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YES – Surgery remains the best option for acute appendicitis
The vast majority of surgeons the world over use operative therapy as the prime mode of treatment for appendicitis. As Dr. Liu argues below, acute appendicitis can be treated successfully nonoperatively with antibiotics. That it can be done so successfully does not mean that this is the correct or best way to treat this disease, however. Appendicitis is a spectrum disease: It can present anywhere from simple and uncomplicated, to retrocecal, to perforated with abscess, and even with free perforation with diffuse purulence and generalized peritonitis.
There continues to be a small, but definite mortality due to appendicitis, mostly in cases of delayed diagnosis, as well as very significant morbidity. In the pediatric population, perforation of the appendix, which usually occurs 36-72 hours after symptoms begin, has a postoperative abscess rate requiring further therapy (drainage and/or further antibiotic treatment) in excess of 15% (Ann. Surg. 2012;256:581-5).
One of the arguments for nonoperative treatment of appendicitis is that the appendix is simply another diverticulum of the colon, and acute diverticulitis can frequently be treated successfully with antibiotics, leaving operative treatment to be delayed for subsequent bouts or for complications of the disease. However, the appendix differs from many colonic diverticula in that it frequently lies free in the abdomen whereas many colonic diverticula are surrounded by mesentery. Thus, perforation of a colonic diverticulum is immediately contained, whereas the appendix often perforates freely into the abdomen, leading to widespread contamination. The result is generalized sepsis versus controlled, localized sepsis that may be treated successfully with powerful antibiotics.
In the case of simple, controlled appendicitis, an argument can certainly be made for early treatment with antibiotics and careful clinical follow-up. Undoubtedly, many of these patients will improve. However, the difficulty lies in diagnosing the simple case without knowing who is going to progress to complication, especially in the pediatric age group. Prompt, not emergent, operation when the diagnosis is made is probably the more prudent course.
Finally, a few brief words should be said about laparoscopic treatment of acute appendicitis as well as drainage of well-established abscesses followed by interval appendectomy. There is little question now that laparoscopic appendectomy treats the disease as well as or better than open operation, even in cases of perforation. A low incidence of complications secondary to laparoscopy notwithstanding, this approach leads to shorter hospitalizations and faster recovery, and compares favorably with nonoperative treatment. This is a clear improvement in care over the past 20 years.
There are cases, however, where a well-established abscess exists. Immediate open operation in these cases can make a stable patient extremely septic. Such cases are probably better managed with percutaneous abscess drainage (a necessity) followed a number of weeks later by interval appendectomy (which some may consider elective). Not removing the appendix later in these cases creates some risk for recurrent appendicitis, however.
Thus, despite data that would argue for a nonoperative approach to acute appendicitis, this author firmly believes that the overwhelming long-term experience favors operative treatment of acute appendicitis once the diagnosis is made. Treatment algorithms for timing of surgery and duration of perioperative antibiotics continue to be the topic of much clinical research. However, the basic principle of operative treatment remains the safest and most expeditious approach for patients. This, after all, should be the surgeon’s goal.
Dr. Lund is an ACS Fellow and surgeon-in-chief, Phoenix Children’s Hospital, and professor of child health and surgery at the University of Arizona College of Medicine–Phoenix.
NO – There is a strong case for antibiotics to treat acute appendicitis
Most surgeons who treat acute appendicitis have had to resort to antibiotic treatment occasionally, either because of significant patient comorbidities or due to the presence of phlegmon/abscess. The first time I did so was nearly 10 years ago in a 70-year-old man with severe COPD, whose surgical mortality was estimated to be greater than 50% by my medical colleagues. After some discussion, the patient elected to try antibiotics, while I stood ready to operate at the first sign of trouble. Within 48 hours, his symptoms resolved, his laboratory findings normalized, and he was headed home.
Despite similar experiences, treating appendicitis with antibiotics has been controversial. Appendectomy has been the treatment since Fitz advocated it in 1886 and Wangensteen proposed obstruction as the cause in 1940. Wangensteen observed histological changes consistent with appendicitis in 5 out of 22 ligated appendices brought out through abdominal incisions in patients undergoing colostomy operations (Ann. Surg. 1939;110:629-47). He later concluded that "obstruction of the lumen, if maintained for a sufficient number of hours, would result in acute gangrenous appendicitis with rupture" (Surg. Gynecol. Obstet. 1940;70:799-808). Since then, generations have accepted this without question, even though many observations suggested otherwise.
One such observation was cited by Fitz himself (Am. J. Med. Sci. 1886;92:321-46) that 110 of 300 postmortem examinations showed diseased appendix incidentally, and spontaneous resolution was observed in 20% of appendicitis in the era of CT (Abdom. Imaging 2003;28:276-9). Other observations include finding appendiceal dilation only in most advanced cases (Am. J. Surg. 1971;122:378-80), and normal intraluminal pressures in 70% of phlegmonous or gangrenous appendices (Am. J. Surg. 1984;147:390-2). Recent studies describing different epidemiologic trends for nonperforated and perforated appendicitis (Ann. Surg. 2007;245:886-92), and dissimilar variables affecting their incidence (BMJ 1994;308:107-10) suggest that appendicitis is probably not a single disease entity.
In addition, antibiotics have become far more effective in recent years, thus making them a viable treatment option in appendicitis. A morbidity rate of 35.6% with immediate appendectomy and 13.5% with antibiotic treatment was demonstrated for complicated appendicitis with phlegmon or abscess (Ann. Surg. 2007;246:741-8), and a similar lower morbidity rate for antibiotics (6.7%-8.0%) compared to appendectomy (13%-18%) was observed in patients with appendicitis without phlegmon or abscess (Surgery 2011;150:673-83, Surg. Infect. 2012;13:74-84).
The strong suit of appendectomy has always been source control. The advantage of antibiotics is their limited complications, such as diarrhea or drug reaction. Some appendectomy complications can be quite major, and are not rendered less likely or less serious by the finding of a normal appendix in 3%-15% of patients.
The limitations of antibiotics are the 7%-10% failure rate and 5%-14% recurrences. However, with a 3%-15% negative appendectomy rate and up to 20% spontaneous resolution, antibiotic treatment may be less harmful and potentially less expensive. Since no increase in morbidity and mortality was observed with a delay of appendectomy for a mean of 26 hours (Arch. Surg. 2010;145:886-92), it should be safe to administer antibiotics for 24 hours and forego appendectomy in patients with significant improvement.
In summary, antibiotic treatment merits consideration in patients with acute appendicitis, not because it could replace surgery, but because, as a first-line treatment, it is safe with less serious and less frequent complications than appendectomy. For patients who have failed antibiotics, the risk of surgical complications becomes necessary. A randomized study comparing the two approaches is being conducted in Finland, and hopefully will provide new information to further our understanding of this common but complex disease entity.
Dr. Liu is a general surgeon at FHN Memorial Hospital in Freeport, Ill., who has studied the role of antibiotics in appendicitis for several years.
YES – Surgery remains the best option for acute appendicitis
The vast majority of surgeons the world over use operative therapy as the prime mode of treatment for appendicitis. As Dr. Liu argues below, acute appendicitis can be treated successfully nonoperatively with antibiotics. That it can be done so successfully does not mean that this is the correct or best way to treat this disease, however. Appendicitis is a spectrum disease: It can present anywhere from simple and uncomplicated, to retrocecal, to perforated with abscess, and even with free perforation with diffuse purulence and generalized peritonitis.
There continues to be a small, but definite mortality due to appendicitis, mostly in cases of delayed diagnosis, as well as very significant morbidity. In the pediatric population, perforation of the appendix, which usually occurs 36-72 hours after symptoms begin, has a postoperative abscess rate requiring further therapy (drainage and/or further antibiotic treatment) in excess of 15% (Ann. Surg. 2012;256:581-5).
One of the arguments for nonoperative treatment of appendicitis is that the appendix is simply another diverticulum of the colon, and acute diverticulitis can frequently be treated successfully with antibiotics, leaving operative treatment to be delayed for subsequent bouts or for complications of the disease. However, the appendix differs from many colonic diverticula in that it frequently lies free in the abdomen whereas many colonic diverticula are surrounded by mesentery. Thus, perforation of a colonic diverticulum is immediately contained, whereas the appendix often perforates freely into the abdomen, leading to widespread contamination. The result is generalized sepsis versus controlled, localized sepsis that may be treated successfully with powerful antibiotics.
In the case of simple, controlled appendicitis, an argument can certainly be made for early treatment with antibiotics and careful clinical follow-up. Undoubtedly, many of these patients will improve. However, the difficulty lies in diagnosing the simple case without knowing who is going to progress to complication, especially in the pediatric age group. Prompt, not emergent, operation when the diagnosis is made is probably the more prudent course.
Finally, a few brief words should be said about laparoscopic treatment of acute appendicitis as well as drainage of well-established abscesses followed by interval appendectomy. There is little question now that laparoscopic appendectomy treats the disease as well as or better than open operation, even in cases of perforation. A low incidence of complications secondary to laparoscopy notwithstanding, this approach leads to shorter hospitalizations and faster recovery, and compares favorably with nonoperative treatment. This is a clear improvement in care over the past 20 years.
There are cases, however, where a well-established abscess exists. Immediate open operation in these cases can make a stable patient extremely septic. Such cases are probably better managed with percutaneous abscess drainage (a necessity) followed a number of weeks later by interval appendectomy (which some may consider elective). Not removing the appendix later in these cases creates some risk for recurrent appendicitis, however.
Thus, despite data that would argue for a nonoperative approach to acute appendicitis, this author firmly believes that the overwhelming long-term experience favors operative treatment of acute appendicitis once the diagnosis is made. Treatment algorithms for timing of surgery and duration of perioperative antibiotics continue to be the topic of much clinical research. However, the basic principle of operative treatment remains the safest and most expeditious approach for patients. This, after all, should be the surgeon’s goal.
Dr. Lund is an ACS Fellow and surgeon-in-chief, Phoenix Children’s Hospital, and professor of child health and surgery at the University of Arizona College of Medicine–Phoenix.
NO – There is a strong case for antibiotics to treat acute appendicitis
Most surgeons who treat acute appendicitis have had to resort to antibiotic treatment occasionally, either because of significant patient comorbidities or due to the presence of phlegmon/abscess. The first time I did so was nearly 10 years ago in a 70-year-old man with severe COPD, whose surgical mortality was estimated to be greater than 50% by my medical colleagues. After some discussion, the patient elected to try antibiotics, while I stood ready to operate at the first sign of trouble. Within 48 hours, his symptoms resolved, his laboratory findings normalized, and he was headed home.
Despite similar experiences, treating appendicitis with antibiotics has been controversial. Appendectomy has been the treatment since Fitz advocated it in 1886 and Wangensteen proposed obstruction as the cause in 1940. Wangensteen observed histological changes consistent with appendicitis in 5 out of 22 ligated appendices brought out through abdominal incisions in patients undergoing colostomy operations (Ann. Surg. 1939;110:629-47). He later concluded that "obstruction of the lumen, if maintained for a sufficient number of hours, would result in acute gangrenous appendicitis with rupture" (Surg. Gynecol. Obstet. 1940;70:799-808). Since then, generations have accepted this without question, even though many observations suggested otherwise.
One such observation was cited by Fitz himself (Am. J. Med. Sci. 1886;92:321-46) that 110 of 300 postmortem examinations showed diseased appendix incidentally, and spontaneous resolution was observed in 20% of appendicitis in the era of CT (Abdom. Imaging 2003;28:276-9). Other observations include finding appendiceal dilation only in most advanced cases (Am. J. Surg. 1971;122:378-80), and normal intraluminal pressures in 70% of phlegmonous or gangrenous appendices (Am. J. Surg. 1984;147:390-2). Recent studies describing different epidemiologic trends for nonperforated and perforated appendicitis (Ann. Surg. 2007;245:886-92), and dissimilar variables affecting their incidence (BMJ 1994;308:107-10) suggest that appendicitis is probably not a single disease entity.
In addition, antibiotics have become far more effective in recent years, thus making them a viable treatment option in appendicitis. A morbidity rate of 35.6% with immediate appendectomy and 13.5% with antibiotic treatment was demonstrated for complicated appendicitis with phlegmon or abscess (Ann. Surg. 2007;246:741-8), and a similar lower morbidity rate for antibiotics (6.7%-8.0%) compared to appendectomy (13%-18%) was observed in patients with appendicitis without phlegmon or abscess (Surgery 2011;150:673-83, Surg. Infect. 2012;13:74-84).
The strong suit of appendectomy has always been source control. The advantage of antibiotics is their limited complications, such as diarrhea or drug reaction. Some appendectomy complications can be quite major, and are not rendered less likely or less serious by the finding of a normal appendix in 3%-15% of patients.
The limitations of antibiotics are the 7%-10% failure rate and 5%-14% recurrences. However, with a 3%-15% negative appendectomy rate and up to 20% spontaneous resolution, antibiotic treatment may be less harmful and potentially less expensive. Since no increase in morbidity and mortality was observed with a delay of appendectomy for a mean of 26 hours (Arch. Surg. 2010;145:886-92), it should be safe to administer antibiotics for 24 hours and forego appendectomy in patients with significant improvement.
In summary, antibiotic treatment merits consideration in patients with acute appendicitis, not because it could replace surgery, but because, as a first-line treatment, it is safe with less serious and less frequent complications than appendectomy. For patients who have failed antibiotics, the risk of surgical complications becomes necessary. A randomized study comparing the two approaches is being conducted in Finland, and hopefully will provide new information to further our understanding of this common but complex disease entity.
Dr. Liu is a general surgeon at FHN Memorial Hospital in Freeport, Ill., who has studied the role of antibiotics in appendicitis for several years.
YES – Surgery remains the best option for acute appendicitis
The vast majority of surgeons the world over use operative therapy as the prime mode of treatment for appendicitis. As Dr. Liu argues below, acute appendicitis can be treated successfully nonoperatively with antibiotics. That it can be done so successfully does not mean that this is the correct or best way to treat this disease, however. Appendicitis is a spectrum disease: It can present anywhere from simple and uncomplicated, to retrocecal, to perforated with abscess, and even with free perforation with diffuse purulence and generalized peritonitis.
There continues to be a small, but definite mortality due to appendicitis, mostly in cases of delayed diagnosis, as well as very significant morbidity. In the pediatric population, perforation of the appendix, which usually occurs 36-72 hours after symptoms begin, has a postoperative abscess rate requiring further therapy (drainage and/or further antibiotic treatment) in excess of 15% (Ann. Surg. 2012;256:581-5).
One of the arguments for nonoperative treatment of appendicitis is that the appendix is simply another diverticulum of the colon, and acute diverticulitis can frequently be treated successfully with antibiotics, leaving operative treatment to be delayed for subsequent bouts or for complications of the disease. However, the appendix differs from many colonic diverticula in that it frequently lies free in the abdomen whereas many colonic diverticula are surrounded by mesentery. Thus, perforation of a colonic diverticulum is immediately contained, whereas the appendix often perforates freely into the abdomen, leading to widespread contamination. The result is generalized sepsis versus controlled, localized sepsis that may be treated successfully with powerful antibiotics.
In the case of simple, controlled appendicitis, an argument can certainly be made for early treatment with antibiotics and careful clinical follow-up. Undoubtedly, many of these patients will improve. However, the difficulty lies in diagnosing the simple case without knowing who is going to progress to complication, especially in the pediatric age group. Prompt, not emergent, operation when the diagnosis is made is probably the more prudent course.
Finally, a few brief words should be said about laparoscopic treatment of acute appendicitis as well as drainage of well-established abscesses followed by interval appendectomy. There is little question now that laparoscopic appendectomy treats the disease as well as or better than open operation, even in cases of perforation. A low incidence of complications secondary to laparoscopy notwithstanding, this approach leads to shorter hospitalizations and faster recovery, and compares favorably with nonoperative treatment. This is a clear improvement in care over the past 20 years.
There are cases, however, where a well-established abscess exists. Immediate open operation in these cases can make a stable patient extremely septic. Such cases are probably better managed with percutaneous abscess drainage (a necessity) followed a number of weeks later by interval appendectomy (which some may consider elective). Not removing the appendix later in these cases creates some risk for recurrent appendicitis, however.
Thus, despite data that would argue for a nonoperative approach to acute appendicitis, this author firmly believes that the overwhelming long-term experience favors operative treatment of acute appendicitis once the diagnosis is made. Treatment algorithms for timing of surgery and duration of perioperative antibiotics continue to be the topic of much clinical research. However, the basic principle of operative treatment remains the safest and most expeditious approach for patients. This, after all, should be the surgeon’s goal.
Dr. Lund is an ACS Fellow and surgeon-in-chief, Phoenix Children’s Hospital, and professor of child health and surgery at the University of Arizona College of Medicine–Phoenix.
NO – There is a strong case for antibiotics to treat acute appendicitis
Most surgeons who treat acute appendicitis have had to resort to antibiotic treatment occasionally, either because of significant patient comorbidities or due to the presence of phlegmon/abscess. The first time I did so was nearly 10 years ago in a 70-year-old man with severe COPD, whose surgical mortality was estimated to be greater than 50% by my medical colleagues. After some discussion, the patient elected to try antibiotics, while I stood ready to operate at the first sign of trouble. Within 48 hours, his symptoms resolved, his laboratory findings normalized, and he was headed home.
Despite similar experiences, treating appendicitis with antibiotics has been controversial. Appendectomy has been the treatment since Fitz advocated it in 1886 and Wangensteen proposed obstruction as the cause in 1940. Wangensteen observed histological changes consistent with appendicitis in 5 out of 22 ligated appendices brought out through abdominal incisions in patients undergoing colostomy operations (Ann. Surg. 1939;110:629-47). He later concluded that "obstruction of the lumen, if maintained for a sufficient number of hours, would result in acute gangrenous appendicitis with rupture" (Surg. Gynecol. Obstet. 1940;70:799-808). Since then, generations have accepted this without question, even though many observations suggested otherwise.
One such observation was cited by Fitz himself (Am. J. Med. Sci. 1886;92:321-46) that 110 of 300 postmortem examinations showed diseased appendix incidentally, and spontaneous resolution was observed in 20% of appendicitis in the era of CT (Abdom. Imaging 2003;28:276-9). Other observations include finding appendiceal dilation only in most advanced cases (Am. J. Surg. 1971;122:378-80), and normal intraluminal pressures in 70% of phlegmonous or gangrenous appendices (Am. J. Surg. 1984;147:390-2). Recent studies describing different epidemiologic trends for nonperforated and perforated appendicitis (Ann. Surg. 2007;245:886-92), and dissimilar variables affecting their incidence (BMJ 1994;308:107-10) suggest that appendicitis is probably not a single disease entity.
In addition, antibiotics have become far more effective in recent years, thus making them a viable treatment option in appendicitis. A morbidity rate of 35.6% with immediate appendectomy and 13.5% with antibiotic treatment was demonstrated for complicated appendicitis with phlegmon or abscess (Ann. Surg. 2007;246:741-8), and a similar lower morbidity rate for antibiotics (6.7%-8.0%) compared to appendectomy (13%-18%) was observed in patients with appendicitis without phlegmon or abscess (Surgery 2011;150:673-83, Surg. Infect. 2012;13:74-84).
The strong suit of appendectomy has always been source control. The advantage of antibiotics is their limited complications, such as diarrhea or drug reaction. Some appendectomy complications can be quite major, and are not rendered less likely or less serious by the finding of a normal appendix in 3%-15% of patients.
The limitations of antibiotics are the 7%-10% failure rate and 5%-14% recurrences. However, with a 3%-15% negative appendectomy rate and up to 20% spontaneous resolution, antibiotic treatment may be less harmful and potentially less expensive. Since no increase in morbidity and mortality was observed with a delay of appendectomy for a mean of 26 hours (Arch. Surg. 2010;145:886-92), it should be safe to administer antibiotics for 24 hours and forego appendectomy in patients with significant improvement.
In summary, antibiotic treatment merits consideration in patients with acute appendicitis, not because it could replace surgery, but because, as a first-line treatment, it is safe with less serious and less frequent complications than appendectomy. For patients who have failed antibiotics, the risk of surgical complications becomes necessary. A randomized study comparing the two approaches is being conducted in Finland, and hopefully will provide new information to further our understanding of this common but complex disease entity.
Dr. Liu is a general surgeon at FHN Memorial Hospital in Freeport, Ill., who has studied the role of antibiotics in appendicitis for several years.
