Doubts About Cutting It Out: Systematic Review and Meta-analysis of Patient-Centered Outcomes in Nonoperative Management vs Surgery in Acute Uncomplicated Appendicitis in Adults

Luo, William; Halabi, Reem; Dodo-Williams, Taiwo; Lobova, Veronika A; Matson, Jared; Cui, Christina; Heskett, Karen; Ramamoorthy, Sonia; Singh, Siddharth; Lopez, Nicole

doi:10.1016/j.jamcollsurg.2021.07.170

Cited by 2 publications

(3 citation statements)

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“…Indeed, several recent prospective randomized control trials both in Europe and the USA have demonstrated non-inferiority of antimicrobial-based pharmacologic management of early-stage acute appendicitis compared with appendectomy [15][16][17][18][19]. While these results have been met with great interest, and have provided therapeutic alternatives in the appropriate patient, the incidence of recurrent acute appendicitis, principally in patients with an appendicolith, ranging from 24 to 31%, is seen by some as a failure of non-operative management [20,21]. Thus, outcomes related to surgical removal of the appendix remain of great importance for surgeons, Emergency Medicine clinicians, Primary Care physicians, as well as patients and their families.…”

Section: Discussionmentioning

confidence: 99%

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Bass

Kaplan

Forssten

et al. 2023

Eur J Trauma Emerg Surg

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Introduction Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. Material and methods We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). Results Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41–0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11–0.96), p = 0.045] complications could be detected when using energy devices. Conclusions Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

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Section: Discussionmentioning

confidence: 99%

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Bass

Kaplan

Forssten

et al. 2023

Eur J Trauma Emerg Surg

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“…4 When considering and implementing methods for the standard of care, surgical intervention with an appendectomy is still the standard method of care if delaying the procedure could increase the in-hospital length of stay (H-LOS), the likelihood of later or recurrent hospital admissions, or more importantly, cause harm to the patient. 3 While there are systematic reviews and meta-analyses evaluating the difference in outcomes, rate of complications, and length of hospitalization between appendectomy and antibiotics, 1,[5][6][7][8][9][10][11] most of them have analyzed studies of varying qualities of evidence. The two reviews that have previously assessed Level 1 quality of evidence were limited in the number of studies included in the analysis.…”

Section: Introductionmentioning

confidence: 99%

“…While there are systematic reviews and meta-analyses evaluating the difference in outcomes, rate of complications, and length of hospitalization between appendectomy and antibiotics, 1,5-11 most of them have analyzed studies of varying qualities of evidence. The two reviews that have previously assessed Level 1 quality of evidence were limited in the number of studies included in the analysis.…”

Section: Introductionmentioning

confidence: 99%

Comparing Outcomes of Appendectomy Versus Non-operative Antibiotic Therapy for Acute Appendicitis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Zagales

Sauder

Selvakumar

et al. 2022

The American Surgeon™

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Background Acute appendicitis is one of the most common etiologies of an acute abdomen in the emergency department and first-line standard surgical care for the condition has recently been reconsidered. We aim to evaluate the effectiveness and outcomes of surgical intervention versus non-operative antibiotic therapy in the treatment of acute appendicitis in adult and pediatric patients. Methods A literature search was conducted using PubMed, Google Scholar, and EMBASE. The search included all studies until January 15th, 2022. Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed for abstracting data and assessing data quality and validity. Data were independently extracted by the authors of the study. Meta-analysis was performed and Cohen’s Q test for heterogeneous effects was performed to determine if fixed or random-effects models were appropriate for use. Results Twelve randomized controlled trials investigating a total of 3703 acute appendicitis patients met inclusion criteria and were included in the meta-analysis. In the systematic review, eleven RCTs demonstrated that appendectomy had improved effectiveness compared to non-operative antibiotic management. The meta-analysis demonstrated that patients undergoing appendectomy had significantly higher treatment effectiveness compared with antibiotics-only treatment (98.4% vs. 73.3%, P < .0001). The meta-analysis did demonstrate a significant .54-day reduction in hospital length of stay for the appendectomy group compared to the non-operative antibiotic therapy group. Conclusions Surgical intervention is associated with increased effectiveness of treatment and reduced in-hospital length of stay among patients with acute appendicitis. Guidelines established by institutions and surgical organizations should indicate appendectomy as the standard and superior treatment option for patients presenting with acute appendicitis.

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Doubts About Cutting It Out: Systematic Review and Meta-analysis of Patient-Centered Outcomes in Nonoperative Management vs Surgery in Acute Uncomplicated Appendicitis in Adults

Cited by 2 publications

References 0 publications

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study

Comparing Outcomes of Appendectomy Versus Non-operative Antibiotic Therapy for Acute Appendicitis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

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