Operation versus antibiotics––The “appendicitis conundrum” continues: A meta-analysis

Joseph Sakran, Konstantinos S. Mylonas, Alexandros Gryparis, Stanislaw P. Stawicki, Christopher J. Burns, Maher M. Matar, Konstantinos P. Economopoulos

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Acute appendicitis continues to constitute a diagnostic and therapeutic challenge. The aim of this study was to synthesize evidence from randomized controlled trials (RCTs) comparing nonoperative versus surgical management of uncomplicated acute appendicitis in adult patients. METHODS: A systematic literature search of the PubMed, Cochrane and Scopus databases was performed with respect to the PRISMA statement (end-of-search date: January 29, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when substantial heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented. Quality assessment of included RCTs was performed using the modified Jadad scale. RESULTS: Five RCTs were included in this review. Overall, 1,430 adult patients with uncomplicated acute appendicitis underwent either nonoperative (n=727) or operative management (n=703). Treatment efficacy at 1-year follow-up was significantly lower (63.8%) for antibiotics compared to the surgery group (93%) (RR 0.68; 95% CI, 0.60-0.77, p<0.001). Overall complications were significantly higher in the surgery group (166/703, 23.6%) compared to the antibiotics group (56/727, 7.7%) (RR: 0.32, 95% CI, 0.24 to 0.43, p<0.001). No difference was found between the two treatment modalities in terms of perforated appendicitis rates (RR: 0.52, 95% CI, 0.14 to 1.92), length of hospital stay (WMD: 0.20, 95%CI -0.16 to 0.56), duration of pain (WMD: 0.22, 95%CI -5.30 to -5.73) and sick leave (WMD: -2; 95%CI, -5.2 to 1.1). CONCLUSIONS: Conservative management of uncomplicated appendicitis in adults warrants further study. Addressing patients’ expectations via a shared-decision making process is a crucial step in optimizing nonoperative outcomes.

Original languageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
DOIs
StateAccepted/In press - Mar 23 2017

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Appendicitis
Meta-Analysis
Randomized Controlled Trials
Length of Stay
Anti-Bacterial Agents
Sick Leave
PubMed
Decision Making
Databases
Pain
Therapeutics

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Sakran, J., Mylonas, K. S., Gryparis, A., Stawicki, S. P., Burns, C. J., Matar, M. M., & Economopoulos, K. P. (Accepted/In press). Operation versus antibiotics––The “appendicitis conundrum” continues: A meta-analysis. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000001450

Operation versus antibiotics––The “appendicitis conundrum” continues : A meta-analysis. / Sakran, Joseph; Mylonas, Konstantinos S.; Gryparis, Alexandros; Stawicki, Stanislaw P.; Burns, Christopher J.; Matar, Maher M.; Economopoulos, Konstantinos P.

In: Journal of Trauma and Acute Care Surgery, 23.03.2017.

Research output: Contribution to journalArticle

Sakran, Joseph ; Mylonas, Konstantinos S. ; Gryparis, Alexandros ; Stawicki, Stanislaw P. ; Burns, Christopher J. ; Matar, Maher M. ; Economopoulos, Konstantinos P. / Operation versus antibiotics––The “appendicitis conundrum” continues : A meta-analysis. In: Journal of Trauma and Acute Care Surgery. 2017.
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abstract = "BACKGROUND: Acute appendicitis continues to constitute a diagnostic and therapeutic challenge. The aim of this study was to synthesize evidence from randomized controlled trials (RCTs) comparing nonoperative versus surgical management of uncomplicated acute appendicitis in adult patients. METHODS: A systematic literature search of the PubMed, Cochrane and Scopus databases was performed with respect to the PRISMA statement (end-of-search date: January 29, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when substantial heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented. Quality assessment of included RCTs was performed using the modified Jadad scale. RESULTS: Five RCTs were included in this review. Overall, 1,430 adult patients with uncomplicated acute appendicitis underwent either nonoperative (n=727) or operative management (n=703). Treatment efficacy at 1-year follow-up was significantly lower (63.8{\%}) for antibiotics compared to the surgery group (93{\%}) (RR 0.68; 95{\%} CI, 0.60-0.77, p<0.001). Overall complications were significantly higher in the surgery group (166/703, 23.6{\%}) compared to the antibiotics group (56/727, 7.7{\%}) (RR: 0.32, 95{\%} CI, 0.24 to 0.43, p<0.001). No difference was found between the two treatment modalities in terms of perforated appendicitis rates (RR: 0.52, 95{\%} CI, 0.14 to 1.92), length of hospital stay (WMD: 0.20, 95{\%}CI -0.16 to 0.56), duration of pain (WMD: 0.22, 95{\%}CI -5.30 to -5.73) and sick leave (WMD: -2; 95{\%}CI, -5.2 to 1.1). CONCLUSIONS: Conservative management of uncomplicated appendicitis in adults warrants further study. Addressing patients’ expectations via a shared-decision making process is a crucial step in optimizing nonoperative outcomes.",
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AU - Mylonas, Konstantinos S.

AU - Gryparis, Alexandros

AU - Stawicki, Stanislaw P.

AU - Burns, Christopher J.

AU - Matar, Maher M.

AU - Economopoulos, Konstantinos P.

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N2 - BACKGROUND: Acute appendicitis continues to constitute a diagnostic and therapeutic challenge. The aim of this study was to synthesize evidence from randomized controlled trials (RCTs) comparing nonoperative versus surgical management of uncomplicated acute appendicitis in adult patients. METHODS: A systematic literature search of the PubMed, Cochrane and Scopus databases was performed with respect to the PRISMA statement (end-of-search date: January 29, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when substantial heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented. Quality assessment of included RCTs was performed using the modified Jadad scale. RESULTS: Five RCTs were included in this review. Overall, 1,430 adult patients with uncomplicated acute appendicitis underwent either nonoperative (n=727) or operative management (n=703). Treatment efficacy at 1-year follow-up was significantly lower (63.8%) for antibiotics compared to the surgery group (93%) (RR 0.68; 95% CI, 0.60-0.77, p<0.001). Overall complications were significantly higher in the surgery group (166/703, 23.6%) compared to the antibiotics group (56/727, 7.7%) (RR: 0.32, 95% CI, 0.24 to 0.43, p<0.001). No difference was found between the two treatment modalities in terms of perforated appendicitis rates (RR: 0.52, 95% CI, 0.14 to 1.92), length of hospital stay (WMD: 0.20, 95%CI -0.16 to 0.56), duration of pain (WMD: 0.22, 95%CI -5.30 to -5.73) and sick leave (WMD: -2; 95%CI, -5.2 to 1.1). CONCLUSIONS: Conservative management of uncomplicated appendicitis in adults warrants further study. Addressing patients’ expectations via a shared-decision making process is a crucial step in optimizing nonoperative outcomes.

AB - BACKGROUND: Acute appendicitis continues to constitute a diagnostic and therapeutic challenge. The aim of this study was to synthesize evidence from randomized controlled trials (RCTs) comparing nonoperative versus surgical management of uncomplicated acute appendicitis in adult patients. METHODS: A systematic literature search of the PubMed, Cochrane and Scopus databases was performed with respect to the PRISMA statement (end-of-search date: January 29, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when substantial heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented. Quality assessment of included RCTs was performed using the modified Jadad scale. RESULTS: Five RCTs were included in this review. Overall, 1,430 adult patients with uncomplicated acute appendicitis underwent either nonoperative (n=727) or operative management (n=703). Treatment efficacy at 1-year follow-up was significantly lower (63.8%) for antibiotics compared to the surgery group (93%) (RR 0.68; 95% CI, 0.60-0.77, p<0.001). Overall complications were significantly higher in the surgery group (166/703, 23.6%) compared to the antibiotics group (56/727, 7.7%) (RR: 0.32, 95% CI, 0.24 to 0.43, p<0.001). No difference was found between the two treatment modalities in terms of perforated appendicitis rates (RR: 0.52, 95% CI, 0.14 to 1.92), length of hospital stay (WMD: 0.20, 95%CI -0.16 to 0.56), duration of pain (WMD: 0.22, 95%CI -5.30 to -5.73) and sick leave (WMD: -2; 95%CI, -5.2 to 1.1). CONCLUSIONS: Conservative management of uncomplicated appendicitis in adults warrants further study. Addressing patients’ expectations via a shared-decision making process is a crucial step in optimizing nonoperative outcomes.

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