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

March is colorectal cancer awareness month

March is Colorectal Cancer Awareness Month

March is Colorectal Cancer Awareness Month, and a good time to learn more about colorectal cancer (cancer of the colon and rectum) and how it can be prevented or best treated. Colorectal cancer is the second leading cause of cancer-related deaths in the United States for both men and women combined. This year, approximately 140,000 new cases of colorectal cancer will be diagnosed and 56,000 people will die from the disease. But colorectal cancer is a disease that can be prevented through regular screenings, a healthy diet and regular exercise. 

 

How can I lower my risk? 

To lower your risk of colorectal cancer, the American Society of Colon and Rectal Surgeons recommends that you: Get regular colorectal cancer screenings after age 50. Between 80-90% of colorectal cancer patients are restored to normal health if their cancer is detected and treated in the earliest stages. 

 

  • Eat a low-fat, high-fiber diet. 
  • If you use alcohol, drink only in moderation. 
  • If you use tobacco, quit. If you don’t use tobacco, don’t start. Alcohol and tobacco in combination are linked to colorectal cancer and other gastrointestinal cancers. Exercise for at least 20 minutes three to four days each week. 
  • Moderate exercise such as walking, gardening or climbing steps may help. 

Can colorectal cancer be cured? 

 

Since there are very few symptoms associated with colorectal cancer, regular screening is essential. Screening is beneficial for two main reasons: colorectal cancer is preventable if polyps that lead to the cancer are detected and removed, and it is curable if the cancer is detected in its early stages. 

 

“If detected, colorectal cancer requires surgery in nearly all cases for complete cure, sometimes in conjunction with radiation and chemotherapy,” says Dr. Mark Glover.  “Between 80-90% of patients are restored to normal health if the cancer is detected and treated in the earliest stages. However, the cure rate drops to 50% or less when diagnosed in the later stages.” Who is at risk for colorectal cancer? 

 

The risk of developing colorectal cancer increases with age. All men and women aged 50 and older are at risk for developing colorectal cancer, and should be screened. Some people are at a higher risk and should be screened at an age younger than 50, including those with a personal or family history of inflammatory bowel disease; colorectal cancer or polyps; or ovarian, endometrial or breast cancer. 

 

Current screening methods include fecal occult blood testing (a simple chemical test that can detect hidden blood in the stool), flexible sigmoidoscopy (a visual examination of the rectum and lower portion of the colon, performed in a doctor’s office), double contrast barium enema (barium x-ray), colonoscopy (a visual examination of the entire colon) and digital rectal exam. Colorectal cancer screening costs are covered by Medicare and many commercial health plans. You should find out from your surgeon or other healthcare provider which screening procedure is right for you and how often you should be screened.