Should conservative treatment of appendicitis be first line?

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, …