Many Kids With Uncomplicated Appendicitis Can Skip Surgery

Troy Brown, RN

December 17, 2015

Most children with uncomplicated appendicitis avoided surgery at 1 year when they and their families initially chose to manage the condition nonoperatively, according to a prospective patient choice cohort study published online December 16 in JAMA Surgery.

"Families who choose to treat their child's appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn't work, have expressed that for them it was worth it to try antibiotics to avoid surgery," Peter C. Minneci, MD, from the Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, and the Department of Surgery, Nationwide Children’s Hospital, Columbus, Ohio, said in a news release.

"These patients avoided the risks of surgery and anesthesia, and they quickly went back to their activities," he said.

The study included 102 patients aged 7 to 17 years diagnosed with acute uncomplicated appendicitis from October 1, 2012, through March 6, 2013. Of those, 37 chose to manage the appendicitis nonoperatively and 65 chose to undergo surgery.

The study's primary outcome was the success rate of nonoperative management at 1 year, where success was defined as "not having undergone an appendectomy at 1 year." Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days for the child, disability rates for the parent, and healthcare costs at 1 year.

The researchers defined complicated appendicitis as having pathological analysis showing ruptured, perforated, or gangrenous appendicitis.

The success rate of nonoperative management was 94.6% (95% confidence interval [CI], 81.8% - 99.3%; 35 of 37 children), 89.2% (95% CI, 74.6% - 97.0%; 33 of 37 children), and 75.7% (95% CI, 58.9% - 88.2%; 28 of 37 children) at hospital discharge, 30 days, and 1 year, respectively.

The overall success rate of nonoperative management was 75.7% (28 of 35 children) at a median follow-up of 21 months.

The nonoperative group had longer hospitalizations compared with the surgery group (median, 37 [interquartile range (IQR), 29 - 41] vs 20 [interquartile range (IQR) 15 - 30] hours, respectively; P < .001). Two patients in the nonsurgical group had readmissions for recurrent appendicitis within 30 days and underwent laparoscopic appendectomy.

The rates of complicated appendicitis at 1 year were not significantly different between the two groups, at 2.7% (1 of 37 children) for the nonoperative management group and 12.3% (8 of 65 children) for the surgery group (P = .15).

At 1 year, the postoperative complication rate in those who chose surgery was 7.7% (five of 65 patients), with two major complications (one readmission, one reoperation). No postoperative complications occurred among the nonoperative patients who underwent appendectomy later.

Healthcare-related quality-of-life scores were similar for the two groups at 1 year. Nonoperative management was associated with significantly fewer disability days at 1 year compared with surgery (median, 8 [IQR, 5 - 18] vs 21 [IQR, 15 - 25] days, respectively; P < .001).

And nonoperative management was associated with lower total appendicitis-related healthcare costs at 1 year compared with surgery (median, $4219 [IQR, $2514 - $7795] vs $5029 [IQR, $4596 - $5482], respectively; P = .01).

The cost sensitivity analysis showed that total appendicitis-related healthcare costs at 1 year remained significantly lower in the nonoperative group compared with in the surgery group (median, $4219 [IQR, $2691 - $6536] vs $4992 [IQR, $4688 - $5636], respectively; P = .01).

"When Should Patients Have the Choice?"

"The idea that patient choice both empowers the patient and improves overall patient satisfaction is well established. The question is, when should patients have the choice?" write Diana Lee Farmer, MD, and Rebecca Anne Stark, MD, from the University of California Davis School of Medicine and the University of California Davis Children’s Hospital, in an invited commentary.

The commentators note that the concept of patient choice has gained favor in "several niches of patient care."

"Demonstrating that different treatment options have equivalent outcomes is the first step in determining whether offering a choice is safe," they explain. "However, balancing the biases of both the physician and the patient is difficult, especially because physician bias is based on personal experience and comfort level and thus may be of more value than the bias of the patient."

They conclude, "Further study is needed in this arena before we completely abdicate the responsibility for guiding our patient's decision making. Many patients still want us to be 'doctors,' not Google impersonators."

The authors and commentators have disclosed no relevant financial relationships.

JAMA Surgery. Published online December 16, 2015. Article full text, Commentary extract

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