Appendectomy versus antibiotic treatment in treating appendicitis – a randomized control trial

Introduction – For years, appendectomy was the treatment of choice for treating appendicitis. In recent years many studies were published, offering only antibiotic treatment as an alternative and conservative treatment option in these cases. Still, many adults (and children) go through appendectomy when being treated for appendicitis.

The purpose of this study was to examine if one method has superiority on the other, even in cases that have been excluded in previous studies.

Methods – Adults only, with imaging based diagnosis of appendicitis (mostly CT scan). Patients with recurrent events, an abdominal infection (such as abscess, perforation of the appendix), malignancy or in a state of shock were excluded from this study. In this study, as opposed to other studies, patients with appendicolith were included. Appendicolith is a very solid stool which obstructs passage in the appendix. In past studies it was stated as a reason for surgical intervention.

Randomization was done between individuals who were willing to participate in this study. Those who were assigned to the antibiotic group, were given IV antibiotics for 24 hours at least, and overall received 10 days of antibiotic treatment (IV antibiotics and then an oral antibiotic course).

Those who went through surgery, could have been operated in an open or laparoscopic surgery.

What data was collected? Numerous objective and subjective data after 1 week, 1 month, and 3 months from the intervention. And of course, rate of complications, amount of work days lost, and more.

Results – 1552 patients went through randomization, 776 patients in each group. The two groups were identical in demographic characters. An important note – 27% of the study’s population was diagnosed with appendicolith.

The antibiotic group – about half received IV antibiotic during the first 24 hours in the ER, the other half was hospitalized.

The surgery group – about 95% were hospitalized, most of them went through laparoscopic surgery (96%).

Though there was need for hospitalization, the time for discharge from the hospital was similar in both groups, regardless if the patient was operated – 1.3 days of hospitalization.

According to the authors, supposedly, after a month there was no superiority for one method over the other in terms of quality of life and in other symptoms (such as fever and pain). But – there were some important differences between the two groups.

In the antibiotic groups only 11% received an additional antibiotic course in the 3 months following the intervention. Moreover – patients in the antibiotic groups eventually had an appendectomy, in the following rates: 11% in two days time, 20% within a month, and 29% within 3 months (41% had appendicolith and 25% did not). In addition, patients in the antibiotic groups only visited the clinic after the intervention in the rate of 9% as opposed to 4% in the surgery group. Re-hospitalization due to complications (which eventually led to appendectomy), was 24% of the cases in the antibiotic group, while only 5% in the surgery group.

Days of work lose – a significant advantage to the antibiotic groups, with only 5.3 days compared with 8.7 days in the surgery group.

Complications – more in the antibiotic group (mostly in the appendicolith group). The antibiotic group needed drainage of an infectious complication, and had more side effects related to the prolonged antibiotic treatment.

Discussion – Depending on our perspective.

On one hand, many patients were treated conservatively (antibiotic only) and after a week or 30 days enjoyed this option tremendously, with no difference from the surgery group. In fact, it was exactly 7 out of every 10 patients being treated in this manner.

On the other hand, a very high percentage of patients (too high in my opinion), from the antibiotic group eventually went through appendectomy, and more importantly – complications.