Antibiotics are an alternative to appendectomy, study suggests

A randomized controlled trial has brought into question the
established medical doctrine that appendicitis should be
treated by surgical removal, finding that a level of success
can alternatively be achieved by use of antibiotics.

Published in the journal JAMA, results in the arm of the study
assigned to receive a 10-day course of antibiotics rather than surgery saw a success rate of just under 73% in terms of
whether patients treated in this way did after all need surgery
within a year of removal of the appendix.

Of the 256 patients available for 1-year follow-up in the
antibiotic group, 186 did not require the later appendectomy.
However, compared with surgical treatment, the antibiotic option did not prove to cross a threshold of effectiveness
established during the design of the study.

Over a quarter (70) of the patients assigned to antibiotic
treatment went on to undergo surgical intervention within a
year of initially presenting with appendicitis.

The researchers' hypothesis was that antibiotic treatment would
not be worse than appendectomy. The threshold set - but not met by the results - was that the benefits from avoiding surgery
would be worthwhile even if there was up to a 24% failure rate in the antibiotic group. The failure rate found, though, was 27.3%.

The safety of delaying appendectomy to first try antibiotics was, however, shown by a lack of intra-abdominal abscesses or other major complications.


Routine appendectomy is a 100-year-old idea

An editorial article about the study in the same issue of the
journal - written by Dr. Edward Livingston, JAMA's deputy editor, and Dr. Corrine Vons, from the Jean Verdier Hospital
in Bondy, France - explains that since late in the 19th century,
surgery has remained unquestioned in the treatment of
appendicitis.

But recent changes, the article outlines, have happened in the
management of appendicitis, "even if appendectomy remains
the end result."

There is now "almost perfect" diagnostic accuracy achieved by
imaging via computed tomography (CT) scanning, and the use of antibiotics perioperatively is changing the condition's natural
history.

The editorial goes on to praise some of the study's strengths -
noting its large sample size and the use of CT scans, which also allowed the researchers to exclude from analysis cases that
would require surgery anyway (because of perforation, abscess, and so on).

The authors of the study conclude: "These results suggest that patients with CT-proven
uncomplicated acute appendicitis should be able to make an
informed decision between antibiotic treatment and
appendectomy."

They call on future studies to focus on early identification of
complicated acute appendicitis patients needing surgery, and to
prospectively evaluate the optimal use of antibiotic treatment in patients with uncomplicated acute appendicitis.