Three years ago, a team of Finnish researchers published a study in the Journal of the American Medical Association (JAMA) that showed antibiotics could be used in place of surgery to treat most cases of uncomplicated acute appendicitis.
The study was met by skepticism in much of the medical community, however, primarily because it followed patients for only one year.
Well, the researchers have returned with a longer follow-up study, and its findings remain encouraging. More than 60 percent of the study’s patients who were initially treated with antibiotics rather than surgery had not experienced a recurrent bout of appendicitis after five years.
That’s down from 73 percent after one year, but still impressive, particularly since none of the patients who subsequently underwent an appendectomy experienced any major complication as a result of the delay in surgery.
“In this new era of appendicitis treatment in which the diagnosis can be made nearly error free with [computed tomography] imaging, most cases of uncomplicated appendicitis can be successfully treated with antibiotics,” writes Dr. Edward Livingston, a surgeon and deputy editor of JAMA, in an editorial that accompanies the study.
“Patients presenting with acute, noncomplicated, CT-proven appendicitis should be given an opportunity for shared decision making, understanding that there is a high probability that they can be successfully treated with antibiotics or undergo appendectomy if they do not want to worry about the chance for recurrence,” he added.
The findings were published Tuesday in JAMA.
The study involved 530 patients, aged 18 to 60, who were diagnosed at a hospital with CT-confirmed uncomplicated acute appendicitis. The patients were randomized into two groups. One group (273 patients) underwent an appendectomy. The other group (257 patients) received an antibiotic intravenously for three days while in the hospital, followed by a week of oral antibiotics at home. After their first 24 hours in the hospital, they were re-evaluated, and if a surgeon suspected that the appendicitis had progressed, they had an appendectomy.
Seventy patients in the antibiotics group (23.7 percent) received an appendectomy within the first year, including 15 who were operated on during their initial hospital stay. (That information was published in the 2015 study.) Over the next four years, 30 more of the antibiotic-treated patients (16.1 percent) experienced a recurrence of their symptoms and underwent surgery.Of the 85 patients whose appendicitis returned, 76 had uncomplicated appendicitis, two had complicated appendicitis, and seven turned out not to have appendicitis at all.
The rate of medical complications (such as wound infections, blocked bowels or injuries to nearby organs) was 24.4 percent among the original group of surgery patients. That compared with 6.5 percent among the antibiotic-treated patients, who, obviously, underwent fewer surgeries.
The length of time of both groups’ initial stays in the hospital was about the same, although there was a significant difference in sick leave. The surgical group took, on average, 11 more days off from work.
A ‘feasible’ alternative
The study has some limitations. One had to do with how the patients were randomized.
“The decision for surgery was left to the discretion of the treating surgeon,” the authors write. “Conceivably, this resulted in more appendectomies than were absolutely necessary since some of the surgeons were not convinced that antibiotics were adequate treatment for appendicitis.”
Another limitation is that most of the patients in the surgical arm of the study underwent open surgery rather than laparoscopic (or “keyhole”) surgery, a less invasive form of appendectomy that is associated with fewer complications. At the time the study was conducted, however, laporoscopic appendectomy was only starting to gain popularity in Finland, the study’s authors explain.
Still, the five-year results of the study support “the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis,” the researchers conclude.
“For most of the 132 years since appendicitis was first described, the disease was considered a surgical emergency because it was believed that untreated appendicitis ultimately progressed to perforation and pelvic sepsis,” writes Livingston.
But thanks to this study and others, he added, we now know “that perforation is not an inevitable consequence of appendicitis, that antibiotic treatment is feasible, and that delay in surgery has few consequences.”
FMI: You’ll find an abstract of the study on the JAMA website, but the full study is behind a paywall.