Appendicitis 1889 to 2012: What, No Surgery?

All medical students learn about McBurney’s point—that’s the spot, named for McBurney, in the right lower quadrant of the abdomen where classical appendicitis pain finally localizes.[1] If the patient’s history fits the classic history of appendicitis with vague abdominal pain eventually localizing to McBurney’s point, the norm has been—at least in the U.S. —to take the appendix out. However, as pointed out in a new systematic review done as a meta-analysis, starting in the late 1950s there were reports of success in treating appendicitis with conservative therapy (antibiotics) and good outcomes without resorting to appendectomy.[2]

This systematic review presents a review of our traditions and lack of conclusive evidence about best practices in managing appendicitis and suggests that, for many patients, avoiding appendectomy may be a reasonable option. The current meta-analysis of four selected randomized controlled trials from 59 eligible trials with a total of 900 patients, reported a relative risk reduction for complications (perforation, peritonitis, wound infection) from appendicitis of 31% for antibiotic treatment compared with appendectomy (risk ratio 0.69 (95% confidence interval 0.54 to 0.89); I2=0%; P=0.004). There were no significant differences between antibiotic treatment and appendectomy for length of hospital stay, efficacy of treatment, or risk of complicated appendicitis.

The biggest problem in this meta-analysis is that the results are based on trials with significant threats to validity. Randomization sequence was computer generated in one trial, by “external randomization” in one trial, by date of birth in one trial and unclear in one trial. Concealment of allocation was by sealed envelopes in two trials and not reported in the other two trials. All trials were unblinded. Withdrawal rates are unclear. Therefore, it is uncertain how much the results of this meta-analysis may have been distorted by bias. In addition, as pointed out by an editorialist, in patients who have persistent problems despite antibiotic treatment, delayed appendectomy might be necessary.[3] Delayed appendectomy has been associated with a high complication rate. Also, if a patient develops an inflammatory phlegmon—a palpable mass at clinical examination or an inflammatory mass or abscess at imaging or at surgical exploration—appendectomy sometimes has to be converted to an ileocecal resection—a much more involved operation. Another important issue with 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 the recurrences, 20% of patients presented with a perforated or gangrenous appendicitis. The editorialist questions whether a failure rate of 20% within one year is acceptable.

These four trials and this meta-analysis suggest that antibiotics may be safe for some patients with uncomplicated appendicitis. If this option is considered, we believe detailed information about the uncertainties regarding benefits and risks should be made known to patients. Details are available at http://www.bmj.com/content/344/bmj.e2156

References

1. Thomas CG Jr. Experiences with Early Operative Interference in Cases of Disease of the Vermiform Appendix by Charles McBurney, M.D., Visiting Surgeon to the Roosevelt Hospital, New York City. Rev Surg. 1969 May-Jun;26(3):153-66. PubMed PMID: 4893208.

2. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ. 2012 Apr 5;344:e2156. doi: 10.1136/bmj.e2156. PubMed PMID: 22491789.

3. BMJ 2012;344:e2546 (Published 5 April 2012).