Appendicitis: Surgery not essential, often drugs are enough, finds study
men. Once considered a useless, vestigial organ that was expendable, the appendix has lately been identified as a reservoir for beneficial “good” gut bacteria, which helps the digestive system recover after bouts of diarrhoeal and other gastrointestinal illnesses.
Since more than a century, surgery has been the standard treatment for appendicitis, which is an inflammation of the appendix because of acute infection and causes symptoms such as sudden, severe pain in the lower abdomen, nausea, vomiting and abdominal bloating. Uncomplicated appendicitis is infection without complications such as perforation, abscess, or suspicion of tumour.
MEDICINES FIRST
Antibiotic treatment led to fewer complications and faster recoveries, with the antibiotic group taking an average of 11 days of sick leave to recover, compared to 22 days taken by those who underwent surgery. Antibiotics also lowered complication rate to 6.5%, compared a rate of 24% post surgery, mostly as a result of infections.
Though the study did not compare costs, patients who do not undergo an operation spend less on treatment, including treating surgical complications.
On average, the surgery patients stayed in the hospital for three days, while those treated using antibiotics were given three days of intravenous drugs in hospital, followed by one week of oral antibiotics prescription after discharge. The antibiotics used were intravenous Ertapenem for three days followed by seven days of oral Levofloxacin and Metronidazole, all of which are broad-spectrum antibiotics that act against a wide range of disease causing bacteria.
An important finding was that none of the patients in the antibiotics group who eventu- ally needed an operation had complications related to delaying surgery. “Although patients may be concerned about the ultimate need for surgery from the health outcome perspective, non-surgical treatment in uncomplicated appendicitis before proceeding for surgery is a reasonable option,” said an accompanying editorial in JAMA.
RIGHT PRICE
The study’s finding is not entirely surprising and is a long-term follow-up Appendicitis Acuta (APPAC) trial in 2015, which compared the outcomes for open appendectomy (appendix removal) with antibiotic therapy for acute uncomplicated appendicitis and declared antibiotics were a reasonable alternative to surgery.
Of the 257 patients in the antibiotic group, 186 (73%) initially treated with antibiotics did not require surgery after one year, but concerns were raised on whether the antibiotics just improved the situation temporarily or if initial drug treatments left patients worse off later if they eventually did need surgery. Despite the evidence on the effectiveness of antibiotics, experts’ groups recommended that the APPAC results could not be used for clinical decision-making until the longterm outcomes were known for the patients on antibiotic treatment, which was provided by the new study.
These findings have great implications in places such as many parts of rural India where surgeons are not available 24x4 for emergency surgeries.
Further research now needs to identify the best treatment for appendicitis compared to minimally invasive laparoscopic surgery, which is replacing conventional open surgery in most parts of the world, including in India.