Patient preference after treatment of uncomplicated appendicitis: surgery or antibiotics?

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Dear Editor Acute appendicitis can be treated with antibiotics or appendectomy1,2. Both treatments score well regarding patient satisfaction1,2. The main disadvantage of antibiotics seems to be the chance of appendicitis recurrence. However, patients differ greatly in how heavily they weigh this argument and what risk they are willing to accept to avoid surgery3. As antibiotic treatment is not yet routinely offered to patients with (uncomplicated) acute appendicitis in (Dutch) practice, how great is this need from a patient perspective? In a previous study, a questionnaire among an average Dutch population (with most of the participants having never experienced appendicitis) showed that 49 per cent preferred antibiotics over appendectomy3. The aim of this study was to evaluate treatment preference in patients who had undergone appendectomy without being offered antibiotic treatment, and compare these results with previously published data on treatment regret. A prospective study in 11 Dutch hospitals included adult patients with imaging-confirmed acute appendicitis who were operated on with the intention of appendectomy. Antibiotics as sole treatment were not routinely discussed or offered, although national guidelines allow this. Participants received a questionnaire 3 months after surgery. Information was given about antibiotic and surgical treatment of uncomplicated appendicitis. Patients were then asked to indicate their treatment preference. A detailed description of the study design and the information letter with the questionnaire can be found in the study protocol4. The results of the present study were compared with the patient-preference results of the CODA1 and APPAC2 trials. In both studies, patients were randomized to antibiotics or appendectomy. The CODA trial also had an observational arm in which patients who did not wish to randomize underwent their preferred treatment. After 30 days1 or 7 years2, patients were asked if they would have preferred the other treatment option in hindsight. Of 1371 prospectively invited patients, 734 completed the questionnaire. In comparison with the 637 patients who did not answer the questionnaire, those who did answer were older (44 (interquartile range 31–57) versus 38 (interquartile range 26–55) years; P < 0.001) and more often had complicated appendicitis (37.2 versus 31.4 per cent; P = 0.024). According to the questionnaire, 185 of 734 patients (25.2 per cent) preferred antibiotics as the treatment for uncomplicated appendicitis versus 510 (69.5 per cent) who chose appendectomy; 39 (5.3 per cent) patients had no preference. No significant differences were seen between the first two groups, apart from a slightly higher median numeric pain rating scale among patients preferring appendectomy (Table S1). The results were compared with other studies and their patients’ view on treatment options in hindsight (Fig. 1). Of patients randomized to appendectomy of the APPAC and CODA trials, 17.5 and 2.5 per cent respectively regretted appendectomy in retrospect. Of patients who were randomized to antibiotic treatment in these trials, 34.0 and 12.9 per cent respectively regretted this treatment when asked afterwards. In the observational arm of the CODA trial, in which patients chose their treatment, none of the patients undergoing appendectomy was regretful after receiving their treatment of choice, compared with 8.6 per cent of the patients who chose antibiotic treatment. Preferred treatment of patients in hindsight after antibiotic or surgical treatment of acute appendicitis Results of the present study compared with the randomization arms of the APPAC and CODA trials, and with the observational arm of the CODA trial in which patients were treated according to their preference. The present study sent the questionnaire about treatment preference 3 months after surgery. The APPAC trial asked about treatment regret in hindsight after 7 years. Patients could choose ‘same treatment’, ‘different treatment’, or ‘uncertain’. In the CODA trial, decisional regret was measured after 30 days using several questions about treatment regret, resulting in a score. A high score was interpreted as ‘high regret’ and a low score was interpreted as ‘low regret’. One in four patients operated on for acute appendicitis, and without being offered antibiotic treatment as an alternative, preferred non-surgical treatment in hindsight after proper explanation. The proportion of patients with treatment regret was lower in patients who had both treatment options offered or in patients who consented to randomization for either of the treatment options1,2. Thus, patients seem to have fewer treatment regrets when counselled on the choice between surgery and antibiotics. When patients can choose their treatment for uncomplicated appendicitis, they are confident it will be successful and treatment outcomes also improve5. Major limitations were a questionnaire response rate of 53.5 per cent, and differences in follow-up time between the compared studies. SAS Collaborator Group F. Alberts (Spaarne Gasthuis, Department of Radiology, Haarlem and Hoofddorp, The Netherlands); S. Bachiri (Noordwest Hospitalgroup, Department of Surgery, Alkmaar, The Netherlands); M. A. den Bakker (Maasstad Hospital, Department of Pathology, Rotterdam, The Netherlands); B. Bisschops (Albert Schweitzer Hospital, Department of Radiology, Dordrecht, The Netherlands); E. Boersma (Rijnstate Hostpital, Department of Surgery, Arnhem, The Netherlands); M. D. M. Bolmers (Dijklander Hospitals, Department of Surgery, Hoorn, The Netherlands); W. M. Bosman (Albert Schweitzer Hospital, Department of Surgery, Dordrecht, The Netherlands); H. Bril (Spaarne Gasthuis, Department of Pathology, Haarlem and Hoofddorp, The Netherlands); C. Buurman (Gelre Hospitals, Department of Emergency Medicine, Zuthpen, The Netherlands); E. F. W, Courrech Staal (Maasstad Hospital, Department of Radiology, Rotterdam, The Netherlands); P. Davids (Diakonessenhuis, Department of Surgery, Utrecht, The Netherlands); R. S. Deniz (Amsterdam University Medical Center, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands); R. Detering (OLVG, Department of Surgery, Amsterdam, The Netherlands); M. G. W. Dijkgraaf (Amsterdam University Medical Center, Department of Epidemiology and Data Science, University of Amsterdam, Amsterdam, The Netherlands); B. L. Dijkstra (Dijklander Hospitals, Department of Emergency Medicine, Hoorn, The Netherlands); P. Drillenburg (OLVG, Department of Pathology, Amsterdam, The Netherlands); A. Dinaux (Albert Schweitzer Hospital, Department of Surgery, Dordrecht, The Netherlands); P. van Duijvendijk (Gelre Hospitals, Department of Surgery, Apeldoorn, The Netherlands); W. J. van Eden (OLVG, Department of Surgery, Amsterdam, The Netherlands); R. Franken (Spaarne Gasthuis, Department of Surgery, Haarlem and Hoofddorp, The Netherlands); S. Gans (Gelre Hospitals, Department of Surgery, Apeldoorn, The Netherlands); M. Gaspersz (Maasstad Hospital, Department of Surgery, Rotterdam, The Netherlands); A. M. van Geel (Noordwest Hospitalgroup, Department of Radiology, Alkmaar, The Netherlands); M. F. Gerhards (OLVG, Department of Surgery, Amsterdam, The Netherlands); H. Ghori (Amsterdam University Medical Center, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands); J. W. C. Gratama (Gelre Hospitals, Department of Radiology, Apeldoorn, The Netherlands); I. Groenendijk (Maasstad Hospital, Department of Surgery, Rotterdam, The Netherlands); P. Hellebrekers (Maasstad Hospital, Department of Radiology, Rotterdam, The Netherlands); A. van Hemert (Spaarne Gasthuis, Department of Surgery, Haarlem and Hoofddorp, The Netherlands); M. Henebiens (Spaarne Gasthuis, Department of Radiology, Haarlem and Hoofddorp, The Netherlands); K. in 't Hof (Flevohospital, Department of Surgery, Almere, The Netherlands); T. Hoogteijling (Spaarne Gasthuis, Department of Surgery, H

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