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Operation versus antibiotics--The "appendicitis conundrum" continues: A meta-analysis.
Sakran JV, Mylonas KS, Gryparis A, Stawicki SP, Burns CJ, Matar MM, Economopoulos KP.
J Trauma Acute Care Surg. 2017 Jun;82(6):1129-1137.

Rationale for inclusion: recent metaanalysis synthesizes evidence from five RCTs comparing nonoperative versus surgical management of uncomplicated acute appendicitis in 1,430 adult patients. Treatment efficacy at 1-year follow-up was significantly lower (63.8%) for antibiotics compared with the surgery group (93%).

Citations - 1 (as of January 2018)

Evidence for an antibiotics-first strategy for uncomplicated appendicitis in adults: a systematic review and gap analysis.
Ehlers AP, Talan DA, Moran GJ, Flum DR, Davidson GH.
J Am Coll Surg. 2016 Mar;222(3):309-14.

Rationale for inclusion: This is an excellent review paper which discusses the limitations and methodological flaws (selection bias, diagnostic criteria, treatment strategy, outcome selection) of recently published randomized trials.

Citations - 10 (as of July 2017)

Laparoscopic surgery or conservative treatment for appendiceal abscess in adults? A randomized controlled trial.
Mentula P, Sammalkorpi H, Leppäniemi A.
Ann Surg. 2015 Aug;262(2):237-42.

Rationale for inclusion: this study challenges the practice of percutaneous treatment for appendiceal abscess.

Citations - 9 (as of July 2017)

Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial.
Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Grönroos JM.
JAMA. 2015 Jun 16;313(23):2340-8.

Rationale for inclusion: this European study concludes that antibiotic therapy is non-inferior to appendectomy for acute appendicitis.

CAVEAT: When trying to decide whether or not this study may be applicable to American practice, it is important to consider that the average hospital length of stay for the surgical group was 3 days and that only 5.5% of appendectomies were performed laparoscopically.  While the overall complication rate was significantly higher in the surgical group (20.5% vs. 2.8%), this was predominantly driven by superficial surgical site infections and incisional pain; this may be related to the overwhelming use of open appendectomy technique. There was a 16% negative appendectomy rate, which seems high in the modern era.  There was a 1.5% incidence to tumors in the surgical group.

Citations - 138 (as of July 2017)

Trial of short-course antimicrobial therapy for intraabdominal infection.
Sawyer RG, Claridge JA, Nathens AB, Rotstein OD, Duane TM, Evans HL, Cook CH, O'Neill PJ, Mazuski JE, Askari R, Wilson MA, Napolitano LM, Namias N, Miller PR, Dellinger EP, Watson CM, Coimbra R, Dent DL, Lowry SF, Cocanour CS, West MA, Banton KL, Cheadle WG, Lipsett PA, Guidry CA, Popovsky K.
N Engl J Med. 2015 May 21;372(21):1996-2005.

Rationale for inclusion: this high-quality randomized trial demonstrated that for complicated intra-abdominal infections (including perforated appendicitis) with adequate surgical source control, four days of post-operative antibiotics is non-inferior to a longer (median eight days) course of antibiotics.

Citations - 130 (as of July 2017)

The NOTA study (non operative treatment for acute appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis.
Di Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S, Coccolini F, Smerieri N, Pisano M, Ansaloni L, Sartelli M, Catena F, Tugnoli G.
Ann Surg. 2014 Jul;260(1):109-17.

Rationale for inclusion: this observational study of 159 patients treated non-operatively for suspected acute appendicitis demonstrated 83% long-term efficacy at 2 years.

CAVEAT: this study included patients suspected of having acute appendicitis by clinical exam, Alvarado and/or Appendicitis Inflammatory Response (AIR) scores, but only 73% underwent ultrasound assessment and only 17% underwent CT scan to confirm the diagnosis.

Citations - 90 (as of July 2017)

Comparison of outcomes of laparoscopic and open appendectomy in management of uncomplicated and complicated appendicitis.
Tiwari MM, Reynoso JF, Tsang AW, Oleynikov D.
Ann Surg. 2011 Dec;254(6):927-32.

Rationale for inclusion: this analysis of the University HealthSystem Consortium database concludes that laparoscopic appendectomy is superior to open appendectomy.

Citations - 113 (as of July 2017)

Appendectomy versus antibiotic treatment for acute appendicitis.
Wilms IM, de Hoog DE, de Visser DC, Janzing HM.
Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008359.

Rationale for inclusion: this Cochrane review concludes that appendectomy remains the standard treatment for acute appendicitis because of the low quality of available evidence.

Citations - 147 (as of July 2017)

Laparoscopic versus open appendectomy: an analysis of outcomes in 17,199 patients using ACS/NSQIP.
Page AJ, Pollock JD, Perez S, Davis SS, Lin E, Sweeney JF.
J Gastrointest Surg. 2010 Dec;14(12):1955-62.

Rationale for inclusion: this very large NSQIP study confirms that laparoscopic appendectomy has better outcomes compared to open appendectomy.

Citations - 49 (as of July 2017)

Laparoscopic versus open surgery for suspected appendicitis.
Sauerland S, Jaschinski T, Neugebauer EA.
Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001546.

Rationale for inclusion: this Cochrane meta-analysis concludes that laparoscopic appendectomy has advantages over open appendectomy.

Citations - 468 (as of July 2017)

Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals.
Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, Esposito TJ.
Surgery. 2010 Oct;148(4):625-35; discussion 635-7.

Rationale for inclusion: this analysis of the NSQIP database concludes that laparoscopic appendectomy (compared to open appendectomy) is associated with lower overall morbidity, but may result in higher rates of organ space infection in patients with complicated appendicitis.

Citations - 159 (as of July 2017)

Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis.
Mason RJ, Moazzez A, Sohn H, Katkhouda N.
Surg Infect (Larchmt). 2012 Apr;13(2):74-84.

Rationale for inclusion: this meta-analysis of randomized trials concludes that non-operative (antibiotics alone) therapy of acute, non-perforated appendicitis has higher recurrence rates compared with immediate appendectomy.

Citations - 92 (as of July 2017)

An acute care surgery model improves outcomes in patients with appendicitis.
Earley AS, Pryor JP, Kim PK, Hedrick JH, Kurichi JE, Minogue AC, Sonnad SS, Reilly PM, Schwab CW.
Ann Surg. 2006 Oct;244(4):498-504.

Rationale for inclusion: this parallel-cohort study demonstrates that an acute care surgery (ACS) model, compared to the traditional home-call model, was associated with decreased time to operation, decreased complications, and shorter hospital length of stay.

Citations - 161 (as of July 2017)

Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database.
Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, Pietrobon R.
Ann Surg. 2004 Jan;239(1):43-52.

Rationale for inclusion: this analysis of the Nationwide Inpatient Sample (NIS) concludes that laparoscopic appendectomy is superior to open appendectomy with regards to hospital length of stay and post-operative in-hospital morbidity.

Citations - 508 (as of July 2017)

A practical score for the early diagnosis of acute appendicitis.
Alvarado A.
Ann Emerg Med. 1986 May;15(5):557-64.

Rationale for inclusion: this widely cited paper describes the “Alvarado score”, a clinical scoring system which can help clinicians decide whether or not to order CT imaging for suspected acute appendicitis.

Citations - 1055 (as of July 2017)

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