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ANNSURG-D-15-00179
The Non Operative
Treatment for Acute
Appendicitis (NOTA)
Study: Is Less Surgery
Better Surgery?
To the Editor:
W e would like to congratulate Di Saverio
et al for presenting the intriguing
results of their single-cohort, prospective,
observational study investigating the efficacy
and safety of antibiotic treatment for patients
with right lower abdominal pain.1
The data presented here implies that in
well-selected patients, treatment with anti-
biotics can be an option with good long-term
efficacy. This is in concordance with the
results of a meta-analysis of 4 randomized
controlled trials with regard to this topic.2
Some points, though, leave room for debate.
The authors used the appendicitis
inflammatory response (AIR) score3 and
the Alvarado score4 for validation of clini-
cally suspected nonperforated acute appen-
dicitis. The mean AIR score was stated to be
4.9 (range: 3.0–10.0), although the mean
Alvarado score was 5.2 (range 5.0–9.0).
These low scores translating to ‘‘indetermi-
nate’’ and ‘‘equivocal’’ probabilities for
acute appendicitis were already mentioned
in an earlier Letter to the Editor by Lubrano
and Menahem.5 They note that these low
scores may have overestimated the actual
incidence of acute appendicitis in the collec-
tive. We agree with this and would like to
point out a discrepancy in the article.
In Table 3 (‘‘Characteristics of
Included Patients’’), the Alvarado score for
all included patients is differentiated (62
patients with a score of 5–6, 81 patients with
a score of 7–8, 14 patients with a score of 9).
Disclosure: No sources of funding have been received
related to this investigation. No potential compet-
ing interests exist for all authors.
Copyright ß 2015 Wolters Kluwer Health, Inc. All
rights reserved.
ISSN: 0003-4932/14/26105-0821
DOI: 10.1097/SLA.0000000000001323
Annals of Surgery  Volume XX, Number X, Month 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTER TO THE EDITOR
First, this adds up to only 157 patients, so the
score is not stated for 2 patients included in
the study.
Second, if the mean Alvarado score
for these 157 patients is calculated with the
lowest possible scores ([62  5 þ 81  7 þ
14  9]/157), the result is 6.4. Therefore,
we would be interested to know how the
authors calculated the mean Alvarado score
of 5.2.
Because a higher score indicates a
higher probability of actual acute appendici-
tis, we believe this to be of importance for the
relevance of the study.
The short-term (<7 d) nonoperative
management (NOM) failure rate was
11.9% (19/159). This group of patients is
particularly interesting because they were
evaluated by the proposed protocol for anti-
biotic treatment but had to be transferred to
the surgical-therapy arm of the study because
of consisting or relapsing symptoms. Inter-
estingly, none of these patients had an Alvar-
ado score of 9 (highly likely appendicitis) but
17 of 19 patients presented at surgery with
‘‘a variable degree of acute appendiceal
inflammation (phlegmonous/gangrenous/
perforated appendicitis).’’ It therefore seems
questionable if the proposed pathway of
patient selection for NOM is adequate. In a
recent publication, the group of Hansson
et al6 proposed a model to identify patients
with phlegmonous appendicitis, as these
patients (in their study) had an 80% prob-
ability to recover with antibiotic therapy.
In summary, it seems unclear at which stage
of disease progression antibiotic therapy is
still feasible.
Despite these controversial facts, the
study by Di Saverio et al provides further
evidence that antibiotic treatment can be
safe and effective in selected patients with
suspected acute appendicitis. Future studies
have to elucidate how patients can be selected
precisely. Furthermore, it has to be evaluated
if the reduction of postsurgical complications
in patients selected for NOM compensates
for patients suffering recurrences or compli-
cations from not being operated initially.
Daniel Foell, MD
Ralf Bahde, MD
Norbert Senninger, MD, FACS, FRCS
Department of General and Visceral Surgery
University Hospital Muenster
Muenster, Germany
daniel.foell@ukmuenster.de
REFERENCES
1. Di Saverio S, Sibilio A, Giorgini E, et al. The
NOTA Study (Non Operative Treatment for Acute
Appendicitis): prospective study on the efficacy
and safety of antibiotics (amoxicillin and clavu-
lanic acid) for treating patients with right lower
quadrant abdominal pain and long-term follow-up
of conservatively treated suspected appendicitis.
Ann Surg. 2014;260:109–117.
2. Varadhan KK, Neal KR, Lobo DN. Safety and
efficacy of antibiotics compared with appendicec-
tomy for treatment of uncomplicated acute appen-
dicitis: meta-analysis of randomised controlled
trials. BMJ. 2012;344:e2156.
3. Andersson M, Andersson RE. The appendicitis
inflammatory response score: a tool for the diag-
nosis of acute appendicitis that outperforms the
Alvarado score. World J Surg. 2008;32:1843–
1849.
4. Alvarado A. A practical score for the early diag-
nosis of acute appendicitis. Ann Emerg Med.
1986;15:557–564.
5. Lubrano J, Menahem B. The NOTA (Non Operat-
ive Treatment for Acute Appendicitis) Study:
One Step Beyond or Nearby? Ann Surg. 2014
[Epub ahead of print]. doi:10.1097/SLA.
0000000000000921.
6. Hansson J, Khorram-Manesh A, Alwindawe A,
et al. A model to select patients who may benefit
from antibiotic therapy as the first line treatment of
acute appendicitis at high probability. J Gastro-
intest Surg. 2014;18:961–967.
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