The mounting evidence for an antibiotic-only treatment approach to acute appendicitis has to some extent only added more uncertainty to the surgeon working in the low-resource setting. The mounting evidence for an antibiotic-only treatment approach to acute appendicitis has to some extent only added more uncertainty to the surgeon working in the low-resource setting 1, 2. On one hand, avoiding appendectomy would seem to bring an abundance of advantages to the patients in these settings both in terms of surgical risks and financial obligations. On the other hand, a surgeon may be hesitant to forgo surgery in a patient who has barriers to accessing medications for outpatient antibiotic treatment and may have difficulty with transportation in the event of recurrent disease 1, 3-5. In light of these competing tensions, our study tracked the clinical course of patients diagnosed with suspected appendicitis on presentation to our hospital in rural Gabon and compared the outcomes of those who underwent up front appendectomy and those who were initially managed with an antibiotics-only approach. This was a prospective observational study from August 28, 2021 to December 28, 2022. All patients presenting to Bongolo Hospital in rural Gabon with suspected appendicitis were included. Patients who were determined to have a different explanation for their symptoms on diagnostic workup were excluded. Imaging studies available included X-ray and point-of-care ultrasound performed by the surgery team. The nearest functioning CT scanner during the study period was more than 500 km away. Participant consent was obtained and key demographic, clinical, and disease course information were recorded from the hospital chart. The decision to treat with antibiotics or with up-front appendectomy was left to the discretion of the provider and the patient. Those who were selected for appendectomy underwent surgery within 24 h, operating room schedule permitting. Those who were selected for antibiotics underwent treatment with broad spectrum IV antibiotics until deemed stable for discharge. Then, they were discharged with 7–14 days of oral antibiotics to complete as an outpatient. Demographic and clinical characteristics were reported as percentages, medians, and means as appropriate with corresponding chi-square, Mann-Whitney U, and Student T-test performed in JASP (JASP Version 0. 95. 3). This study was approved by the Bongolo Hospital IRB committee. During the study period, 77 patients presented with an acute abdominal complaint. Thirty-five patients were excluded due to another more likely diagnosis; the remaining 42 patients were suspected of having appendicitis. The average Alvarado score on presentation was 6. 5 and no patient had a score lower than 3. Of the 42 patients with suspected appendicitis 26 (62%) underwent appendectomy (APPY) and 16 (38%) were treated with antibiotics only (ABO). Of the 26 APPY patients, 24 underwent successful appendectomy while 2 were aborted due to appendiceal phlegmon and crossed over to antibiotic management (Figure 1). Six of the appendectomies (25%) were performed laparoscopically. Clinical course of patients in each group. Of the 16 patients in the ABO group, 13 patients were successfully treated without subsequent appendectomy at the study site. Three patients failed ABO management and underwent appendectomy an average of 3. 5 months (range 2–6 months) after initial admission (Figure 1). At a follow up interval exceeding 12 months, 46% responded confirming that they had remained asymptomatic. There was a trend toward shorter median days to presentation in the APPY group (2. 5 vs. 3, p = 0. 74) as well as higher median Alvarado score (6 vs. 7, p = 0. 60) (Table 1). In regards to complications, six of those in the APPY group and one of those who failed ABO management underwent delayed primary closure as their wounds were left open at initial surgery. No surgical site infections or postoperative abscesses were found in either group. The cost of treatment was significantly higher in the appendectomy group (252 vs. 63). The appendectomy is a procedure of some irony to the surgeon working in a low-resource environment. Although occasionally touted as a benchmark for access to safe, prompt, and affordable surgical care, it remains unclear which of the patients who eventually find their way to a surgeon actually stand to benefit from this quintessential general surgical procedure 6, 7. Our study demonstrates that both appendectomy and antibiotic-only management of acute appendicitis have low rates of complications in the rural region studied. Both groups had a greater than 80% success rate of the initial management approach with a low rate of crossover to the other treatment approach. More than 50% of our patients presented more than 2 days after the onset of symptoms with those in the ABO group presenting a little later than those in the APPY group. This may suggest that some patient were selected for ABO management due to concern for complicated appendicitis at time of presentation 8. Conversely, the lower median Alvarado score among our ABO patients (6 vs. 7) suggest that some of the patients were selected for ABO management due to lower suspicion for acute appendicitis. This is further supported by the fact 4 patients in the ABO group had an Alvarado score of four or less, while all the APPY patients had a score of at least 5. Of note, no elective interval appendectomies were performed in the studied population, the only appendectomies performed in the ABO group were in the setting of treatment failure. One patient in the ABO group did undergo follow up colonoscopy to rule out malignancy. Our limitations include the small sample size, single-site location, and low follow-up rate, which affect the generalizability of our findings. Our study shows that patients managed with antibiotics-only had a high rate of successful treatment and low rate of recurrence, while patients who underwent upfront appendectomy had low rate of post-operative complications. Our work should stimulate larger multicenter studies across rural hospitals that will further delineate the benefits and economic-impact of each approach in the low-resource setting. A. F. Camara: conceptualization, investigation, writing – original draft, data curation. A. Elvam: conceptualization, investigation, methodology. J. M. O'Connor: conceptualization, investigation, project administration, supervision. Z. O'Connor: conceptualization, project administration, supervision, methodology. H. D. Schaeffer: data curation, formal analysis, writing – review and editing. D. H. Skavdahl: supervision, methodology, investigation. S. Tchoba: conceptualization, investigation, supervision. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.
CÂMARA et al. (Thu,) studied this question.