Operations for appendicitis could be cut out for good

 

One of the most common operations performed in Britain – on which generations of trainee surgeons have honed their skills – is outmoded, research suggests. Surgery for appendicitis should be abandoned and replaced with a course of antibiotics, experts say.

Surgical removal of an inflamed appendix – an appendicectomy – has been the mainstay of treatment for acute appendicitis for more than a century. For most surgeons, it is the first operation they ever carried out.

But researchers who reviewed four trials involving 900 patients with appendicitis found almost two-thirds of them (63 per cent) were successfully treated with antibiotics, avoiding the complications of surgery.

Appendicitis is caused by bacteria collecting in the appendix, causing infection and abdominal pain. In rare cases the appendix may burst, releasing the bacteria into the abdominal cavity causing peritonitis, which can be fatal.

Last year 47,000 appendicectomies were carried out in England to avoid the risk of a rupture of the appendix. But Dileep Lobo, Professor of gastro-intestinal surgery at Queen's Medical Centre, Nottingham, and colleagues say in the British Medical Journal that this is driven by tradition rather than evidence and that the role of antibiotics has been "overlooked".

They suggest treating patients with suspected appendicitis with antibiotics and "watching and waiting". If there is no improvement in 48 hours, the patients should have surgery.

Treating patients with antibiotics could reduce the numbers requiring surgery by two-thirds and cut the rate of complications by almost a third, they say, making big savings for the NHS.

However, for patients with signs of perforation or peritonitis "early appendicectomy still remains the gold standard", they say. Professor Lobo said the availability of ultrasound and CT scans makes identifying them more straightforward than in the past.

If appendicectomies start to go out of fashion they will follow other outmoded operations. Fifty years ago, removal of the tonsils was routine and thousands of children went under the surgeon's knife in a misguided attempt to protect them from tonsillitis – a sore throat that could develop into a fatal infection.

Struck off: The list out-of-date ops

* Tonsillectomy, the removal of tonsils to prevent repeated sore throats. More than 200,000 were carried out every year in the 1950s, but only 49,000 in 2009. There is no evidence that it works.

* Grommets (valves inserted in the ear drum) to treat "glue ear". Most children grow out of it naturally.

* A mastectomy for breast cancer. Today, surgeons remove only the lump, and survival is just as good.

* Hysterectomy for fibroids – benign growths in the womb. They can now be treated by an injection.

* Surgery for stomach ulcers. Can now be treated by an over-the-counter drug.

Jeremy Laurance

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