Editorial
Antibiotics for Appendicitis: Something to Think About?
Andrew Deytrikh and Samon Tou*
Department of Colorectal Surgery, Royal Derby Hospital, UK
*Corresponding author: Samson Tou, Department of Colorectal Surgery, Royal Derby Hospital, Uttoxeter Road, DE22 3NE, UK
Published: 08 Dec, 2016
Cite this article as: Deytrikh A, Tou S. Antibiotics for
Appendicitis: Something to Think
About?. Clin Surg. 2016; 1: 1239.
Editorial
Since Claudius Amyand performed the first successful appendicectomy in 1735 in his role
as surgeon in the English Army, this procedure has formed the bread-and-butter of the General
Surgeons workload to date. Professional controversy has surrounded this otherwise well established
practice in recent years, centred on the role of conservative (antibiotic) management for both
uncomplicated and complicated appendicitis, and in interval appendicectomy. Moreover, the
growing body of research into appendiceal neoplasms has created a clinically relevant focus for this
debate.
Acute appendicitis is one of the commonest surgical pathologies, with a lifetime incidence of
approximately 7-8% [1]. Treatment of uncomplicated appendicitis by antibiotic therapy alone has
been the subject of a number of meta-analyses and systematic reviews in recent years. With negative
appendicectomy rates in most institutions of around 20%, and a growing belief that a significant
proportion of uncomplicated cases of appendicitis will resolve spontaneously, can it be defensible
to proceed straight to operative management without a trial of antibiotic therapy if there is then an
operative complication, particularly if the appendix is normal?
Conservative management has been shown to reduce complication rates from appendicitis
when compared with appendicectomy, and is associated with faster recovery and reduced analgesic
requirements [2]. However, greater treatment efficacy has been seen with operative management
compared to antibiotic therapy. A Cochrane group review found 73% of patients treated with
antibiotic therapy were free of complications or recurrence combined within 1 year compared
to 97% in those who underwent appendicectomy at index admission [3]. In addition, the recent
Appendicitis Acuta (APPAC) randomised trial found 1 year failure rates of between 25-30% in
those patients treated conservatively [4]. However, these studies show significant heterogeneity
which questions the validity of their findings, and certainly may not be applicable worldwide due to
the non-uniform distribution of healthcare resources globally.
It is the cases of complicated appendicitis (gangrenous/perforated) which will often be
considered for interval appendicectomy by the Surgeon, usually as a result of the presence of
appendiceal mass. It is no new thing however, to question the practice of interval appendicectomy
in favour of conservative management in these more challenging cases too. Studies have surmised
that conservative management of patients with appendiceal mass is preferable to interval
appendicectomy. One of the few prospective studies found recurrence rates of 10% [5], similar to
that of the initial lifetime risk of appendicitis, and represent one argument for abandoning interval
appendicectomy in preference of conservative management.
But what of the significance of appendiceal neoplasms? It is true to say that since their first
description in 1882, appendiceal neoplasms remain rare. Carcinoid tumours are the most common
primary malignant lesion of the appendix with an incidence of between 0.3 – 0.9% [6], and show a
slight female predominance. The problem surgeons face in relation to appendiceal neoplasms is one
of identification. One study (n = 7592) investigated the incidence of appendiceal carcinoids over 16
years, and found that they were not suspected in any patient before, nor identified at operation for
appendicitis [7]. Appendiceal neoplasms remain, on the whole, an incidental diagnosis following
surgery for suspected acute appendicitis. They are often small (< 1 cm), and more commonly located
at the tip of the appendix, and as a result, pre-operative imaging has been ineffectual at identifying
these lesions. [8]. It seems that despite advances in imaging and the move towards laparoscopic
appendicectomy, the diagnosis of appendiceal neoplasia can only be reliably made on histological
evaluation.
So for the surgeon undertaking an appendicectomy are there any patient factors or clinical
features which may raise suspicion of an underlying neoplasm? A recent large scale study found that
whilst the incidence of appendiceal neoplasms was only 0.5% at the
index hospital admission, this increased to 12% for those undergoing
interval appendicectomy, and rose further to 16% in patients over 40
[9]. The conclusion of these findings is that the patients at greatest
risk are those over 40 with complicated appendicitis. In addition,
the majority of the index neoplasms were small carcinoid tumours,
whereas those removed at interval appendicectomy were more
commonly mucinous in origin [9]. This has implications in terms
of the proliferative index and risk of pseudomyxoma peritonei
development. Of note, failure to remove the mesoappendix at time of
operation may have implications in terms of clear margins and need
for reoperation.
The practice of operatively managing appendicitis in both
uncomplicated and complicated disease at either index admission or
interval appendicectomy is being questioned in favour of conservative
management. Indeed there are many advantages to this approach,
namely lower cost and hospital admission days, low perforation
rates, and the clinical complications associated with performing
appendicectomies. However, appendiceal neoplasms remain an
incidental finding, lacking clinical features, and it is possible to miss
occult tumours in normal-appearing appendixes unless sent for
histology. It is reasonable to leave it to the acumen of the responsible
surgeon to select the cases where conservative management is
appropriate, in the knowledge that a clinically relevant proportion of
cases of complicated appendicitis in the over 40 age group represent
neoplastic changes.
References
- Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, et al. Global disease burden of conditions requiring emergency surgery. Br J Surg. 2014; 101: e9-22.
- Rocha LL, Rossi FM, Pessoa CM, Campos FN, Pires CE, Steinman M, et al. Antibiotics alone versus appendectomy to treat uncomplicated acute appendicitis in adults: what do meta-analyses say? World J Emerg Surg. 2015; 10: 51.
- Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011; CD008359.
- Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, et al. Antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015; 313: 2340-2348.
- Kumar S, Jain S. Treatment of appendiceal mass: prospective randomized clinical trial. Indian J Gastroenterol. 2004; 23:165-167.
- Goede AC, Caplin ME, Winslet MC. Carcinoid tumour of the appendix. Br J Surg. 2003; 90: 1317-1322.
- Shapiro R, Eldar S, Sadot E, Venturero M, Papa MZ, Zippel DB, et al. The significance of occult carcinoids in the era of laparoscopic appendectomies. Surg Endosc. 2010; 24: 2197-2199.
- Corsey CA, Nelson RC, Moreno RD, Dodd LG, Patel MB, Vaslef S, et al. Carcinoid tumors of the appendix: are these tumors identifiable prospectively on preoperative CT? Am Surg. 2010; 76: 273-275.
- Wright GP, Mater ME, Carroll JT, Choy JS, Chung MH. Is there truly an oncologic indication for interval appendectomy? Am J Surg. 2015; 209: 442-446.