The report in JAMA advises that, of 1,068 patients from 10 health centers enrolled in the study, 67.1% of those who elected to initially manage their care through antibiotics alone had no problems.
Researchers from Nationwide Children’s Hospital and The Ohio State University College of Medicine also point out that patients in the nonoperative group experienced an average of 6.6 disability days, compared with the 10.9 days in the group receiving surgery.
The findings are important, according to the authors, because appendicitis is the most common cause for emergency abdominal surgery in childhood, affecting 80,000 children in the United States each year. Yet viable nonoperative treatment options are available, they emphasize.
“For surgery, patients need to go under general anesthesia, and there is 1-2% chance of a major complication and 5-10% chance of a minor complication,” said coprincipal investigator of the study Peter Minneci, MD. “And patients will definitely experience post-operative pain and disability. Treatment-related disability is important to kids, because it means missing activities in their lives that may directly affect their development and quality of life such as school, athletics and vacations.”
Researchers sought to determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis. The multi-institutional nonrandomized controlled intervention study included children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children’s hospitals across seven U.S. states. The study was conducted between May 2015 and October 2018, with 1-year follow-up through October 2019.
Overall, 370 patients and families selected nonoperative management with antibiotics alone, while 698 opted for urgent laparoscopic appendectomy with 12 hours of admission. The patients, 38% girls, had a median age of 12.4 years.
The authors assessed two primary outcomes at 1 year; disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%).
Follow-up involved 806 patients—284 (77%) in the nonoperative group and 522 (75%) in the surgery group.
Results indicate that patients in the nonoperative group were more often younger (median age, 12.3 years vs. 12.5 years); Black (9.6% vs. 4.9%) or other race (14.6% vs. 8.7%); had caregivers with a bachelor’s degree (29.8% vs. 23.5%), and underwent diagnostic ultrasound (79.7% vs. 74.5%).
After analysis, researchers determined that the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than was surgery (adjusted mean, 6.6 vs. 10.9 days; mean difference, −4.3 days (99% CI, −6.17 to −2.43; P < .001).
“Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year,” the authors conclude. “However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met.”
“Culture change and rethinking how we treat patients is always hard,” added coprincipal investigator Katherine Deans, MD. “Right now, some of the standards for success among surgeons are different than among patients and families. Surgeons’ tend to be passionate about operations, and an appendectomy is a well-tested and trusted procedure. However, some patients want to avoid surgery at all costs, and the results of our studies reflect the effectiveness of offering a non-operative management to patients and their families in clinical practice. This allows us to move away from a one-size-fits-all model of appendicitis care and treat each child based on his or her values and preferences.”
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