Quality of life and patient satisfaction at 7-year follow-up of antibiotic therapy vs appendectomy for uncomplicated acute appendicitis: a secondary analysis of a randomized clinical trial
Sippola S, Haijanen J, Viinikainen L, et al. JAMA Surg. 2020;155(4):283-289.
SUMMARY:
Recently, several large and well-conducted RCTs and meta-analyses have suggested that antibiotics may provide a safe and effective treatment alternative to appendectomy.
Here, the authors examine patients from their original Appendicitis Acuta (APPAC) trial to provide information on long-term follow up.
The initial APPAC trial was a multicenter, open-label, noninferiority clinical trial conducted from November 2009 to June 2012 at 6 Finnish hospitals, where 530 adults with uncomplicated acute appendicitis were randomized to surgery or 3 days of IV antibiotics followed by 1 week of oral antibiotics.
Quality of life was measured with the EQ-5D-5L questionnaire, which covers dimensions of everyday life and anxiety/depression. Patient satisfaction was assessed with a Likert score.
At 7 years, the authors followed up with 80% of the original cohort.
Of the patients in the antibiotic group, 39% had undergone appendectomy.
Quality of life did not differ between groups.
Satisfaction was higher in the surgery group, but the difference was driven by a much lower satisfaction among patients who were assigned to antibiotics and later needed surgery (patients in the antibiotic group who never needed surgery had the highest overall satisfaction).
Of the 81 patients taking antibiotics who underwent appendectomy, only 33% would again choose antibiotics as their primary treatment.
This study has some notable limitations, mainly those from the original trial, including that patients in the operative group had open and not laparoscopic procedures, and patients in the antibiotic group were admitted for 3 days; both these aspects may have influenced the satisfaction outcomes in highly unpredictable directions.
EDITOR’S COMMENTARY: In this long-term follow-up study of patients from an original nonoperative appendicitis trial, the authors reported that just over one-third of the patients in the antibiotic group needed surgery at 7 years. The goal was to provide information for shared decision-making, and although the authors report higher satisfaction in the surgical group, the type of surgery and length of antibiotic treatment aren’t in line with current best practices for appendicitis treatment and thus become difficult to apply.
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