Antibiotics are as good as surgery for appendicitis, study reports
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3870 (Published 05 October 2020) Cite this as: BMJ 2020;371:m3870
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Dear Editor
Acute appendicitis is inflammation of the vermiform appendix and remains the most common cause of the acute abdomen in young adults. The mainstay of treatment in most centers is an appendectomy, and, consequently, this is one of the most common operations performed on the acute abdomen. Though the success rate of surgical treatment has been shown to be higher than the success rate of conservative management, this must be balanced with the associated tradeoffs related to conservative management. The lifetime risk of appendectomy is 12% for males and 23.1% for females.
The advantages of non-operative treatment include avoidance of complications related to surgery and general anesthesia as well as the associated stress and psychosocial trauma that parents and children may face from having to go through surgery. The total costs incurred per patient from conservative management including readmission costs have been significantly lower than that of index appendectomy. However, this must be carefully balanced against the potential psychological impact of repeated assessment for recurrent appendicitis in non operative treatment children with recurrent symptoms.
Due to postoperative complications including wound infections, intra-abdominal abscesses, ileus and, in the longer term, adhesions, it is worth considering that the mainstay of treatment for other intra-abdominal
inflammatory processes, such as diverticulitis, consists initially of conservative management with antibiotics.(1). A very recent report highlights safety of antibiotics over appendectomy.(2) Similarly in addition to low cost, there was no significant difference in post-intervention complications between the surgical group and antibiotic treatment group.(3,4). According to another report, the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure.(5)
Major approach for appendicitis remains as surgical removal of appendix. Several reports have described the superiority of LA compared to open appendectomy (OA) (6,7). Despite safety and wide applications of surgical procedures, antibiotics remain the module of choice for most of the patients.
An unexplored and non highlighted advantage of antibiotics lies in the cosmetic value of antibiotics in females and pediatric population. Although the scar of either LA or OA is present on the normally covered portion of the skin yet it compromises the cosmetic value of any female. Hence antibiotics can be a better alternative with an additional advantage of no scar marks that might affect the marital life of female patients.
1. Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E. Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence. Canadian journal of Surgery. 2011;54(5):307.
2. Tan AP, Yap TL, Cheong YL, Rai R, Choo C, Ong C, Low Y, Jacobsen A, Loh A, Ong LY, Chen Y. Conservative antibiotic treatment of pediatric acute uncomplicated appendicitis during the COVID-19 pandemic: a prospective comparative cohort study. Pediatric Surgery International. 2022;39(1):60.
3. Podda M, Gerardi C, Cillara N, Fearnhead N, Gomes CA, Birindelli A, Mulliri A, Davies RJ, Di Saverio S. Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: a systematic review and meta-analysis. Annals of surgery. 2019;270(6):1028-40.
4. Gorter RR, The SM, Gorter-Stam MA, Eker HH, Bakx R, van der Lee JH, Heij HA. Systematic review of nonoperative versus operative treatment of uncomplicated appendicitis. Journal of Pediatric Surgery. 2017;52(8):1219-27.
5. CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. New England Journal of Medicine. 2020;383(20):1907-19.
6. Kocataş A, Gönenç M, Bozkurt MA, Karabulut M, Gemici E, Alış H. Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis: a prospective randomized clinical trial. Ulus Travma Acil Cerrahi Derg. 2013;19(3):200-4.
7. Shimoda M, Maruyama T, Nishida K, Suzuki K, Tago T, Shimazaki J, Suzuki S. Comparison of clinical outcome of laparoscopic versus open appendectomy, single center experience. Heliyon. 2018;4(5):e00635.
Competing interests: No competing interests
Dear Editor,
After earning my MD, thereafter working as a Lecturer in Medicine, I chose to work in a village where I did my schooling.
With a view to save the encumbrance of surgery, its cost, trauma, risk and experience, I thought of treating acute appendicitis with antibiotics. One case after another, people got relief and during past 30 years none of the conservatively managed had a recurrence of appendicitis. I was happy all this while that I could save the people in and around my village of hardships of the surgery. Now I am at peace that what I did is found at least non inferior by some authoritative people!
Competing interests: No competing interests
Reevaluating Antibiotics as a Standalone Treatment for Appendicitis: Insights and Implications for Future Research
Dear Editor,
I read with keen interest the recent study published in your journal, which investigated the efficacy of antibiotics compared to appendectomy for treating appendicitis, finding them non-inferior at 30 days. However, I would like to highlight some considerations regarding the short-term and long-term outcomes, subgroups with appendicolith, cost-effectiveness, follow-up duration, and generalizability of the findings.
Notably, the study observed that 29% of patients in the antibiotic group required an appendectomy within 90 days, indicating that antibiotics might serve more as a short-term solution rather than a definitive alternative to surgery. This distinction is crucial for understanding the practical implications of adopting antibiotic treatment as standard care for appendicitis.
Further, the higher complication rate and surgical conversion observed in patients with appendicolith necessitate a more nuanced approach to patient selection. This subgroup analysis underscores the importance of risk stratification in clinical decision-making and suggests the need for more detailed investigation into how appendicolith presence influences treatment outcomes.
While the study mentions the potential benefits of reduced surgery rates and work absences in the antibiotic group, a comprehensive cost-effectiveness analysis was lacking. Such analysis is vital for evaluating the broader economic implications of the two treatment modalities and could significantly inform public health policy and clinical practice.
The study’s follow-up period, limited to 90 days, may not fully capture the long-term recurrence and complications associated with antibiotic treatment. Extended follow-up in future research would provide a more complete picture of the treatment’s durability and long-term safety.
Lastly, the generalizability of the study’s findings, derived from 25 centers across the U.S., to different healthcare contexts, remains a concern. Considering the variability in healthcare resources, demographic profiles, and clinical practices globally, it is imperative to evaluate how these results translate to diverse settings.
In conclusion, while the study provides valuable insights into the non-inferiority of antibiotics for appendicitis treatment, a deeper exploration into the outlined areas would enhance our understanding and guide more nuanced clinical applications.
Competing interests: No competing interests