Antibiotic treatment is as good as appendectomy for most adults with appendicitis

reviewed by Emily Henderson, Bachelor of ScienceOct 6, 2020

Seven out of 10 adults with appendicitis can safely avoid surgical removal of their appendix (appendectomy) for at least several months by receiving a course of antibiotics, according to the first results of a US study that is the largest to compare use. of these drugs alone versus an operation for the treatment of appendicitis.

The three-month findings of the ongoing Comparison of Antibiotics and Appendectomy Results (CODA) trial are being presented today at the 2020 American College of Surgeons Clinical Congress, concurrently with posting online on the website of the New England Journal of Medicine.

Led by the University of Washington (UW) School of Medicine in Seattle, CODA is a randomized clinical trial being conducted at 25 U.S. medical centers in 1,552 adults with appendicitis to find out if antibiotic treatment it is as good as appendectomy.

In the results published earlier due to the interest of physicians, the researchers found that, in general, the health of patients who received antibiotic therapy was no worse a month later than that of patients who had their appendix removed.

“For the first time, these results will inform typical appendicitis patients in US practice what the options are and what the expected outcomes are for patients like them,” said study co-principal investigator David R. Flum , MD, MPH, FACS, professor and associate chair of surgery at the UW School of Medicine. David Talan, MD, physician of emergency medicine, UCLA Geffen School of Medicine, is also a co-principal investigator.

Dr. Flum said he hopes the CODA results will significantly change the treatment of appendicitis in the United States. “Antibiotic treatment will be good for many people, but not for all,” he explained.

Appendectomy has been the standard treatment for appendicitis for more than 120 years and is the most common emergency abdominal procedure performed in the United States.

Despite evidence from European studies over the past 25 years that antibiotics successfully treat the majority of patients with appendicitis, a recent study finds that less than 5 percent of all US patients with appendicitis receive non-treatment. surgical.⁴

How CODA was unique

Dr. Flum said that some American physicians believed the European studies had shortcomings, which CODA, with input from patient advisers, was designed to address. The new trial is answering patient-centered questions that Dr. Flum says were left unanswered in European studies.

These include whether the initial antibiotic treatment affects time away from work and in the hospital.

In addition, he said the CODA patient population better represents typical US surgical practices.The study includes patients with a wide range of appendicitis severity and those with an appendicolith, a small stone at the base of the appendix. Of the CODA participants, 27 percent had an appendicolith on imaging, but the European studies excluded those patients because an appendicolith may indicate more complicated appendicitis, said Dr. Flum.

CODA researchers studied patients who had an appendicolith together and separately from other patients.

The researchers randomly assigned 776 patients each to either undergo an appendectomy or receive a 10-day course of antibiotics given intravenously for the first 24 hours and then as pills for the remaining days.

Compensations with each treatment

The main outcome was the health status of the patients 30 days after treatment using a general health measure, the European Quality of Life-5 dimensions (EQ-5D). Both treatment groups had similarly improved health with the EQ-5D, the researchers found, but each treatment had advantages and disadvantages.

The results for the group of antibiotics alone were as follows:

• The chance of needing an appendectomy three months after initial treatment was three in 10.
• The 90-day appendectomy rate was higher for patients with appendicolith than for those without: 41 percent versus 25 percent.
• Complications, although infrequent, appeared to be more frequent in those who received antibiotics, but were attributable to the appendicolith group.
• On average, patients lost 3.4 fewer days of work than those undergoing appendectomy (5.3 vs. 8.7 days), but were more likely to require another hospitalization, including an appendectomy (24 percent vs. 5 percent). hundred).
• Forty-seven percent of patients received their initial care in the emergency department only and avoided hospitalization for initial treatment.

Without an appendectomy, there is a chance to miss appendix cancer, but this type of cancer is rare, said Giana H. Davidson, MD, MPH, FACS, a study investigator and associate professor of surgery in the School of Medicine. of the UW.

Patients with appendicitis need individualized treatment that meets their goals and needs, Dr. Davidson said.

Surgeons, he noted, may be concerned about a 30 percent appendectomy rate within three months of antibiotic treatment. This rate exceeded the 16 percent rate at 90 days privately reported by the principal investigator of the most recent and largest European trial, the Acuta Appendicitis Trial (APPAC).³ However, he said that many study participants view statistics differently.

“When you are talking to some patients, depending on their personal priorities, health and concerns, a 7 out of 10 chance that they will not have to have surgery may be reasonable for them as long as it is safe,” said Dr. Davidson. He said.

A non-surgical treatment option may be especially relevant during the Coronavirus Disease 2019 (COVID-19) pandemic.

When COVID arrived, there were recommendations, including from the American College of Surgeons, to restrict time in the operating room to minimize exposure to the virus and reserve personal protective equipment for healthcare providers. We received calls from all over the country asking for our CODA data. “

Giana H. Davidson, MD, MPH, FACS, Study Investigator, Associate Professor of Surgery, School of Medicine, University of Washington

Therefore, the researchers announced the findings 90 days in advance of the one to three year follow-up results expected in one year.

“This study is the largest randomized surgical trial of its kind in the United States. These initial results will be informative to surgeons and beneficial to patients as they review the latest data-based recommendations on treatment options for appendicitis.” said ACS CEO David B Hoyt, MD, FACS, a member of the CODA National Advisory Board.