If your child comes to Children’s Mercy Hospital with appendicitis, you’re probably going to be asked whether you want to participate in a clinical trial that could change how the common illness is treated worldwide — and how insurance covers those treatments.
“Guaranteed,” said Shawn St. Peter, the surgeon leading the study that also includes researchers in Sweden, Finland and Canada.
Appendicitis traditionally has had one of medicine’s clearest courses of treatment: get in there and remove the appendix.
But there’s growing evidence that surgery might not be necessary for adults with nonperforated appendicitis, because antibiotics are just as effective. St. Peter and Children’s Mercy are on the cutting edge of research to determine if the same is true for children.
It’s a straightforward question, but one that’s fraught with cultural baggage from generations of routine appendix removal, surgeons’ preference for a quick, clean solution and some parents’ outsized fear of surgery and anesthesia in general.
“Frankly, they shouldn’t be afraid of” appendectomies, St. Peter said. They’re “overwhelmingly safe. Far safer than having gotten to the hospital in the first place. Having said that, now that we are treating with antibiotics, it’s remarkable that those kids really are normal immediately. As soon as that pain subsides, then they’re fine. They can all go to school the next day.”
The complicating factor that looms over the whole study is cost. Appendectomies are affordable as surgeries go, but a course of antibiotics is still much cheaper.
Depending on how the study turns out, St. Peter said it could lead insurance companies to cover appendectomies for nonperforated cases only after antibiotic treatments had failed.
“That would be possible,” St. Peter said. “But that would also depend on the study results showing a dramatic difference in costs between the standard therapies, including the people who fail. The most expensive patient here is going to be the one who gets admitted to the hospital, gets a day or two of antibiotics, goes home, then recurs and still has the same course that the other had, so they get both expenses added up together.”
The plan is to enroll about 1,000 kids with appendicitis who will be randomly assigned to either an antibiotics-only group or an antibiotics and appendectomy group and then follow up with them after six weeks and again after one year to see how they fared.
The object of the study, St. Peter said, is not to determine whether one method is better than the other. It’s to determine what percentage of cases treated with only antibiotics end up with a recurrence of appendicitis and surgery anyway. With that information, each patient — or parent — would then have to make their own decision.
Each will bring their own biases.
Jody Hanson, a mother of a 14-year-old and a 16-year-old who lives in Olathe, said if she faced that choice with her kids, it would depend on a number of factors, including how much pain they were in, as well as the chance of recurrence.
“You don’t really want to play around with your kid’s health,” she said. “But if they think surgery can be avoided, well, nobody wants their kids to have surgery and the risks that come with that.”
Hanson said her husband had a successful emergency appendectomy, and her faith in the procedure would also affect the failure rate she would accept for antibiotic treatment.
“It would have to be very low,” Hanson said. “If there’s a 5 percent chance or lower, I think I would try it.”
St. Peter said he expects major differences of opinion — from providers as well as patients — when it comes to determining what is an acceptable recurrence rate. Surgeons who can do appendectomies in their sleep will probably think anything above 10 percent is unacceptable. Pediatricians who are used to dispensing antibiotics might be inclined to accept a higher failure rate.
There’s other clinical considerations. St. Peter said some in the medical community theorize that the appendix might have some immune system benefits that are as yet unknown, and the appendix can sometimes be useful material for surgeons to use to repair other gastrointestinal problems that a patient may develop later. But on the flip side, removing the appendix can occasionally reveal other hidden conditions, including cancer.