Risks associated with nonoperative management of uncomplicated pediatric appendicitis

1. In a retrospective cohort study of approximately 73,000 children with non-perforated appendicitis, 14% were managed non-operatively with antibiotics, of which 20% experienced subsequent perforated appendicitis and/or required appendectomy.

2. Nonoperative management of nonperforated pediatric appendicitis increased by approximately 30% between 2011 and 2020.

Evidence Rating Level: 2 (Good)

Study Rundown: Appendectomy has traditionally been considered the standard of care for management of uncomplicated appendicitis in children. Recently, nonoperative management using antibiotics has become more common, and is endorsed by international guidelines under select circumstances. However, evidence regarding its success and safety in a pediatric population is limited to a small number of prospective trials. The objective of this large retrospective cohort study was to compare outcomes in children <19 years of age who received nonoperative (i.e., antibiotics) versus operative management (i.e., appendectomy) for nonperforated appendicitis. In total, nonoperative management increased from 3 to 33% between 2011-2020. Among children who were managed nonoperatively, the rate of treatment failure was 19% at 1 year and 23% at 5 years. In children who experienced treatment failure, the rate of perforated appendicitis was 46%, compared to 38% in children who initially presented with perforated appendicitis in the larger cohort (p<0.001). Nonoperative management was additionally associated with higher rates of future hospitalization, emergency department visits, and postsurgical complications within 1 year. Overall, this study indicates that children with appendicitis are at risk for several complications including perforated appendicitis, although the majority of children do not experience treatment failure. Future trials should investigate patient-specific factors that may contribute to the success or failure of nonoperative management of pediatric appendicitis.

Click to read the study in PEDIATRICS

Relevant Reading: Association of nonoperative management using antibiotic therapy vs laparoscopic appendectomy with treatment success and disability days in children with uncomplicated appendicitis

In-Depth [retrospective cohort]: Administrative data from the Pediatric Health Information System (PHIS), which includes data from >50 tertiary care pediatric hospitals in the United States, was analyzed. In the nonoperative management group, treatment outcomes included failure (i.e., appendectomy or perforated appendicitis) that were early (within <14 days of index visit) or late (>14 days of index visit), postsurgical complications (i.e., wound dehiscence, wound infection, incisional hernia or intestinal obstruction), and subsequent healthcare utilization (i.e., repeat emergency department or hospital visits for appendicitis, abdominal pain, intestinal obstruction, vomiting, diarrhea, dehydration, or postsurgical complication). Between 2011-2020, 73,544 children <19 years of age had a primary diagnosis of nonperforated appendicitis, of which 10,394 children (14%) received nonoperative management. The odds of nonoperative management of appendicitis increased from 3% to 33% over the study period (OR 1.10 per study quarter). Failure rates were approximately 19% and 23% at the 1-year and 5-year mark, respectively. Both treatment failure outcomes were increased after nonoperative management compared to operative management, with higher rates of perforated appendicitis (46% versus 38%, p<0.001), subsequent related emergency department visits (8% versus 5%, p<0.001) and hospitalizations (4% versus 1%, p<0.001) over the 1-year follow-up period.

Image: PD

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