Author response to: Comment on: Prospective cohort study of appendicectomy for treatment of therapy‐refractory ulcerative colitis

Abstract

Editor We thank Herfarth and Barnes for their valuable comment and justified questions regarding our paper analysing the effect of appendicectomy in patients with refractory ulcerative colitis (UC)1. We acknowledge that a clear definition of previously failed therapies is needed to put the current results on the role of appendicectomy in therapy-refractory patients into perspective. According to European Crohn and Colitis Organisation (ECCO) guidelines2, medical therapy follows a standard step-up protocol starting with aminosalicylates (5-ASA), followed by immunomodulators and biologicals. In this study, all included patients had failed this standard step-up treatment including at least one biological (infliximab or adalimumab). Patients were excluded if enhancement of medical therapy within the standard step-up approach (intensifying dose, shortening interval or starting combination therapy) was still considered appropriate after multidisciplinary discussion. At the time of appendicectomy, most included patients had already stopped (most) medication due to a lack of response, and only six were still using biologicals. At the start of the current study, vedolizumab and tofacitinib were not registered as medical therapy for UC, and therapeutic drug monitoring by trough levels was not yet daily practice. Therefore, we agree that the definition of a therapy-refractory patient would now be different, which should be borne in mind when counselling patients. However, there was a clinical response to appendicectomy in 46 per cent of patients, which is well in line with the response rates of expensive biological therapies. This suggests that appendicectomy could be considered as an alternative in these patients. Future studies should elaborate on the position of appendicectomy with respect to new (biological) therapies.