SGEM#256: Doctor Doctor Give Me the News, I Gotta Bad Case of RLQ Pain – Should I have an Appendectomy?

Date: May 6th, 2019 Reference: Sceats et al. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surgery 2018 Guest Skeptic: Dr. Robert Leeper is an assistant professor of surgery at Western University and the London Health Sciences Centre. His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation. Case: An 18-year-old woman presents with a Grade 1 appendicitis (Tominaga et al J Trauma Acute Care Surg 2016).  Background: The first documented appendectomy was done by Claudius Amyand in 1735. The standard treatment for acute appendicitis has been appendectomy ever since Charles McBurney described it in 1889. Omar et al (2008) showed just how safe laparoscopic appendectomies have become. They found in a study of over 230,000 UK patients under the age of 49 there were no deaths. Being that there are doctors out there without scalpels, and that diverticulitis has often been treated successfully with antibiotics.  Some clinicians have hypothesized that perhaps acute appendicitis could also be treated successfully with antibiotics. Two meta-analyses have been done and they looked at nearly the same studies on “uncomplicated” acute appendicitis and came up with two opposite conclusions. This is an example of why things in evidence-based medicine can be “complicated” (SGEM#115 and SGEM#180 Clinical Question: Operative treatment or non-operative treatment of acute Grade 1 (uncomplicated) appendicitis? Reference: Sceats et al. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surgery 2018 Population: Adult patients admitted to hospital with a diagnosis of acute uncomplicated (Grade I) appendicitis. Exclusion: Patients with co-occurring diagnosis or procedure codes consistent with complicated appendicitis and patients lacking appendectomy codes. Exposure: Non-operative management of appendicitis Comparison: Operative management of appendicitis Outcome: Primary Outcomes: Short Term (<30 days) Complications: ED visits, all-cause readmissions, appendicitis-associated readmissions, rate of abdominal abscess and C. difficile. Long Term (>30 days) Complications: Readmission for small-bowel obstruction, diagnosis of incisional hernia, and diagnosis of appendiceal cancer. Secondary Outcomes: “Length of stay during index hospitalization, cost of index hospitalization, number of follow-up visits required in the following year, and the total cost of appendicitis-associated care in the year after diagnosis. Total cost of appendicitis-associated care was determined by summing the total cost for every in-patient and outpatient encounter associated with appendicitis for the following year, including the index hospitalization.” Post Hoc Analysis: Rates of non-operative management failure (<30 days) and rates of appendicitis recurrence (>29d days) as well as timing of the failure or recurrence. Authors’ Conclusions: “According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results?