Correspondence

Antibiotic treatment for uncomplicated acute appendicitis

After reading the Correspondence on Corinne Vons and colleagues trial of antibiotic treatment for uncomplicated acute appendicitis,1 we were surprised to nd that there were no comments concerning the chance of overlooking an appendiceal neoplasm when treating appendicitis with antibiotics. Because appendiceal neoplasms (ranging from mucinous adenocarcinomas to carcinoid-type tumours) are found in 0509% of appendectomies,2,3 and that their clinical presentation is as acute appendicitis in around 50% of cases,24 we are concerned about the lack of imaging explorations during follow-up of the antibiotic treatment group unless the patient is symptomatic or has an elevated white-blood-cell count or C-reactive protein concentration. We believe that this absence of imaging could lead to appendiceal neoplasms being overlooked in a small but real number of patients. Most of these tumours, which can either mimic or cause acute appendicitis, will be detected at the initial CT scan before treatment, but we believe that appendicitis inammatory reaction could mask incipient tumours that will not be evident until inammation has resolved later on. In fact, the need to do a CT scan and a colonoscopy during the follow-up of non-operative treatment for patients with appendiceal mass is a well established routine in many groups to rule out colonic or appendiceal tumours.5 We believe that a CT scan should be done as part of the routine follow-up of all patients treated with antibiotics (even the asymptomatic ones) to minimise the risk of overlooking an appendiceal neoplasm. Colonoscopy could be useful, but to a much lesser extent, since it would not detect tumours located at the tip of the appendix.
www.thelancet.com Vol 379 March 31, 2012

We declare that we have no conicts of interest.

*David Juli, Nria Gmez, Antoni Codina-Cazador

djuliabergkvist@yahoo.es
Servei de Cirurgia General i Digestiva, Hospital Universitari de Girona Dr Josep Trueta, 17007 Girona, Spain 1 Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011; 377: 157379. Connor SJ, Hanna GB, Frizelle FA. Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7970 appendectomies. Dis Colon Rectum 1998; 41: 7580. Esmer-Sanchez DD, Martinez-Ordaz JL, Roman-Zepeda P, Sanchez-Fernandez P, Medina-Gonnzalez E. Appendiceal tumors: clinicopathologic review of 5307 appendectomies. Cir Cir 2004; 72: 37578. Murphy EM, Farquharson SM, Moran BJ. Management of an unexpected appendiceal neoplasm. Br J Surg 2006; 93: 78392. Meshikhes AW. Management of appendiceal mass: controversial issues revisited. J Gastrointest Surg 2008; 4: 76775.

treated by antibiotics after complete resolution of their symptoms. The correspondents plead for a post-therapeutic survey on the basis of the results of the trial by Murphy and colleagues.4 However, the patients included in that study were treated with antibiotics for an appendiceal mass, and the authors recommended a posttherapeutic survey to avoid an interval appendectomy. Patients with such a presentation of complicated appendicitis were excluded from our trial.
I declare that I have no conicts of interest.

Corinne Vons
corinne.vons@jvr.aphp.fr
Assistance Publique Hpitaux de Paris, Hpital Jean Verdier, 93143 Bondy, France 1 Meshikhes AW. Management of appendiceal mass: controversial issues revisited. J Gastrointest Surg 2008; 4: 76775. Lee WS, Choi ST, Lee JN, Kim KK, Park YH, Baek JH. A retrospective clinicopathological analysis of appendiceal tumors from 3,744 appendectomies: a single-institution study. Int J Colorectal Dis 2011; 26: 61721. Pickard PJ, Levy AD, Rohrmann CA Jr, Kende AI. Primary neoplasms of the appendix manifesting as acute appendicitis: CT ndings with pathological comparison. Radiology 2002; 224: 77581. Murphy EM, Farquharson SM, Moran BJ. Management of an unexpected appendiceal neoplasm. Br J Surg 2006; 93: 78392.

Authors reply
David Juli and colleagues raise the important question of overlooking a primary neoplasm of the appendix during antibiotic treatment of acute appendicitis.1 We took this possibility into consideration in our trial and attempted to exclude all patients who presented with this risk. All the patients included in our trial had a CT scan before inclusion, and those with signs of complicated appendicitis were excluded from the study. Appendiceal neoplasms are more frequently found in patients with complicated appendicitis.2 Patients with an appendix with a diameter of more than 15 mm were also excluded. CT ndings strongly suggest that underlying neoplasms occur most commonly in patients with suspicious appendicitisie, an appendiceal diameter greater than 15 mm or a morphological abnormality such as cystic dilatation or soft-tissue mass with or without an associated perforation.3 Therefore, we did not consider that a morphological examination (by CT scan or colonoscopy) was necessary in the follow-up of our patients

Council of the European Union conclusions on chronic respiratory diseases in children

Asthma, allergic rhinitis, and other chronic respiratory diseases are the most common non-communicable diseases in children, and their prevalence and burden have increased in recent decades.1 This is why the Polish Presidency of the Council of the European Union (EU) has made their prevention, early diagnosis, and treatment a priority for the EUs public health policy. On Sept 2021, 2011, the Polish Presidency held an experts conference2 to prepare the conclusions of the Council. These conclusions3 were adopted during an interministerial

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