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Treatment of Appendicitis Could Become Even Less Invasive
Treatment of Appendicitis Could Become Even Less Invasive

For more than 100 years, appendectomy has been the sole strategy for treating appendicitis. However, the treatment of appendicitis slowly started to become less invasive when the first randomised controlled trial on antibiotic treatment was conducted at the beginning of the 1990s [1]. An increasing amount of evidence now suggests that, for selected patients, uncomplicated appendicitis might be treated with antibiotics only. In this issue of the journal, the meta-analysis by Andersson et al. further strengthens the grounds for reducing the invasiveness of the treatment of appendicitis [2]. They conducted a comprehensive systematic search and included data on more than 100,000 patients treated for appendicitis in identical calendar periods before and during COVID-19. They carefully deduced why others have reported a higher proportion of patients with complicated appendicitis during COVID-19 that some misinterpreted to be caused by the delay of treatment and progression of appendicitis. Instead, the meta-analysis by Anderson et al. shows that the incidence of complicated appendicitis was stable during COVID-19, but the concurrent incidence of uncomplicated appendicitis decreased, causing a seemingly higher proportion of complicated appendicitis during COVID-19 [2]. The certainty of their finding is further strengthened by the direction of the results in subgroup analyses of regional and multi-centre studies. The findings of this thorough meta-analysis [2] should direct us to revisit two important perspectives [3], that uncomplicated and complicated appendicitis may be two separate entities, and that some patients might resolve uncomplicated appendicitis on their own. The hypothesis that uncomplicated appendicitis can resolve spontaneously has already been taken one step further. Randomised controlled trials, comparing pain medication to either appendectomy or antibiotics, are about to start with paediatric patients [4] or have been published on adults [2]. This is very interesting in terms of reducing the invasiveness of the treatment of appendicitis even further than the current discussion on whether antibiotics are equally effective compared with appendectomy. There is, however, also another possible explanation for the decreased incidence of uncomplicated appendicitis. Some patients operated for suspected appendicitis will undergo a negative appendectomy, where the appendix is without inflammation in the histopathological report. It could be that during COVID-19, some of these patients may have abstained from or delayed their contact with the healthcare system due to restrained access; thus, their pain had enough time to resolve, and surgery was avoided. Ultimately, the future strategies for treating appendicitis depend on developing more accurate, non-invasive, and unharmful preoperative diagnostic methods and understanding the pathogenesis of appendicitis. While we await these efforts, we should strive towards uniform and improved reporting on appendicitis. The current gold standard for diagnosing appendicitis is the histopathological report. Still, there is no universal definition of uncomplicated and complicated appendicitis. Many will agree that a perforated appendix covers complicated appendicitis, but whether to include, e.g. a phlegmon, a gangrenous appendix, and an abscess varies greatly [5]. By simply stating these definitions clearly in our reports, analyses of the clinical impact of these different definitions can be undertaken, and we can start progressing towards a universal definition that will ensure optimal treatment for the patients. The current meta-analysis had to rely on various definitions between studies, but they specifically defined gangrenous appendix as complicated [2]. A major strength of their methods was that they only included studies where populations before and during COVID-19 had comparable criteria for defining appendicitis, its severity, and identical calendar periods. This resulted in a high internal validity despite the shortcomings of the reporting of included studies. Andersson et al. should be applauded for their impressive work. Future studies should ensure transparent reporting on their definition of appendicitis as well as uncomplicated and complicated appendicitis. Especially accurate, non-invasive, and unharmful diagnostic measures should be investigated to ensure that patients are preoperatively and accurately diagnosed with either uncomplicated or complicated appendicitis, or even without appendicitis, so patients can be treated with different strategies. Soon, the treatment of appendicitis could become even less invasive.