Monday, December 28, 2015

Appendicitis: Continuing debate about treatment

The other day on Twitter, Kenny Goldberg (@kghealth), a health reporter at KPBS News in San Diego, asked me, "Why all the stories on antibiotics vs. surgery for appendicitis? Are appendectomies inherently dangerous?" My answer was "Great question. The answer is a resounding 'No.' The complication rate is very low."

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.


Anonymous said...


Strich said...

"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."

Ahem !
Weird since laparoscopic was first performed in Europe, and as an old world based doc I rarely see non laparoscopic appies.

Skeptical Scalpel said...

In the recent, widely cited Finnish study, 95% of the appendectomies were done as open cases. The authors said most Finnsh surgeons don't perform laparoscopic appendectomies.

artiger said...

I've said it on this site before, but it bears repeating...I've offered patients the option of antibiotics for appendicitis (after reviewing the current "research" mentioned above), and exactly zero have chosen this route over surgery. Patients appear to be smarter than some of the researchers.

I'm all for letting patients participate in their care, but they need to be well educated about their choices. That is where we as surgeons come in.

Skeptical Scalpel said...

Offer the choice, but make sure they understand the risk, benefits and cure rates of both options.

Unknown said...

I know about the Finnish study. With all due respect to the Finnish, they are numerically a very small part of Europe. ANd I was surprised at the low %of laparoscopies.
Their study was also impaired by the choice of antibiotics they made. Imipenem if I'm not mistaken. ANyway antibiotics no decent hospital antibiotics commitee would allow for community infections. Plus the longer length of stay for infusions than an appendectomy. .

Skeptical Scalpel said...

Ingo, I agree with you about the Finnish study. Here's what I said when it first came out

patient said...

Hello, I am writing as a patient. I was successfully treated at a US facility for appendicitis with oral antibiotics. I appreciated my surgeon giving the alternatives and discussing my choices, and ultimately agreeing to assist me with a non surgical option. That was 3 years ago and I have not had a recurrence. I think you need to open your mind a bit and consider it might be a good option.

Skeptical Scalpel said...

If 65% of patients get better with antibiotics and don't have a recurrence they are both lucky and happy and you are one of them. I would like to hear from someone who was initially treated with antibiotics and later had to have an appendectomy. I wonder what they would say?

What if longer term follow-up reveals that the recurrence rate is 50% at 5 years and yours recurs? Will you still think it was such a good outcome?

What if the recurrence rate is 75% at 10 years? Oh, it's a hypothetical question? That's right. We don't know what the recurrence rate is at 5 or 10 years because it has not been studied.

PS: None of the current published papers used only oral antibiotics. Patients had at least a day or two of IV antibiotics. By the way, was your appendicitis diagnosed clinically [if so, you may not have even had appendicitis], or did you have a positive ultrasound or CT scan?

Anonymous said...

The most recent study was done here in the US in Ohio (Trial Registration Identifier: NCT01718275) and the JAMA version of the results showed, higher morbidity for surgery. Patients (or their parents in this case) need to know the facts to make an informed choice along with their surgeon but you have already decided for them

"The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01)."

Conclusions and Relevance When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.

Skeptical Scalpel said...

It wasn't a randomized trial. The surgical patients did not have more morbidity. The difference in morbidity WAS NOT SIGNIFICANT. Please reread the fourth from last paragraph of my post.

artiger said...

I realize this thread is a bit aged, but I just had to report that this morning I FINALLY have a patient who has selected the antibiotic option for simple appendicitis (it's kind of a hedge, I mean, soft call, judging by both the report as well as my viewing, but certainly not perforated).

I expect to report tomorrow that the patient has been discharged, postoperatively. But I'm keeping an open mind.

Skeptical Scalpel said...

Please let us know when the antibiotic treatment fails. Thanks.

artiger said...

As a matter of fact, it failed today. The patient started feeling better, and tolerated a regular diet, but he was still pretty tender on exam. With the initial scan being so equivocal, I elected to expose him to more radiation and repeat the scan (I know, I know). I guess I began to wonder if I was treating appendicitis or something else. Well, today's scan showed definitive evidence of simple acute appendicitis, notably worse than the admission scan 48 hours ago. The patient and I decided that was enough, his acutely inflamed, fibrinous exudate-covered appendix was removed via laparoscopy, and he was discharged 2 hours later.

In fairness, I don't know that I really gave it enough of a shot, but surgery cured it instantly. I'll continue to give patients the options but I'll also continue to speak up for my bias.

In case anyone is curious, my test antibiotics were Flagyl and Levaquin.

Skeptical Scalpel said...

Thanks for the update. I doubt that conservative treatment failed because of the antibiotic choices.

pippo said...

La apendicitis aguda es un diagnóstico histopatologico. Mientras no haya un espécimen y un patologo que nos diga que en verdad es apendicitis aguda, no podemos concluir que el paciente cursó con esa patología. Se requieren mas estudios sobre este tema, y mientras no los haya, la evidencia actual es clara: el mejor tratamiento para la apendicitis aguda es la apendicectomía

Skeptical Scalpel said...

Translation: "Acute appendicitis is a histopathological diagnosis. While there is no specimen and a pathologist to tell us that it is indeed acute appendicitis , we can not conclude that the patient had with this pathology . Further studies on this subject are required, and while they do not exist , the current evidence is clear : the best treatment for acute appendicitis is appendectomy."

Thanks, Pippo

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