Antibiotic management of acute appendicitis avoids surgery in over 70% of adults: One-year follow-up from a prospective, multicentre, observational study

Background: Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited are unknown rates of recurrent appendicitis and The risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine The long-term efficacy of antibiotic versus operative management of appendicitis. Method(s): One-year follow-up of patients enrolled in The multicentre observational CoVID:HAREM cohort study during March-June 2020 was undertaken. Patients were diagnosed with appendicitis either clinically or radiologically;initial operative or non-operative management was determined On a case-by-case basis by The responsible surgeon. Outcomes were The one-year appendicectomy rate, resected appendix histology and predictors of antibiotic failure. Result(s): A total of 625 patients who underwent non-operative management were identified from 49 of The original 97 hospital sites. The overall appendicectomy rate at one-year in The initial non-operative group was 29% (180/625), with a median time to appendicectomy of 29 days [IQR 2-124]. Elective appendicectomy accounted for 17% (31/180) of operations with normal histology found in 39% (12/31). The overall normal histology rate was 11% (19/167). There were 7/167 malignancies and 3/167 neuroendocrine tumours identified at delayed operation. The presence of a faecolith (HR 1.72;95% CI 1.18-2.51) and CRp>300 versus <50 (HR 3.05;95% CI 1.6-5.81) were independent risk factors for failure of antibiotic-management (n=441). Conclusion(s): The success rate of non-operative appendicitis management was 71% at one-year. Appendicitis recurrence was associated with The presence of a faecolith, malignancy and significantly raised CRp. These factors should be considered when counselling patients On non-operative management.

Appendiceal malignancy in adult appendicitis managed with antibiotics: Retrospective case review from a multicentre, observational one-year follow-up study

Background: Appendiceal malignancy is uncommon, usually diagnosed as an incidental histological finding after appendicectomy for acute appendicitis. A significant concern in antibiotic-management of adult appendicitis is the risk of missed malignancy. The aim of this study was to examine the cases managed initially non-operatively and subsequently found to have appendiceal malignancy. Method(s): Patients enrolled in the multicentre observational COVID:HAREM study between March-June 2020 were followed- up at one-year. Individual case review was undertaken for all patients diagnosed with malignancy at delayed operation following antibiotic-management of appendicitis. Outcomes of interest were predictors of malignancy at index admission, rates and modalities of follow up and necessity for further treatment. Result(s): Of 625 patients managed non-operatively, 180 had appendicectomy during the follow-up period (29%). Histology was available for 167/180. There were seven malignancies and three neuroendocrine tumours identified at delayed operation, with an overall malignancy rate at one-year of 1.6%. All ten patients had a CT on index admission. Eight patients had risk factors for malignancy at presentation including age > 40 (8/10), complicated appendicitis (4/10) and appendiceal dilatation on CT (3/10). Seven patients had routine follow-up: Two had colonoscopy only, four had a CT (two CT colonography) and one had both. Half of malignancies were removed at emergency reattendance. Two patients required a further resection post-appendicectomy, one required systemic chemotherapy. Conclusion(s): Although the malignancy rate was low, the majority of patients found to have appendiceal malignancy had recognised risk factors at index presentation, highlighting the importance of developing robust selection criteria for patients treated non-operatively.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study.

BACKGROUND: Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS: A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS: A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION: This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

The quantitative impact of COVID-19 on surgical training in the United Kingdom.

BACKGROUND: COVID-19 has had a global impact on all aspects of healthcare including surgical training. This study aimed to quantify the impact of COVID-19 on operative case numbers recorded by surgeons in training, and annual review of competency progression (ARCP) outcomes in the UK. METHODS: Anonymized operative logbook numbers were collated from electronic logbook and ARCP outcome data from the Intercollegiate Surgical Curriculum Programme database for trainees in the 10 surgical specialty training specialties.Operative logbook numbers and awarded ARCP outcomes were compared between predefined dates. Effect sizes are reported as incident rate ratios (IRR) with 95 per cent confidence intervals. RESULTS: Some 5599 surgical trainees in 2019, and 5310 in surgical specialty training in 2020 were included. The IRR was reduced across all specialties as a result of the COVID-19 pandemic (0.62; 95 per cent c.i. 0.60 to 0.64). Elective surgery (0.53; 95 per cent c.i. 0.50 to 0.56) was affected more than emergency surgery (0.85; 95 per cent c.i. 0.84 to 0.87). Regional variation indicating reduced operative activity was demonstrated across all specialties. More than 1 in 8 trainees in the final year of training have had their training extended and more than a quarter of trainees entering their final year of training are behind their expected training trajectory. CONCLUSION: The COVID-19 pandemic has had a major effect on surgical training in the UK. Urgent, coordinated action is required to minimize the impacts from the reduction in training in 2020.

Correction to: The management of adult appendicitis during the COVID‑19 pandemic: an interim analysis of a UK cohort study (Techniques in Coloproctology, (2020), 10.1007/s10151-020-02297-4)

Unfortunately, few of the collaborators names were incorrectly published in the original publication. The correct names of the collaborators are given below. Talal Majeed Mina Mesri Hannah Byrne Eduardo Raimundo Da Silva Bento Fadzlien Zahari Farah Roslan John R O’Neil Dimitrios Damaskos Jamaal Jackman The original article has been updated.

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study.

BACKGROUND: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). METHODS: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. RESULTS: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. CONCLUSION: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.