Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery.
The first paper was 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 two 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 figures from Table 3:
♦ US done 116 (73%)
♦ US positive88 (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 six 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 six (13%) of the 47 patients who underwent surgery had complicated appendicitis (two with gangrenous and four 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. What if 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 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 retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 10,000 followers on Twitter.