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The Management of Uncomplicated Acute Appendicitis: The Analysis of 211 Adults
KENJI NANISHI*
Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Kyoto Pref., Japan
<Background and objective>
Previous studies have shown that interval appendectomy and delayed appendectomy after conservative therapy (CT) are more effective than emergency appendectomy (EA). However, other studies have shown contrasting findings; thus, guidelines have not yet been established. This study compared the effectiveness of EA and CT and clarified the appropriate management for appendicitis.
<Materials and methods>
This was a single-center, retrospective cohort study of 211 adults with uncomplicated appendicitis who were not administered prehospital antibiotics between January 2011 and December 2014. The primary outcome was the normal treatment rate (only antibiotic + laparoscopic appendectomy + McBurney incision appendectomy in all cases). The secondary outcome included the normal surgery rate (laparoscopic appendectomy + McBurney incision appendectomy in all surgery cases), surgical complication rate, operative duration, and hospitalization duration. The correlation between pre-hospital delay, C-reactive protein (CRP) level, and treatment results was analyzed. The response rate (cases controlled inflammation/all cases) of the CT group was also assessed.
<Results>
EA was selected in 164 cases and CT was performed in 47 cases. No significant intergroup differences were found in background factors (age, sex, white blood cell count, CRP level). Fecal stones were more common in the EA group (50.0% [82/164] vs. 27.7% [13/47]). The normal treatment rate was higher in the CT group than in the EA group (86.0% [141/164] vs. 97.8% [46/47], respectively). The normal surgery rate was insignificantly higher in the CT group (86.0% [141/164] vs. 94.1% [16/17]). The intergroup surgical complication rate, operative duration, and hospitalization duration were similar. All cases were divided into four groups: pre-hospital delay <24 hours (day 0), pre-hospital delay >24 hours but <72 hours and CRP level < 3.0 mg/L (day 1-2; CRP < 3.0), pre-hospital delay > 24 hours but < 72 hours and CRP level > 3.0 mg/L (day 1-2, CRP ≥ 3.0), and pre-hospital delay > 72 hours (day 3+). In the EA group, longer delay and higher CRP level decreased the normal treatment rate; however, in the CT group, the delay and CRP did not affect the normal treatment rate (EA: day 0, 92.9% [92/99], day1-2, CRP < 3.0, 95.7% [22/23], day 1-2, CRP ≥ 3.0: 64.5% [20/31], day 3+: 63.6% [7/11] vs. CT day 0: 96.6% [28/29], day 1-2, CRP < 3.0: 100% [8/8], day 1-2, CRP ≥ 3.0: 100% [8/8], day 3+: 100% [2/2]).
<Conclusions>
Our data suggested that use of CT could increase the normal treatment rate and pre-surgical CT could improve surgical quality. The incline was more significant in cases with a long pre-hospital delay and high CRP level. CT should be selected in cases of a delay > 3 days or 1-2 days and a CRP ≥ 3.0.
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