Arandomized controlled trial has brought into question the established medical doctrine that appendicitis should be treated by surgical removal, finding that a level of success can alternatively be achieved by use of antibiotics.
Published in the journal JAMA, results in the arm of the study assigned to receive a 10-day course of antibioticsrather than surgery saw a success rate of just under 73% in terms of whether patients treated in this way did after all need surgery within a year of removal of the appendix.
Of the 256 patients available for 1-year follow-up in the antibiotic group, 186 did not require the later appendectomy.
However, compared with surgical treatment, the antibiotic option did not prove to cross a threshold of effectiveness established during the design of the study.
Over a quarter (70) of the patients assigned to antibiotic treatment went on to undergo surgical intervention within a year of initially presenting with appendicitis.
The researchers’ hypothesis was that antibiotic treatment would not be worse than appendectomy. The threshold set – but not met by the results – was that the benefits from avoiding surgery would be worthwhile even if there was up to a 24% failure rate in the antibiotic group. The failure rate found, though, was 27.3%.
The safety of delaying appendectomy to first try antibiotics was, however, shown by a lack of intra-abdominal abscesses or other major complications.
Routine appendectomy is a 100-year-old idea
An editorial article about the study in the same issue of the journal – written by Dr. Edward Livingston, JAMA‘s deputy editor, and Dr. Corrine Vons, from the Jean Verdier Hospital in Bondy, France – explains that since late in the 19th century, surgery has remained unquestioned in the treatment of appendicitis.
But recent changes, the article outlines, have happened in the management of appendicitis, “even if appendectomy remains the end result.”
There is now “almost perfect” diagnostic accuracy achieved by imaging via computed tomography (CT) scanning, and the use of antibiotics perioperatively is changing the condition’s natural history.
The editorial goes on to praise some of the study’s strengths – noting its large sample size and the use of CT scans, which also allowed the researchers to exclude from analysis cases that would require surgery anyway (because of perforation, abscess, and so on).
Drs. Livingston and Vons reach this conclusion:
“The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis.
The operation served patients well for more than 100 years. With development of more precise diagnostic capabilities like CT and effective broad-spectrum antibiotics, appendectomy may be unnecessary for uncomplicated appendicitis, which now occurs in the majority of acute appendicitis cases.”
The authors of the study conclude:
“These results suggest that patients with CT-proven uncomplicated acute appendicitis should be able to make an informed decision between antibiotic treatment and appendectomy.”
They call on future studies to focus on early identification of complicated acute appendicitis patients needing surgery, and to prospectively evaluate the optimal use of antibiotic treatment in patients with uncomplicated acute appendicitis.
Written by Markus MacGill