Appendicitis: Surgery Safely Avoided in Some Children

Jennifer Garcia

April 25, 2014

Uncomplicated acute appendicitis in children may be managed successfully using nonsurgical techniques, according to a study published online April 12 in the Journal of the American College of Surgeons.

A prospective nonrandomized trial by Peter C. Minneci, MD, MHSc, from the Nationwide Children's Hospital, Columbus, Ohio, and colleagues compared surgical vs nonsurgical management of uncomplicated acute appendicitis in 77 children. The nonsurgical approach consisted of hospitalization for a minimum of 24 hours with intravenous antibiotic therapy, a minimum 12-hour period of nothing to eat or drink, and observation. Patients were switched to oral antibiotics (for a total 10-day course) as soon as they were tolerating a regular diet.

Patients were enrolled between October 2012 and October 2013, and all shared similar demographic and clinical characteristics. Patients were between 7 and 17 years of age and had 48 hours or less of abdominal pain. Only patients with radiographic (ultrasound or computed tomography) evidence of nonruptured acute appendicitis, an appendiceal diameter 1.1 cm or less, and no evidence of phlegmon, abscess, or fecalith were eligible in the study.

Among the 30 children in the nonsurgery group, the immediate and 30-day success rates were 93% and 90%, respectively. Of the 3 treatment failures in this group, 2 patients underwent laparoscopic appendectomy during their initial hospitalization when they did not show sufficient improvement with intravenous antibiotics. The third child initially responded but was readmitted to the hospital with recurrent pain and also had a laparoscopic appendectomy.

Compared with patients in the surgical group, all of whom underwent laparoscopic appendectomy (n = 47), nonsurgical patients returned to school sooner (3 vs 5 days; P = .008), experienced fewer disability days (3 vs 17 days; P < .0001), and reported higher quality-of-life scores for the patient (93 vs 88; P = .01), as well as the parent (96 vs 90; P = .03).

"This study is the first prospective trial of a non-operative management strategy for acute appendicitis in the United States and is the first in children internationally," write Dr. Minneci and colleagues. The authors note that nonsurgical management of these cases has a high success rate and add that among patients who failed nonoperative management (n = 3), "there was no progression to rupture at the time of appendectomy."

"These results support non-operative management of appendicitis as a viable treatment option for children with acute appendicitis," they conclude.

Patients in the nonoperative group had longer hospital stays compared with patients in the surgical group (38 vs 20 hours; P < .0001); however, the authors note that patients undergoing nonoperative management will still require in-hospital monitoring for clinical changes that may warrant surgical intervention.

The authors acknowledge the possibility of selection bias in the study but note they attempted to control for this by using a scripted consenting process and limiting the number of enrolling physicians. A 1-year follow-up evaluation of the safety, success rate, and cost-effectiveness of a nonsurgical approach to uncomplicated appendicitis in children is planned.

Dr. Minneci and colleagues point out that results of this study are consistent with previously reported results in adults and note that nonoperative management of appendicitis is the initial therapy for adults in many European hospitals.

"A successful non-operative treatment strategy for early appendicitis can markedly decrease the number of appendectomies performed, thereby limiting the number of children and families exposed to the risks and stress associated with surgery," the authors write.

Funding for this study was provided by grants from the National Institutes of Health and intramural funding from the Research Institute at Nationwide Children's Hospital. The authors have disclosed no relevant financial relationships.

J Am Coll Surg. Published online April 12, 2014. Abstract

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