Appendicitis is the most common cause for emergency abdominal surgery in childhood, affecting 80,000 children in the US each year, but non-operative treatment options are viable. A study performed by the Midwest Paediatric Surgery Consortium, led by Dr Peter Minneci, and Dr Katherine Deans, co-founders and directors of the Centre for Surgical Outcomes Research at Nationwide Children’s Hospital found that antibiotics alone successfully treated children with uncomplicated appendicitis and was associated with fewer disability days at one year.
Of 1,068 patients from 10 health centres enrolled in the study, 67.1% of those who elected to initially manage their care through antibiotics alone experienced no harmful side effects and did not later require an appendectomy by their one-year follow-up. Patients in the non-operative group experienced an average of 6.6 disability days, compared to the 10.9 days in the surgery group. Non-operative management was also associated with fewer disability days for caregivers.
This research, funded by a Patient Centred Outcomes Research Institute (PCORI) award, expands on an initial pilot study Minneci and Deans published in 2015, which first demonstrated the efficacy and safety of non-operative management of appendicitis in children by showing that children who were hospitalized for uncomplicated appendicitis – who experienced abdominal pain for no more than 48 hours, had a white blood cell count below 18,000 and underwent an ultrasound or CT scan to rule out rupture and to verify that their appendix was 1.1 centimetre thick or smaller with no evidence of an abscess or fecalith – and who elected initially to be treated with antibiotics could be successfully sent home without the use of traditional surgery.
“For surgery, patients need to go under general anaesthesia, and there is 1-2% chance of a major complication and 5-10% chance of a minor complication,” says Minneci, principal investigator of the studies with Deans. “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.”
Additionally, the study, which was designed to mimic clinical practice and used a decision aid to educate patients about the risks and benefits of each treatment option, found that both the patients who elected to undergo surgery and those who chose nonoperative management with antibiotics alone had similar rates of complicated appendicitis, and reported similar health care satisfaction at 30 days and quality of life at 1 year.
Minneci and Deans say that future research could study how to disseminate these results so that more patients can be informed of the two options and the risks and benefits of each. The decision aid and treatment protocols developed for this study were developed to minimize risks and can be easily translated into paediatric clinical practice.
“Culture change and rethinking how we treat patients is always hard,” says Deans. “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 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.”
Abstract
Importance: Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery.
Objective: 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.
Design, Setting, and Participants: Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children’s hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study.
Interventions: Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698).
Main Outcomes and Measures: The 2 primary outcomes assessed at 1 year were 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%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments.
Results: Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. 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 IPTW, 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 did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, −4.3 days (99% CI, −6.17 to −2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference.
Conclusion and Relevance: 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. 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.
Authors
Minneci PC, Hade EM, Lawrence AE, Sebastiao YV, Saito JM, Maki GZ, Fox C, Hirschi RB, Gadepalli S, Helmrath MA, Kohler JE, Leys CM, Sato TT, Lal DR, Landman MP, Kabre R, Fallat ME, Cooper JN, Deans KJ for the Midwest Pediatric Surgery Consortium
[link url="https://www.nationwidechildrens.org/newsroom/news-releases/2020/07/midwest-pediatric-surgery-consortium#:~:text=A%20study%20performed%20by%20the,alone%20successfully%20treated%20children%20with"]Nationwide Children's Hospital material[/link]
[link url="https://jamanetwork.com/journals/jama/fullarticle/2768929"]JAMA abstract[/link]
See also…
[link url="https://www.medicalbrief.co.za/archives/antibiotic-treatment-acute-appendicitis-mostly-safe-children/"]Antibiotic treatment of acute appendicitis mostly safe for children[/link]
[link url="https://www.medicalbrief.co.za/archives/antibiotics-successfully-treating-appendicitis/"]Antibiotics an alternative to surgery for appendicitis[/link]
[link url="https://www.medicalbrief.co.za/archives/treating-child-appendicitis/"]Treating child appendicitis[/link]