Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

Changes in the management of patients with suspicion of appendicitis may have a large impact on the health system in view of the large volume of patients. There is no doubt that assumed uncomplicated appendicitis can resolve under non-surgical treatment but the meta-analysis of non-surgical treatment of Varadhan et al may be misleading.1

It is supposed that the patients with appendicitis in the surgical group in the randomised trials really needed surgery. However, it is well known that many pathologists report on minor, clinically non-significant, inflammatory changes that are often erroneously classified as appendicitis. Vons et al thus accepted mucosal ulceration with neutrophil infiltration restricted to the mucosa as criterion for the appendicitis diagnosis. The other studies do not report on the criteria used. An unknown proportion of the patients thus had clinically non-significant appendicitis.

A common rate of negative appendectomy is about 10-15% in most studies of conventional treatment. Most of these patients will belong to the selected group of patients with assumed uncomplicated appendicitis. It is therefore remarkable that the included studies report extremely low rates of negative appendectomies, if at all. Further, there are many indications that appendicitis may commonly resolve with expectant management without any treatment.2

The resolution of “assumed uncomplicated appendicitis” may therefore not represent the effect of the antibiotics treatment but is simply a consequence of the natural history when surgeons venture a more expectant management under the antibiotics cover. The efficiency of the antibiotics treatment is therefore heavily biased. We do not even know if these patients needed any treatment at all.

Non-surgical treatment of appendicitis with antibiotics may have a role in selected cases to avoid the surgical trauma especially in frail patients or in situations where safe surgery is not at hand. However, the eventual acceptance of early trial of antibiotics treatment of patients with “assumed uncomplicated appendicitis” is questionable. The diagnosis of acute appendicitis is difficult. It is likely that the threshold will be lower for starting antibiotics treatment compared with surgery. Consequently more patients with mild symptoms, that were previously managed with observation, will be treated with antibiotics. Many of these patients will probably have recurrent non-specific abdominal pain which will cause future pedagogical problems when the abdominal pain recurs if they have had previous treatment for “assumed uncomplicated appendicitis”.

The consequences in terms of use of hospital beds, length of stay, delays in surgical treatment, increase in the need of follow up for patients with an unclear diagnosis, delayed diagnosis for patients with an underlying cancer in the appendix or colon and the ecological effects with an increased risk of antibiotics resistance therefore need to be investigated further before we can calculate the cost/benefit of this treatment.

Krishna K Varadhan, Keith R Neal, Dileep N Lobo. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials
BMJ 2012;344:e2156

2 Andersson RE. The Natural History and Traditional Management of Appendicitis Revisited: Spontaneous Resolution and Predominance of Prehospital Perforations Imply That a Correct Diagnosis is More Important Than an Early Diagnosis. World J Surg. 2007 Jan;31(1):86-92.