An article and accompanying editorial in the June 16, 2015 issue of JAMA looks at the issue and the practical implications of antibiotics versus surgery for acute appendicitis. For years we have treated diverticulitis nonsurgically with few complications. This study was undertaken in Finland but also studies in the US at UCLA are also underway.
The article concluded that their are two types of appendicitis. One at risk of rupture and a second milder version where treatment with antibiotics alone was concluded to be “noninferior” to surgery for cases of uncomplicated acute appendicitis. The milder form makes up about 80% of the cases of appendicitis.
A CT scan can accurately detect which type of appendicitis someone has, the author added.
Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications.
The researchers found that appendectomies were 99.6 percent successful. Among patients treated with antibiotics and followed for a year, 73 percent did not need surgery. However, 27 percent of the patients treated with antibiotics went on to have their appendix removed within the year. The study concluded there were no major complications associated with delaying surgery.
In this randomized clinical trial among patients with uncomplicated appendicitis proven by a computed tomographic scan, antibiotic treatment did not meet the prespecified criteria for noninferiority compared with appendectomy.
So when do we have enough information to consider changing the standard? Do we need more studies? What are the medical legal and cost considerations? How will our patients and our surgical colleagues feel about this approach?
A lot of questions probably still need to be answered.