Antibiotics vs Surgery: The Appendicitis
The Timeless Appendix
Appendicitis: If It Ain’t Broke, Don’t Fix It

The Appendix Agenda: If It Ain’t Broke, Don’t Fix It

Answering Appendicitis: If It Ain’t Broke, Don’t Fix It

No wonder this has been the management for 200 years

why change a 200-year-old management plan?

200 years of management challenged in 10
Managing Appendicitis: If It Ain’t Broke, Don’t Fix It
Please join me for a trip down memory lane…

In the 19th century, we had proper, no-nonsense surgeons.

Anything that looked even slightly suspicious was swiftly removed.

An ulcer on the foot? 🤔Amputate the whole leg.

Think you're followed by evil spirits? 🤔Frontal lobotomy will do the trick!

Suffering from a stomachache? 🤔Let’s cut you open and remove the appendix. That’ll solve that.

Surgical removal of an ingrown toenail

With time, science, and a bit of common sense, we collectively decided perhaps some of these surgeries were a little bit unhinged.

While lobotomies fell out of fashion and amputations were reserved for the diabetics. One surgery persisted.
Appendicectomies for anyone with uncomplicated appendicitis.

Simple as that. No questions asked. Age Six or Sixty. Mild or Severe. That appendix is getting gone!

This was the law, and the law was good.
Until, of course, the 21st Century…
The century the world got soft

Modern medicine looked at the prevalence of appendicitis in children and thought:

Surely, we don’t have to put those poor babies through surgery 🥺. Won’t non-operative management (NOM) like antibiotics do?

As if pain wasn’t character-building.
Studies started to emerge speaking on the effectiveness of NOM: "Look! no surgery, no scar, and little Timmy’s back at school in a week!"

But what they all failed to do was look into the future 🔮– aka more than three months.

So… Is NOM actually non-inferior to surgery in terms of safety and effectiveness?

Published in JAMA Paediatrics, this meta-analysis and systematic review aimed to investigate just that.

After scouring high and low for relevant RCTs, 7 were included with 1,480 paeds patients total. The primary outcome being treatment success and failure(within 1 year).

They had 5 key findings:

Treatment Failure - Significantly higher with NOM: Failure rate 36.6% vs 7.0%; Risk Ratio (RR), 4.97 (95% CI, 3.57-6.91)

Treatment Success - Significantly lower with NOM: Success rate: 65.1% vs 94.1%; Risk Ratio (RR), 0.67 (95% CI, 0.60-0.75)

Major Complications - Significantly more frequent with NOM:

Recurrence Rate - 18.5 events per 100 patients in NOM. None with surgery(because they removed the appendix lol)

Return to Normal Activity - Faster with NOM by ≈ 4.9 days.

So yes, antibiotics will get little Timmy back on the playground slightly faster. But it’s likely delaying the inevitable - his appendix on a steel kidney dish.

Like all academic work, this review has its flaws…especially when you’re Frankensteining seven imperfect RCTs into one. Follow-up durations varied, outcome definitions weren’t always aligned, and some sample sizes were on the small side.

But ultimately, tough love prevails after all.

Got an angry appendix?
See it. Say it. Surgery.

Simple.