There is one thing (out of a list of many) that makes me disappointed with a surgical trainee; it comes after they describe a new case to me and offer their preferred surgical treatment. I then ask them for the evidence supporting their recommendation. They say: “Well, I saw a guy do one once.” This short statement says so much. Firstly, how we are influenced by what we see, particularly when somebody considered to be senior or authoritative does it. It also shows how readily we recommend treatments without good knowledge of the outcomes of that treatment, or of the alternatives. It is easier just to think: “If this guy did it, then it must be OK”.
This is why appendicectomy is so commonly done. Randomised trials have told us that removing the appendix is not necessary on first presentation, and it is associated with a worse long term outcome. Yet if you present to any of my hospitals with suspected appendicitis, you are unlikely to be leaving hospital without having your appendix removed.
Now a recent review published in the British Medical Journal has summarised the randomised trials that compared immediate appendicectomy to antibiotics and observation for patients presenting with uncomplicated appendicitis. There were four studies involving a total of 900 patients. They concluded that the overall complication rate was significantly lower in the group initially treated non-operatively. It seems that we may have been overestimating the benefits of having an appendix removed straight away, and we might also have been underestimating the harms from the surgery (such as infections and adhesive bowel obstructions). What a surprise.
The fact that some patients later had an appendicectomy does not alter the results of initially treating them non-operatively. The bottom line is that most appendicectomies can be avoided, resulting in and overall reduction in the complication rate.
On questioning surgical colleagues I come up against unscientific, emotive responses like “What if it was your child?” The answer of course, is that I would want them to have antibiotics and observation rather than an immediate appendicectomy.