Friday, May 2, 2014

Antibiotics instead of surgery for appendicitis? I'm still not convinced


Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery.

The first paper is 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 2 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 from Table 3:
US done 116 (73%)
US positive 88 (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 6 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 6 (13%) of the 47 patients who underwent surgery had complicated appendicitis (2 with gangrenous and 4 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. Let's say that 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 let's say that 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?

24 comments:

Anonymous said...

Not at all on topic but several times there have been submissions to the effect that robot assisted surgery is, to put it mildly, oversold. I see in my local paper that our regional cancer center (RPCI) held work shops on DaVinci surgery for our local high school kids. What do you think they are going to want for themselves or family members?

Justin said...

Another way we are moving toward only the complex stuff gets the old standard. I'd rather do 10 straightforward appies than one partially frozen and friable abdomen appy.

Skeptical Scalpel said...

Anon, yes, hospitals have taken robots to shopping malls and baseball stadiums too.

Justin, I couldn't agree more.

Anonymous said...

A lawyer would say ANYTHING that enhances his professional reputation and his personal wallet.

Anonymous said...

Oh hey, marketers & make up artists have taken to promoting doctors like models. I saw one instance where they were in the makeup/hair room. I'm like ... can you make sure their clinical skills are as good as the fluff you're showing to us?

artiger said...

I saw these studies, and I can't help but pile on. We've got an effective, definitive 20 minute outpatient procedure, but we're going to spend more time in the hospital and give 7-10 days of antibiotics, with no guarantee of success?

Just how much disability arises from a lap appy anyway? And let's just use antibiotics even more, so that the problem of resistance becomes insurmountable in my lifetime, not to mention C diff.

Special circumstances may arise that call for nonoperative treatment of appendicitis, and I have managed a rare such case that way myself, but it should not become the norm. Not until an antibiotic is developed that can treat it successfully in a day or two with the morbidity rate of surgery.

Skeptical Scalpel said...

Artiger, I agree. The morbidity of a laparoscopic appendectomy is minimal.

Anonymous said...

In an effort to play the devil's advocate, I would like your thoughts on this article, which explains the benefits of the appendix.
http://www.sciencedaily.com/releases/2007/10/071008102334.htm
Clearly, the laparoscopic appendectomy is an effective procedure, but wouldn't it be prudent to make an effort to save the appendix if it serves a beneficial function?

Skeptical Scalpel said...

Anon, I am familiar with that paper. It is an interesting theory, but only a theory. There are about 250,000 appendectomies done every year in the US alone. Don't you think that if the absence of the appendix was causing immunologic or infectious problems, someone would have noticed by now?

Would it be better for say 100,000 people per year to be put on a 5 to 7 day course of antibiotics? I'd venture a guess that would cause more problems that the theoretical risk of removing the "safe house" for bacteria.

Steven Schrenzel said...

There could easily have been a perforated appendix in the nonsurgical group that just responded well to the antibiotic. Virtually all the complications in these patients are surgical. Ironically, the surgical patients get the same antibiotics - maybe the real reason they recovered!

artiger said...

@Steven Schenzel: Are you talking about just the perforated appy's, or all of them? People who undergo a lap or even open appy for uncomplicated appendicitis do not get a week of antibiotics (at least they shouldn't be getting them). Usually one preop dose is sufficient.

And I don't give my perforated appy's that many days of antibiotics either, unless it's just a real mess.

Skeptical Scalpel said...

Steve, I agree with Artiger. Unless it's perforated or really nasty, patients get only one preop dose of antibiotics. I think the majority of surgeons do the same thing. The data on one preop dose comes from before the laparoscopic appendectomy era. I'm not even sure that patients with short durations of pain and simple appendicitis even need one dose.

hope said...

agree with the Artiger and Skeptical Scalpel. I personally would much rather just get my appendix out and go home than be subject to abx with a high recurrence rate. Also, based on personal experience, the few patients I saw who were placed on abx initially and then recurred and had appendectomies were a junky fibrinous mess and needed open appys. But I like quick, definitive solutions to problems - hence I'm in surgery. Probably not everyone feels this way...

Skeptical Scalpel said...

Hope, I certainly agree. If it's me or anyone in my family, that appendix is coming out.

RuggerMD said...

I think that these recent pushes for non-op management is good (at least in my practice) for just one thing.
That (mostly young) patient who has RLQ abdominal pain and other wise normal CT findings or unequivocal findings. The CT that doesn't really show appendicitis (or can't see appendix) in that really thin pedi patient.
After admission and serial exams and still with pain, I let the parents or patient if older know that we can treat appendicitis with abxs only and give them option of abxs or diagnostic laparoscopy.

Skeptical Scalpel said...

Rugger, that's a common sense way to handle an equivocal situation.

Anonymous said...

Here's the answer: stick a scope in. If it is appendicitis, take out the appendix. If it is PID, give them antibiotics. . .and still take the appendix out. If the ER calls and has a r/o appy, stick a scope in and take the appendix out. Antibiotics? Nope...surgery is the cure for appendicitis...and for the lazy Ob/Gyn who doesn't want to r/o gynecological disease.

Skeptical Scalpel said...

Anon, I'm not sure. Do you favor taking out the appendix? :-)

Julian David Peña Cortés said...

In my opinion its easier and more cost-effective to take out the appendix than giving patients for 7 days of intrahospitalary antibiotics. Also no recurrence ever.

Skeptical Scalpel said...

Julian, I agree although the antibiotics are usually given for 3 days or so intravenously in hospital and the rest are oral as outpatients.

Korhomme said...

S Scalpel, are there up to date figures about recurrent appendicitis after antibiotic treatment for an initial episode?

Skeptical Scalpel said...

Nothing other than what I have mentioned in my many posts on the subject including the one I posted today. A short-term recurrence rate of 25% or more seems about average.

Anonymous said...

The APPAC study (JAMA. 2015 Jun 16;313(23):2340-8. doi: 10.1001/jama.2015.6154)from Finland is misleading. 27% fail rate within 1 year is unacceptable. I don't understand.. taking care of the problem quickly and permanently with Lap. Appendectomy has a >99% success!!! And for the nonop group, I am sure there were many extra ER visits and tests, increasing the cost of care for those patients. Lets go back back to ancient times when "surgical treatment was always postponed until the last possible moment or let the infection evacuate itself spontaneously or allow the patient to die a peaceful death". Yes, there is such study....Do nothing, not even antibiotics in early appendicitis....I can't wait to see results but I suspect that they will be similar to ancient observations!!

Skeptical Scalpel said...

I agree with you. However, rumor has it that the current study in the US may be showing an advantage for antibiotics. I hope they follow the patients for at least 2 or 3 years.

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