A new study suggests that appendicitis doesn’t always need to be treated with surgery. This is a radical idea, given that most physicians and patients believe that acute appendicitis requires emergency appendectomy.
History of an Idea:
That idea got started back in 1886, when Dr. Reginald H. Fitz did autopsies at Massachusetts General Hospital. He was the first designated pathologist there. Dr. Fitz inferred from his autopsy findings that appendicitis progressed from mild mucosal inflammation to a condition affecting the wall of the appendix. He concluded that at some point thereafter the appendix would become gangrenous, burst and cause life-threatening infection.
Keep in mind that 1886 was prior to the advent of antibiotics, so no wonder Dr. Fitz’s colleagues concluded that appendicitis always required removal of the appendix. What was ignored was Dr. Fitz’s observation that many people showed signs of spontaneous recovery from appendicitis.
Antibiotics to Treat Appendicitis
Many decades later, in 1959, Dr. E. Coldrey treated a large number of people who had acute appendicitis. These patients were given antibiotics instead of surgery, and most did well. But this treatment went against the norms of American medicine and was soon forgotten.
The report on the current research is a bit confusing, but the results are fascinating. Finnish investigators recruited 530 patients with acute uncomplicated appendicitis. Their condition was confirmed with CT imaging, the gold standard for an appendicitis diagnosis. These people were randomly assigned to undergo immediate appendectomy or to receive a broad-spectrum antibiotic (injected ertapenem first, followed by oral levofloxacin) to knock out the infection underlying the inflammation. The follow-up period lasted a year.
The results were quite encouraging. Of 257 people assigned to get antibiotic treatment, only 70 required surgery for persistent or recurrent appendicitis. There was a worry that having delayed surgery would lead to complications of the procedure, but that didn’t happen with any of the folks who did need surgery following antibiotic treatment.
The scientists set up the study so that they would consider it a success if 24% or fewer of those who got antibiotics needed surgery later. Since 70 out of 257 is actually about 27%, they had to classify their study as a failure.
Nonetheless, for uncomplicated appendicitis confirmed by CT imaging, this still sounds like a good balance of benefit to risk for many people. It would require an in-depth conversation with the doctor or hospital to make sure everyone is on the same page. An editorial in JAMA that accompanied this research concluded that
“The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis.”
JAMA, June 16, 2015