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Comment & Response
February 19, 2019

Long-term Follow-up of Antibiotics vs Surgery for Appendicitis

Author Affiliations
  • 1Yong Loo Lin School of Medicine, National University of Singapore, Singapore
JAMA. 2019;321(7):706-707. doi:10.1001/jama.2018.19588

To the Editor Dr Salminen et al1 reported 5-year follow-up results from a clinical trial that randomized patients with acute uncomplicated appendicitis to antibiotics vs surgical management. The authors reported the cumulative incidence of recurrence at various time points up to 5 years according to the intention-to-treat principle.

However, a total of 100 patients in the antibiotic group received appendectomy at some point in the study (15 during initial hospitalization and 85 after successful antibiotic therapy), which eliminated their risk of developing a subsequent recurrence. Stated differently, if the 85 patients had not undergone appendectomy, they would have remained at risk of developing a second recurrence of acute appendicitis. The incidence of a second recurrence is clinically important: approximately 13.0% for patients whose treatment was nonoperatively managed during the first 2 bouts of acute appendicitis.2 In fact, 7 of these 85 patients did not have pathologically confirmed appendicitis but nonetheless had their appendices removed, thus eliminating their risk of an actual first recurrence. Likewise, for the 15 patients who were randomized to receive antibiotic treatment but instead underwent primary appendectomy, the risk of a first recurrence was effectively abolished immediately after surgical intervention.