Since the late 1800s, surgery has been the standard treatment for appendicitis, the medical term for an inflamed appendix, the odd tube-shaped pouch of tissue that hangs off the colon on the lower right side of the abdomen.
After antibiotics came into widespread use in the 1940s, some doctors, including U.S. Navy doctors working on submarines during the Cold War — reported that the drugs were as effective as surgery for treating appendicitis. The idea never really caught on, however, in part because of the longstanding belief in the medical community that without surgery (appendectomy), an inflamed appendix will inevitably burst (perforate), causing the infection to spread throughout the abdomen.
The surgical approach to treating appendicitis may soon change, however. On Tuesday, a team of Finnish researchers published a study in JAMA that offers the most compelling evidence to date that antibiotics can successfully treat the majority of cases of uncomplicated acute appendicitis.
“The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis,” write two of JAMA’s deputy editors — both physicians — in an editorial that accompanies the study.
More than 300,000 appendectomies are performed each year in the United States. Although this type of surgery is usually quite safe, it does have risks, including excessive bleeding and infection.
In the past, scientists believed that the appendix was a vestigial structure — a body organ that no longer had a functional purpose. But, as I’ve noted here before, new research suggests that the appendix may be a storehouse for beneficial microbes that help fight off infection.
So preserving the appendix — if doing so does not put a patient’s health or life at risk — is becoming recognized as a desirable goal.
The JAMA study involved 530 patients, aged 18 to 60, who agreed to be randomly assigned to be treated with either antibiotics or surgery after showing up in the emergency room of a Finnish hospital with uncomplicated appendicitis, as confirmed by a computed tomography (CT) scan. (Uncomplicated appendicitis means that the scan revealed no signs of perforation, abscesses, calcified fecal deposits or possible tumors.)
The patients who were in the drug arm of the study were given an antibiotic (ertapenem) intravenously for three days while in the hospital, followed by a week of oral antibiotics at home. These patients were reevaluated within 24 hours of being admitted to the hospital, and if a surgeon suspected that the appendicitis had progressed, they had an appendectomy.
Most of the patients in the surgical arm of the study underwent open surgery rather than laparoscopic surgery, which is the more common and less invasive form of appendectomy. The researchers chose open surgery so that the findings from their study could be applied to areas of the world where laparoscopic surgery is not available.
The study found that three-quarters of the 257 patients who were given antibiotics recovered completely from their appendicitis. The other patients either received an appendectomy while in the hospital or experienced a recurrence of symptoms within a year and underwent surgery.
Those who eventually had an appendectomy did not appear to be any worse off for going the antibiotic route first.
About 20 percent of the patients in the original surgical arm of the study experienced some kind of surgery-related complication, mostly an infection or an incisional hernia. One patient died within five days of surgery, but of an unrelated heart problem.
Of course, that percentage of surgical complications would probably have been lower if more of the procedures had been laparoscopic.
The rate of failure for the antibiotics treatment was 27.3 percent — higher than the arbitrary rate of 24 percent the researchers had set as being acceptable to show that antibiotics were non-inferior to (not worse than) surgery. So the study concludes that antibiotics are not non-inferior to surgery.
“Nevertheless,” write the authors, “the majority (73%) of patients with uncomplicated acute appendicitis were successfully treated with antibiotics [and] none of the patients treated initially with antibiotics and later with appendectomy had major complications.”
“These results suggest,” they add, “that patients with CT-proven uncomplicated acute appendicitis should be able to make an informed decision between antibiotic treatment and appendectomy.”
You’ll find an abstract of the study on the JAMA website, but the full study and the editorial are behind a paywall.