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Long‐term outcomes of revisional surgery following laparoscopic fundoplication (Br J Surg 2009; 96: 391–397)

Sir We are pleased to observe that our study on the effectiveness of antibiotic treatment of acute appendicitis compared to conventional surgery has been found interesting actually far beyond a surgical forum. We are particularly grateful to Doctors Sanabria, Sanchez, Brown, Majumder and Patel with colleagues who took their time to provide written comments on our work. We are the first to admit that our work is not the final answer how to treat acute appendicitis, but it may be the beginning of the end to offering all patients surgery as a first treatment option. Such a development should be a stepwise process to improve and simplify treatment with less harm to patients and costs to the society. The design of our study was to mimic, as closely as possible, daily practical conditions in treatment of patients with acute appendicitis in most hospitals including our own. This should by no means introduce additional diagnostic procedures or increased costs to our departments. We agree that evaluations by intention to treat or per protocol in clinical studies may end up with different conclusions. Complication rates may also appear different, when either open or laparoscopic surgery is applied by more or less experienced surgeons. It is also true that the diagnostic accuracy of appendicitis is usually recognized to be improved to some extent, when all available imaging techniques are applied. All these concerns are real and represent factors that should be considered in evaluation of our study. However, we feel confident that the use of a simultaneous reference population in our neighbouring hospital makes it unlikely that important bias was introduced in selection of our patients and thereby misled us to entirely wrong final conclusions. It is important to emphasize that it was not possible to refuse eligible patients to be treated either by antibiotics or surgery considering ethical considerations and patient integrity. Therefore, it was necessary to allow both patients and the surgeons to make their own decision when ‘deemed necessary’ or wished according to patient preference. Of course, this may have introduced unidentified bias, although our registered information did not confirm such worries when comparing clinical information among subgroups of patients. A study of this kind may also be a matter of how to correctly define endpoints in comparison between antibiotic treatment and surgery. We agree that intellectual aspects of study design may end up with different solutions. However, from the patients’ perspective it should be enough to be relieved from acute medical symptoms at low risk followed by rapid recovery (antibiotics). Of course, this may introduce some over-treatment by antibiotics, but on the other hand it will also reduce negative explorations in patients intended for conventional appendicectomy. With all these limitations in mind, we now encourage our patients, according to our next protocol, to try antibiotic treatment as their first treatment in order to confirm or reject our previous conclusion that antibiotic treatment is a safe first line therapy in acute appendicitis in the majority of unselected patients. We would also comment that we find it equally valid for patients to be randomized according to birth date compared to a conventional envelope procedure, which was also the view of our ethical board. J. Hansson and K. Lundholm Department of Surgery, Sahlgrenska University Hospital, SE 413 45 Gothenburg, Sweden DOI: 10.1002/bjs.6765