Surgery should remain as mainstay for treating acute uncomplicated appendicitis: COMMA trial

Published in the Annals of Surgery and led by researchers from the RCSI University of Medicine and Health Sciences, the study entitled the COMMA trial (Conservative versus Open Management of Acute uncomplicated Appendicitis) examined the efficacy and quality of life associated with antibiotic-only treatment of acute uncomplicated appendicitis versus surgical intervention. The results revealed that antibiotic-only treatment resulted in high recurrence rates and an inferior quality of life for patients.

Acute uncomplicated appendicitis is a commonly encountered acute surgical condition. Traditional management of the condition has involved surgery to remove the appendix (appendectomy). Antibiotic-only treatment has emerged as a potential alternative option that could offer benefits to patients and hospitals, such as a faster recovery, less scaring, less pain, a better quality of life for patients and reduced demand on operating theatres. There has been a reluctance to adopt antibiotic-only treatment due to previous research that has shown wide variability in failure rates and a lack of evidence regarding the impact on quality of life for patients.

In this research, 186 patients with radiological evidence of acute, uncomplicated appendicitis were randomised to two groups. One group received antibiotic-only treatment and patients in the other group were treated with surgery. Patients in the surgery group underwent a laparoscopic appendectomy. In those treated with antibiotics-only, intravenous (IV) antibiotics were administered until there was an improvement in a patient's signs and symptoms and this was followed by five days of oral antibiotics.

In the weeks and months following treatment, patients were followed up with questionnaires including a quality of life questionnaire at 1 week, 1 month, 3 months and 12 months. At these points, the patient's pain score, need for additional sick leave, surgical site infections and the development of recurrent appendicitis were recorded.

The results from the antibiotic-only group demonstrated that 23 patients (25%) experienced a recurrence of acute appendicitis within one year. In the quality of life questionnaires, it was found that patients in the surgery group experienced a significantly better quality of life score compared with the antibiotic-only group.

Professor Arnold Hill, Head of School of Medicine and Professor of Surgery, RCSI, said: 'Antibiotic-only treatment of acute uncomplicated appendicitis has been proposed as an alternative less-invasive treatment option for patients. The COMMA Trial set out to establish if antibiotic-only treatment could replace surgery in some cases, which could offer many benefits for patients and hospitals alike. The results indicate that the treatment protocols should not change. Surgery will deliver the best outcomes for patients in terms of quality of life and recurrence and therefore should remain as the mainstay of treatment for acute uncomplicated appendicitis.'