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After more than a century of cutting tiny and inflamed organs in people's bowels, doctors have found that surgery may not be necessary after all.
The revelation comes from a large randomized trial in Finland, published on Tuesday, September 25th at JAMA.
Despite the long-standing standard of care, the findings of the study are not entirely surprising; It follows several other randomized trials over the years that have shown that antibiotics alone can treat acute appendicitis. These studies, however, left questions unanswered, especially if antibiotics only temporarily improve the situation and if the initial drug treatments worsened the situation of the patients later on they needed to see the situation. ;a surgical intervention.
New JAMA The study, with its full five-year follow-up, effectively cauterized the remaining problems. Nearly two-thirds of the randomly assigned patients in the study to obtain antibiotics for uncomplicated appendicitis did not require surgery during the follow-up period, report Finnish authors, based on the University of Turku. And the drug-treated patients who ended up having an appendectomy later were no less well off for the delay of the surgery.
"This long-term follow-up supports the feasibility of antibiotic therapy alone as an alternative to surgery for uncomplicated acute appendicitis," the authors conclude.
The discovery suggests that many patients with appendicitis could be spared the risks of surgical procedures, such as infections. They may also be able to save money by not needing such an invasive procedure (although the study did not compare costs), and they could take advantage of the processing times and shorter recovery times. Researchers will need to collect more data to safeguard these benefits.
For their first review of the simpler treatment of appendicitis, researchers led by Paulina Salminen randomly assigned 530 patients who presented to the hospital with uncomplicated acute appendicitis to obtain standard open surgery to remove their organ (By "uncomplicated", the authors mean that there are no other problems such as perforation, abscess or suspicion of a tumor.)
Patients were aged 18 to 60 years and participated in the trial between November 2009 and June 2012. Those who went under the knife stayed in the hospital for three days, while patients treated with antibiotics spent three days in the hospital. days to get intravenous medication, followed by seven days of oral antibiotics outside the hospital.
A couple of patients were lost to follow-up, including one unbound death, leaving 272 patients in the surgical group and 256 in the antibiotic group.
In the antibiotic group, 70 patients were operated on during the first year of treatment. Over the next five years, another 30 were also operated. This left 156 patients treated with antibiotics, about 61%, who were able to escape the scalpel.
Vestigial medicine
The authors believe that this percentage could be even higher in follow-up studies. They note that the decision to undergo surgery after the initial randomization was entirely the responsibility of the patient's surgeons – most of whom were not involved in the trial and some of whom were skeptical about the idea that antibiotics alone could treat appendicitis. This fact, the authors note, could have artificially inflated the number of people who eventually had an appendectomy. They point out that seven of the 100 patients treated with an antibiotic and operated on had no evidence of appendicitis at the time of the operation, based on their medical records.
Yet the use of antibiotics initially meant fewer complications and faster recoveries in general. The antibiotic group had a complication rate of 6.5%, while the surgeon group had a rate of 24%, mainly due to infections. Of the 100 patients treated with antibiotics who underwent surgery, they had typical complication rates of the procedure. This suggests that delaying surgery for this group did not lead to other problems.
Complications or not, the group of antibiotics in general took 11 days of sick leave on average to recover, while the surgery group took 22 days.
There have been a few catches in the study that warrant follow-up. One of the big problems is that the study compared antibiotic treatment with open standard surgery, and not more modern minimally invasive laparoscopic surgery, which is now common in the United States. Had this been the standard of care in the surgical group for this study, it could have altered the cost-benefit scales, potentially reducing complication rates and recovery times.
That said, the authors note that antibiotic treatment was also heavy in the study. The researchers followed intravenous "conservative" treatment for three days followed by oral antibiotics, which could be excessive. They did it because[w]When this protocol was designed, there was little information available to guide the application of antibiotic therapy for appendicitis, they note. Future studies may find that shorter and less intense antibiotic treatments may also be of concern, further reducing complication rates and duration of treatment.
Finally, the study did not compare the costs of interventions or the bills that would have been incurred by the two treatment groups. This will be another issue to be addressed in follow-up studies, as doctors refine the best way to treat appendicitis after all these years.
JAMA, 2018. DOI: 10.1001 / jama.2018.13201 (About DOIs).
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