Acute Appendicitis: No More a Synonym for Appendicectomy?
Acute appendicitis is the most common cause of acute abdomen requiring surgical intervention. It occurs in 7% of population and around 250,000 cases of acute appendicitis are reported in the United States, each year. This figure represents around 1 million patient-days of admission.
Whenever we talk about acute appendicitis, the next word that comes into our mind is appendicectomy. Well, there is no question about this fact that appendicectomy is the universally accepted procedure for appendicitis and the only curative treatment. That well explains more than 300,000 cases of appendicectomy performed each year in the United States alone.
But is there any alternative option? The answer to this question has been a subject to great debate. But recent studies have shown that there might be an alternative option for the management of appendicitis. This option doesn’t mean a different incision, or a faster procedure, or a more cosmetically acceptable one, but it means non-operative management, or in other words, medical management of acute appendicitis.
The role of antibiotics to treat acute appendicitis as a bridge to surgery is not a novel concept but has been attempted and described decades ago . In 1959, Coldrey treated 471 patients with acute appendicitis non-surgically with antibiotics and concluded in his series that parenteral antibiotics alone are sufficient for the treatment of acute appendicitis. He showed that the rate of recurrence among these patients was less than 20% and rate of interval-appendicectomy was less than 16%. Adams ML showed two decades ago that patients suffering from appendicitis in remote environment where access to immediate surgical intervention is not possible can be treated using antibiotics that cover both aerobes and anaerobes. This protocol may result in complete resolution of symptoms allowing the patient to have elective appendicectomy or when they have recurrence.
Although controversial some authorities have suggested that acute appendicitis can be treated by antibiotics alone.
To further support the role of antibiotics, S. Eriksson in a randomized control trial published in British Journal of Surgery showed that antibiotics were as effective as surgery in the management of acute event without perforation, although the rate of recurrence was higher in the former group.
A recent meta-analysis published in BMJ also concluded that uncomplicated acute appendicitis can be treated with proper antibiotics without the need of appendicectomy.
it was surprising to see that there was no difference between antibiotic management of uncomplicated appendicitis and appendicectomy in terms of complications, pain control or duration of sick leave. Many surgeons believe that if the inflamed appendix is not removed surgically it may progress to perforated appendicitis causing peritonitis. However, this was disproved by a research article published in British Medical Journal in 2012 that showed significant reduction in risk of complications including peritonitis with antibiotic treatment compared with appendicectomy.
We can conclude that although appendicectomy is considered the definitive treatment of appendicitis and is popular among surgeons, but the importance of antibiotics should not be overlooked. Appendicectomy is not a benign procedure and is associated with many complications. Therefore, comparison between the two should not be made on the basis of tradition, but on scientific evidence. And from the recent meta-analysis in BMJ, we now have the evidence that antibiotics are both safe and effective treatment option for patients with acute uncomplicated appendicitis.
About the author: Irfan Masood graduated from Dow Medical College in 2011. He has a commendable academic record and is an author of several books. He aspires to become a Surgical Oncologist in future.
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