After 10 years, more than half still did not need an appendectomy, new data shows
More than half of people who receive antibiotics to treat appendicitis do not see their disease return 10 years after the initial illness, new study finds. The data comes from one of the first clinical trials of the approach and reinforces recently updated guidelines for the treatment of appendicitis.
A quarter of a million people in the United States suffer from appendicitis each year, when a blockage or infection inflames the appendix. For more than a century, doctors treating appendicitis have typically removed the organ, lest it rupture and cause a serious infection. But over the past decade, trials of antibiotics have shown that appendicitis often resolves without surgery.
In 2009, Finnish researchers launched the Appendicitis Acuta trial, treat 530 adults with appendicitis with appendectomy or antibiotics. All patients were diagnosed with uncomplicated appendicitis, where the appendix is inflamed but has not ruptured or developed infected pockets.
After 10 years, the team was able to contact 224 out of 257 people who had received antibiotics and 219 out of 273 people who had had an appendectomy. For those they couldn’t reach, they looked at medical records for results. In total, 112 patients who received antibiotics ended up having an appendectomy – 70 patients in the first year, 30 people between two and five years later, and 12 people between six and 10 years later, the researchers reported on January 21. JAMA.
The study protocol called for an appendectomy for anyone suspected of recurrence. So it’s possible that some of these additional surgeries weren’t necessary, says lead researcher Paulina Salminen, a surgeon at Turku University Hospital in Finland.
Two of the patients treated with antibiotics reported new complications between five and ten years, both related to subsequent appendectomy; two people in the appendectomy group reported new numbness or scar pain. “You don’t have to operate,” says Salminen. “The majority can be treated without an appendectomy, and it is safe for patients” in the long term.
In addition to helping patients avoid surgery, antibiotic treatment could save money by using hospital resources more efficiently and helping patients avoid sick leave, Salminen says. Between 60 and 70 percent of people with acute appendicitis have a simple form, making them eligible for antibiotics, she estimates.
The results confirm that antibiotics are a reasonable treatment, says David Flum, a surgeon at the University of Washington in Seattle. Flum is an investigator for the Comparative Outcomes of Antibiotics and Appendectomy Trial, or CODA, a U.S.-based trial modeled after the Finnish study.
The latest results are “just a little bit more reassuring for people who want to go down the antibiotic route, because it’s not inevitable that they’ll have their appendix removed,” he says. “It’s important.”
Approximately 40% of CODA participants who received antibiotics had an appendectomy within a year, which increased to 49 percent within four years.
The evidence collectively shows that treatment decisions should be made based on the patient’s needs and priorities, he says. “There is no right answer here.”
Flum has developed an online tool to help patients learn about treatment options and inform their decisions during discussions with their doctors. Initially, 55 percent of the 8,243 patients who accessed the site were undecided between antibiotics and surgery. Using the site reduced this indecision to 49 percent. An analysis of 356 participants who went through the decision-making process showed that more than 90 percent felt comfortable with his choice. “It didn’t freak people out,” Flum says.
Both Flum and Salminen are part of a committee that announced the updated guidelines to treat appendicitis on January 28 at JAMA Surgery. Previous versions recommended antibiotics as a possible treatment. New to the guidelines is a recommendation to use shared decision-making, such as the tool created by Flum, to develop a treatment plan with patients.
For Salminen, even this change is not the final step. It’s possible that appendicitis will resolve without treatment, she says. She is currently recruiting patients for a clinical trial comparing antibiotics and a placebo.
“You have to be able to think outside the box,” she says. “‘We’ve always done this’ is not a good justification for doing something.”
