Questions about antibiotics vs surgery for acute appendicitis

A study from Finland suggesting that antibiotics may be a viable alternative to surgery for acute appendicitis has created a stir. As you might have expected, I had some concerns about the paper which you can read in my blog post here.

On Twitter, many surgeons have commented on both the paper and my post. Several interesting questions come to mind.

Based on this and other similar studies, is the treatment of acute appendicitis with antibiotics now a mainstream alternative to surgery?

Should surgeons now mention the Finnish study results during their informed consent discussions with patients?

Is CT scanning accurate enough to differentiate a reasonable percentage of uncomplicated appendicitis from more complex cases? Previous papers have reported conflicting data on this topic. Will this lead to more CT scanning (if that is even possible)?

What do patients want? In an effort to avoid surgery, are they willing to take a 25-30% chance of a recurrence of appendicitis?

Will patients be able to understand the distinction between complicated and uncomplicated appendicitis?

We all agreed that ertapenem is not a first-choice antibiotic in the United States. In fact, the real questions may be is a three-day hospitalization for intravenous antibiotics really necessary, or as is the case with acute sigmoid diverticulitis, would a course of oral antibiotics as an outpatient be sufficient to deal with an attack of uncomplicated appendicitis?

How will it work if antibiotics and surgery are considered equivalent treatments? Although I am retired, I think I am qualified to say that I would not have enjoyed going to an emergency department at 10 o’clock at night to see a patient with acute appendicitis who after a discussion, chooses to be treated with antibiotics. Should these medically-treated patients be admitted to surgery or another service? Should the emergency physician have the discussion with the patient and only call the surgeon if the patient elects to have an operation?

Is it appropriate for an anonymous blogger to be questioning the methods and results of a paper published in a top-tier journal such as JAMA?

What do you think about all of these questions?

Many thanks to the following for their input. If I omitted someone, I apologize. @jdimick1, @NirajGusani, @TomVargheseJr, @ChrisFriese_RN, @LVSelbs, @NatalieBlencowe, @JBMatthews, @ehldallas, @zuckerbraun, @SarahB_MD, @docaggarwal, @aneelbhangu, @smootholdfart, @DRSoup34, @hswapnil, @qdtrinh, @TimLaheyMD, @jonessurgery, @RogueRad, @DrKathyHughes, @putrescine, @krchhabra, @Apathetic_Cynic, @SimonRBarron

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