PhD defence E.M.L. (Elisabeth) de Wijkerslooth de Weerdesteijn

Summary:

This thesis focuses on improvement of efficiency in the surgical treatment of acute appendicitis. Particularly, the distinction between simple and complex appendicitis, postoperative length of hospital stay and postoperative antibiotic use are addressed. 

Key outcomes in this thesis are:

• The clinical and economic burden of surgically treated appendicitis in the Netherlands is substantial
• A preference for laparoscopic technique in a teaching hospital seems justified
• Agreement among surgeons is poor considering the intraoperative assessment of appendicitis, definitions used for complex appendicitis and related views on postoperative antibiotic use. 
• Opinions vary especially regarding nonperforated, gangrenous appendicitis
• Nonperforated, gangrenous appendicitis is associated with a significantly increased risk of infectious complications compared to phlegmonous appendicitis. Yet, gangrenous disease is not an independent predictor of infectious complications.
• Same-day discharge seems safe and feasible in a large proportion of pediatric and adult patients, without increased risk of readmission, unplanned hospital visits or postoperative complications.
• 2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days, in terms of infectious complications after appendectomy, as well as reinterventions. 2 days resulted in fewer adverse effects to antibiotics, but more frequent readmission. Nevertheless, total length of stay was significantly shorter and costs were significantly reduced. 
• We argue that the benefits of restrictive postoperative antibiotic use for complex appendicitis outweigh potential disadvantages. Restricting postoperative antibiotics to 2 days is expected to lead to a clinically relevant reduction in antibiotic use and hospital stay. Special consideration should be given to patients undergoing open surgery, for whom no definite conclusions can be drawn based on this trial.