Salminen P, et al. - For treatment of uncomplicated acute appendicitis, researchers assessed the late recurrence rate of appendicitis following antibiotic therapy in this 5-year observational follow-up study. Findings revealed that the possibility of late recurrence within 5 years was 39.1% among patients who were at first treated with antibiotics for uncomplicated acute appendicitis. According to the long-term follow up of patients with uncomplicated acute appendicitis, initial treatment with antibiotics vs surgery might be a feasible option.

Methods

• It was a 5-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter randomized clinical trial.
• For this trial, 530 subjects aged 18 to 60 years with computed tomography–confirmed uncomplicated acute appendicitis were randomly allocated to undergo an appendectomy (n = 273) or get antibiotic therapy (n = 257).
• From November 2009 to June 2012, the initial trial was conducted in Finland; last follow-up was September 6, 2017.
• This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone.
• Main interventions analyzed were open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.
• Prespecified secondary end points reported at 5-year follow-up included late (after 1 year) appendicitis recurrence following antibiotic treatment, complications, length of hospital stay, and sick leave.

Results

• According to the findings, out of 530 subjects (201 women; 329 men) enrolled in the trial, 273 patients (median age, 35 years [IQR, 27-46]) were randomized to undergo appendectomy, and 257 (median age, 33 years, [IQR, 26-47]) were randomized to receive antibiotic therapy.
• Aside from 70 patients who, at first, received antibiotics but had appendectomy within the first year (27.3% [95% CI, 22.0%-33.2%]; 70/256), 30 additional antibiotic-treated patients (16.1% [95% CI, 11.2%-22.2%]; 30/186) had appendectomy between 1 and 5 years.
• Findings revealed that the cumulative incidence of appendicitis recurrence was 34.0% (95% CI, 28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at 3 years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95% CI, 33.1%-45.3%; 100/256) at 5 years.
• Out of 85 subjects in the antibiotic group who subsequently had appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, 2 had complicated appendicitis, and 7 did not have appendicitis.
• It was noted that the overall complication rate (surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms) was 24.4% (95% CI, 19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5% (95% CI, 3.8%-10.4%) (n = 16/246) in antibiotic group (P < .001), which calculates to 17.9 percentage points (95% CI, 11.7-24.1) higher after surgery at 5 years.
• No difference was found between groups for length of hospital stay, however, significant difference in sick leave (11 days more for the appendectomy group) was noted.