Don’t have your appendix out... just take a dose of antibiotics
THOUSANDS of children suffering from acute appendicitis are to be offered medication rather than an operation, in an NHS-backed trial.
Currently, appendicectomy – removal of the appendix – is the treatment recommended by health watchdogs the National Institute for Health and Care Excellence. However, one patient in five suffers complications including abscesses and infections.
The new move comes following a groundbreaking Finnish study published last year, in which the majority of appendicitis patients who were treated with antibiotics did not require surgery later.
Paediatric surgeons at University Hospital Southampton NHS Foundation Trust believe that a similar trial in children will produce the same result.
The appendix is a tube-shaped sac attached to and opening into the lower right end of the large intestine. Its function is unknown. One theory is that the appendix acts as a storehouse for digestive system bacteria. Some believe the appendix is a useless remnant from our evolutionary past.
For unclear reasons, the appendix often becomes inflamed, infected, and can rupture. This causes severe pain, nausea and vomiting, and in severe cases can trigger potential fatal bodywide reactions.
Surgery on an acutely inflamed appendix became routine after it saved the life of King Edward VII in 1910, two days before his coronation.
Today the NHS spends £200million a year on the procedure and inpatient costs, treating 70,000 adults and children.
However Nigel Hall, a paediatric surgeon who is leading the Southampton trial, is convinced that in a few years the majority of the 18,000 children a year who end up in the operating theatre for an appendectomy will be successfully treated by intravenous antibiotics alone.
He said: ‘It is one of the more minor operations we do, but any surgery has its risks and if you can safely avoid surgery, then you should.
‘We do most of our appendectomies using keyhole surgery but the operation still has a 15 per cent complication rate, mainly caused by infections. Most of our children are in for a day or two after the operation.
‘Parents often ask after the surgery if there was anything else we could have done apart from operate. At present I have to answer no because surgery is the gold standard and without the evidence, no surgeon is going to try something that has not been tested on children.’
Adults also suffer appendicitis. Actress Lindsay Lohan had an appendectomy in 2007, when she was 20.
In the Finnish study, researchers from Turku University Hospital randomly divided 530 patients with appendicitis into two groups.
Half received an appendectomy, and all but one recovered successfully. The other half were given antibiotics for ten days, after which 73 per cent recovered fully while the remaining 27 per cent then had their appendix removed.
Mr Hall said: ‘We have stuck religiously by surgery for so long that it has become hard to think of an alternative, but I am convinced that a success rate of more than two-thirds of patients with antibiotics alone means that that is a very viable alternative.’
Before the treatment is rolled out further, Mr Hall and his team, along with colleagues at St George’s Hospital in Tooting, Alder Hey Children’s Hospital in Liverpool and Great Ormond Street Hospital, will carry out a year-long ‘feasibility trial’ which will see children with appendicitis randomly allocated to have either surgery or antibiotic treatment.
The study, known as CONservative TReatment of Appendicitis in Children a randomised controlled Trial (CONTRACT), is being funded with a £483,000 grant from the NHS National Institute for Health Research. Children who are not selected for surgery will be given intravenous antibiotics for 24 hours which, say doctors, should clear most of the infection, followed by an oral course of antibiotics to take home. A larger trial could lead to a change in policy among paediatricians. Mr Hall stressed that children in the trial chosen for antibiotic treatment would be closely monitored.
He said: ‘We will be taking no risks. ‘If a child needs to go to surgery, then we will take them. ‘There will always be some patients who don’t respond to drugs and who will need an operation.’