. Acta Radiologica 1995; 36: 173-7

Randomized Trial – O.R. vs. Antibiotics Amox/Clav 8-16 days O.R. (119) Ab (120) 30 d peritonitis 2 (2%) 9 (8%) Length of stay 3.04 d 3.96 d Appe_itis at 30d 0 14 (12%) Appe_itis 30d-1 yr 0 30 (25%) SBO at 1 year 0 1 Vans. Lancet 2011; 377:1573-9

NOTA (Nonoperative Treatment for Acute Appendicitis) –Amox/Clav To O.R. in 7d 19/159 (12%) SSI 6/19 (32%) Recurrence in 2 yr 22/140 (16%) To O.R. 7 d-2 yr 8/140 (6%) Total operations @ 2 yr 27/159 (17%) Di Saverio. Ann Surg 2014; 260: 109-17

Surgical Appendectomy Length of Hospital Stay Time of Adm 0700-1500 32.3 hr 1500-2300 28.1 hr 2300-0700 25.0 hr Ave for 176 pts 27.9 hr Crandall. Surg Infect 2009; 10: 65-69

Randomized Trial – Children Appendectomy vs. Antibiotics Appe (26) Ab (24) Complications 0 2 O.R. 1 d – 1 yr 0 9/24 (38%) Length of Stay 34.5 hr 51.5 hr Svensson. Ann Surg 2015; 261: 67-71

Varadhan Meta-analysis 5 studies with 900 pts Surgery Antibiotic Total 430 470 “Success” 398 (93%) 274 (58%) Recurrence 0 68 (14%) Late Surgery -- 158 (34%) Varadhan. BMJ 2012; 344: e2156

Appendicitis – L.O.S. & Charges CA Office Statewide Health Planning & Development 231,678 patients Surg Ab p L.O.S. (days) 2.1 4.4 <0.001 Cost (x $1,000) 23.2 36.2 <0.001 McCutcheon. J Amer Coll Surg 2014; 218: 905-13

Cochrane Review Cured within 2 weeks and No Recurrence in 2 years Appendectomy 97.4% Antibiotics 73.4% Wilms.Cochrane DataSyst Rev 2011; #11.CD008359

Meta-Analysis Appendectomy vs. Ab First Negative appendectomy 11% Recurrence after Ab 14% Range 7% – 35% over 1 year 14% / 0.89 16% Mason. Surg Infect 2012; 13:74-84

Treatment Failure Index Adm Appendectomy vs. Ab First Mason. Surg Infect 2012; 13:74-84

Overall Treatment Failure Appendectomy vs. Ab First Mason. Surg Infect 2012; 13:74-84

Length of Stay Appendectomy vs. Ab First Mason. Surg Infect 2012; 13:74-84

Better to Operate Fewer failures No recurrence Less expensive Less time in hospital

Rebuttal

Be Modern Single Incision Appendectomy