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Original Investigation
February 19, 2020

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

Author Affiliations
  • 1Turku University Hospital, Division of Digestive Surgery and Urology, University of Turku, Turku, Finland
  • 2Department of Surgery, University of Turku, Turku, Finland
  • 3Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
  • 4Department of Surgery, Oulu University Hospital, Oulu, Finland
  • 5Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
  • 6Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
  • 7Department of Surgery, Kuopio University Hospital, Kuopio, Finland
  • 8Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
  • 9Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
  • 10Department of Biostatistics, University of Turku, Turku, Finland
  • 11Department of Sport and Health Sciences, Jyväskylä University, Jyväskylä, Finland
  • 12Department of Health and Medical Services, Päijät-Häme Joint Authority for Health and Wellbeing, Lahti, Finland
  • 13Department of Radiology, Oulu University Hospital, Oulu, Finland
  • 14Satakunta Central Hospital, Pori, Finland
JAMA Surg. 2020;155(4):283-289. doi:10.1001/jamasurg.2019.6028
Key Points

Question  What is the long-term quality of life (QOL) and patient satisfaction after antibiotic treatment or appendectomy for uncomplicated acute appendicitis?

Findings  In this secondary analysis of a randomized clinical trial with 7-year observational follow-up of 423 patients, there was no difference in QOL between the treatments. Patients who underwent appendectomy were more satisfied in their treatment than patients taking antibiotics based on the antibiotic group patients undergoing appendectomy; patient satisfaction after successful antibiotic treatment and appendectomy was similar.

Meaning  The long-term QOL of patients with uncomplicated acute appendicitis is similar after appendectomy and antibiotics, but the lower satisfaction of patients who underwent an operation and took antibiotics calls for identifying predictive parameters for appendicitis recurrence.

Abstract

Importance  Long-term results support antibiotics for uncomplicated acute appendicitis as an alternative to appendectomy. To our knowledge, treatment-related long-term patient satisfaction and quality of life (QOL) are not known.

Objective  To determine patient satisfaction and QOL after antibiotic therapy and appendectomy for treating uncomplicated acute appendicitis.

Interventions  Open appendectomy vs antibiotics with intravenous ertapenem, 1 g once daily, for 3 days followed by 7 days of oral levofloxacin, 500 mg once daily, and metronidazole, 500 mg 3 times per day.

Design, Setting, and Participants  This observational follow-up of the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotics included 530 patients age 18 to 60 years with computed tomography–confirmed uncomplicated acute appendicitis who were randomized to undergo appendectomy (273 [52%]) or receive antibiotics (257 [49%]). The trial was conducted from November 2009 to June 2012; the last follow-up was May 9, 2018. The data were analyzed in February 2019.

Main Outcomes and Measures  In this analysis, post hoc secondary end points of postintervention QOL (EQ-5D-5L) and patient satisfaction and treatment preference were evaluated.

Results  Of the 530 patients enrolled in the trial (appendectomy group: 273 [174 men (64%)] with a median age of 35 years; (antibiotic group: 257 [155 men (60%)] with a median age of 33 years), 423 patients (80%) were available for phone interview at a median follow-up of 7 years; 206 patients (80%) took antibiotics and 217 (79%) underwent appendectomy. Of the 206 patients taking antibiotics, 81 (39%) had undergone appendectomy. The QOL between appendectomy and antibiotic group patients was similar (median health index value, 1.0 in both groups; 95% CI, 0.86-1.0; P = .96). Patients who underwent appendectomy were more satisfied in the treatment than patients taking antibiotics (68% very satisfied, 21% satisfied, 6% indifferent, 4% unsatisfied, and 1% very unsatisfied in the appendectomy group and 53% very satisfied, 21% satisfied, 13% indifferent, 7% unsatisfied, and 6% very unsatisfied in the antibiotic group; P < .001) and in a subgroup analysis this difference was based on the antibiotic group patients undergoing appendectomy. There was no difference in patient satisfaction after successful antibiotic treatment compared with appendectomy (cumulative odds ratio [COR], 7.8; 95% CI, 0.5-1.3; P < .36). Patients with appendectomy or with successful antibiotic therapy were more satisfied than antibiotic group patients who later underwent appendectomy (COR, 7.7; 95% CI, 4.6-12.9; P < .001; COR, 9.7; 95% CI, 5.4-15.3; P < .001, respectively). Of the 81 patients taking antibiotics who underwent appendectomy, 27 (33%) would again choose antibiotics as their primary treatment.

Conclusions and Relevance  In this analysis, long-term QOL was similar after appendectomy and antibiotic therapy for the treatment of uncomplicated acute appendicitis. Patients taking antibiotics who later underwent appendectomy were less satisfied than patients with successful antibiotics or appendectomy.

Trial Registration  Clinicaltrials.gov Identifier: NCT01022567

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