Doctors have been performing appendectomies to treat appendicitis since the 1880s. Basically, as soon as general anesthesia and infection control had caught on enough that surgery was not an inherent last resort, a pathologist figured out that many or even most of the deaths from “typhlitis” and “perityphlitis” could be prevented with the surgical removal of the appendix. There have been a few developments over the years, like in 1981 someone pioneered a laparoscopic version, but overall, “if it’s inflamed, take it out” has been the approach for around 130 years.
I’ve wondered for a long time (actually, since having my own appendix out at 15) why we don’t treat appendicitis with antibiotics, like we do for most other infections. In part it’s because we can get by so easily without an appendix (unlike our kidneys, for instance) and in part it’s because a ruptured appendix can be so serious. But in part, it may be habit.
There was a study done in Finland that was published in the JAMA earlier this year where they tested antibiotic treatment for uncomplicated appendicitis. (It’s “uncomplicated” if nothing’s ruptured.) They randomly assigned study participants to surgical and non-surgical treatment. Those in the “appendectomy” group got an open (non-laparoscopic) appendectomy; those in the antibiotic group got three days of IV antibiotics in a hospital setting. Of the patients in the antibiotics group, about 25% had to have their appendix out anyway — either at the time, or within a year. But almost 75% recovered with no further incident and no surgery.
And, this wasn’t the first study that had these results. A Swedish study in 2006 showed something similar. As did a 2011 meta-analysis. All of these studies showed that if you treat with antibiotics, some patients will still need surgery. None of them found any increased risks to waiting — the number of patients who suffered a rupture was about the same. There was even a group back in the 1950s1 that had appendicitis treated, successfully, with antibiotics — down the memory hole they went, and surgery remains the standard.
The New York Times article quoted the JAMA editorial that ran along with the study:
“The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis,” wrote Edward H. Livingston, the executive editor of the journal.
The NYT then called up a working surgeon at a nearby medical school for a counterpoint view.
Dr. Philip S. Barie, a surgeon at Weill Cornell Medical College, noted that antibiotics were not sufficient for more than a quarter of the patients in the new study and said the failure rate was unacceptable. Patients should have the simple and safe operation to remove their appendix, he said, taking care of the problem quickly and permanently.
I have to say, I’m not sure I’d have asked a surgeon for his opinion on the value of a surgical procedure if I wanted an unbiased view. If the “failure rate” here were leading to significant complications, I’d be right there with him that 25% is way too many, but what it’s leading to is the surgery that they’d have otherwise gotten by default.
It’s worth noting, from the American perspective, that their antibiotic alternative avoided the costs of surgery but not the costs of hospitalization. A new U.S. clinical trial that is in the planning stages is going to use a one-day infusion or a single injection, followed by oral antibiotics, rather than hospitalizing patients for IV antibiotics. They’re also looking at the question of whether patients treated with antibiotics later rush to the ER for a CT scan for every gastric upset, since that will cancel out the cost savings of avoiding surgery rather quickly.2
Appendectomies are reasonably safe surgeries, with quick recovery times, but they are still surgeries. When I had my appendix out in 1989, I was delighted to be excused from an entirely month of gym class, but less happy about how much it hurt to laugh. There are people who have complications — infections, bleeding, adhesions. A study done by the VA found a 1.8% mortality rate in the 30 days following an appendectomy, which seems truly shockingly high even with the caveat that many of these deaths had absolutely nothing to do with the appendicitis.
The “give antibiotics, operate if necessary” approach is bog standard for diverticulitis and any number of other serious illnesses. Given the studies so far, I think eventually we’ll get there for appendicitis. The main question is…when?
[Post image via Shutterstock]