Columbus, OH—Over the last decade or so, evidence has increased that many uncomplicated cases of appendicitis—even in children—can be managed nonoperatively and primarily with antibiotic therapy. Why this works in some cases and not in others has remained unclear.

A new study in the Journal of the American Medical Association Network Open looks at the factors associated with the failure of nonoperative management of appendicitis. It also asks if patient-reported outcomes differ between those whose treatment succeeded versus those whose treatment failed.

In the subgroup analysis of a nonrandomized clinical trial of 1,068 patients, a study team led by researchers from Nationwide Children's Hospital and The Ohio State University College of Medicine reported that higher pain scores at presentation signaled an increased risk of in-hospital treatment failure. Longer pain duration was found to be linked to decreased risk of delayed treatment failure.

"Although satisfaction was high overall, patients with successful nonoperative management had higher satisfaction with their decision at 1 year than those whose treatment failed," the authors noted.

The study was conducted in 10 children's hospitals and included 370 children aged 7 to 17 years with uncomplicated appendicitis. They were enrolled in a prospective, nonrandomized clinical trial between May 1, 2015, and October 31, 2018, with 1-year follow-up comparing nonoperative management with antibiotics versus surgery for uncomplicated appendicitis. Statistical analysis was performed from November 1, 2019, to February 12, 2022.

Those 370 patients were part of a larger group of 1,068 total patients participating in the study; 61.9% were boys with a median age of 12.3 years (interquartile range, 10.0-14.6 years) enrolled in the nonoperative group.

Researchers advise that treatment failure occurred for 125 patients (33.8%) at 1 year, with 53 patients (14.3%) undergoing appendectomy during initial hospitalization and 72 patients (19.5%) having delayed treatment failure after hospital discharge.

"Higher patient-reported pain at presentation was associated with increased risk of in-hospital treatment failure (RR [relative risk], 2.1 [95% CI, 1.0-4.4]) but not delayed treatment failure (RR, 1.3 [95% CI, 0.7-2.3]) or overall treatment failure at 1 year (RR, 1.5 [95% CI, 1.0-2.2]). Pain duration greater than 24 hours was associated with decreased risk of delayed treatment failure (RR, 0.3 [95% CI, 0.1-1.0]) but not in-hospital treatment failure (RR, 1.2 [95% CI, 0.5-2.7]) or treatment failure at 1 year (RR, 0.7 [95% CI, 0.4-1.2])."

Neither age, white blood cell count, sex, race, ethnicity, primary language, insurance status, transfer status, symptoms at presentation, nor imaging results were determined to be associated with treatment failure, according to the report.

In addition, healthcare satisfaction at 30 days and patient-reported, health-related quality of life at 30 days and 1 year did not differ between groups. Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs. 27.0; difference, 1.0 [95% CI, 0.01-2.0]) and 1 year (28.1 vs. 27.0; difference, 1.1 [95% CI, 0.2-2.0]), the authors added.

"This analysis suggests that a higher pain level at presentation was associated with a higher risk of initial failure of nonoperative management and that a longer duration of pain was associated with lower risk of delayed treatment failure," the researchers concluded. "Although satisfaction was high in both groups, satisfaction with the treatment decision was higher among patients with successful nonoperative management at 1 year."

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