Thursday, December 4, 2014

Antibiotics vs. surgery for appendicitis: It's time for a randomized trial

Maybe you've heard that there is a growing debate about whether antibiotics are as good or better than surgery for treating appendicitis.

So far there have been several studies from Europe showing that antibiotics may be safely used to treat appendicitis in many cases. However, the studies have involved small numbers of patients and have exhibited some flaws in their methods. A few studies from the US have been published, but they were not randomized or prospective.

I have blogged about some of these studies on three occasions. If you would like to read these posts, click on their titles.

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

Antibiotics instead of surgery for appendicitis? No way

Antibiotics instead of surgery for appendicitis? I don’t think so.

A group of surgeons in Washington State are putting together what will be the first randomized prospective trial of antibiotics vs. surgery for appendicitis in the United States. In order to obtain a grant from the Patient-Centered Outcomes Research Institute to help fund the project, the investigators must demonstrate that people in this country would be willing to participate in such a study.

To help determine the level of interest, they have written a brief explanation of why this study is being proposed. It parallels my thinking on the subject.

At the end of their post is a link to survey involving one question:

If you had appendicitis, would you be willing to join a study that would randomize you (a 50% chance, or flip of a coin) to “surgery ” or “antibiotics?”

You don't have to read the Washington researchers' post to take the survey.

You may click here to answer that question. Thanks.


artiger said...

Scalpel, I would answer that question, but I am quite biased. Perhaps I should stay out?

Still, I'm glad the investigators are trying to set up the study properly. I guess it's a question that needs to be asked and answered.

Skeptical Scalpel said...

I took the survey and said I would agree to be randomized. I'm not so sure I would though.

J D Patten said...

All I had was a couple of days of mild tummyache around the navel, of all places. No classic manipulation elicited anything more. CT, "just to be sure", revealed that surgery was "necessary". Well, my surgeon removed a blackened necrotic appendix, too swollen to be removed without morcellation. Five days on IV antibiotics followed.

How can these people be certain that this type situation wouldn't get the antibiotics-instead treatment? Who might they think would bear the consequences??

Skeptical Scalpel said...

JD, I agree and said so in one of my previous posts that I linked to above. CT scan is pretty accurate but not 100% reliable at differentiating simple from complicated appendicitis. And you know what would happen if there was a bad outcome after a course of antibiotics.

artiger said...

Another significant issue that I would like the study to follow would be the incidence of C diff, Candida, and other antibiotic-associated events in the nonoperative group.

Anonymous said...

Thank you for being one of perhaps a handful of doctors I have met or read about who actually recognizes that antibiotics are dangerous and therefore not to be taken lightly.

As someone who has been permanently maimed by a fluoroquinolone, and will now die young from the heart failure that it caused, I cannot believe that doctors continue to use these big gun drugs with little regard or concern for the side effects they COMMONLY cause.

And before anyone jumps down my throat with a "correlation does not equal causation" argument that my sudden CHF was not caused by the antibiotic, I have several allopathic doctors who have confirmed the connection.

If I ever have appendicitis, I will take the surgery over the antibiotics-only option and will beg and plead to minimize any use of antibiotics during and after my surgery.

Skeptical Scalpel said...

A couple of votes for surgery. There are about 300,000 appendectomies for appendicitis performed every year. If half of those patients have simple appendicitis, that would be 150,000 more people per year on one or two week courses of antibiotics, not counting those who relapse and require a second course.

Unknown said...

Dear Dr. Skeptical,

I just returned from the hospital (live in Athens, Greece) for a laparoscopic appendectomy. You are one of the only doctors posting on the web in favor of surgery rather than antibiotics and I thought I may find some comfort in your honest opinion. I've become very discouraged from posts about successful antibiotic treatment when I had mine removed.
This is my story...
On Friday early morning, I was awakened with shaking, and abdominal pain at the navel reaching down to the right side. It lasted about an hour and then subsided for the most part (was bearable) and I went back to sleep. I continued to feel slight pain the next day at work. On Friday evening I went to see a doctor who did a physical and identified the pain in the appendix area (not severe pain). He had an U/S done and blood work. The Ultrasound medical doctor said he identified inflammation in the appendix (6.5mm). The CRP came positive at 25.6. The doctor told me to take two antibiotics (Augmentin 825 & flagyl 500 - which thank God have European price tags, totaling at 11 euros without insurance) and try to eat soups for the weekend. He said if the pain did not leave entirely I would need surgery on Monday morning. I did not entirely trust him as he seemed to be amused by the whole predicament ("You have appendicitis! It's not April Fools!" with grin)

Twenty four hrs after the medication, the pain did subside although I then had stomach pain (I am assuming from eating only soup with heavy antibiotics)and I had diarrhea. I also felt very tired.

To be on the safe side, Monday morning (following 60 hours of antibiotics) I went to a well known and reputable hospital. There, the head surgeon conducted a physical at which I did not feel localized pain at the appendix - more so stomach and uterus. He had blood tests, including CRP which came back good (nothing raised). The Ultrasound medical doctor though, found that my appendix had become more inflamed since Friday (don't have exact measurements yet) and that I had a ton of fluid in my abdomen (which I had originally accredited to ovulation, as I had noticed it too vaginally). I thought I would be told to go home, but the surgeon and the U/S doctor were both convinced I needed surgery. I had to make a decision quickly, and I decided (although with much, much reservation) to go ahead with the laparoscopy. Following surgery, surgeon said he was very pleased with the decision to remove appendix and that it was indeed infected, although not at an extreme state. I, however, have a hard time accepting that I removed my appendix when I had no pain and felt fine.
Did I make the right decision doctor?

Unknown said...

(ps: appendix & cysts he found in uterus will be sent for laboratory testing, so I will have confirmation in about ten days)

Skeptical Scalpel said...

Sevi, Thanks for reading my blog and for commenting. I find it hard to believe that your CRP went from 25.6 to not elevated at all in 3 days.

I think you made the right decision. You will never have to worry about appendicitis again. You didn't mention it, but I assume you are feeling fine now.

Some other thoughts. Augementin costs about $3 per pill in the US. A 7-day supply would cost about $42. Were you seen by a surgeon at the time of your first encounter Friday evening? Are surgeons in Greece compensated by the case (fee-for-service) or are they salaried (salary not linked to the number of operations they do)?

Anonymous said...

(I am replying as anonymous because for some reason site no longer accepts my Gmail accounts)

Thank you so much for your quick reply!

The doctor I saw on Friday was a surgeon, specialized in obesity surgeries but conducted other laparoscopies as well. He was affiliated with a hospital not covered by my insurance, or any private insurance, and generally more expensive. The specific doctor did not seem to care at all to be honest with you (I was the one who insisted on the U/S and blood tests on Friday!), so even if I wanted to pay out of pocket I would not have went there. At the end of our visit at the clinic/small hospital (he works in both a clinic covered by my insurance and a hospital not covered) as I was leaving he said "oh sign this quickly before you leave" with an "oh-its-typical form". When I looked closely it was an I-refuse-to-be-hospitalized notice.

I do keep wondering though, if I had stuck with him perhaps I would have avoided surgery. He said only if you feel pain, you need to have surgery on Monday.

Surgeons do receive a fee for their services, but there is a cap on how much can be asked according to the insurance companies & hospital rates. Furthermore, medical doctors from the insurance companies request exams immediately prior to approval of covering the fees. At least that was what happened in my case prior to my surgery on Monday. The surgeon’s approximate fee for a surgery like mine is approximately 900e. Do you believe that was a factor? :(

The surgeon on Monday did appear far more concerned. I do not have the blood tests from the hospital in my hands yet, but I was told there were no elevated measures by the surgeon. He actually told me that if it weren't for the imaging results he would have released me. It was from his viewing of the U/S images and talking to the radiologist that made him very concerned. The surgeon said he has been working with this radiologist for many years and that he is not often so absolute or alarmed. This time he said the radiologist said it is appendicitis 100%. I asked whether there was better imaging available, and surgeon said that they gathered clear information from the U/S and that there was no need for unnecessary radiation and that an MRI would not work in this case. (I was not crazy about having an abdominal CT Scan either).

I DO keep thinking I should have waited- there was no way this surgeon was ever going to tell me to go home and face possible liability. He had told me very honestly that the responsibility was placed on him and he did not want to be held responsible if something bad happened to me. Over-protective medical treatment? Perhaps…

I am more concerned about the health implications of not having an appendix. There is much research indicating the immunological benefits of the appendix.

I mentioned cost because I was shocked by the astronomical differences in medical costs in Greece versus NY where I am from. The prices you mentioned for Augmentin out of pocket do not seem that much higher though.

I apologize for the massive response. I am a bit worked up about this. I really do appreciate your time. Really.

Anonymous said...

One last and final question from the Greek girl (promise!):
Is it possible for antibiotics to mask the symptoms of a person originally diagnosed with appendicitis, to the point where the appendix keeps growing but other symptoms such as pain/alarming blood-work subside? In your many years of experience, have you ever seen this and, if so, still feel the need to operate?

Skeptical Scalpel said...

900 Euros is not a bad fee for the surgeon. It is higher than the average fee for the procedure here in the US. Of course I cannot know whether that was a factor in your situation.

I think the health implications of not having an appendix are mostly theoretical. There are about 250,000 appendectomies done in the US every year. If there were major health problems after the surgery surely someone would have reported on them by now.

Yes, I have seen antibiotics mask the symptoms of appendicitis. If fact, antibiotics can completely eliminate the symptoms and the inflammation. That is why people are pushing for treated antibiotics without surgery. For antibiotic treatment, the recurrence rate of appendicitis is 25-30% after one year. What will it be after 3 or 5 years? What is an acceptable rate?

Anonymous said...

Thank you for your response! I found that amount by doing some googling. Won't know until I get paperwork from hospital.

Thank you for your time! Didn't mean to rant!

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