Surgical vs. Nonoperative Management for Pediatric Appendicitis

Katherine Bakes, MD reviewing Minneci PC et al. JAMA Surg 2015 Dec 16.

At 1 year, the rate of perforated appendicitis was similar between groups, while total disability days and healthcare costs were lower in the nonoperative group.

Is nonoperative management of uncomplicated appendicitis in children safe? To find out, researchers at a pediatric emergency department prospectively studied children aged 7 to 17 years who presented with nonperforated acute appendicitis and ≤48 hours of abdominal pain and who underwent either laparoscopic appendectomy or nonoperative medical management based on patient and family choice. Patients in the surgery group received intravenous antibiotics and underwent appendectomy within 12 hours. Those undergoing nonoperative management received IV antibiotics for at least 24 hours followed by a 10-day course of oral antibiotics. Patients with worsening or nonchanging symptoms after 24 hours underwent appendectomy.

Of 102 children enrolled, 37 chose nonoperative management and 65 chose surgery. Nonoperative patients were less likely to have been transferred and less likely to speak primarily English. The success rate of nonoperative management (i.e., no appendectomy) at 1 year (the primary outcome) was 76%. In the surgery group, the negative appendectomy rate was 6% and the 1-year postoperative complication rate was 8%. At 1 year, the rate of perforated appendicitis was similar between the nonoperative and surgery groups (3% and 12%), and the nonoperative group had fewer median disability days (8 vs. 21) and lower appendicitis-related healthcare costs ($4219 vs. $5029). The two groups had similar quality of life scores.

Citation(s):

Minneci PC et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis. JAMA Surg 2015 Dec 16; [e-pub].