Appendectomy is allways  one good treatment of acute appendicitis

The dillema is: Is antibiotic therapy in UNCOMPLICATED acute appendicitis better option due to elimination of the possibility of: (1) uterine manipulation that could lead to spontaneous abortion or preterm labor; (2) uterine injury, mostly during blind Veress needle insertion or trocar insertion and possible intrauterine infection inoculation - chorioamnionitis; (3) scientifically unproven consequences of CO2 insufflation; and (4) negative effects of anesthesia/medications on the fetus

In a recent Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis were Five studies including 1116 patients reported major complications in 25 (4⋅9 per cent) of 510 patients in the antibiotic and 41 (8⋅4 per cent) of 489 in the appendicectomy group: risk difference −2⋅6 (95 per cent c.i. –6⋅3 to 1⋅1) per cent (low-quality evidence). 

In conclusion in this stuy the choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value- and preference-dependent, suggesting a change in practice towards shared decision-making is necessary.

BJS 2016; 103: 656–667  DOI: 10.1002/bjs.10147

One of the problems of antibiotic therapy in general population is significant rate of recurrence during 1-3 years post-treatment. But maybe this time frame is enough for pregnant patients when let's say mean pregnancy period is 4-5 months...

How long will we have effective antibiotics - Increasing resistance. There are bacteria resistant to all antibiotics. We need to limit the use of antibiotics if thera is available effective surgical treatment.

I agree with you Jaroslaw. My opinion for general population is, that appendectomy, especially in the era on minimal invasive surgery, is better option than antibiotic treatment. There are several reasons:

1. antibiotic resistance

2. possibility of recurrence

3. due to the possibility of recurrence there is presumably higher probability of abdominal CT use

4. possibly more challenging operation with subsequent attacks

5. exclusion of appendicitis in patients with complicated intra-abdominal diseases, such as inflammatory bowel diseases, chronic gynecologic diseases, nephro/urolithiasis...

6. around 1% of appendiceal neoplasms that cannot be detected with antibiotic therapy. Such patients then present in more advanced disease.

7. lower incidence of ulcerative colitis with previous appendectomy.

The only idea for the antibiotic therapy in pregnancy is to eliminate theoretical negative effects on the continuation of pregnancy and the fetus.

But again, with all current knowledge on the topic, even in pregnancy, my opinion is that appendectomy is a safer option.

Yes, we do. It is possible to treat umcomplicated appendicitis using antibiotic regimen. Close monitoring of the patient is enough. If we see any signs or symptomatology that appendicitis is changing its pattern so we take the patient to the operating theatre., otherwise, I think its the best way to avoid of patient anxiety, anesthesia, technical manipilations, etc.

Dear Osman, yes it is possible to treat it conservatively. But several criteria should be fullfilled to carry it out.

1. Abdominal ultrasound (as well as clinical examination) is not enough accurate for the diagnosis. Up to 70% of ultrasound examinations in advanced pregnancy cannot visualize the appendix. Examination for appendicitis needs graded compression for the diagnosis which is difficult to perform in advanced pregnancy.

2. To be sure that (1) the acute appendicitis is the underlying cause, and to be sure that (2) it is uncomplicated one, the emergeent abdominal MRI should be available. We know that this cannot be achieved in all hospitals. If it is available that conservative therapy is possible.

Dear Alejandro

I read with great interest the study by Sallinen et al. It is too early for such meta-analysis due to small number of patients and short follow-up. Currently, for general population, laparoscopic appendectomy is still a better option than antibiotic treatment. The reasons are stated in one of my previous posts.

Ony 22% of patient were operated by laparoscopy. This low percentage puts in a question other diagnostic and treatment strategies and comparisons (length of stay, wound infections...)  in this meta-analysis. All these facts puts in question conclusions of this meta-analysis

In my experience patients recover faster after laparoscopic (or open) appendectomy than With antibiotic treatment only. Perhaps theree is a bias her, because Our tradition is surgery unless there iss a rather large inflammatary region around the appendix, usually With the patient presentting several days after the symptoms started.

I would also support the statement to remove the appendix to have an histopathology of the specimen, it seems there are a more agressive treatment of carsinoids now compared to 10-20 years ago.

We can do clinical trials. But is there someone who decides to treat acute appendicitis without surgery . I will never. How do you know that this is not  appendicitis phlegmonosa,  If you can treat with antibiotic, you may not have to deal with appendicitis at all.

My opinion written here on Resesearchgate are published as a 'Your View' in the British Journal of Surgery as a comment on the article by Sallinen et al.

http://www.bjs.co.uk/details/yourviews/9193551/Metaanalysis-of-antibiotics-versus-appendicectomy-for-nonperforated-acute-append.html

= How do you know it is appendicitis?  Do you have a  fail safe criterion (criteria) to distinguish what is an "uncomplicated" versus a "complicated appendicitis? The only criterion I know is watching  the progression/regression  of the clinical signs and symptoms every 6 hours, without giving antibiotics nor pain killers. This is true for all patients except the pediatric cases and those whose affect obscure the  interpretation of your objectivity. ... and your labs will  then function as confirmatory tests as they are supposed to do.