Dear Editor,
We read with interest the recent ‘Analysis’ piece regarding the role of non-operative management in patients with acute appendicitis. In this, the authors argue that the risks associated with non-operative management mean that surgery is the ‘best’ approach. We believe that in selected cases, surgery is not the ‘best’ option and that for shared decision making, non-operative management needs to be offered to the patient.
The authors base their conclusion on several aspects - the comparative complication rate, the risk of recurrence or missing a malignancy, cost effectiveness and patient satisfaction. A recent meta-analysis did not show a significant difference in post-treatment complication rate between patients treated with surgery or antibiotics.[1] The authors criticise studies for not including recurrence as a complication in patients treated non-operatively and cite a selection of articles to justify their arguments. There is, however, a wealth of literature that disagrees with this view. We would argue that just as cancer recurrence is not considered a complication, appendicitis recurrence should not be considered a complication. Patients opting for antibiotics who are appropriately informed as part of shared decision making, will be acknowledging and accepting this foreseeable risk of long term failure of medical management.
The authors cite organ failure as a complication of antibiotic usage in the CODA trial, however a review of the CODA paper contains no mention of organ failure.[2] Importantly the CODA trial clearly attributes the higher rate of complications in the antibiotic arm of the trial to patients with an appendicolith, rather than those without.[2] This has confirmed, as previously thought, that appendicitis with an appendicolith should be treated as a different pathology and not be managed non-operatively.[3]
Appendiceal malignancy remains a rarity (occurring in approximately 1.5% of cases).[4] It occurs most commonly in patients aged >40 and has been strongly associated with CT proven complicated appendicitis.[4] It is therefore imperative to disentangle the considerations for varied patient populations and ensure that decisions are made contextually, accepting the evidence base for antibiotic management in the younger, uncomplicated group, where the malignancy risk is notably low.
Despite claiming a lack of robust cost analysis studies, the authors cited a comprehensive cost-effectiveness study, which considers the cost of repeat presentations.[5] Cost-effectiveness analysis that include wider societal costs are available from the APPAC teams, which favoured antibiotic therapy.[6] CODA and APPAC found operative patients had significantly longer time away from work or caregiving, which formed the majority of the societal cost.[2, 6]
Other aspects which we feel the authors may have omitted include patient choice, healthcare system and paediatric patients. Patient choice is fundamental within the shared decision making model. Several studies have shown that when presented with balanced and comprehensive information regarding both treatment choices, there remains a substantial percentage of patients who would prefer a trial of antibiotic management.[7, 8] The presumption that surgery is best risks surgeons not disclosing the alternative of antibiotics treatment to their patients, therefore denying them of choice (as well as being a clear breach of GMC guidance regarding consent). The authors do not consider global access to safe anaesthesia and surgery worldwide; the risk profile may alter considerably in low-income versus middle or high-income countries. Finally, the authors make no mention of children in their article despite a wealth of paediatric literature on the topic and ongoing research. Thus ensues a risk that children, as well as adults, may be denied the option of antibiotic treatment for uncomplicated appendicitis despite evidence of efficacy and safety.
References
Herrod PJJ, Kwok AT, Lobo DN. Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis. BJS Open [Internet]. 2022 Jul 7 [cited 2023 Sep 29]; 6(4): zrac100. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9379374/.
CODA Collaborative, Flum DR, Davidson GH, Monsell SE, Shapiro NI, Odom SR et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020;383:1907–1919.
Di Saverio S, PoddaM, De Simone B, Ceresoli M, Augustin G, Gori A et al. Diagnosis and treatment of acute appendicitis: 2020 update of theWSES Jerusalem guidelines. World J Emerg Surg 2020;15:27.
Naar L, Kim P, Byerly S, Vasileiou G, Zhang H, Yeh DD, Kaafarani HMA; EAST Appendicitis Study Group. Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study. Surgery. 2020 Oct;168(4):701-706.
Javanmard Emamghissi H, Hollyman M, Boyd-Carson H, Doleman B, Adiamah A, Lund JN et al. Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study. Br J Surg. November 2021; 108 (11): 1351–1359.
Sippola S , Grönroos J, Tuominen R, Paajanen H, Rautio T, Nordström P et al. Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 2017;104:1355–1361.
Bom WJ, Scheijmans JCG, Gans SL, Van Geloven AAW, Boermeester MA. Population preference for treatment of uncomplicated appendicitis [internet]. BJS Open, July 2021; 5(4): zrab058. Available from: https://doi.org/10.1093/bjsopen/zrab058.
Hanson AL, Crosby RD, Basson MD. Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis. JAMA Surg. 2018 May 1;153(5):471-478.
Competing interests: No competing interests
Re: Tackling climate change: the pivotal role of clinicians
Dear Editor
Whilst I agree with almost every word of this article, the use of the phrase 'Carbon Footprint' makes me uncomfortable [1]. It wasn't the only piece in this edition of the BMJ that used the term and it is of course a convenient expression to use. However, I wonder if those who use it realise the origins of the phrase?
Although it is probably impossible to know when the words ‘Carbon’ and ‘Footprint’ were first used together, it is possible to know when and why this phrase was popularised. In 2004 the advertising agency Ogilvy and Mather came up with the concept of a ‘carbon footprint calculator’ for their clients. Who were their clients? British Petroleum (BP). [2]
The concept was that the individual and their actions were/are responsible for their own emissions rather than the fossil fuel industry. It was therefore up to individuals to mend their ways and reduce their emissions and to do this they could use the handy carbon footprint calculator provided. The industry itself did not mention its own hefty footprint, as that would have defeated the aim.
Individuals and organisations do of course need to be aware of how much of the planets resources they consume and I appreciate that carbon footprint is a useful shorthand for this. But I think, both because of its origins and the relatively narrower focus of the term carbon footprint, we could use the term ‘Climate Footprint’ instead. This keeps the concept of a heavy or light tread but allows a more direct connection with the climate crisis that we are undoubtedly in.
Competing interests: No competing interests