Medical Versus Surgical Management of Acute Appendicitis in a Regional Hospital in South Africa: A Six‐Year Review

BACKGROUND: Appendectomy is the current standard of care for acute appendicitis. However, accumulating international evidence suggests that medical antibiotic therapy is not inferior to appendectomy. Local factors may work for and against a medical approach. While prospective randomized trials are still to be performed in a South African setting, this study aimed to describe existing data within a geographically defined area. MATERIALS AND METHODS: A retrospective audit from 01/01/2018-31/12/2023 was performed at George Regional Hospital, South Africa. All adults and children over 12 years with a clinical or radiological diagnosis of acute appendicitis, without complicated disease mandating direct surgical appendectomy, were identified and separated into two groups, namely, those with initial medical management and those who underwent direct appendectomy. The primary aims were to compare the presentations and outcomes of acute appendicitis managed by antibiotic therapy or appendectomy. Secondary aims included describing the proportion of cases eligible for medical management, as well as post-treatment complications, including the recurrence rate. Analysis was descriptive and comparative with patients grouped as Direct Surgery (DS), Antibiotics Successful (AS) and Antibiotics Unsuccessful (AU). RESULTS: Direct surgical appendectomy was performed on 44% of the 650 cases. Of 365 (56%) cases that received antibiotic therapy, 190 (52%) were discharged without symptoms (AS), while 175 (48%) failed antibiotic therapy and underwent surgical appendectomy (AU) during first admission. Of the 190 patients who were discharged after antibiotic therapy only, 16 had recurrent symptoms, of which 14 underwent surgery and 2 had repeat antibiotic therapy. When comparing the AS to AU group, AS cases had a lower median heart rate (89 vs. 95 bpm; p < 0.05), lower C-reactive protein level (51 vs. 108 mg/L; p < 0.01) and lower Alvarado score (6 vs. 7; p < 0.01). Patients in the AS group had a median hospitalization of one day less than the DS group (p < 0.001), and two days less than the AU group (p < 0.001). When compared with DS, patients in the AU group experienced significantly fewer (p < 0.001) Clavien-Dindo grade 3-5 events. CONCLUSION: Half of patients with acute appendicitis treated medically, safely avoided appendectomy. In this context, antibiotic therapy may be considered in selected patients.