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Antibiotics Instead Of Surgery For Appendicitis? I'm Still Not Convinced

Mon, 05/05/2014 - 9:10am
Skeptical Scalpel

Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery.

The first paper is a prospective observational study from Italy involving 159 patients over the age of 14 who were thought to have uncomplicated appendicitis. Nonoperative management with oral antibiotics was planned for all of the patients.

Nonoperative management failed within 7 days in 19 (11.9 percent) patients, all of whom underwent immediate surgery. Appendicitis was found in 17 patients, and 2 had tubo-ovarian abscesses

The abstract says "After 2 years, the overall recurrence rate was 13.8 percent (22/159)." This is blatantly misleading. The overall recurrence rate was 19 recurrences within 7 days plus 22 more recurrences between 7 days and 2 years for a total of 41 (25.8%) recurrences with 27/159 (17%) of the patients requiring surgery.

If you look at this paper more carefully, you will find the following from Table 3:
US done 116 (73%)
US positive 88 (76%)
CT scan done 27 (17%)
CT scan positive 21 (78%)
Clinical diagnosis only of acute appendicitis 16 (10%)

The authors do not explain why patients with negative ultrasounds and CT scans were included in the cohort of nonoperatively treated patients with appendicitis. If they were going to disregard the results of the imaging studies, they shouldn't have done them in the first place.

If you add the 16 patients with clinical diagnoses only, the 28 with negative ultrasounds and the 6 with negative CT scans, a total of 50 (31%) of the patients may not have even had appendicitis. These patients would have gotten better no matter how they were treated.

The second study, from Ohio State University, was a prospective nonrandomized trial of nonoperative management with antibiotics vs. surgery in children with uncomplicated appendicitis. Patients were allocated to each group according to the preference of the parents.

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