Antibiotics-first Strategy for Uncomplicated

Acute Appendicitis in Adults is Associated

with Increased Rates of Peritonitis at Surgery.
A Systematic Review with Meta-analysis of
Randomized Controlled Trials Comparing
Appendectomy and Non-operative
Management with Antibiotics
Mauro Podda a,*, Nicola Cillara b, Salomone Di Saverio c, Antonio Lai a, Francesco Feroci d, Gianluigi
Luridiana e, Ferdinando Agresta f, Nereo Vettoretto g, On behalf of the ACOI (Italian Society of Hospital
Surgeons) Study Group on Acute Appendicitis

The Surgeon , Journal of the Royal Colleges of Surgeons of Edinburgh and

Ireland XXX 1-12, 2017.
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• The aim of this systematic review and meta-analysis of randomized controlled trials
(RCTs) was the up-to-date reassessment of the current available evidence on the
antibiotic approach to uncomplicated acute appendicitis when compared to the
stan-dard surgical treatment, with particular focus on safety and efficacy

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 Introduction
• Acute appendicitis (AA) is among the most common causes
of lower abdominal pain leading patients to emergency
department

• Significant debate remains on whether uncomplicated

(non-perforated) AA should be operated or not.

• Therefore the main question is whether it is possible to

treat patients having uncomplicated AA with antibiotic
therapy and how to distinguish during the patients’
assessment those who might respond well to antibiotic
treatment alone from those who would require surgery

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• Many autopsy specimens were showing pathologic signs
consistent with AA, therefore hypothesizing that in some
patients the disease could resolve without any surgery (Fitz,
1886)

• 42 of 47 cases of AA being successfully treated using

antibiotics (Harrison, 1953)

• “Jerusalem guidelines” stated that the antibiotic therapy can

be successful in selected patients with uncomplicated
appendicitis who wish to avoid surgery, and accept the risk
up to 38% recurrence (published in 2016)

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 Method
• Systematic literature search was performed using
PubMed, EMBASE, Medline, Google Scholar and
Cochrane Central Register of Controlled Trials
databases for randomized controlled trials comparing
antibiotic therapy (AT) and surgical therapy-
appendectomy (ST) for uncomplicated AA

• RCTs comparing AT and ST as primary treatment for

uncomplicated AA in adults were included in the
systematic review and meta-analysis

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A total of five RCTs comparing AT and ST
qualified for inclusion in this systematic review
and meta analysis, with a total of 1.351 patients:
632 in the AT group and 719 in the ST

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 Discussion
• Our results showed that AT was associated
with a significant lower treatment efficacy
based on one year follow-up when compared
to ST (75.9% vs 98.3%, P < 0.0001). In partic-
ular, recurrence rate was 22.5%, with a mean
length of time for recurrence of 4.65 months

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• In 2011, Wilms et al. concluded that ST
remains the standard of care for AA due to the
higher success rate (97.4%) when compared
to AT (73.4%)

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Compared to previous systematic reviews, this
journal reported no statistically significant
difference between the two groups regarding
the length of hospital stay and period of sick
leave

AT and ST groups had similar rates of overall

complications (4.3% vs 10.9%, P 1⁄4 0.32)

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a higher rate of complicated appendicitis with
peritonitis identified at the time of surgical
operation in the AT group was found in our
analysis, with a statistically significant difference
(19.9% vs 8.5%, P 1⁄4 0.02)

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 Limitation
• An important limitation of this systematic
review and meta-analysis is the small number
of well-designed randomized controlled trials
that have published on this subject to date.

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 Conclusion
• With its high efficacy and low complication rates,
appendectomy remains undoubtedly the most effective
treatment for patients with uncomplicated AA.
• Similar complication rates have been reported when
comparing appendectomy and AT, even among patients
who underwent surgery after failure of the AT
• when AT approach is considered, patient should be
accurately selected and assessed, and the choice of most
appropriate treatment option must be carried out through
a precise clinical evaluation of potential advan- tages and
risks of expectant management vs a straightforward
appendectomy

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