Friday, November 4, 2016

A medical oncologist weighs in on the treatment of appendicitis

It was an interesting fortnight for the debate about the treatment of appendicitis.

On November 1, David Agus, a medical oncologist and Director of the University Of Southern California's Center for Applied Molecular Medicine, had some thoughts about how appendicitis should be treated. He cited the Finnish randomized trial of antibiotics vs. surgery and said a 70% cure rate was good enough.

In a brief article on the Fortune magazine website, Agus wondered why appendectomy "continues to reign supreme." He said it was "because 24/7 we’re taught you have to take it out if there’s appendicitis” and that the healthcare community is "stubborn and pigheaded" [pigheaded means stubborn] and that we focus on treatment instead of prevention.

Because I am not aware of any method of preventing appendicitis, I say, "Guilty as charged." I admit I cured appendicitis for my entire professional life.

Only 5 days before Agus's rant, a meta-analysis of six randomized trials comparing the nonoperative treatment of appendicitis to surgery appeared online in the Journal of the American College of Surgeons. Agus should read it.

The authors, surgeons and biomedical researchers from Oxford, England, covered many of the points that I have made in my posts on this subject.

Some of their major findings were as follows:
  • In the six studies, 71% of the patients underwent open appendectomy which is not the standard in Europe or the US where more than 90% of appendectomies for simple appendicitis are done laparoscopically. In the largest and most recent study from Finland, 94.5% of the appendectomies were done as open procedures.
  • All of the studies suffered from one or more important methodological flaws such as poor randomization schemes, incomplete follow-up, exclusion of females, variability in defining and reporting complications, and more.
  • There was "no convincing evidence of reduction in complications" with nonoperative management.
  • The nonoperative management of uncomplicated appendicitis had an immediate success rate of 91% which dropped to 71% after one year of follow-up. The risk of recurrent appendicitis after one year is unknown.
The Fortune piece ended with this paragraph. [Trigger warning: Buzzwords ahead.]

"The good news? We’re at inflection point, Agus argues, in terms of technology and know-how: we’re ready to disrupt health care."

Dr. Agus, please confine your inflection points and disruptions to molecular medicine.


Korhomme said...

I guess you and I grew up against a background of those who treated appendicitis before there was effective antibiotic treatment. Then, it was a 'sin' to permit an appendix to perforate, to the extent that we were usually expected to remove 20% of normal appendices because of the risk or perforation, peritonitis and residual abscesses. You remember residual abscesses? Unfortunate patients who rotted for weeks after operation with pyrexias, people that were treated with antibiotics that did nothing — and all in the days before scans were available.

The discovery of GNABs and appropriate antibiotic therapy changed all this. I can remember well the first time I operated on a young girl with a perforated appendix, and prescribed 'Clindamycin' afterwards — before metronidazole was the accepted treatment. I was eaten by 'Sir' the next morning; but he didn't change the prescription. the patient went home, well and symptom free, after two or three days. 'Sir' rapidly changed his view.

I'm sure you can recall instances where a rather dubious indication to appendicectomy produced a grossly inflamed organ.

And isn't this the problem with control arms? Just how certain can you be that the patient has appendicitis? Because, unless you visualise the organ, you can't be that certain. Perhaps it doesn't matter; but can you be sure of this?

All a matter of anecdote? Perhaps, and perhaps it just reflects my background; but it doesn't make it any the less relevant today.

And as an aside, I'm not at all sure that so many appendices are removed laparoscopically in the UK as you say — not that that is so important in the overall management. And anyway, what is a cancer doctor doing advising on a condition that he never treats?

Anonymous said...

How can someone who at least can't show where is the appendix to comment about it's treatment ;)

Anonymous said...

Are you sure that inflection point isn't just puss under pressure?

Skeptical Scalpel said...

Kor, I agree that the gold standard for the diagnosis of appendicitis is the path report. Some of the RCTs relied on the clinical diagnosis of appendicitis only, not even a CT scan.

As far as the percent of laparoscopic appys done-- we're talking about simple appendicitis only, not complicated.

I think if Dr. Agus reads the meta-analysis I referred to in the post, he might not be so enthusiastic about treating appendicitis with antibiotics.

I might add that no surgeon is getting rich doing appendectomies. The reimbursement for the procedure is not that great. Maybe he should comment on oncologists who do 12-point reviews of systems, family histories and copy and paste most of the previous note in their charts every month.

artiger said...

Maybe Dr. Agus should focus his criticism on giving chemo until the patient is nothing but dust.

Since he threw out the terms stubborn and pigheaded, I'll throw one out to him...arrogant.

Skeptical Scalpel said...

No argument from me on your point.

William Reichert said...

You have to be understanding with Dr. Agnus. . Any oncologic treatment with a 70 % cure rate would be approved by the FDA faster than you can say '"BOARD CERTIFIED IN HEMATOLOGY AND ONCOLOGY". He is not a surgeon and ,hence, is unfamiliar with the concept of the goal of a complete cure.
Oncologists don't cure, they "manage". Seventy % is good enough for him.

Skeptical Scalpel said...

William, great points. The 70% solution.

Anonymous said...

Sometimes an outsider can really cast a new light on an old problem. This is obviously not such a case. In my general surgery rotation I did wonder why appendicitis is treated differently from diverticulitis. When I looked at recurrence I asked myself this: If I had acute appendicitis and was offered an appendectomy vs. antibiotics which would I choose and why? ... I would choose the appendectomy. Why? That recurrence might happen when I've got other stuff going on in my life. If I get appendicitis and have been sick and hospitalized I'd just as soon get the problem taken care of. What if it recurs when I am traveling internationally or on a backcountry trip? More than disrupting my schedule, that could be life-threatening. Wonder Dr. Scalpel's thoughts on how he'd decide on treatment if it were him.

Skeptical Scalpel said...

For all the reasons you mentioned and more, I would have a laparoscopic appendectomy as soon as possible and not give my appendix another thought.

Korhomme said...

Anonymous: back in the day if you wanted to go to Antarctica as a scientist, you had your appendix removed as a precaution. And if you had a history of duodenal ulceration, you didn't get to be a submariner.

artiger said...

Anonymous at 4:23pm on 11/11, that is similar to some comments I have made to people with cholelithiasis who have intermittent flare ups. Do you want to get hit with "the big one" on your child's wedding day, or on a cruise, etc? Or would you like a trial of pancreatitis? Would you like to be one of the few open cholecystectomies still being done these days?

Usually that is all I have to say.

Skeptical Scalpel said...

I'd rather have it done at my convenience than at a random time of nature's choosing.

artiger said...

Congrats, Scalpel, this post made it to Doximity, and you were given credit for setting things straight.

Skeptical Scalpel said...

Artiger, I saw that. Doximity occasionally picks up a post of mine. Thanks.

Rugger said...

I guess this Oncologist, Dr. Agus, missed the part in school where sometimes appendicitis is caused by a cancer. I sure would hate to leave that behind. I almost exclusively will remove them for this reason. I have found over 15 carcinoids and a few adenocarcinomas...including one adenocarcinoma that I incidentally found in a 19 y/o trauma victim, where I removed the appendix, because I thought to myself "I don't want to go back in that belly in the future if she ever happens to get appendicitis. That trauma probably saved her life. I did go back in thought and remove right colon.

Skeptical Scalpel said...

Rugger, good point. The review I cited noted that 0.59% (5 of 843 patients) had tumors including 3 cancers, three neuroendocrine tumors, and one dysplastic adenoma.

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