Surgery for appendicitis? Antibiotics alone may be enough

I remember when my best friend in fifth grade couldn't make our much-anticipated end-of-the-school-year camping trip because he had just undergone surgery for appendicitis. Now I prevent kids from participating in their school activities for four to six weeks after I remove their appendix. But what is the appendix, why do we have an organ that causes so many problems, and do you need surgery for appendicitis?

Role of the appendix is unclear

The appendix is a fingerlike tube, about three to four inches long, that comes off of the first portion of the colon. It is normally located in the lower right abdomen, just after the small intestine (needed for digestion and absorption) turns into the colon (whose purpose is to reclaim water and remove waste products).

The true function of the appendix remains unknown today, but one debated theory is that the appendix acts as a storehouse for good bacteria, to reboot the digestive system after a diarrheal illness. Other experts believe the appendix is just a useless remnant from our evolutionary past. Surgical removal of the appendix appears to cause no observable health problems.

Today, appendicitis is usually treated with surgery

In the medical community, the suffix "-itis" refers to inflammation (think arthritis, which is inflammation of a joint). Many times, "-itis" is due to an infection — pharyngitis, or strep throat, for example. After much research and debate, the cause of "-itis" of the appendix is still unclear. However, it appears that most causes of appendicitis are infectious agents, such as bacteria, viruses, parasites, or fungi.

Whatever the cause, whenever there is an obstruction of the entrance to the appendix — either from swelling or inflammation, or from mechanical blockage, like a hard piece of stool or a tumor — appendicitis may ensue. The real danger from appendicitis comes from the potential of the appendix to perforate, or burst, which can spread infection throughout the abdomen.

Even before 1886, when Dr. Reginald Fitz, a Harvard pathologist, first described appendicitis as a surgical disease, physicians had dealt with the pain and complications stemming from this tiny, menacing organ. Today, the standard of care for the treatment of appendicitis remains surgical removal of the appendix (appendectomy), along with intravenous fluids and antibiotics. In fact, appendectomy is one of the most common abdominal operations in the world. It is also the most common emergency general surgical operation performed in the United States. Most appendectomies are performed by the laparoscopic technique, also known as "keyhole" or minimally invasive surgery. Patients usually remain at the hospital for less than 24 hours post-operatively.

Emerging evidence suggests antibiotics alone may be enough to treat appendicitis

Many studies have demonstrated that surgery may not be necessary for all cases of appendicitis. A paper published in June 2015 received international visibility and challenged the status quo when antibiotic therapy was compared with surgery for the treatment of appendicitis. The conclusion of the APPAC trial (APPendicitis ACuta), which ran in Finland from November 2009 to June 2012, was that most patients who were treated with antibiotics for uncomplicated acute appendicitis did not require surgery during the one-year follow-up period. (Uncomplicated appendicitis refers to those cases in which there is no evidence of perforation or abscess formation, and in which the inflammation is mostly confined to the appendix.) Those who eventually did require appendectomy after failure of the antibiotic regimen did not experience significant complications.

In 2018, the APPAC authors published a follow-up in which they concluded that six out every 10 patients who were initially treated with antibiotics for uncomplicated acute appendicitis remained disease-free at five years. They again concluded that antibiotic treatment alone appears feasible as an alternative to surgery for uncomplicated acute appendicitis. Many additional studies also support a nonoperative approach to appendicitis. (And having spent almost 15 years in the navy, I know that for sailors suffering from appendicitis at sea, the use of powerful antibiotics has been the standard of care for decades when access to a surgeon is not readily available.)

As is always the case in scientific research, these studies have many limitations, including basic study design, multiple confounding variables, misinterpretation of results, and intrinsic flaws known to anyone using statistics. You can also find many articles and rebuttals describing the problems with using medication for a "surgical disease." So as of now, while we eagerly await more data on the integrity of antibiotics for the safe use and definitive treatment of uncomplicated appendicitis, surgery remains the gold standard.