One in five operations with in-network surgeons and facilities could result in surprise bills
At the time of the APPAC study, a non-surgical approach to acute appendicitis was unheard of. To get enough cases in the study, the investigators were forced to compromise with the surgeons involved, that if in their judgment it was required, operative treatment could be given even to the patients in the non-surgical arm. The scenarios envisaged included signs of progressive infection, perforation of the appendix , or peritonitis.
Moreover, the antibiotics were probably stronger than strictly necessary because the trial was, in part, an attempt to prove the reliability of medical treatment in acute uncomplicated appendicitis. In short, the trial results provide a lower than the actual estimate of the favorable outcome of these patients when treated with antibiotics. The findings
The results showed that patients who had successful treatment had similar rates of satisfaction with their treatment and similar quality of life. However, those patients who were first treated with antibiotics but later had an appendectomy were less satisfied with their treatment.
The study is limited by the fact that open surgery was used in the first part of the trial for appendectomy, because today laparoscopic appendectomy is the standard of care for this condition, due to the briefer stay in hospital and the reduction in postoperative pain. The implications
In an accompanying editorial, Edward Livingstone points out that patients in either arm had no measurable difference in the quality of life or satisfaction with treatment. Even though those who failed to show adequate response to the antibiotic were eventually taken up for surgery, this does not change the fact that in the group who were successfully treated non-surgically, there is no evidence of lingering infection. The most feared complication of infection is its spread, which could cause disability or death unless appropriately managed.
The editorial concludes, “Future studies should refine the approach used by the APPAC investigators to better understand how to nonoperatively manage acute appendicitis.” Journal reference:
Sippola S, Haijanen J, Viinikainen L, et al. Quality of Life and Patient Satisfaction at 7-Year Follow-up of Antibiotic Therapy vs Appendectomy for Uncomplicated Acute Appendicitis: A Secondary Analysis of a Randomized Clinical Trial. JAMA Surg. Published online February 19, 2020. doi:10.1001/jamasurg.2019.6028
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