It was an interesting fortnight for the debate about the treatment of appendicitis.

On November 1, David Agus, a medical oncologist, and director of the University Of Southern California’s Center for Applied Molecular Medicine, had some thoughts about how appendicitis should be treated. He cited the Finnish randomized trial of antibiotics vs. surgery and said a 70 percent cure rate was good enough.

In a brief article on the Fortune magazine website, Agus wondered why appendectomy “continues to reign supreme.” He said it was “because 24/7 we’re taught you have to take it out if there’s appendicitis” and that the healthcare community is “stubborn and pigheaded” [pigheaded means stubborn] and that we focus on treatment instead of prevention.

Because I am not aware of any method of preventing appendicitis, I say, “Guilty as charged.” I admit I cured appendicitis for my entire professional life.

Only five days before Agus’s rant, a meta-analysis of six randomized trials comparing the nonoperative treatment of appendicitis to surgery appeared online in the Journal of the American College of Surgeons. Agus should read it.

The authors, surgeons and biomedical researchers from Oxford, England, covered many of the points that I have made in my posts on this subject.

Some of their major findings were as follows:

• In the six studies, 71 percent of the patients underwent open appendectomy which is not the standard in Europe or the U.S. where more than 90 percent of appendectomies for simple appendicitis are done laparoscopically. In the largest and most recent study from Finland, 94.5 percent of the appendectomies were done as open procedures.
• All of the studies suffered from one or more important methodological flaws such as poor randomization schemes, incomplete follow-up, exclusion of females, variability in defining and reporting complications, and more.
• There was “no convincing evidence of reduction in complications” with nonoperative management.
• The nonoperative management of uncomplicated appendicitis had an immediate success rate of 91 percent which dropped to 71 percent after one year of follow-up. The risk of recurrent appendicitis after one year is unknown.

The Fortune piece ended with this paragraph.

[Trigger warning: Buzzwords ahead.]

“The good news? We’re at inflection point, Agus argues, in terms of technology and know-how: We’re ready to disrupt health care.”

Dr. Agus, please confine your inflection points and disruptions to molecular medicine.

“Skeptical Scalpel” is a surgeon who blogs at his self-titled site, Skeptical Scalpel.  

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