Appendicitis: Appendectomy or Antibiotics?

Back in the day, in the dark ages of my training, a chance to cut was a chance to cure.  With regards to pathology reports of appendix specimens, if we didn't remove the occasional normal appendix, our clinical acumen was not sensitive enough.  Of course this was also a time when we still routinely performed open laparotomies to gain access to said appendix rather than the more common laparoscopic approach used these days.

So here I am, almost two decades after completion of my training, stumbling across a study published online last week in the British Medical Journal suggesting that antibiotics may be a safe and effective option for those with uncomplicated acute appendicitis.  Apparently the authors arrived at their conclusion after performing a meta-analysis of 4 randomized controlled trials comparing 470 patients who initially received antibiotics only to 430 patients who underwent initial appendectomy.

Patients with complicated appendicitis as determined by presence of gas outside the bowel, fluid around the appendix, and/or widespread fluid in the belly were excluded from the study.  Otherwise, they were included in the study assuming classic history, clinical signs, and elevated inflammatory markers.  Ultrasound was used in one study while abdominal CT scan was used in two others.

The statistical analysis is beyond what I can cover in this post.  Nevertheless, it's interesting to note that close to two-thirds of those initially randomized to antibiotics only did not require surgical intervention within the year and thus were considered a success.  Furthermore, they had a lower risk of complications.  Only 1 in 5 failed antibiotics to such a degree as to require appendectomy.

While this is not conclusive proof that treatment of acute appendicitis has left the operating room and entered the domain of the internist or hospitalist, I'm certain that Dr. Leonid Ivanovich Rogozov would have appreciated the option of oral amoxicillin plus clavulanic acid vs intravenous cefotaxime rather than having to remove his own appendix while stranded in the middle of the Antartic winter 51 years ago this month.

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