Is there a new innovative treatment for acute appendicitis?
- Carlos E Costa Almeida
- há 5 horas
- 2 min de leitura
Acute appendicitis is one of the common diseases in ER departments worldwide. Appendectomy is one of the most frequently performed operations by surgeons, and, if performed well, it definitely treats the disease.
Recently, new ideas have emerged regarding the use of isolated antibiotics to treat uncomplicated appendicitis. When people discuss this, I always recall the following history of Sir. Frederick Treves (in the 1890s) of London Hospital, who advocated the conservative management of acute appendicitis followed by appendectomy when the inflammation had subsided. His daughter had an acute appendicitis, which evolved to perforation, and the child died. Of course, there were no antibiotics at that time (penicillin was discovered in 1928; mass production and the antibiotic era began in the 1940s), but suggesting antibiotics only to treat an uncomplicated appendicitis in the present day is nonsense to me. We must not forget that the natural history of an acute appendicitis is gangrene and perforation, and an appendectomy in an uncomplicated appendicitis is usually a safe and fast procedure with low risk of complications.
A recent paper from China presents the results of an endoscopic technique for treating uncomplicated appendicitis. The authors say that 35% of patients with uncomplicated appendicitis have appendicoliths, which put these patients at risk for recurrence after the antibiotics-only treatment. The Endoscopic Retrograde Appendicitis Therapy (ERAT) and the Visual ERAT (V-ERAT) include colonoscopy till the cecum, canulation of the appendix, and flush/removal of the appendicoliths and pus from the appendix lumen. Zhu-Hui et al. compared 105 patients submitted to ERAT with 105 patients submitted to laparoscopic appendectomy (LA). Results were… the… expected, I think!
The treatment success rate was 85.7% and 100% for ERAT and LA, respectively (p<0.001). This primary outcome is all I need to say NO to this endoscopic technique. The authors state that procedure time and costs of the ERAT were lower compared to the LA (p<0.001). However, these results are completely overwhelmed by the substantially lower success rate of the ERAT compared to the LA. Who cares about a cheaper and faster procedure that is significantly worse? Interestingly, the mean in-hospital days after a successful ERAT was similar to the LA. The authors reported perforation and abdominal abscess complicating the ERAT procedure, but not after the LA (no significant difference). It is easy to understand when the authors conclude that “ERAT should be considered less effective than LA in treating uncomplicated acute appendicitis in the presence of appendicoliths.” Is it a future possibility for high-risk patients? I have some doubts, but... who knows?
New ideas and innovation are crucial for human evolution. Trials, data, and results analysis are important. This is the way to know whether innovation is needed or not. Trying to do things differently is important, but knowing when to step backwards and keep it old-school is also paramount for the success of a true innovation.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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