Appendicectomy should still be the gold standard for treatment of acute appendicitis
Simon Ulyett1, Henry Hoffmann1, Sukphal Singh1
1 Frimley Park Hospital, Department of General Surgery, Frimley, Surrey, GU16 7UJ
We read with interest the meta-analysis by Varadhan (1) which concludes antibiotics can be safely used as a primary treatment in acute, uncomplicated appendicitis. However, we would challenge their conclusion for the following reasons.
Firstly, we consider the original studies to be weak. Eriksson, et al. (2) excluded patients with increased abdominal pain or signs of generalised peritonism from their statistical analysis, violating the principle of analysing the results on the intention to treat. Selection bias occurred in the trial by Styrud, et al. (3) for three reasons: women were excluded. Two hundred and twenty five patients were recruited from six centres over 39 months (an average of only 1 patient/centre/month), as a comparison Frimley Park Hospital serving a population of 400,000 performed 51 appendicectomies in the month of April 2012. The researchers quote an unusually high appendicitis rate of 97% at histology in the appendicectomy arm, suggesting many patients with less typical presentations may have been excluded.
We would also like to highlight that in the paper by Vons (4) the diagnosis of uncomplicated appendicitis was based on CT. This group reported a four-fold increase in the rate of peritonitis in the antibiotic arm compared to appendicectomy. As a consequence Vons et al. concluded that appendicectomy remains the gold standard for treatment. As cited in this article a recent Cochrane meta-analysis in 2011 (5) including 901 patients failed to draw any clear conclusions comparing appendicectomy vs. antibiotic treatment and had an antibiotic treatment failure rate of 26.6% at 2 weeks.
At a time when the NHS financial burden is increasing we would dispute Varadhan’s assertion (1) that comparing efficacies of antibiotic therapy and surgery is inappropriate. We would like to emphasise that primary treatment with antibiotics is very resource intense. Patients require regular re-assessment and may require further imaging and laboratory tests. Furthermore, antibiotic treatment will fail in 24-59% of patients at one year (3,6), most of the time resulting in an appendicectomy.
GPs are currently being encouraged to management more patients in the community possibly to reduce costs. We are, therefore, concerned this paper would encourage community treatment of suspected appendicitis. We strongly feel this would be inappropriate. Appendicitis is a very common, acute abdominal disease, which we feel it is best assessed and treated by surgeons in a secondary centre.Although, the natural history of appendicitis is vague several studies have demonstrated a clear correlation between delayed hospital admission and perforation (7,8). Therefore, delayed referral by GPs due to antibiotic failure or missed diagnosis may lead to increased numbers of complicated appendicitis.
Despite the “robust methodology” of this study it is disadvantaged by the low quality of the included studies. For this and all the other reasons given above we conclude that a patient suspected of acute appendicitis should be referred to hospital for urgent assessment. Based on recent data antibiotics may be used as a bridge to surgery, but appendicectomy should still be considered the gold standard.
References:
1. 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. BMJ. 2012;2156:1–15.
2. Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg. 1995 Feb [cited 2012 May 25];82(2):166–9.
3. Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, et al. Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial. World J Surg. 2006 Jun [cited 2012 Mar 29];30(6):1033–7.
4. Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet. 2011;377(9777):1573–9.
5. Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Db Syst Rev. 2011;11(11):CD008359.
6. Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg. 2009;96(5):473–81.
7. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Annals of surgery. 1995;221(3):278–81.
8. Hansson L-E, Laurell H, Gunnarsson U. Impact of time in the development of acute appendicitis. Dig Surg. 2008;25(5):394–9.