Should conservative treatment of appendicitis be first line?BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2546 (Published 05 April 2012) Cite this as: BMJ 2012;344:e2546
- Olaf J Bakker, MD
Because a perforated appendix can lead to peritonitis and other potentially life threatening complications, surgeons have been treating appendicitis with prompt appendicectomy for more than a century. As recently as 20 years ago, it was considered good surgical practice to remove a normal appendix in patients with suspected appendicitis to rule out any chance of eventual perforation.1 A linked meta-analysis by Varadhan and colleagues (doi:10.1136/bmj.e2156) presents findings that, at first glance, seem to overthrow this classic surgical dogma.2 The authors present pooled data from four randomised trials of conservative treatment using antibiotics versus appendicectomy and conclude that antibiotics can be considered as a primary treatment option for early uncomplicated appendicitis. Complications were reduced by 31% after antibiotic treatment compared with appendicectomy.
It is possible that uncomplicated appendicitis is a self limiting illness, the natural course of which would not include progression to perforation without prompt surgical intervention. Uncomplicated appendicitis could perhaps be compared with uncomplicated diverticulitis, which, rather than being treated primarily with resection, is managed conservatively, and even antibiotics seem to be obsolete.3 However, the comparison must end with conservative treatment because an appendicectomy in uncomplicated appendicitis does not carry the same risk of postoperative anastomotic leakage as, for example, a sigmoid resection for diverticular disease. Compared with colorectal surgery, appendicectomy for uncomplicated appendicitis is a relatively safe procedure.4
Varadhan and colleagues’ meta-analysis updates previous meta-analyses by incorporating data from a recent French trial,5 the primary endpoint of which was peritonitis after the intervention. In the conservative group, peritonitis was diagnosed when a complicated appendicitis was identified at surgery (in patients who needed appendicectomy because of lack of improvement). In the appendicectomy group, peritonitis was diagnosed on computed tomography in patients with persistent abdominal signs and symptoms after appendicectomy. A complicated appendicitis identified at surgery in the appendicectomy group was not counted as a primary endpoint but as a failure of preoperative imaging. However, in the meta-analysis, peritonitis diagnosed at surgery in the appendicectomy group was considered a complication and was scored as a primary outcome. Consequently, the meta-analysis found that complications were significantly reduced after antibiotic treatment compared with appendicectomy.
What is the ideal primary endpoint in a trial of antibiotic treatment versus appendicectomy in uncomplicated appendicitis? Varadhan and colleagues seem to provide an answer in their definition of the secondary outcome measure “treatment efficacy.” In the conservative group, treatment efficacy was defined as “Patients who were successfully treated with antibiotics only and had none of the following: failure of antibiotic treatment or recurrence of symptoms needing appendicectomy; development of any post-therapeutic or postoperative complications.” For the appendicectomy group, treatment efficacy was defined as “Patients who were successfully treated with appendicectomy and had none of the following: no appendicitis on histology; development of any post-therapeutic or postoperative complications including readmissions.” The authors found no difference between groups for this secondary outcome.
The use of antibiotics as first line treatment for appendicitis has major disadvantages. In patients who have persistent problems despite antibiotic treatment, delayed appendicectomy might be necessary. Delayed appendicectomy has been associated with a high complication rate, however, and should be discouraged.6 In a patient with an inflammatory phlegmon—a palpable mass at clinical examination or an inflammatory mass or abscess at imaging or at surgical exploration—appendicectomy sometimes has to be converted to an ileocaecal resection. Another important disadvantage of antibiotic treatment is the chance of recurrence. The current meta-analysis found a 20% chance of recurrence of appendicitis after conservative treatment within one year. Of these recurrences, 20% of patients presented with a perforated or gangrenous appendicitis. It is questionable whether a failure rate of 20% within one year is acceptable. Long term recurrence rates might be even higher. Finally, before the patient starts antibiotics the treating doctor must exclude a perforated appendicitis, which means that computed tomography would be required in every patient, including children and fertile women, with its attendant risks.
What are the major disadvantages of appendicectomy? The patient must undergo general anaesthesia, which can be hazardous in a subgroup of patients, particularly those with comorbidity. After appendicectomy patients risk developing procedure related complications such as wound infection. Other potential disadvantages, such as length of hospital stay, duration of pain, or duration of disability, did not differ between groups in the current meta-analysis, which is perhaps surprising.
Varadhan and colleagues have dealt with this difficult and controversial question well. They are appropriately circumspect in concluding that conservative treatment merits consideration as a primary treatment option. However, until more convincing studies and longer term results are published, appendicectomy will probably continue to be used for uncomplicated appendicitis.
Cite this as: BMJ 2012;344:e2546
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.