Can appendicitis be managed without surgery?

Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery.

The first paper is a prospective observational study from Italy involving 159 patients over the age of 14 who were thought to have uncomplicated appendicitis. Nonoperative management with oral antibiotics was planned for all of the patients.

Nonoperative management failed within 7 days in 19 (11.9%) patients, all of whom underwent immediate surgery. Appendicitis was found in 17 patients, and 2 had tubo-ovarian abscesses

The abstract says, “After 2 years, the overall recurrence rate was 13.8% (22/159).” This is blatantly misleading. The overall recurrence rate was 19 recurrences within 7 days plus 22 more recurrences between 7 days and 2 years for a total of 41 (25.8%) recurrences with 27/159 (17%) of the patients requiring surgery.

If you look at this paper more carefully, you will find the following from Table 3:

US done 116 (73%)
US positive 88 (76%)
CT scan done 27 (17%)
CT scan positive 21 (78%)
Clinical diagnosis only of acute appendicitis 16 (10%)

The authors do not explain why patients with negative ultrasounds and CT scans were included in the cohort of nonoperatively treated patients with appendicitis. If they were going to disregard the results of the imaging studies, they shouldn’t have done them in the first place.

If you add the 16 patients with clinical diagnoses only, the 28 with negative ultrasounds and the 6 with negative CT scans, a total of 50 (31%) of the patients may not have even had appendicitis. These patients would have gotten better no matter how they were treated.

The second study, from Ohio State University, was a prospective nonrandomized trial of nonoperative management with antibiotics vs. surgery in children with uncomplicated appendicitis. Patients were allocated to each group according to the preference of the parents.

Of the 77 patients enrolled, 47 underwent surgery, and 30 were managed nonoperatively. During a follow-up of 30 days, only 3 (10%) of the nonoperative group required appendectomy. The nonoperative group had significantly fewer days of disability, fewer days out of school and higher quality of life scores but spent a significantly longer average time in the hospital, 38 vs. 20 hours.

As the previous paper clearly showed, a follow-up of 30 days is not long enough. More than half of the recurrences in that paper occurred between 6 months and 2 years after the initial presentation.

The nonrandomized nature of the second study created imbalances in the cohorts as 6 (13%) of the 47 patients who underwent surgery had complicated appendicitis (2 with gangrenous and 4 with perforated appendicitis), compared to no instances of complicated appendicitis in the nonoperative group.

This also shows that even with imaging, which all patients in this study had, it isn’t always possible to tell with 100% accuracy who has simple appendicitis and who doesn’t.

Antibiotics may well become the treatment of choice for appendicitis, but these papers do not prove anything. There is a randomized prospective study ongoing in Finland. I hope it clarifies the situation.

Meanwhile, here’s a hypothetical situation. Let’s say that the parents of one of the children operated on and found to have perforated appendicitis had chosen instead to put the child in the nonoperative group. And let’s say that nonoperative management led to sepsis, a lengthy hospital stay, and the need for a laparotomy to drain multiple abscesses.

What do you suppose a lawyer would say?

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • SteveCaley

    Why, of course – what do you think they do in Burundi and Mozambique? Ethiopia and the Central African Republic don’t have enough doctors to go around. Guinea-Bissau, Chad and Mali sell antibiotics over the counter – who can see a doctor and where would one be, anyway? Burkina Faso, Sierra Leone and Niger do without obstetricians for high-risk pregnancy; human birth is as old as the species.
    Yes, there are many things that can be done, and may work more cheaply. The question is “Why do we seek Best Practices that are current in Costa Rica and Madagascar?”

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I love your thinking and writing style :-)

    • Skeptical Scalpel

      Steve, that is a very interesting question. I don’t have an answer for you.

  • doc99

    Skep, How’re those antibiotics going to work out long term in the age of Cdiff and MRSA?

    • Skeptical Scalpel

      Yes, great question. There are 250,000 to 300,000 appendectomies done every year in the US. If half of them are for uncomplicated appendicitis and will in the future be treated with antibiotics, how many new cases of C. diff will result?

      • JR

        I thought appendicitis was already being treated with antibiotics, even when surgery is performed too?

        • Skeptical Scalpel

          No, simple appendicitis is treated with a single dose of a prophylactic antibiotic preoperatively. After the appendix is removed, no further antibiotics are given. Gangrenous and perforated appendicitis patients usually get 5 to 7 days of antibiotics.

          • Chris Porter MD

            That’s the tx evidence supports, but I’d bet a small minority use those guidelines, favoring the longer regimens of yore.

          • Skeptical Scalpel

            You may be right. It would be an interesting subject for a research paper.

  • Skeptical Scalpel

    Thanks for the comment. I wish you or someone would publish your data.

  • Skeptical Scalpel

    I didn’t miss that meta-analysis paper. I blogged about it when it appeared. It was full of flaws which I listed in my post. You can read it here http://skepticalscalpel.blogspot.com/2012/04/antibiotics-instead-of-surgery-for.html.

    I don’t consider CBC News a valid medical reference.

  • traumadoc

    I studied and Graduated in 1982 from Rome. This argument and my Thesis was done on chronic appendix flare ups. Yes, Antibiotics can take appendicitis down, but, as with individuality–Surgery is a last option.
    i have operated 3rd world for 25+ years(Think Drs without borders).
    In America–surgery was the 1st choice. Very easy decision such as a C-Section….