Appendectomy vs. Antibiotics

Since 1886, when the operation was first described, appendectomy has been the standard for treating appendicitis, the most common surgical emergency for children (with a lifetime risk of 7-8%); only recently have antibiotics alone been explored in place of surgery, according to research recently published by Le Bonheur Pediatric Surgeon Tim Jancelewicz, MD, in The Lancet.

With the decision between appendectomy and antibiotics for best treating patients, Jancelewicz and his colleagues sought to determine which treatment for uncomplicated appendicitis (meaning an appendix that is inflamed but has not yet ruptured) was inferior. Their research showed that ultimately an appendectomy is the better choice for kids over antibiotics.

Results from research published by Le Bonheur Pediatric Surgeon Tim Jancelewicz, MD, said that around a quarter to a third of kids treated with antibiotics only will get recurrent appendicitis within a year.

 “The APPY Trial shows that around a quarter to a third of kids that are treated with antibiotics and don’t get their appendix removed will get recurrent appendicitis within a year,” stated Jancelewicz. “That may sound like a risky proposition if you’re a surgeon. But imagine a family that has, for example, a big trip planned or a major sports event for their child coming up next weekend. They may really want to avoid surgery and want to know about nonoperative management of their appendicitis. Now we have the numbers for them to make an informed decision.”

While several studies have claimed that antibiotics alone is a more effective treatment plan, this study was the first “large, pragmatic, randomised trial to compare antibiotics and appendicectomy for the treatment of uncomplicated appendicitis in children.” To compare these treatments side by side, they had to first decide what “failure” meant for each of them. For antibiotics, failure was defined as the need for appendectomy within one year. For appendectomy, it was defined as a negative appendectomy, which is when an appendix is removed that is not inflamed.

The study ran from 2016 to 2021 and consisted of 936 children ages 5 to 16 from 11 children’s hospitals across Canada, the United States, Finland, Sweden and Singapore with non-perforated appendicitis. Patients were randomly assigned to either antibiotic treatment or appendectomy.

They found the failure rate to be 34% in the antibiotic group compared to only 7% in the appendectomy group. In addition, the appendectomy group had a shorter initial hospital stay compared to the antibiotic group. While the antibiotic group returned to normal activities faster and required fewer pain medications, complications were more frequent for them overall.

The conclusion made in this rigorous study led Jancelewicz and his colleagues to determine that for uncomplicated appendicitis in children, antibiotics alone were inferior to appendectomy and had a higher failure rate. Their findings, combined with past findings in previous studies, shows that additional comparative studies in this vein are not likely to produce different results. Appendectomy remains the best choice for most patients over a century later.

In regard to his place in the study, Jancelewicz had this to say: “Le Bonheur was one of 11 centers in this landmark trial. I’m so grateful to everyone involved, from the Children’s Foundation Research Institute at Le Bonheur to my partners and nurse practitioners to the patients and families who participated in the trial. All that work has resulted in this very important paper that answers lots of questions we have had about the management of appendicitis.”