When appendicitis is mentioned, a surgical procedure usually comes to mind; however, a new study has reported that antibiotics rather than surgery may be the best option for a child diagnosed with appendicitis. The findings were published on December 16 in the journal JAMA Surgery by researchers at the Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio.
The study authors note that acute appendicitis accounts for 11.4% of pediatric emergency department admissions; more than 70,000 children are hospitalized for it annually in the US. An appendectomy is curative; however, it is an invasive procedure requiring general anesthesia with associated risks and postoperative pain and disability. Children may miss up to two weeks of activities and their caregivers may experience a similar disruption to their normal schedule. Reported complication rates of patients undergoing an appendectomy for uncomplicated appendicitis range from 5% to 10%, with serious complications, such as reoperation or readmission, occurring in 1% to 7% of patients. Several recent studies have reported that nonoperative management of appendicitis is medically safe and effective for adults, with a success rate ranging from 63% to 85%. Furthermore, a recent European study in children reported a one-year success rate of nonoperative management of 66% and no difference in the rates of complicated appendicitis.
In view of the foregoing, the purpose of the new study was to assess the overall effectiveness of nonoperative management for acute uncomplicated pediatric appendicitis, in the context of engaging the family in the treatment decision. This study involved a patient choice design and assessed patient-centered outcomes and healthcare costs in addition to medical outcomes. The researchers theorized that a successful nonoperative management strategy for uncomplicated appendicitis may improve the quality of care related to the treatment of pediatric appendicitis with potentially less morbidity, less disability, and lower costs than surgery.
The study group comprised patients aged 7 to 17 years with acute uncomplicated appendicitis who presented at a single pediatric tertiary acute care hospital from October 1, 2012 through March 6, 2013. Both the patients and their families gave informed consent and chose between nonoperative management and urgent appendectomy.
The authors explained that nonoperative management involved at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics. The primary outcome measurement was the one-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and healthcare costs between nonoperative management and surgery.
A total of 102 patients were enrolled in the study; 65 patients and their families chose appendectomy (average age: 12 years; 45 male) and 37 patients and their families chose nonoperative management (average age: 11 years; 24 male). Baseline characteristics were similar between the two groups. The success rate of nonoperative management was 89.2% at 30 days (33 of 37 children) and 75.7% at one year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children). After one year, children managed nonoperatively compared to the surgery group had fewer disability days and lower appendicitis-related healthcare costs.
The authors concluded that, when chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis. This management incurs less morbidity and lower costs than surgery.