Rethinking mechanisms, diagnosis and management of endometriosis

Our understanding of endometriosis has evolved substantially over the last decade. This is a fairly recent review of the current conceptualization of this multi-system inflammatory disease. James W. Mold, MD, MPH

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Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Author/s:

Chapton, Charles, Marcellin, Louis, Borghese, Bruno, Santulli, Pietro

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

Devin Evans — Thu, 10 Sep 2020 05:00:00 +0000

Date Added:

October 9, 2020

Journal/Publication:

The New England Journal of Medicine

Publication Date:

October 5, 2020

URL:

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa2014320

Keywords

PMID (1):

33017106

MeSH

Appendectomy

Appendicitis

anti-bacterial agents

Laparoscopy

This looks like the definitive short-term RCT on antibiotics vs. appendectomy for appendicitis. Antibiotics were “non-inferior.” However, 3/10 patients required appendectomy within 90 days. James W. Mold, MD, MPH

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BACKGROUND

Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis.

METHODS

We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life–5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith.

RESULTS

In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], −0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50).

CONCLUSIONS

For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.

Author/s:

CODA Collaborative, Flum, David R., Davidson, Giana H., Monsell, Sarah E., Shapiro, Nathan I., Odom, Stephen R., Sanchez, Sabrina E., Drake, F.T., Fischkoff, Katherine, Johnson, Jeffrey, Patton, Joe H., Evans, Heather, Cuschieri, Joseph, Sabbatini, Amber K., Faine, Brett A., Skeete, Dionne A., Liang, Mike K., Sohn, Vance, McGrane, Karen", Matthew E., Chung, Bruce, Carter, Damien W., Ayoung-Chee, Patricia, Chiang, William, Rushing, Amy, Steinberg, Steven, Foster, Careen S., Schaetzel, Shaina M., Price, Thea P., Mandell, Kathrine A., Ferrigno, Lisa, Salzberg, Matthew, DeUgarte, Daniel A., Kaji, Amy H., Moran, Gregory J., Saltzman, Darin, Alam, Hasan B., Park, Pauline K., Kao, Lilian S., Thompson, Callie M., Self, Wesley H., Yu, Julianna T., Wiebusch, Abigail, Winchell, Robert J., Clark, Sunday, Krishnadasan, Anusha, Fannon, Erin, Lavallee, Danielle C., Comstock, Bryan A., Bizzell, Bonnie, Heagerty, Patrick J., Kessler, Larry G., Talan, David A.