Thursday, June 18, 2015

Questions about antibiotics vs. surgery for acute appendicitis

A study from Finland suggesting that antibiotics may be a viable alternative to surgery for acute appendicitis has created a stir. As you might have expected, I had some concerns about the paper which you can read in my blog post here.

On Twitter, many surgeons have commented on both the paper and my post. Several interesting questions come to mind.

Based on this and other similar studies, is the treatment of acute appendicitis with antibiotics now a mainstream alternative to surgery?

Should surgeons now mention the Finnish study results during their informed consent discussions with patients?

Is CT scanning accurate enough to differentiate a reasonable percentage of uncomplicated appendicitis from more complex cases? Previous papers have reported conflicting data on this topic. Will this lead to more CT scanning (if that is even possible)?

What do patients want? In an effort to avoid surgery, are they willing to take a 25-30% chance of a recurrence of appendicitis?

Will patients be able to understand the distinction between complicated and uncomplicated appendicitis?

We all agreed that ertapenem is not a first-choice antibiotic in the United States. In fact, the real questions may be is a three-day hospitalization for intravenous antibiotics really necessary, or as is the case with acute sigmoid diverticulitis, would a course of oral antibiotics as an outpatient be sufficient to deal with an attack of uncomplicated appendicitis?

How will it work if antibiotics and surgery are considered equivalent treatments? Although I am retired, I think I am qualified to say that I would not have enjoyed going to an emergency department at 10 o’clock at night to see a patient with acute appendicitis who after a discussion, chooses to be treated with antibiotics. Should these medically-treated patients be admitted to surgery or another service? Should the emergency physician have the discussion with the patient and only call the surgeon if the patient elects to have an operation?

Is it appropriate for an anonymous blogger to be questioning the methods and results of a paper published in a top-tier journal such as JAMA?

What do you think about all of these questions?

Many thanks to the following for their input. If I omitted someone, I apologize. @jdimick1, @NirajGusani, @TomVargheseJr, @ChrisFriese_RN, @LVSelbs, @NatalieBlencowe, @JBMatthews, @ehldallas, @zuckerbraun, @SarahB_MD, @docaggarwal, @aneelbhangu, @smootholdfart, @DRSoup34, @hswapnil, @qdtrinh, @TimLaheyMD, @jonessurgery, @RogueRad, @DrKathyHughes, @putrescine, @krchhabra, @Apathetic_Cynic, @SimonRBarron


David Milgrom said...

"Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery" I may be misinterpreting this but dies failure to demonstrate noninferiority not constitute demonstrating inferiority?

artiger said...

For the last year, I have made an effort to inform the patients of the possibility of antibiotics as an alternative to appendectomy. I have yet to have any takers for nonoperative treatment. The percentages usually convince the patient without any prodding from me.

Studies such as this just make the case for surgery even stronger. So keep 'em coming.

Skeptical Scalpel said...

David, according to statisticians, the answer to your question is "No." Don't ask me why.

Artiger, interesting point. Others have made similar comments on Twitter. The American public may not want to go with antibiotics. BTW, the Finns had some trouble recruiting subjects for the study. They had to "recalculate" their sample size (downward) because of "a slower than anticipated enrollment period."

JDPatten said...

Fortunately for me, I didn't have to decide, my appendectomy having been done before all this. If I'd had the opportunity and decided on antibiotics, the established necrosis might well have spread to my cecum, requiring open repair. As it was, my fairly symptom free case was completed with a scope and closed with staples, but required five days of intravenous antibiotic due to the nasty condition of the little organ.
Could you have guaranteed spotting the necrosis on CT?

artiger said...

Scalpel, this made me think of a slightly related question. If you have a skinny patient, i.e., one that would allow for an open appendectomy via a very small incision (like 2 cm in length), and the diagnosis was certain (such as it sometimes is with CT being so common now), would you opt for that rather than a laparoscopic approach? Given the increasing girth of U.S. patients, it's less and less common, but it occasionally happens. Such a small incision would still allow for an outpatient procedure. Just curious.

Skeptical Scalpel said...

JD, no you cannot guarantee that all cases of complicated appendicitis will be spotted by CT. See my previous posts on this topic for details,. In the search field [upper right part of the blog site], type in appendectomy.

Artiger, I prefer the laparoscopic approach for patients of all sizes. What if the inflammation is worse than the CT predicted?

artiger said...

I'd agree, and I'm 100% lap for appendectomy these days. I have a, uh, cough cough, older colleague that doesn't do these via laparoscopy, and we were discussing this a while back.

Skeptical Scalpel said...

I know a few surgeons who just never learned how to do a laparoscopic appendectomy. They keep trying to convince themselves that an open procedure is just as good. No way. Not for the surgeon and especially not for the patient.

Anonymous said...

Thank you for posting this thread. As the mother of a young appendicitis patient (under five years old), the discussion has been helpful in trying to better understand and evaluate treatment options with regard to an upcoming scheduled appendectomy for my child (following in-hospital IV antibiotic treatment a few weeks ago for complicated appendicitis).

Our surgeon noted that instead of the scheduled surgery, there was also the option to forgo surgery and mentioned the recent studies re: antibiotics vs. surgery. He said that the decision was up to us, though he did note that historically, surgery would be recommended in a case like our son's. So, my husband and I kept the scheduled surgery date, but have also been trying to wade through the available studies to determine what is the best option for our son and if it would make sense to forgo the surgery or not.

We're planning to go ahead with the surgery because, among other things, (i) an approximate 25% recurrence rate at one year seems pretty high when thinking about a child's whole life ahead, and we have not found any long term studies of this issue (e.g., recurrence rates at 5+
or 10+ years out), perhaps because this is a relatively new approach; (ii) it looks like most of the available studies were in teenagers and adults, not young children, (iii) it looks like the available studies were of antibiotic treatment for uncomplicated appendicitis, not cases with complications such as my son's (perforated appendix and an abdominal abscess); (iv) we don't ever want him to go through the pain of appendicitis again; and (v) even if he never has a recurrence, we don't want him to have to live the rest of his life wondering if he has appendicitis again any time he has abdominal pain.

Skeptical Scalpel said...

Please understand that I can't give you medical advice. I have not seen your child or the imaging studies.

I agree with your interpretation of the literature. There are some studies on antibiotics for definitively treating kids with simple, not complicated, appendicitis. They were not randomized trials.

The Finnish trial everyone (but not me) is excited about involved adults with simple appendicitis. Patients were only followed for a year. There are no long-term studies about what would happen to a 5-year-old treated with only antibiotics and no long-term studies that followed adults for more than 2 years.

The textbook treatment of a child who has undergone antibiotic therapy for complicated appendicitis is a so-called interval appendectomy.

I've written about this topic on several occasions. If you haven't read my other posts, type "appendicitis" in the search field of my blog.

Good luck. Let me know how things turn out.

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