Multicenter Study of the Treatment of Appendicitis in America

Abstract

Objective: We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States. Summary Background Data: Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons. Methods: This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a “complicated” outcome variable and risk factors were assessed using multivariable logistic regression. Results: A total 3597 subjects were enrolled across 28 sites: median age was 37 (27–52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1–2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of “complicated” appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not. Conclusion: In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for “complicated” appendicitis.

Conditional CT Strategy—An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT

“…CT seems to be commonly used both in adults (83%) and in children (73%) with AA in hospitals in the United States [ 17 ], despite the increased risk of hematologic malignancies in young adults related to ionizing radiation [ 18 ]. Recent studies by Yeh et al and by Sugiura K et al included patients with already diagnosed acute appendicitis, where their reported NA rate was 10% and 2.5% with 85% and 95% use of preoperative CT. Their experience of US use was very limited—14% and 19%, respectively [ 19 , 20 ]. Our results, which highlight the importance of the conditional CT strategy, are similar to a previous study [ 21 ] where the TUS was able to identify the appendix in 53% of patients.…”

Laparoscopic Appendectomy: A Safe and Definitive Solution for Suspected Appendicitis

“…Conservatively, patients were initially treated with intravenous-antibiotic inpatient treatment for 3 days, with continued uncertainty about the further course of the disease. Thereafter, 27–46% of the patients underwent surgery during the following 1–5 years because of an at least suspected disease recurrence [8, 13, 14, 18, 26]. Leaving the conservatively treated patients in uncertainty whether the disease might strike again obviously results in some kind of appendicitis anxiety described in the literature [27].…”

“…The open surgical technique that was compared to conservative treatment within the publication of Salminen et al [4], which is now more than 5 years ago, is no longer state of the art at least in Germany [21]. This is highlighted above all in an American collective study which, with also a 98% rate of minimally invasive interventions and a routine hospital stay of around 24 h postoperatively, is openly questioning the conservative treatment approach in Europe [26].…”

“…The comparison of open surgery appendectomy versus a minimally invasive procedure, which is still considered in current meta-analyses [33, 34], appears to be no relevant question any more looking to our own results and the status quo in Germany [20]. As mentioned above in the USA [26, 35] there is a very high frequency of minimally invasive appendectomies and no one really wants to dispense with the advantages of full diagnostic laparoscopy especially in surgical units where laparoscopic procedures are meanwhile by far more frequent than open ones. The technique of sealing the appendix stump exclusively by a stapler device is highly standardized and apparently very safe.…”

“…In our opinion, the diagnosis of suspected appendicitis is based on the precise evaluation of the case history. A short-term illness with lower abdominal pain out of complete health is a particularly important argument [5, 26]. The standard laboratory values for white blood cell count and C-reactive protein should then be related to the duration of symptoms (S-A).…”