1. Antibiotic therapy vs appendectomy for unselected patients with acute appendicitis: a regional ACOI study
POILLUCCI Gaetano, MORTOLA Lorenzo, PODDA Mauro, SERVENTI Fernando, PIRAS Danilo, PAU Renata, LEDDA Simona, MADEDDU Francesco, ARESU Simona, CARBONI Gian Marco, COSSU Franca, PINNA Giovanni, BALESTRA Francesco, ARGENIO Giulio, TILOCCA Pier Luigi, PISANO Marcello, BERTULU Daniele, CILLARA Nicola, on behalf of the ACOI Sardegna Study Group on Acute Appendicitis.

2. ACOI SARDEGNA STUDY GROUP ON ACUTE APPENDICITIS
Gaetano Poillucci: II Clinica Chirurgica, Policlinico Universitario Umberto I, Roma
Lorenzo Mortola: Chirurgia Vascolare e Toracica, Policlinico Universitario, Cagliari
Mauro Podda: Chirurgia Generale, Ospedale San Francesco, Nuoro
Fernando Serventi: Chirurgia Generale, Ospedale Giovanni Paolo II, Olbia
Danilo Piras: Chirurgia Generale, Ospedale San Martino, Oristano
Renata Pau: Chirurgia Generale, Ospedale SS Trinità, Cagliari
Simona Ledda: Chirurgia Generale, Ospedale N.S. Bonaria, San Gavino
Francesco Madeddu: Chirurgia Generale, CTO, Iglesias
Simona Aresu: Chirurgia Generale, Ospedale Nostra Signora della Mercede, Lanusei
Gian Marco Carboni: Chirurgia Generale, Ospedale A. Segni, Ozieri
Franca Cossu: Chirurgia Generale, Ospedale Civile, Alghero
Giovanni Pinna: Chirurgia Generale, Ospedale Sirai, Carbonia
Francesco Balestra: Chirurgia Generale, Ospedale San Francesco, Nuoro
Giulio Argenio: Chirurgia Generale, Ospedale San Francesco, Nuoro
Pier Luigi Tilocca: Patologia Chirurgica, AOU Sassari
Marcello Pisano: Chirurgia Generale, Ospedale San Marcellino, Muravera
Daniele Bertulu: Chirurgia Generale, Ospedale Giovanni Paolo II, Olbia
Nicola Cillara: Chirurgia Generale, Ospedale SS Trinità, Cagliari

3. Objectives
Comparison between surgical treatment and antibiotic therapy in unselected patients with acute appendicitis with special regards to efficacy and complication rates.

4. Materials and methods Retrospective multicenter cohort study;
15 Sardinian surgical units;
patients admitted between 1st January 2014 and 31 December 2014;
mean follow-up period of 20 months collected through phone interview;
data collected through online questionnaire

5. Collected data Included patients
Patients treated with antibiotic therapy first
Patients treated with surgery first n
346
162
184 %
100%
46,82%
53,18%

6. Epidemiology Antibiotic therapy group Surgical therapy group
Mean age (years)
28,80 ± 16.53
34,82 ± 17,65
M:F ratio
63:99
98:86

7. Lenght of hospital and AIR score
Antibiotic therapy
Surgical therapy
Lenght of hospitalization (days)
3,38 days (± 1,89)
4,84 (± 2,69)
AIR score
<5 points 83 (51,23%)
5-8 points 75 (46,30%)
>8 points 4 (2,47%)
<5 points 62 (33,70%)
5-8 points 109 (59,24%)
>8 points 13 (7,06%)

8. Diagnosis
Clinical-laboratoristic (AIR score, Alvarado score et al.) diagnosis alone US TC
US + TC
Antibiotic group
64 (39,51%)
90 (55,55%)
3 (1,85%)
5 (3,09%)
Surgery group
64 (34,78%)
94 (51,09%)
14 (7,61%)
12 (6,52%)

9. Surgical-first treatment
Videolaparoscopic appendectomy (VLA)
Open surgery (Mc Burney incision, median laparothomy, other)
Number of patients
139 45 %
75,55%
24,45%

10. Antibiotic-first treatment
Drug
Number of patients %
Piperacillin + Tazobactam 60
37,04%
Ceftriaxone 30
18,52%
Amoxicillin + Clavulanic Acid 28
17,28%
Ceftazidima 15
9,26%
Cefotaxime 14
8,64%
Other

11. Efficacy Efficacy rate Persistency Recurrence Surgical-first therapy
184 (100%)
0 (0%)
Antibiotic-first therapy
95 (58,63%)
34 (20,99%)
33 (20,38%)

12. Univariate analysis p-value
Antibiotic therapy
Surgical therapy
P-value
Sex (M:F)
63:99
98:86
p=0,0103
Age
28,80 ± 16,53
34,82 ± 17,65
p=0,0012
Lenght of stay (days)
3,38 ± 1,89
4,84 ± 2,69
p=0,0001
AIR score (mean)
6,1 ± 1,35
6,5 ± 1,71
p=0,0173
Persistency rate
34:128
0:184
p < 0,000001
Recurrence rate
33:129

13. Multiple analysis p-value
Variabili
Terapia antibiotica
p-value
Successo
Fallimento
Età
27,14 (± 14,26)
35,03 (± 22,37)
0,0129
Sesso
Maschi
39,06%
38,24%
0,9299
Femmine
60,94%
61,76%
AIR score
1,91
2,32
0,1166
Esordio sintomatologia
<12 ore
42,19%
44,12%
0,3254
oltre le 48 ore
23,44%
26,47%
tra 12 e 24 ore
24,22%
20,59%
tra 24 e 48 ore
10,16%
8,82%

14. Persistency and recurrence treatment after antibiotic therapy failure
in the 55,89% of patients with persistence of acute appendicitis an open surgical approach was necessary;
17,39% of patients with recurrence underwent open surgery;
75,55% of patients in the surgical group were successfully treated with laparoscopy (p= 0, vs p=0,605464)

15. Complications sec. Clavien-Dindo
2,94% of patients with persistency and 8,70% of patients with recurrence reported complications after appendectomy;
in the surgical group the rate of complications observed was 13,59% (p=0, vs p=0,745406)

16. Return to normal activity
93,69% of patients treated succesfully with antibiotics returned to normal activity within two weeks after the primary treatment;
67,65% of patients affected from persistency after antiobiotic therapy and treated surgically returned to normal activity within two weeks;
76,09% of patients primarily treated with surgery returned to normal activity within two weeks (p=0, vs p=0,291234)

17. Conclusions
Surgery is the most effective treatment for unselected patients with acute appendicitis;
antibiotic therapy exposes patients to a persistency rate of 20,99% and recurrence rate of 20,38%;
higher rates of open surgery and conversion to open approach were reported for patients with persistent appendicitis after antibiotic-first approach;
patients who underwent appendectomy for recurrent appendicitis were not more prone to be operated with open technique when compared to patients enrolled in the surgery group;

18. Conclusions
no statistical difference in the rate of post-operation complications between the two groups;
lenght of the stay is significantly lower in the antibiotic group;
persistent and recurrent appendicitis should be considered as two different clinical entities;
further studies are needed in order to identify a subgroup of patients affected from acute appendicitis for whom antibiotic treatment can be highly effective