Appendectomy or Antibiotics?

Appendectomy or Antibiotics?

There’s been a lot of conversation about the treatment of appendicitis recently. 5 year results were recently published in JAMA Surgery regarding the Swedish study in treatment of appendicitis with primarily antibiotics alone.  The conclusion of the study was that appendicitis could be safely treated with antibiotics alone.  The problem is many people are reading the conclusion alone, when the problem is more complex than this simple conclusion. Here is a surgeon’s perspective. 

Exclusion criteria

Firstly, this conclusion does not apply to all patients with appendicitis. The study has exclusion criteria, which means that there are certain patients that are not a candidate for antibiotic treatment. Examples of patients excluded are those with perforation, an abscess, appendicolith, renal insufficiency, or systemic illness. I have already seen patients inappropriately treated outpatient with antibiotics who were shown to have an appendicolith on their CT scan. An appendicolith is hard petrified stool in the lumen of the appendix that obstructs the appendix and makes antibiotic treatment more likely to fail.  

Inpatient treatment

The patients in the study were treated inpatient (in the hospital) in a monitored setting for signs of deterioration that would require surgery for 3 days. There has been no recommendation to treat appendicitis with outpatient oral antibiotics alone. Furthermore, 10% of those treated with antibiotics required surgery within the first 24 hours. 

Duration of Treatment

Patients were treated in the hospital with IV antibiotics for 3 days. Most patients with uncomplicated appendicitis who undergo laparoscopic appendectomy are home within 6-8 hours of arrival and are cured of their appendicitis, unlike with antibiotics. 

Recurrence and Treatment failure

Initial  data  showed that 10% of patient went on to have complicated appendicitis. 27% of patient with antibiotic treatment had an appendectomy within one year of diagnosis.  Data 5 years out shows that 39% of those patients went on to have recurrent appendicitis.  That number will likely continue to rise at 10 and 20 years. Meaning the chance of a 20 year old having appendicitis again in ten years is probably anywhere from 50-80%. 

Tumors

Approximately 1% of appendicitis is caused by a benign or malignant tumor of the appendix. These are not usually seen on CT scan or intraoperatively, but found after the fact by the pathologist under the microscope. Appendectomy is usually curative of these tumors, such as carcinoid. However, if treated with antibiotics, these small tumors may go from curable to incurable if not removed.  

Apples to Oranges

The only reason this study showed non-inferiority to surgery is it was compared to OPEN appendectomy, which in their hands carried a complication rate of 25%! My own complication rate (and for all of my colleagues) for LAPAROSCOPIC appendectomy is somewhere on the order of <1%.  

My Conclusions:

  • If you’re on a submarine, antibiotics may be the treatment of choice. 
  • High risk individuals such as those too sick to undergo anesthesia may be treated in an inpatient setting with antibiotics with monitoring by a surgeon.  
  • If I’m traveling in a third world country, antibiotic treatment may give enough time to return to the United States for an appendectomy.
  • The recommendation of the American College of Surgeons is still that appendectomy is the preferred treatment modality. 

Read more on the benefits of laparoscopy

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