Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score-matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial).

PURPOSE: The aim of this prospective multicenter study was to compare antibiotic therapy and appendectomy as treatment for patients with uncomplicated appendicitis confirmed by ultrasound and/or computed tomography. METHODS: The study was conducted from January 2017 to January 2018. Data regarding all patients discharged from the participating centers with a diagnosis of uncomplicated appendicitis were collected prospectively. RESULTS: Of the 318 patients enrolled in the study, 27.4% underwent antibiotic-first therapy, and 72.6% underwent appendectomy. The matched group was composed of 87 patients in both study arms. Of the 87 patients available of 1-year follow-up in the antibiotic-first group, 64 (73.6%) did not require appendectomy. The complication-free treatment success in the antibiotic-first group was 64.4%. A statistically significant higher complication-free treatment success was found in the appendectomy group: 81.8% in the pre-matching sample and 83.9% in the post-matching sample. Patients in the antibiotic-first group reported lower VAS scores compared to those treated with an appendectomy, both at discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs 2.1 ± 1.7). The mean of the days of absence from work was higher in the appendectomy group (ß 0.63; 95% CI 0.08-1.18). CONCLUSION: Although laparoscopic appendectomy remains the gold standard of treatment for uncomplicated appendicitis, conservative treatment with antibiotics is a safe option in most cases. Approximately 65% of patients treated with antibiotics are symptom-free at 1 year, without increased risk of adverse events should symptoms recur, and better outcomes in terms of less pain and shorter period of absence from work compared to patients undergoing an appendectomy. TRIAL REGISTRATION: Clinicaltrials.gov identifier (NCT number): NCT03080103.

[Anastomotic leak following colorectal surgery: incidence, risk factors and treatment]. / La deiscenza anastomotica in chirurgia colorettale: incidenza, fattori di rischio e trattamnento.

The aim of this study was to assess the incidence and identify the risk factors associated with colorectal anastomotic leakage. A further objective was to investigate the therapeutic choices. We reviewed the clinical files of 124 patients who underwent mechanical end-to-end anastomosis after colorectal resection during the period 2000-2007. The mean age was 66.9 years and the male:female ratio was 1.2:1. Indications for surgery were malignant neoplasms in 109 cases (87.9%) and benign disease in 15 cases (12.1%). The anastomosis was always performed in an elective setting in the framework of a procedure of one or more stages (87.9% and 7.3% respectively). A pelvic drain was positioned in a routine manner and no protective ileostomies were constructed. Among the various risk factors, co-morbidities, ASA risk and low anastomotic level were the most important we examined. Student's t-test, the Chi-square test and Fisher's test were used for comparative univariate analysis, with significant results for p < or = 0.05. The incidence of anastomotic leak was 10.5% (13/124), but only 4.8% (6/124) required a second operation or failed to heal with simple conservative therapy. The pelvic drain was always effective in allowing the early diagnosis of leakages and limiting the spread of peritoneal inflammation. Mortality was 1.6% (2/124) overall, but, if leakages alone were considered, it increased to 15.4%. Among the risk factors examined, only low anastomotic level was confirmed by statistical analysis. In conclusion, the study confirms low anastomotic level as a negative prognostic factor for the healing of colorectal anastomosis. The pelvic drain proved to be effective in allowing early diagnosis and conservative management of leakages.