Should conservative treatment of appendicitis be first line?
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2546 (Published 05 April 2012) Cite this as: BMJ 2012;344:e2546
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Sir
Bakker's editorial(1) and Varadhan and colleagues meta-analysis(2) raise the question of the benefits and dis-benefits for patients treated with non-operative approaches for possible appendicitis.
As long ago as 1968, I attempted to assess the subsequent appendicectomy rate for patients admitted with possible appendicitis and discharged without operation(3). 32 of 209 patients (17.5%)had an appendicectomy within 2 years of dicharge (12 having acute appendicitis at operation) and a projection from records of other patients' past histories suggested a further 8% would be likely to have a re-admission and appendicectomy beyond that two year limit. These figures suggest that the contributors' current estimates of a 20% operation rate within a year of conservative treatment is not that far different from what applied nearly half a century ago.
As important is the question of deaths from operative and non-operative approaches. In a further epidemiological study of all 870 deaths from appendicitis or appendicectomy in Scotland between 1954 and 1963(4), I found that 34 of 650 deaths (5%) were in patients whose appendices were possibly or probably normal at operation, but also 21 (3%) deaths in patients who had appendicitis and had previously been treated non-operatively for possible appendicitis. Thus the risks of operating 'unnecessarily' against not operating when it might have been the right option were fairly evenly matched half a century ago and are likely to be more in favour of operation now than then.
In the first of my studies, a strong predictor of a later re-admission and operation was when the patient had been told by a medical attendant that appendicitis was a possible diagnosis. Assuming that that is still the case, the case for prefering the antibiotic approach would need to be stronger than that presented now to seem an attractive option.
references
1. Bakkar OJ. Should conservative treatment of appendicitis be first line? BMJ2012;344:e2546
2. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectoy for treatment of uncomplicated appendicitis: meta-analysis of randomised controlled trials. BMJ2012;344:e2156
3. Howie J G R. The morbidity of non-operative treatment of possible appendicitis. Scot Med J,1968;13:68-71
4. Howie J G R. Death from appendicitis and appendicectomy. Lancet 1966;ii:1344-47
Competing interests: No competing interests
Dear Editor,
I read this article in the printed edition of the BMJ. However, my attention was drawn to the misleading photograph included in the article.
The strapline of the photograph states "Appendicectomy is not without risks". Well neither is examining for hepatojugular reflux when trying to elicit a tender McBurney's point!
Kind regards.
Competing interests: No competing interests
Dear Editor
We read this article with great interest and broadly agree with its sentiment. We would like to highlight, however, that appendicectomies whilst generally safe operations do carry significant risks when they do occur.
One such complication is bleeding from port sites which may or may not be immediately recognised. We came across such a case recently after laparoscopic appendicectomy that was relatively straight forward. After discharge the patient returned with a significant secondary bleed leading to further laparoscopic surgery.
I feel that it is important not to underestimate the significant risks that any operation carries, although we agree with the authors that overall in the case of appendicectomies that surgery will tend to be the first line.
Kind regards
Competing interests: No competing interests
Re: Should conservative treatment of appendicitis be first line?
Sir,
In the editorial and in the research article by Varadhan et. al. there seems to be an implied assumption that there is strict comparability between the surgical and the conservative management of acute appendicitis. Emphasis on imaging based on American practise is biased in favour of CT scanning. Although CT is widely recognised as having an edge over ultrasound, the principal reason for dependence on CT is the lack of expertise in the expertise in the use of ultrasound for the diagnosis of acute appendicitis and its complications.
This is not surprising in view of the limited training of radiologists in bowel related pathology. This in some institutions extends as far as to say that it is of little value if not a waste of time. This attitude spills over on to the clinicians who in turn have little faith in ultrasound and not uncommonly proceed to have the ultrasound findings confirmed with CT.
If valid comparisons are to be made, management of both groups should be as good as achievable. It is therefore encouraging to see that there is potential to improve the outcome in conservative management of appendicitis.
In the analysis of the four randomised control trials Varadhan et. al. found a 63% success rate at one year with antibiotic treatment. However 20% (nine perforated appendicitis and four gangrenous appendicitis) had appendicectomy after readmission.
All these patients were discharged with antibiotics since there was thought to be adequate resolution of the symptoms and signs. In my experience and others I hope would agree, resolution of symptoms does not necessarily imply resolution of the underlying pathology with the distinct possibility of progression to form abscesses or undergo early gangrenous change while symptoms and signs subside. This progression is true of not just of acute appendicitis but would also be applicable to diverticulitis, liver abscesses etc. This is often best recognised with progression of necrosis in liver abscesses. It is therefore entirely possible that these patients who had subsequent appendicectomy may have been discharged with unresolved occult pathology. Pre discharge scan may well have identified these individuals, but would have necessitated additional imaging. If cost efficacy is not the primary objective then further imaging would lead to improved management. The assumption that the antibiotic arm had only uncomplicated acute appendicitis may not be entirely valid.
It is therefore my personal opinion that the encouraging results reported by Varadhan et.al. could only be improved with improved management. This is precisely where ultrasound expertise would make a definite contribution.
Further, good clinical judgment and reliable imaging would be of particular value in avoiding unnecessary appendicectomy. Reliable negative findings with imaging would save unnecessary appendicectomy, identify appendix masses which may be a contraindication for surgery, find other causes such as acute cholecystitis, renal pathology and gynaecological pathology: an aspect which has not received adequate emphasis in the review. It is my opinion that no patient with equivocal signs and symptoms should be subjected to appendicectomy without prior imaging. I am no economist but these reasons would entirely justify the added cost of imaging.
Pain in the RIF with an appendicolith visible on X-ray is highly suggestive (90% probability) of appendicitis. Similarly loss of properitoneal fat line with pain in the RIF is also of great significance. Most of the signs of appendicitis on ultrasound describe appearances in the inflamed appendix. Although the presence of the periappendiceal fluid is well recognised on ultrasound its significance is probably as high as with the appendicolith and the properitoneal fat line. Particularly in the obese individual the inflamed appendix may not be identified but the presence of fluid in the RIF associated with tenderness on probe pressure I believe is highly significant. Fluid is almost always associated with rebound tenderness – a cruel sign! This ultrasound sign does not seem to merit the recognition it deserves. Though often serous in a small but significant number surgical notes record the presence of pus. This raises the importance of definition of uncomplicated appendicitis, since on imaging it is not possible with any degree of certainty to distinguish between serous fluid and pus. Presence of serous fluid may still justify the classification as uncomplicated but it is questionable if it is pus.
I am glad that the BMJ has done a good deed by addressing this controversial subject. I hope it would also bring to the attention of the clinicians the totally incongruous situation of surgeons opposed to even a trial of antibiotics and advocate surgery for acute appendicitis would in the vast majority of instances accept conservative management of acute cholecystitis with a much higher morbidity and mortality. Those who perform cholecystectomy within seventy two hours of presentation do not seem to believe that surgery is any more difficult. Increased risk of damaging the common bile duct (CBD) is probably a myth. Reviewing over seventy patients referred to Lord Rodney Smith at St. Georges Hospital with damaged bile ducts during cholecystectomy I found only one CBD which had been tied during surgery for acute cholecystectomy. The accompanying referral letter not infrequently commented on the cholecystectomy having being performed ‘while I was away’!
The rationale behind the current views on the management of acute appendicitis, diverticulitis and cholecystitis is interesting if not intriguing.
Hence I would conclude Yes, antibiotic treatment of acute appendicitis is justifiable with greater use of imaging.
Competing interests: No competing interests