Long-term follow-up of antibiotics for appendicitis: Shocking but expected results

After a median follow-up of 7 years, 39% of patients who underwent treatment of uncomplicated acute appendicitis with antibiotics eventually required appendectomy.

This bombshell finding appears in a JAMA Surgery paper by the authors of the Finnish randomized trial of antibiotics vs. appendectomy. Patient satisfaction and retrospective treatment preferences were obtained by telephone interviews from 80% of the 530 patients in the original randomized clinical trial.

Patients who had undergone appendectomy at their first presentation were significantly more satisfied with the treatment than those who were initially treated with antibiotics, P = 0.001. Not surprisingly, a subgroup analysis found those who had antibiotics first and later needed an appendectomy were significantly less satisfied than those successfully treated initially with antibiotics or appendectomy.

Patients were asked if they would have undergone the same or a different treatment. The 39% who required a subsequent appendectomy were more likely to say they would have chosen a different treatment compared to those who had an initial appendectomy and those who had a successful course of antibiotics. The difference was significant, P = 0.001.

Although this paper seems like a testimonial for appendectomy, the authors managed to put a positive spin on antibiotic treatment. In the discussion section of the paper, they said “The fact that 33% of patients who later underwent appendectomy after primary antibiotic treatment would still choose primary antibiotic treatment, accepting the risk of recurrence and potential later appendectomy, illustrates that in some situations, patients accept the risk of recurrence to possibly avoid surgery.”

They cited a prior study showing after the risks and benefits of surgery and antibiotic treatment were explained to a group of medical students, they were more likely to opt for surgery and said their “answers may have been influenced by the manner in which the summary data of each treatment arm were presented.” Another possibility is that medical students were smart enough to make the right choice.

I agree the way evidence is presented is important. Let’s hope the 39% 7-year recurrence rate becomes part of any informed consent discussion of antibiotics vs. appendectomy from this point forward. Do not forget the median follow-up of 7 years means that half of the study cohort has not yet reached that milestone. More late appendectomies are certain to be needed because the risk of recurrent appendicitis is life-long.

To their credit, the authors noted in their initial randomized clinical trial involving these patients, only 5.5% of appendectomies were done laparoscopically. Currently in the United States, laparoscopic appendectomy is performed in more than 90% of uncomplicated appendicitis cases. Patients are usually discharged within 24 hours of surgery, and their smaller incisions, less pain, fewer complications, and shorter recovery times would likely yield much better satisfaction scores than those of the Finnish patients.

The authors wrote “future studies should also be directed at reducing the failure and recurrence rates of antibiotic treatment for appendicitis by identifying potential predictive factors indicating the risk of recurrence.” Since antibiotics fail in 2 of 5 cases, would such studies be ethical?

I can save them the trouble. Treating appendicitis with antibiotics is the number 1 risk factor for needing a subsequent appendectomy.

Skeptical Scalpel is a retired surgeon and was a surgical department chair and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times.For the last 9 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.