In today s JAMA, a group of Finnish researchers published the results of their randomized, prospectively controlled study attempting to determine if acute appendicitis can be treated non-surgically: with antibiotics and observation.
Appendicitis strikes about 300,000 Americans each year; almost ten percent of us will eventually have surgery (appendectomy) for this condition.
At least, that has been the case until now.
Several prior studies have shown a reasonable rate of complete response to antibiotics among patients with uncomplicated acute AP, without recourse to surgery. However, those patients treated non-surgically do have a higher rate of subsequent acute AP and surgery than those who have never had the condition (between 5 percent and 15 percent have surgery within one year after the initial attack), and of course those who have the operation have a close to zero risk of recurrence.
The current study involved 530 adults randomized upon admission with a diagnosis of acute AP to either surgery as has been traditional (273), or to a 10-day course of antibiotics, intravenous for 3 days and 7 days thereafter of oral therapy (257). All patients were shown to have uncomplicated AP by exam, lab parameters and CT scans. Of the surgical patients, all but one had successful appendectomy (done via open procedure, not by minimally-invasive laparoscopy), yielding a success rate of 99.6 percent. Of the 257 antibiotic-first group, 70 (27 percent) had to undergo surgery within the year after the initial admission, while 73 percent avoided surgery entirely.
Of importance, among those 70 patients who deferred surgery but had it later on, none developed intra-abdominal abscesses or other serious complications. According to the authors abstract, Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who did did not experience significant complications.
ACSH s Dr. Gil Ross had this comment: When I was in training, anyone diagnosed with an acute abdomen went directly to the OR, as rapidly as possible. That is changing, albeit gradually. This study adds credence to the others cited, to wit, it is within the realm of standard practice to consider non-surgical treatment of uncomplicated appendicitis, as long as the risks and benefits are discussed with the patient. Non-surgical treatment always leads to less lost work time and less pain, and lower costs, if surgery remains off the table (no pun intended). The major flaw with this study is the non-use of minimally-invasive laparoscopy, as the methodology required open laparotomy as the procedure; the authors stated that was because they wanted to make the results generalizable to those centers not equipped for laparoscopic surgery. But in the real world, most AP surgeries can and should be done with the minimally-invasive technique, which might change the outcomes. I m certain more such studies are in the works, and I d predict that more and more often, patients will be encouraged to avoid surgery.
