Like the villain in a bad horror movie, the idea of treating appendicitis with antibiotics refuses to die.
A meta-analysis published in the British Medical Journal claims that treating uncomplicated appendicitis with antibiotics is better than appendectomy. Four studies involving 900 patients were included in the paper. [Full text here.]
Treatment with antibiotics was said to have resulted in fewer complications (relative risk reduction of 31%) and similar hospital lengths of stay of just over 3 days for each group.
Medical news outlets such as MedPage Today “Antibiotics May Be Enough for Appendicitis” and Eurekalert “Antibiotics a safe and viable alternative to surgery for uncomplicated appendicitis, say experts” and the BBC “Appendicitis: Antibiotics may be better than surgery” touted the study without much criticism. That will not be the case here.
The authors state, “Diagnosis of acute appendicitis at admission was confirmed by ultrasonography in one study and by computed tomography in two studies, although this was done only in some patients in the study by Hansson et al.” In the fourth study, the diagnosis was based on clinical factors only. Translation: An unknown number of patients in the group treated with antibiotics may not have actually had appendicitis.
There were issues concerning the methods of randomization in the four studies. The paper says, “Randomization methods were reported as computer generated, external randomization [not explained, my comment], and by date of birth. The randomization method was not clear in one study.” Date of birth is a notoriously poor way to randomize subjects in a study because the treating physicians can know which group the subject is assigned to before entering him in the experiment. This means that two of the four studies had questionable randomization schemes.
In one of the four studies, almost half of the patients (96/202) in the antibiotic group required appendectomy. And 20% of all patients treated with antibiotics required appendectomy within one year of entry into their respective studies.
The mean length of stay for both treatments was just over 3 days for both antibiotics and surgery. Maybe that is true in Europe where these four studies were done. Only one of the four studies included patients with complicated appendicitis. But here in the US, the median length of stay for almost 17,000 appendectomy patients with uncomplicated appendicitis is 1 day (Advani et al Am J Surg). In my personal series of 171 appendectomies during 2009-2011, the mean length of stay for all patients, including those with complicated appendicitis, was 2.4 days with both a median and mode of 1 day.
The complication rate comparison raises a “straw man.” The 25% rate of complications for the appendectomy group in the meta-analysis is more than twice that quoted in the series by Advani. Laparoscopic appendectomy results in fewer complications than open appendectomy. One of the studies used in the meta-analysis is from 1995, when very few laparoscopic appendectomies were being done.
The success rates for the two treatments are compared. According to the paper’s Table 2, 58.3% patients were successfully treated with antibiotics vs 92.6% successfully treated with surgery. Unsuccessful surgical treatment is defined as removal of a normal appendix.
The recurrence rate of appendicitis in those who underwent surgery was 0.
If I proposed treating you with drugs that had a 58.3% rate of success in curing your illness for one year with the possibility that you could still suffer another attack of the illness two or twenty years later, would you choose that treatment? Or would you opt for a treatment which would keep you in the hospital for less than 24 hours with no risk of recurrence of the problem? Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 275,000 page views, and he has over 3600 followers on Twitter.