Long-term outcomes for non-surgical treatment of appendicitis found to be positive.

Long-term outcomes for non-surgical treatment of appendicitis found to be positive.

Antibiotics may be a viable alternative to surgery for appendicitis, study finds

Most people with appendicitis who receive antibiotics as treatment rather than surgery have positive long-term outcomes, according to new research conducted in Sweden. The study tracked patient outcomes for approximately two decades, revealing that fewer than half of those who were initially treated with antibiotics experienced another attack or required additional appendix-related surgery.

Previously, appendicitis was often fatal before the advent of surgical advances, which allowed for safe removal of the appendix. However, with a greater understanding of bacteria in the gut, including the appendix, researchers are now exploring the potential long-term advantages of retaining the organ. Additionally, some individuals may prefer alternative treatments due to fear of surgery or the potential recurrence of appendicitis.

The use of antibiotics as an alternative treatment for appendicitis first emerged in the 1990s, with earlier studies primarily analyzing short-term outcomes spanning five years or less. To gain insight into the long-term effects of antibiotic treatment, the researchers followed nearly 300 Swedish appendicitis patients, with data available for up to 26 years after treatment. Approximately 260 patients were included in the analysis, half of whom underwent surgery and the other half received antibiotic treatment alone.

The results showed that 10% of the individuals treated solely with antibiotics sought outpatient care for abdominal pain during the study timeframe, compared to only one patient in the surgery group. Additionally, 15% of the antibiotic-only group required an appendectomy while still hospitalized, and nearly 30% underwent the procedure later on. Despite these figures, approximately 60% of the patients treated with antibiotics in the 1990s did not require an appendectomy, and they did not face a higher risk of developing inflammatory bowel disease compared to the surgery group.

Simon Eaton, the study’s lead author and a senior lecturer in pediatric surgery and metabolic biochemistry at University College London’s Great Ormond Street Institute of Child Health, emphasized that both surgical and non-operative approaches have their merits. Providing patients with the option to choose their preferred treatment strategy based on individual considerations can improve decision-making.

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Dr. Paulina Salminen, a professor of surgery at the University of Turku in Finland, highlighted the distinction between mild and complicated cases of appendicitis. The study primarily focused on mild cases, where surgical intervention may not be necessary and patients could experience spontaneous resolution, avoiding unnecessary surgery and reducing healthcare costs.

Although the positive outcomes of antibiotic-only treatment are not surprising for Salminen, the research further confirms the strong evidence supporting non-surgical approaches for uncomplicated acute appendicitis. Dr. Salomone Di Saverio, a consultant surgeon with Cambridge Colorectal Unit at Cambridge University Hospitals NHS Foundation Trust’s Addenbrooke’s Hospital, added that this finding can be particularly beneficial for older patients with comorbidities who may face higher risks associated with surgery.

On the other hand, Dr. Philip Barie, a professor emeritus of surgery and public health at Weill Cornell Medicine in New York City, expressed a more reserved perspective on the study’s findings. Highlighting the small pool of patients analyzed, Barie suggested that individuals treated non-surgically may require urgent evaluations of acute abdominal pain later in life. For the first five years, the risk of future surgery remains at approximately 40% for patients who choose not to undergo an initial appendectomy.

While surgery is still considered the preferred treatment for appendicitis due to its curative nature, low risk of complications, and cost-effectiveness, the research provides valuable evidence supporting antibiotic treatment for specific patients and circumstances. The ability to choose between surgical and non-operative treatments based on individual preferences and medical considerations allows for more personalized and informed decision-making.

The study was published in JAMA Surgery on August 9, 2023.

Key Points:

• Antibiotic treatment has shown positive long-term outcomes for appendicitis patients compared to surgery.
• Long-term use of antibiotics may have advantages in retaining the appendix, although the standard of care remains surgical removal.
• Patient preferences and individual circumstances should play a role in determining the appropriate treatment strategy.
• For uncomplicated acute appendicitis, antibiotic treatment can provide feasible and safe long-term results, reducing the need for surgery.
• Older patients or individuals with comorbidities might benefit from antibiotic treatment, avoiding the risks associated with surgery.
• Patients who opt for non-operative treatment should be aware of the potential need for further evaluations and subsequent surgery in the future.

For further information about appendicitis, visit the U.S. National Institute of Diabetes and Digestive and Kidney Diseases.

Sources: – Simon Eaton, senior lecturer, pediatric surgery and metabolic biochemistry, University College London’s Great Ormond Street Institute of Child Health, United Kingdom – Paulina Salminen, professor, surgery, University of Turku, Finland – Salomone Di Saverio, MD, consultant surgeon, Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust’s Addenbrooke’s Hospital, Cambridge, U.K. – Philip Barie, MD, professor emeritus, surgery and of public health in medicine, Weill Cornell Medicine, New York City – JAMA Surgery, Aug. 9, 2023