Antibiotics versus appendicectomy in the management of acute appendicitis: an ongoing debate

Appendicitis remains the commonest cause of the acute abdomen in young adults and the mainstay of treatment at most centres remains an appendicectomy [1]. This is despite the fact that many other intra-abdominal pathologies, such as diverticulitis, are routinely managed conservatively with antibiotics. A study by Varadhan et al (2012) aimed to assess the safety and efficacy of antibiotic treatment compared to appendicectomy, specifically in the management of uncomplicated appendicitis, through a meta-analysis of randomized controlled trials [2]. The authors included only randomized controlled trials with clearly defined management protocols and excluded all other types of studies including those related to complicated appendicitis. The primary outcome measures were complications such as wound infections or peritonitis, and secondary outcome measures included duration of hospitalization, readmission rate, and treatment efficacy. The authors completed a wide ranging literature search covering January 1966 to December 2011 with associated back-chaining of articles. The meta-analysis followed the Cochrane Collaboration guidelines, assessed outcomes on an intention-to-treat basis, and separately accounted for the potential confounder of alternate antibiotic regimens. Following evaluation of 6 trials, the study included a total of 900 patients (n = 470 antibiotic treatment, n = 430 appendicectomy) derived from four trials as the other two trials met the exclusion criteria. The results indicated a 63% (277 / 438 patients) success rate following antibiotic treatment at one year. There was a 31% reduction in relative risk (95% CI 0.54 - 0.89, p = 0.004) in the antibiotic treatment group versus the appendicectomy group, which increased to 39% on exclusion of one of the trials due to crossover effects (p = 0.02). There were no significant differences found in the duration of hospitalization or risk of complicated appendicitis between the two groups. The authors concluded that antibiotics were both safe and effective as primary treatment strategies for patients with uncomplicated appendicitis.