tag:blogger.com,1999:blog-4968787219619380438.post50214825334486464..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Nonoperative treatment of appendicitis in children: Is it safe?Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger19125tag:blogger.com,1999:blog-4968787219619380438.post-51628312074463394902017-08-03T07:31:26.676-04:002017-08-03T07:31:26.676-04:00Luqman, I got that. My response was that exposing ...Luqman, I got that. My response was that exposing large numbers of people to a 7-10 day course of antibiotics to treat a disease that is cured by surgery might also cause C. diff colitis. In fact, it might lead to even more cases than those found in people without appendices.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-56408755111604323012017-08-02T01:32:50.437-04:002017-08-02T01:32:50.437-04:00I believe he meant the risk of C. diff will be red...I believe he meant the risk of C. diff will be reduced in the future due to preservation of the appendix.Luqmanhttps://www.blogger.com/profile/12144548172937229260noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-36514428357571537202017-03-27T11:57:59.605-04:002017-03-27T11:57:59.605-04:00Anon, you are correct in that sham surgery would n...Anon, you are correct in that sham surgery would not be appropriate in the setting. The study needs to be blinded because if parents or doctors conducting the trial can decide to which group the child is assigned, kids who look sicker would be more likely to be enrolled in the surgery arm of the study.<br /><br />As I wrote back in 2014, a study from Ohio State [http://skepticalscalpel.blogspot.com/2014/05/antibiotics-instead-of-surgery-for.html] had this very problem. I wrote “The nonrandomized nature of the ... study created imbalances in the cohorts as 6 (13%) of the 47 patients who underwent surgery had complicated appendicitis (2 with gangrenous and 4 with perforated appendicitis), compared to no instances of complicated appendicitis in the nonoperative group.”<br /><br />The subject of whether the appendix is useful or not is debatable. For example, several studies have shown that appendectomy is protective against the development of ulcerative colitis.<br /><br />Geboes K: Appendiceal function and dysfunction: what are the implications for inflammatory bowel disease? Nature Clin Pract (Gastroenterology and Hepatology) 2:339, 2005. 16265384<br />Radford-Smith GL, Edwards JE, Purdie DM, et al: Protective role of appendicectomy on onset and severity of ulcerative colitis and Crohn's disease. Gut 51:808, 2002. 12427781<br />Andersson RE, Olaison G, Tysk C, et al: Appendectomy and protection against ulcerative colitis. N Engl J Med 344:808, 2001. 11248156<br />Frisch M, Pedersen BV, Andersson RE: Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis: cohort studies in Sweden and Denmark. BMJ 338:716, 2009. 19273506<br />Matsushita M, Takakuwa H, Matsubayashi Y, et al: Appendix is a priming site in the development of ulcerative colitis. World J Gastroenterol 31:4869, 2005. 16097061<br /><br />I don’t understand your comment about antibiotics. You say “you will also be at lower risk of C. diff following antibiotic treatment.” Since the number one cause of C. diff colitis is antibiotic treatment, I fail to see how exposing more people to courses of antibiotics lasting 7-10 days will result in fewer cases of C. diff colitis.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-87233555169372920742017-03-27T10:35:46.977-04:002017-03-27T10:35:46.977-04:00Difficult to see here why lack of blinding to assi...Difficult to see here why lack of blinding to assignment would be likely to affect results (except inasmuch as, in some studies, every antibiotic user with recurrent abdominal pain was hustled in for appendectomy, which obviously was not done for pain in the appendectomy group). I presume you do not want everyone to be given sham surgery.<br /><br />There is no blood-appendix barrier and therefore no a priori reason that appendicitis should always require surgical treatment any more than colitis or pneumonia. The cultural belief that it does is a historical contingency based on the fact that appendectomy was a simple enough surgery that it could be invented before antibiotics. <br /><br />Second, there is a belief that the appendix is useless. It is not. It helps repopulate the gut with necessary flora after illness, so if in future you are going to travel to or live in places where one gets diarrhea a lot, you will benefit from having an appendix. You will also be at lower risk of C.diff. following antibiotic treatment, which is not meaningless. You probably can't envision being sued for someone's C.diff. a decade down the line because our culture favors "Doing Everything" and will almost never punish you for it. That doesn't mean that those harms aren't equally significant to patients.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-9776241409713449172017-03-17T23:16:42.364-04:002017-03-17T23:16:42.364-04:00Scalpel, I predict an award of at least 8 digits, ...Scalpel, I predict an award of at least 8 digits, perhaps 9. artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-59021106591693884432017-03-17T15:43:07.411-04:002017-03-17T15:43:07.411-04:00Artiger, yes tumors are possible, but they are fou...Artiger, yes tumors are possible, but they are found in <1% of specimens removed at appendectomy. I don't believe a strong case can be made that appendectomy should be done to prevent advance cancer of the appendix.<br /><br />However, it will be interesting to see what happens when the first lawsuit for delay in diagnosis of cancer of the appendix after nonoperative treatment of appendicitis is filed.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-81717859591127480122017-03-17T15:22:24.480-04:002017-03-17T15:22:24.480-04:00Anon at 2:40pm, occasionally appendicitis is the r...Anon at 2:40pm, occasionally appendicitis is the result of a tumor, such as a carcinoid or even adenocarcinoma. All the antibiotics in the world are not going to kill a tumor. So yeah, there are long-term complications, because sometimes you don't discover a tumor was involved until you read the pathology report. artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-38267158039147420772017-03-17T15:21:16.599-04:002017-03-17T15:21:16.599-04:00Anon, I am not sure that there would be any other ...Anon, I am not sure that there would be any other complications besides the recurrence of appendicitis. If the recurrence was treated with antibiotics again, then the patience would still have the risk of a third or fourth attack.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-70790760190057210292017-03-17T14:40:33.000-04:002017-03-17T14:40:33.000-04:00Do you think there would be any other potential lo...Do you think there would be any other potential long-term complications other than recurring appendicitis caused by the nonoperative treatment as opposed to the permanent 'cure' of the appendectomy? If so, what then makes the nonoperative treatment beneficial compared to the appendectomy? Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-31545650537186271512017-03-17T10:46:53.315-04:002017-03-17T10:46:53.315-04:00Interesting. Thanks for enlightening me. I'm a...Interesting. Thanks for enlightening me. I'm about 20 years behind current thinking!Oldfoolrnhttps://www.blogger.com/profile/01747485143127099085noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-56502869676140816392017-03-17T07:19:49.983-04:002017-03-17T07:19:49.983-04:00Artiger, I agree.
Old, You may be right but so fa...Artiger, I agree.<br /><br />Old, You may be right but so far that has not been a big problem. Some experts feel that perforated appendicitis is a different entity than uncomplicated appendicitis which usually does not progress to perforation.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-86831641498579891462017-03-16T21:46:50.730-04:002017-03-16T21:46:50.730-04:00Nonoperative treatment of appendicitis could be co...Nonoperative treatment of appendicitis could be complicated by rupture. Not so safe.Oldfoolrnhttps://www.blogger.com/profile/01747485143127099085noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-36933940417656115822017-03-16T19:46:09.378-04:002017-03-16T19:46:09.378-04:00As far as nonoperative treatment of appendicitis, ...As far as nonoperative treatment of appendicitis, we might could call it safe, but I would question effective.artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-38054333176317698712017-03-16T07:39:43.637-04:002017-03-16T07:39:43.637-04:00Artiger, yes and C diff is not likely to be report...Artiger, yes and C diff is not likely to be reported as a complication.<br /><br />Anon, way to recognize the prime numbers :-).<br /><br />Kor, I am retired, but if I was still practicing, I would tell patients the following:<br /><br />Antibiotics have been used to treat uncomplicated appendicitis.<br />18-27% of patients treated with antibiotics will experience a recurrence within 2 years. Beyond that time, no one knows the recurrence rate. <br />The treatment is experimental.<br />The type and doses of antibiotic(s) have not been agreed upon.<br />I recommend a laparoscopic appendectomy. The operation is safe and cures the disease.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-76583622859102902722017-03-15T18:33:33.238-04:002017-03-15T18:33:33.238-04:00Cost of treatment is not a (direct) problem so far...Cost of treatment is not a (direct) problem so far in the UK.<br /><br />What, SS, would you now do and recommend? Korhommehttps://www.blogger.com/profile/05497111884933914657noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-79388503008652638302017-03-15T16:24:11.928-04:002017-03-15T16:24:11.928-04:00I am glad to see that they all concurred with the ...I am glad to see that they all concurred with the principle of using a prime number of days as the duration of antibiotics.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-37911645519565702622017-03-15T15:04:18.808-04:002017-03-15T15:04:18.808-04:00Let's not forget risks of C diff and increasin...Let's not forget risks of C diff and increasing antibiotic resistance either. <br /><br />Welcome back Scalpel.artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-73001664300816510172017-03-15T12:29:49.925-04:002017-03-15T12:29:49.925-04:00As far as I know, cost has not been completely add...As far as I know, cost has not been completely addressed. No doubt antibiotic treatment costs less at first. But if 25% of adults initially treated with antibiotics need surgery for recurrent appendicitis within a year or two, there may be no cost difference on average.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-88678531186926548302017-03-15T10:51:14.074-04:002017-03-15T10:51:14.074-04:00OK.Time to get serious. So which method of care,...OK.Time to get serious. So which method of care, surgery first or antibiotics first cost the least?William Reicherthttps://www.blogger.com/profile/10062067819184876941noreply@blogger.com