A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

Sage wisdom or anecdotal dictum? Equivalent opioid use after open, laparoscopic, and robotic inguinal hernia repair.

BACKGROUND: Purported benefits of minimally-invasive inguinal hernia repair techniques include less postoperative pain, but objective data is lacking. We analyzed prescribing habits and opiate requirements to provide an objective comparison. METHODOLOGY: Inguinal hernia repairs performed on patients aged 18-65 from October 2016 through February 2018 were examined. Patients with prior opiate use or complicated operative courses were excluded. Discharge prescriptions, morphine milligram equivalents(MME), and additional prescriptions within three months were evaluated. RESULTS: 173 patients met criteria including 90 open(OMR), 34 laparoscopic(TEP), and 49 robotic(RTAPP) repairs. There was no difference in age or gender. There was no difference in average opiate prescriptions(OMR 230 MME, TEP 229 MME, RTAP 208 MME; p = 0.581), percentage prescribed acetaminophen(OMR 96.7%, TEP 97.1%, RTAPP 98.0%; p = 0.910), or percentage prescribed NSAIDs(OMR 43.3%, TEP 44.1%, RTAP 46.9%; p = 0.919). On follow up, there was no difference in repeat opiate prescriptions(OMR 10.0%, TEP 8.8%, RTAPP 8.2%; p = 0.934). CONCLUSIONS: Patients undergoing open, laparoscopic, and robotic inguinal hernia repairs showed no evidence of differing pain medication requirements. The implication that minimally-invasive techniques cause less pain may be inaccurate.