Yet the papers keep coming.
A new systematic review of all the randomized controlled studies on appendicitis found important shortcomings in all of them. Here are a few:
Bias in selecting patients was a problem in all six of the studies reviewed. Diagnostic criteria for inclusion in the studies were not standardized. Some of the studies enrolled patients with clinically diagnosed appendicitis only. Since some patients may not have had appendicitis, they would probably have improved regardless of how they were treated.
Patients were treated with a variety of antibiotics, Since most of the studies were done in Europe, open appendectomy was the more common surgical intervention. Laparoscopic appendectomy results in fewer complications and shorter lengths of stay than the traditional open procedure.
Follow-up in five of the six studies was one year with only one study following patients as long as a median of 17 months. Rates of recurrent appendicitis necessitating appendectomy ranged from 24% to 60% with an average of 35.4%. What will the recurrence rates be at 3 years? 5 years?
The authors concluded that although more evidence for treating appendicitis with antibiotics has emerged, the comparative effectiveness of that strategy is still unknown. They recommend that patients should be enrolled in clinical trials or registries to help answer this therapeutic question.
The second recent paper involves two issues I have commented about many times—research and medical reporting.
It's a study of 102 pediatric patients between the ages of 7 and 17 with uncomplicated appendicitis as judged by CT scan parameters. After informed consent was discussed, parents were permitted to choose the therapeutic arm, antibiotics or laparoscopic surgery.
Of the 629 patients who presented with acute appendicitis during the study period, only 102 (21%) met the study's inclusion criteria of whom 37 were selected for antibiotic therapy by their parents.
During the median follow-up period of 21 months, 9 (24.3%) patients initially treated with antibiotics had to undergo appendectomy.
I blogged about this study's preliminary results when they were published back in 2014. If you would like more details about its limitations, read that post.
The inadequacies of medical reporting on this paper were rather glaring. Under the headline "Not all kids with appendicitis need surgery. Antibiotics can work just fine," the Boston Globe's new website Stat News said the following:
“'Their parents began to question whether they needed surgery [for appendicitis],' said [lead author] Dr. Peter Minneci, a pediatric surgeon at Nationwide in Columbus, Ohio. Minneci decided to answer the question with a controlled study." Sorry folks, this wasn't a controlled study.
The New York Times reported: "The surgery group had more complications and two of those who chose antibiotics had to be readmitted to the hospital for appendectomies in the first 30 days." This is misleading because although 5 of 65 patients in the surgery group had postoperative complications compared to none of the 9 who eventually had appendectomies in the antibiotic group, the difference was not statistically significant (p = 1.0, Fisher's exact test).
But the most interesting thing about this paper was an entire page explaining why allowing parents to select the therapy was a better method than randomizing patients to one group or the other. It's very clever and must be read to be appreciated.
Here is an excerpt: "The patient choice design allows a therapy to be aligned with the preferences of the patient and his or her family, thereby minimizing the potential negative effects of preferences."
I don't know about you, but if I or anyone in my family had appendicitis, my preference would be for a laparoscopic appendectomy.