Are Antibiotics the New Appendectomy?

Prior to the development of laparoscopic procedures, open appendectomy was the standard of care for the majority of appendicitis cases. Recently, studies have debated using antibiotics as a first-line treatment in uncomplicated appendicitis cases. The definition of uncomplicated appendicitis is not always clear-cut; however, with the large-scale accessibility of radiologic techniques, it is becoming increasingly easier to classify patient groups. As suggested by clinical and radiological patient data, this has raised the speculation of considering antibiotic therapy as the sole treatment modality in uncomplicated appendicitis cases. We aim to compare the options of surgery and antibiotics only in terms of efficacy, complications, and financial cost. A range of databases and search strategies were adopted, and various databases were used, including PubMed, ScienceDirect, Google Scholar, and JAMA. Collectively, 30 studies were reviewed, but only 18 were included. Efficacy rates were higher in the appendectomy group. Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up. Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin. Complications were more frequent and significant in the surgery group. These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism. Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. Given the high success rates post-appendectomy for acute appendicitis over the decades, the efficacy of conservatively treated acute appendicitis raises a strong argument when choosing one of the two options. The efficacy remained consistently higher across the literature in the surgery group than in the antibiotics-only group. However, it is still arguable that antibiotics may be a preferable option given an efficacy rate of more than 70% at one year and overall higher complications associated with surgery. The argument of missing a neoplasm by avoiding surgery is valid. However, most are carcinoid neuroendocrine neoplasms with a low probability of metastasis (<5%) and are usually considered benign. Given the current practice focused on conservative and minimally invasive treatments and recently the COVID-19 pandemic, with its restrictions and lessons learnt, antibiotics may be the future standard for treating uncomplicated acute appendicitis. Lastly, we noticed higher efficacy rates in articles published recently than those published at least five to ten years earlier. Antibiotics-only therapy for uncomplicated appendicitis is cost-effective with fewer complications than surgery. However, appendectomies have higher efficacy. Thus, surgical treatment prevails as the standard of care. Future literature should yield larger sample sizes and explore the numbers of emergency appendectomies mandated following antibiotics-only therapy.

Venous thromboembolism prophylaxis and the impact of a thrombosis service at a Canadian level 1 trauma centre

Background: Venous thromboembolism (VTE) is a common and serious complication seen in patients with trauma. Guidelines recommend the routine use of pharmacologic prophylaxis; however, compliance rates vary widely. The aim of this study was to describe the clinical practice related to VTE prophylaxis in the first 24 hours after injury at our level 1 Canadian trauma centre and the impact of a thrombosis consultation service. Methods: We performed a retrospective review of the health records of adult patients with trauma admitted between Jan. 1, 2012, and June 30, 2013. The rate of VTE was ascertained. The use of an initial prophylactic regimen, potential contraindications to prophylaxis and involvement of the thrombosis service were determined. Results: A total of 633 patients were included, 459 men and 174 women with a mean age of 47.4 years. The mean Injury Severity Score was 15.8. The overall VTE rate was 2.8%. A total of 514 patients (81.2%) received VTE prophylaxis, mechanical in 302 (47.7%) and pharmacologic in 231 (36.5%) (19 patients received both types). The thrombosis service was involved in the care of 164 patients (25.9%). Patients seen by the thrombosis service were more likely to receive VTE prophylaxis than those not seen by the service (145 [88.4%] v. 369 [78.7%], p < 0.01). Conclusion: Compliance with VTE prophylaxis administration was suboptimal, and opportunities for improvement exist. The involvement of a thrombosis consultation service appears to improve compliance with VTE prophylaxis, and augmented use of this service may improve clinical outcomes.

Contexte: La thromboembolie veineuse (TEV) est une complication grave et fréquente chez les patients vus en traumatologie. Les lignes directrices recommandent l'utilisation systématique d'une prophylaxie pharmacologique; par contre, les taux de conformité aux lignes directrices varient beaucoup. Le but de cette étude était de décrire la pratique clinique en matière de thromboprophylaxie dans notre centre de traumatologie canadien de niveau 1 au cours des 24 premières heures suivant un traumatisme et l'impact d'un service de prévention des thromboses. Méthodes: Nous avons procédé à une revue rétrospective des dossiers médicaux de patients adultes hospitalisés en traumatologie entre le 1er janvier 2012 et le 30 juin 2013. Le taux de TEV a été mesuré et nous avons vérifié si un schéma prophylactique initial avait été utilisé, s'il y avait des contre-indications potentielles à la prophylaxie et si le service de prévention des thromboses avait été mis à contribution. Résultats: En tout, 633 patients ont été inclus, 459 hommes et 174 femmes âgés en moyenne de 47,4 ans. L'indice moyen de gravité de la blessure (IGB) était de 15,8. Le taux global de TEV a été de 2,8 %. En tout 514 patients (81,2 %) ont reçu une thromboprophylaxie (mécanique chez 302 [47,7 %] et pharmacologique chez 231 [36,5 %]; 19 patients ont reçu les 2 types de prophylaxie). Le service de prévention des thromboses a été impliqué dans 164 dossiers (25,9 %). Les patients vus par le service de prévention des thromboses étaient plus susceptibles que les autres patients de recevoir une thromboprophylaxie (145 [88,4 %] c. 369 [78,7 %], p < 0,01). Conclusion: La conformité aux lignes directrices sur la thromboprophylaxie a été sous-optimale, et il est possible de l'améliorer. L'implication d'un service de prévention des thromboses semble améliorer la conformité aux lignes directrices sur la thromboprophylaxie et y faire appel plus souvent pourrait améliorer les résultats cliniques.