You operate on appendicitis, right? Right?!

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If Grey’s Anatomy has taught us anything, it’s that you have to operate on appendicitis. This fact is imbued in the cultural zeitgeist - it’s the first book of the Madeline series for crying out loud. But paradigms, even one as inertial as this one, can shift.

Appearing in the Journal of the American Medical Association, a clinical trial attempted to show that, for appendicitis, antibiotic treatment alone may be no worse than a surgical approach.

Finnish researchers, led by Paulina Salminen, took 530 individuals with uncomplicated appendicitis (no perforation or appendicolith, basically), and randomized them to go to the operating room, or to get antibiotics instead: 3 doses of ertapenem (a broad-spectrum, IV antibiotic) followed by a week of oral levofloxacin and flagyl.  After about a year of follow-up, the big question was how many people in the antibiotic group would have had to undergo surgery.

Of the 257 patients in the antibiotic group, 15 got operated on during the initial hospital stay. Another 40 would be operated on within the following year, a total of roughly 27% of the group.  This missed the pre-specified non-inferiority target, but there are still some interesting numbers to look at.

First of all, let’s consider why there was a surgical group at all. The only reason, really, is to look at the complication rate so we can see what antibiotics might help us avoid.  Of the 273 people in the surgical group, 20% had complications, about half of which were surgical site infections and the remainder were due to pain and abdominal complications. Surgery has risk - and avoiding those risks, even in just 73% of cases, might be worthwhile.

But major caveat here: Almost all of these appendectomies were performed using an open technique, not laparoscopically. This is sort of crazy.  Laparoscopic appendectomies lead to fewer infections, fewer abdominal complications, and a shorter length of stay. In speaking with some surgeons, I was told that the only reason they’d consider an open technique is for cases of complicated appendicitis, cases which were specifically excluded from this trial.

The authors write that they encouraged open appendectomies since resource-poor areas of the world might not have laparoscopic equipment, but this really ends up stacking the deck against surgery. If I were given the choice of a quick laparoscopic appendectomy with guaranteed results versus a 25% recurrence rate with antibiotics, I might take the surgery.  But if my only choice was open surgery - with a risk of adhesions, obstruction, infection - well, antibiotics might just make the cut.