Antibiotics Could Avert Surgery in Uncomplicated Appendicitis

Patients were randomly assigned to standard open appendectomy or to an antibiotic regimen that involved intravenous ertapenem for three days, followed by seven days of oral levofloxacin and metronidazole. End points were surgical success or hospital discharge without the need for surgery, and no recurrent appendicitis during the follow-up period.

The results showed that of the 273 patients in the surgical group, all but one underwent successful appendectomy, resulting in a success rate of 99.6%. Of the 256 patients available for follow-up in the antibiotic group, 72.7% did not require subsequent surgery. Of those that did require surgery, 82.9% had uncomplicated appendicitis, 10% had complicated acute appendicitis, and 7.1% did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy. The study was published on June 16, 2015, in the Journal of the American Medical Association (JAMA).

“For more than a century, appendectomy has been the standard treatment; but about 80% of patients with an inflamed appendix don't need to have their appendix surgically removed, and those who ultimately do need the surgery aren't hurt by waiting,” said lead author Paulina Salminen, MD, PhD, of Turku University Hospital. “Now we know that only a small proportion of appendicitis patients need an emergency operation.”

“It's kind of lost to history why people started doing appendectomies, but it has become so routine that when someone comes in with appendicitis they get whisked into the operating room. However, a lot has changed in 130 years, for example the ability to diagnose appendicitis; it's almost perfect with CT scans,” said Edward Livingston, MD, coauthor of an accompanying editorial and deputy editor of JAMA. “I am a surgeon and I hope to get through life without ever having an operation. So if I were given the option of taking antibiotics and not have surgery, I would take antibiotics in a heartbeat.”

Appendectomy is the surgical removal of the vermiform appendix. The procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation.

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