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Evidence-based Clinical Practice Guidelines for

Acute Nontraumatic RLQ Abdominal Pain and Tenderness and

Acute Appendicitis

 

Clinical Issue/Question
 

With a definite diagnosis of acute appendicitis, what is the most cost-effective treatment, operative or non-operative?

 

Format of Guidelines Development

 

 

 

Clinical Scenario and Issue

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

 

 With a definite diagnosis of acute appendicitis, what is the most cost-effective treatment, operative or non-operative?

 

 

Statement of Premises:

 

Non-immunocompromised patient with a definite diagnosis of acute appendicitis.

 

Goal of Treatment of Acute Appendicitis:

 

To resolve the inflammation in the appendicitis

with the least morbidity and mortality consequences

 

 

Operational Definition of Terms in the Issue/Question:

 

·        Treatment – treatment modality: either operative or nonoperative;

Operative treatment – removal of appendix either through open or laparoscopic technique

Nonoperative treatment – use of antibiotics

 

·        Cost-effective procedure – the best after weighing the benefit-risk-cost-availability factors of treatment

modality  options.

 

·        Mortality – death occurring after treatment of acute appendicitis is instituted.

 

·        Morbidity – unwanted events short of death occurring after treatment of acute appendicitis is instituted.

 

 

Evidence Appraisal Plan:

 

 End-points in answering the question:

 

·        In patients with an acute appendicitis, what is the most cost-effective treatment modality that will resolve the inflammation with the least morbidity and mortality consequences? 

 

Option

Benefit

Risk

Cost*

Availability

 Operative

 

 

 

 

 Nonoperative

 

 

 

 

 

*Cost – stat basis (private setting) – most recent

 

 

 

Comparison of Treatment Modalities for Acute Appendicitis

 

Options

 Efficacy

(disappearance of RLQ abdominal pain or appendicitis)

Perforation

Recurrence

 Mortality

Nonoperative

 

 

 

 

Operative

 

 

 

 

 

 

Search Methodology:

 

Tracking:

            Medline – for international journal publications

            Herdin – for local journal publications

            Internet using various search engines such as AltaVista, Infoseek, Lycos, etc.

 

Retrieval:

 

Retrieval of whole journal article was done through the various libraries of the Metro Manila medical schools, Department of Science and Technology (DOST), and acquaintances.

 

Appraisal (Inclusion Criteria):

 

·        Focus of paper is on treatment modality for acute appendicitis

·        With gold standard (intraoperative findings, histopathological results, follow-up)

·        More than 30 subjects

·        With data on efficacy, morbidity and mortality

 

 

Search and Tracking Outcome:

 

·        Total no. of papers and abstracts appraised: 500

 

·        Level of evidences:

 

The two primary evidences are of Level I Evidence

(Randomized Controlled Trials)

 

Tracking and Retrieval Results:

 

Database

Search engine

Search span

Search words

No. of titles

Relevant abstracts/papers

Medline

1966-1999 (August)

 Ap + nonoperative treatment

 9

2

 

 

 Ap + treatment

 503

 2

Herdin

 

Appendicitis

      107

 0

AltaVista, Infoseek, Lycos, etc

 

Appendicitis

Tntc

 1

 

 

 

 

 Presentation of Primary Evidences:

 

Comparison of Treatment Modalities for Acute Appendicitis

 

Option

Benefit

Risk

Cost*

Availability

 Nonoperative

 Resolution of appendicitis without operation

(see efficacy)

 Side effects of antibiotics

P5600

**

Readily

Available (RA)

 

 Operative

Instant removal of inflamed appendix

 Side effects of operation

P 7000

***

RA

 

*Cost in Philippine Pesos – stat basis (private hospital) [1999]

** Cost of antibiotics only:

P200/injectable antibiotics x 4 (q6) x 7 days

*** Operating room expenses only (without room and professional fees)

 

 

Comparison of Treatment Modalities for Acute Appendicitis

 

Options

N

 Efficacy

(disappearance of RLQ abdominal pain)

Perforated

Recurrence

(within a year)

Nonoperative

20

          19 (  95%)

1 (5%)

7(35%)

Operative

20

 20 (100%)

NA

NA

 

Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. 

Eriksson S; Granström L

Department of Surgery, Karolinska Institute, Danderyd Hospital, Sweden.

Br J Surg, 1995 Feb, 82:2, 166-9

 

Options

N

Efficacy

Appendicitis

at 10 days on UTS

Efficacy

Appendicitis

 at 30 days on UTS

Perforated

Recurrences (within a year)

Nonoperative

19

8 (42%)

5 (26%)

1 (5%)

3 (16%)

Operative

21

NA

NA

NA

NA

 

Ultrasonographic findings after conservative treatment of acute appendicitis and open appendicectomy.

Eriksson S; Tisell A; Granström L

Department of Surgery, Karolinska Institute and Danderyd Hospital, Sweden.

Acta Radiol, 1995 Mar, 36:2, 173-7

 

 

See References

 

 

 

Distillation of all available evidences to come out with recommendations or answers to the clinical issue/question:

 

In terms of benefit, the operative modality is more efficacious.  There is an instant complete resolution of the appendicitis problem without the associated risk of perforation and recurrences as seen with the nonoperative treatment modality.

 

Although the nonoperative treatment has an efficacy rate of 95%, the margin of safety is less than that of the operative treatment.  There is the risk of perforation if the antibiotic therapy is not successful.

With perforation, there is an accompanying higher incidence of morbidity and mortality.  See tables below.

 

With 16 to 35% recurrence rates eventually necessitating an operation, the operative option is more cost-beneficial.

 

Comparison of morbidity and mortality rates among  normal appendix,  acute appendicitis, and perforated appendicitis in 10,023 appendectomies done over 15 years from 1977 - 1992

 

 

Scenarios after appendectomy

Mortality

Complications

Normal appendix

0.14%

4.60%

Acute appendicitis

0.24%

6.10%

Perforated appendicitis

1.66%

(11x normal)

19.30%

(4x normal)

 

From:

Velanovich V, Satava R. Balancing the normal appendectomy rate with the perforated appendicitis rate: Implications for quality assurance.  Am Surg 1992;58:4,264-269.

 

 

Comparison of the morbidity and mortality rates among normal appendix, acute appendicitis, and perforated appendicitis in 4,950 appendectomies  done in 147 United States Department of Defense hospitals worldwide from 1992-1993

 

Complication

Normal

(n=653)

Acute

(n=3265)

Perforated

(n=1032)

Total

 (n=4950)

Wound infection

12 (1.8)

46 (1.4)

66 (6.4)

124 (2.5)

Intraperitoneal abscess

NA

11 (0.3)

  8 (0.8)

  19 (0.4)

Bowel obstruction

  2 (0.3)

  8 (0.2)

12 (1.2)

  22 (0.4)

Intestinal fistula

NA

NA

  5 (0.5)

    5 (0.1)

Urinary retention

  5 (0.8)

28 (0.9)

19 (1.8)

  52 (1.0)

Urinary tract infection

  4 (0.6)

  5 (0.2)

  3 (0.3)

  12 (0.2)

Pneumonia

  2 (0.3)

  3 (0.1)

  6 (0.6)

  11 (0.2)

C. difficile colitis

  1 (0.2)

NA

  3 (0.3)

    4 (0.1)

Pulmonary embolism

NA

NA

  1 (0.1)

      1 (0.02)

Acute renal failure

NA

NA

  1 (0.1)   

      1 (0.02)

Myocardial infarction

NA

NA

  1 (0.1)

      1 (0.02)

Deep  vein thrombosis

NA

NA

  1 (0.1)

      1 (0.02)

Cricothyroidotomy

NA

    1 (0.03)

NA

      1 (0.02)

Vascular injury

   1 (0.2)

NA

NA

      1 (0.02)

 

 

 

 

 

DEATH

   1 (0.2)

    1 (0.03)

    2 (0.2)

   4 (0.1)

 

 

 

 

 

Total

27 (4.0)

103 (3.0)

128 (12)

259 (5.2)

Values in parentheses are percentages.

 

From: Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP.  Appendectomy:   A contemporary appraisal.  Ann Surg 1997; 225:3, 253-61.

 

  

 Summary of Answer to Question or Recommendations:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

 

 With a definite diagnosis of acute appendicitis, what is the most cost-effective treatment, operative or non-operative?

 

With a definite diagnosis of acute appendicitis,

 

the most cost-effective treatment  is operation –

 

removing the inflamed appendix.

 

 

 

 

Future Research Issues/Questions Arising from Attempts to Answer Issue:

 

What is the most cost-effective antibiotic regimen that can be used if operative modality is not feasible (absence of surgeon)?

 

 

 

References:

 

1.      Eriksson S, Granstrom L.  Randomized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis. Br J Surg, 1995 Feb, 82:2, 166-9.

 

2.      Eriksson S; Tisell A; Granström L. Ultrasonographic findings after conservative treatment of acute

appendicitis and open appendicectomy. Acta Radiol, 1995 Mar, 36:2, 173-7.

 

 

 

Quick Reference Guide or Algorithm:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

 

 With a definite diagnosis of acute appendicitis, what is the most cost-effective treatment, operative or non-operative?

 

With a definite diagnosis of acute appendicitis,

 

the most cost-effective treatment  is operation –

 

removing the inflamed appendix.

 

See algorithm