Hold that knife

Study says 63 per cent appendicitis patients do not need surgery

The conventional wisdom that an infected appendix must necessarily be excised has been challenged in an article in the British Medical Journal. Researchers analysed results of four different trials to conclude that 63 per cent patients of uncomplicated acute appendicitis respond to treatment with antibiotics and do not need surgery. This,the article says,is contrary to the medical outlook for the disease since it was first reported in 1889 and has always been thought to progress to a more complicated perforated appendicitis without surgery.

Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment,430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63 per cent (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31 per cent for antibiotic treatment compared with appendicectomy, the study reported. About 20 per cent of patients who were treated with antibiotics had appendicectomy for recurrence of symptoms,and of these only about one in five had complicated appendicitis.

Doctors in New Delhi say the findings are at par with what they have themselves seen in their practice but the myth of surgery for appendicitis may have got to do with vested interests rather than any actual medical evidence. One of the four studies did not include any women which the authors reported as a possible confounder of the results. Another interesting observation was the extra low rate of perforation after acute appendicitis (at 8 per cent,it was below the reported 15-25 per cent).

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The findings,researchers concluded have significant health policy implications. Appendicectomy is one of the most common operations performed,and small increases in health benefit in the management of acute appendicitis deliver considerable health gains. Antibiotic treatment as the initial management of uncomplicated appendicitis is safe and effective. Starting antibiotics when the diagnosis of uncomplicated acute appendicitis is made,with reassessment of the patient,will prevent the need for the most appendectomies,reducing patient morbidity, it said.

Dr S P Byotra,senior consultant,medicine at Sir Ganga Ram Hospital says it is standard practice to start off by treating an acute appendicitis patient with antibiotics and advise surgery only if she does not respond. About 70-80 per cent of our patients get cured by medicines alone and it is not correct to assume that surgery is the only option. The study reinforces that.

However senior doctors in the government setup,speaking on condition of anonymity,say that the myth of surgery being the sole treatment for appendicitis has in many ways been perpetrated by private hospitals for whom it makes much more financial sense to get a patient into the OT rather than keeping them under conservative management.

Unlike in the government where the load is so high that only people who really need surgery are operated upon,there is a higher inclination among private doctors to fast forward the surgery option. It has got nothing to do with knowledge. To that extent,the study does not say anything new, said a senior doctor at Safdarjung Hospital.

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