1. ANTIBIOTICS VERSUS APPENDECTOMY AS INITIAL TREATMENT FOR ACUTE APPENDICITIS Aileen Hwang, MD R2 Swedish Medical Center Department of General Surgery

2.  First Anatomic Drawing?  1492 – Leonardo Da Vinci  When was appendicitis recognized to be a surgical disease? And by who?  1886-Reginal Heber Fitz  Harvard Pathologist  First to describe the appendectomy procedure?  1894 Charles McBurney

3. ACUTE APPENDICITIS  Accounts for over 1 million inpatient hospital days per year = >$3,000,000,000 a year  Lifetime risk of developing appendicitis is ~7% Occurs most frequently in 2 nd and 3 rd decades of life Incidence 233/100,000 in 10yo-19yo  Mortality is 0.2 deaths per 100,000

4. PATHOPHYSIOLOGY  Luminal obstruction  Subsequent localized venous ischemia  Mucosal disruption  Invasive bacterial infection  Localized inflammation  Progress to full thickness necrosis and possible gangrene of the appendiceal wall

5. GOLD STANDARD

9. METHODS  Study population >16 yo  Acute appendicitis determined by ‘anamnesis, abdominal status, laboratory tests’ CT and US used only in uncertain diagnoses  Offered antibiotics therapy as first choice Received 3 doses of Zosyn, 4g q8hr within the first 24 hours PO ciprofloxacin and PO flagyl for an additional 9 days **Patient could be removed from antibiotic pathway by ‘Surgeon in Charge’** Sahlgrenska University Hospital Gothensburg, Sweden

10. OUTCOME MEASURES  Primary Endpoints  Treatment efficacy  1 yr FU without recurrence and need for surgery  Major complications  Secondary Endpoints  Minor complications  Durations of hospital stay  Abdominal pain

11. RESULTS

12. RESULTS – PATIENT CHARACTERISTICS

13. RESULTS – PRIMARY OUTCOME TREATMENT EFFICACY

14. RESULTS

17. DISCUSSION  Lack of CT and US in diagnosis?  Study design represents algorithm that represents future application?  Would you change your practice?  Can relapse be treated with abx?

18. QUESTIONS?

19. REFERENCES Cameron and Cameron. Current Surgical Therapy 10th edition, Elsevier/Mosby, 2010 Fisher, J, Lowry, S. Master of Surgery: Appendicitis and Appendiceal abscess. 5 th edition; Lippincott and Williams, 2006. Hansson, J et al (2012) Antiobiotics as First-line therapy for Acute Appendicitis: Evidence for a change in clinical practice. World J Surgery 36(1): 2028-2036 Mulholland, Lillemoe, et al. Greenfield’s Surgery: Scientific Principles and Practice 3 rd edition. Lippincott and Williams, 2010. Varadhan et al safety and efficacy of Antibiotics compared with appendectomy for treatment of uncomplicated acut appendicitis: Meta analysis of randomized controlled trials

20. ALVARADO SCORE

22.  Primary outcome: complications  Wound infection  Incidence of perforated appendicitis or peritonitis  Secondary outcome  Length of primary hospital stay  Readmissions  Efficacy of treatment  Incidence of perforation  Pain  Body temperature