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Review
. 2016 May;103(6):656-667.
doi: 10.1002/bjs.10147. Epub 2016 Mar 17.

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

V Sallinen  1   2 , E A Akl  3   4 , J J You  4   5 , A Agarwal  4   6 , S Shoucair  7 , P O Vandvik  8 , T Agoritsas  4   9 , D Heels-Ansdell  4 , G H Guyatt  4   5 , K A O Tikkinen  10
Affiliations
Review

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis

V Sallinen et al. Br J Surg. 2016 May.

Abstract

Background: For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non-perforated appendicitis.

Methods: A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non-perforated appendicitis. Key outcomes were analysed using random-effects meta-analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results: Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference -2·6 (95 per cent c.i. -6·3 to 1·1) per cent (low-quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference -7·2 (-18·1 to 3·8) per cent (very low-quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high-quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high-quality evidence). For every 100 patients with non-perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.

Conclusion: The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value- and preference-dependent, suggesting a change in practice towards shared decision-making is necessary.

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Figures

Figure 1
Figure 1
Flow chart showing selection of articles for review. WHO, World Health Organization; ICTRP, International Clinical Trials Registry Platform Search Portal
Figure 2
Figure 2
Forest plot showing absolute risk difference in major complications in antibiotic therapy versus appendicectomy group. Risk differences are shown with 95 per cent c.i.
Figure 3
Figure 3
Forest plot showing absolute risk difference in minor complications in antibiotic therapy versus appendicectomy group. Risk differences are shown with 95 per cent c.i.
Figure 4
Figure 4
Forest plot showing mean difference in length of hospital stay in antibiotic therapy versus appendicectomy group. Mean differences are shown with 95 per cent c.i. *Values are mean(s.d.)
Figure 5
Figure 5
Forest plot showing mean difference in length of sick leave in antibiotic therapy versus appendicectomy group. Mean differences are shown with 95 per cent c.i. *Values are mean(s.d.)
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Comment in

References

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