Evidence-based Clinical
Practice Guidelines for
Acute Nontraumatic RLQ
Abdominal Pain and Tenderness and
Acute Appendicitis
With a definite diagnosis of acute
appendicitis, what is the most cost-effective treatment, operative or
non-operative?
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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? |
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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 |
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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. |
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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?
*Cost – stat
basis (private setting) – most recent Comparison
of Treatment Modalities for Acute Appendicitis
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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 |
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· 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:
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Presentation
of Primary Evidences: Comparison of Treatment Modalities for Acute Appendicitis
*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
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
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 |
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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
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
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. |
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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)? |
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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 |