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When A Burst Appendix Doesn't Kill You: Big New Study Adds Data

If you're a regular reader, you may have noticed that certain posts tend to dominate our most-popular list: on birth control and sex, on diet and exercise. Pretty predictable crowd-pleasers.

But one sleeper's appearance on the list has repeatedly surprised us: "When A Burst Appendix Doesn't Kill You." Turns out, appendicitis is no lightning strike: It hits 300,000 Americans a year, one-tenth of adults over their lifetimes.

That 2012 post shared the story of Martha Little, who was then WBUR's news director and who kept toiling away in the newsroom even though her appendix had burst — not because she was a hopeless workaholic, but because she was undergoing antibiotic treatment.

The post prompted dozens of edifying appendicitis stories in the comments section, and now a new study adds some helpful data. But first, the necessary background in the post, from Dr. Douglas Smink of Brigham and Women's Hospital:

Twenty years ago, Dr. Smink said, surgeons would go in and operate on virtually all cases of appendicitis, whatever the level of inflammation. But research found that for a certain group of patients, it was better to wait. Now, even the “interval appendectomy” is becoming controversial; a newer school of thought holds that some patients may do best with antibiotics alone, no operation at all.

The problem right now, he said, is that there’s some data on the antibiotics-only strategy, but not enough to make clear which patients really need an appendectomy and which can get along without one. Patients who have a stone in the appendix, called an appendicolith, definitely need the organ removed, for example, but many other cases are not so clear cut. More research is needed, he said, to explore the effects of age, severity of illness and other factors on whether antibiotics-only treatment will work for a given patient.

Meanwhile, some studies also suggest that for many patients with uncomplicated appendicitis — the appendix still intact — antibiotic treatment alone may be enough as well.

Now for the news, a bit more of that research Dr. Smink said was needed: A study just out in JAMA adds more evidence that antibiotics are a reasonable first option for many patients with uncomplicated appendicits — but does not end the discussion. From the study abstract:

Conclusions and Relevance: Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications.

And from The New York Times:

Three out of four who took antibiotics recovered easily, the researchers found. And none who had surgery after taking antibiotics were worse off for having waited.

“The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis, ” Dr. Edward H. Livingston, a surgeon and editor at the journal, who was not involved with the study, wrote in an editorial accompanying the report.

But Dr. Philip S. Barie, a surgeon at Weill Cornell Medical College, noted that antibiotics were not sufficient for more than a quarter of the patients in the new study and said the failure rate was unacceptable. Patients should have the simple and safe operation to remove their appendix, he said, taking care of the problem quickly and permanently.

The new study comes amid growing questions about the routine use of surgery to treat appendicitis...

Readers, thoughts?

Carey Goldberg Editor, CommonHealth
Carey Goldberg is the co-host of WBUR's CommonHealth blog.

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