Each year, more than 180,000 adults and 70,000 children undergo an appendectomy in the United States. “Although the surgery is curative, appendectomy is still a major operation that is associated with perioperative risks as well as postoperative pain and disability,” explains Peter C. Minneci, MD, MHSc. “In addition, the recovery of patients undergoing an uncomplicated appendectomy will require a period of disability that can be difficult for patients and caregivers.”

Several clinical trials have assessed nonoperative management of uncomplicated appendicitis and have demonstrated that treatment with antibiotics appears to be both safe and effective in both adults and children. Success rates for nonoperative management have ranged between 65% and 75% at 1 year in these clinical trials, with the added benefits of fewer disability days, improved health-related quality of life (HRQOL), and high parental healthcare satisfaction.

“Most children and adolescents with appendicitis are treated with an appendectomy, but it’s possible that nonoperative management with antibiotics alone may be preferred by patients and their caregivers,” says Dr. Minneci. “This approach has the potential to effectively treat the disease with fewer negative effects on patients.”

New Research

For a study published in JAMA, Dr. Minneci and colleagues sought to determine the success rate of nonoperative management in children with uncomplicated appendicitis. The analysis also compared differences in disability days, HRQOL, complications, and patient satisfaction between an antibiotic alone approach and surgery.

For the study, investigators enrolled 1,068 children aged 7 through 17 years with uncomplicated appendicitis who were treated at 10 U.S. children’s hospitals between 2015 and 2018 and conducted a 1-year follow-up. Patients and their caregivers were given the option to receive nonoperative management or surgery after being counseled using a decision aid. Nonoperative management was selected by 370 patients (35%) whereas 698 (65%) opted for urgent laparoscopic appendectomy (within 12 hours of admission). The nonoperative management group was more likely to be younger, non-Caucasian, have caregivers with more education, and had undergone a diagnostic ultrasound.

Important Findings

According to the results, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% for patients who completed the study follow-up (Table). “When compared with urgent laparoscopic appendectomy, nonoperative management was associated with significantly fewer disability days when assessed at 30 days and at 1 year,” Dr. Minneci says. “Furthermore, the rates of complicated appendicitis and healthcare satisfaction scores were not significantly different between treatment groups.”

The data echoes findings from previous research demonstrating the efficacy and safety of nonoperative management for uncomplicated appendicitis in adults and children. The results can be used to further characterize differences in the risks and benefits of surgery and nonoperative management to treat uncomplicated pediatric appendicitis.

Key Implications

An important aspect of their study was to get input from a multidisciplinary team to design the study to mimic clinical practice and measure outcomes important to patients and families, according to Dr. Minneci. “During the study, each site used a decision aid to explain to patients the risks and benefits of each treatment,” he says. “All treatment decisions after enrollment were made by the clinical team using standardized protocols for each treatment with minimal involvement of the research team. As such, our study protocol should be straightforward to implement because the decision aid and treatment algorithms can be easily translated into pediatric clinical practice.”

Collectively, the study results support offering nonoperative management as a treatment option for uncomplicated pediatric appendicitis. “Giving patients and caregivers a choice in treatment may improve satisfaction with care,” says Dr. Minneci. “As we gain more experience, we may be able to expand the criteria for offering nonoperative management and consider outpatient nonoperative management protocols in the near future.”

One way to increase the potential benefits of nonoperative management would be to decrease or eliminate the hospital stay by performing outpatient management with a long-acting antibiotic and short period of observation in the emergency department. “This approach has been successfully reported in adult patients and continues to be evaluated, but studies are needed to determine if this approach is safe and effective for children,” Dr. Minneci says.

References

Minneci PC, Hade EM, Lawrence AE, et al; for the Midwest Pediatric Surgery Consortium. Association of nonoperative management using antibiotic therapy vs laparoscopic appendectomy with treatment success and disability days in children with uncomplicated appendicitis. JAMA. 2020;324(6):581-593. Available at: https://jamanetwork.com/journals/jama/fullarticle/2768929.

Kyaw L, Pereira NK, Ang CX, Choo CSC, Nah SA. Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation. Eur J Pediatr. 2020;179(5):735-742.

Svensson JF, Patkova B, Almstrom M, et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg. 2015;261(1):67-71.

Tanaka Y, Uchida H, Kawashima H, et al. Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis. J Pediatr Surg. 2015;50(11):1893-1897.

Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320(12):1259-1265.

Minneci PC, Cooper JN, Leonhart K, et al. Effects of a patient activation tool on decision making between surgery and nonoperative management for pediatric appendicitis: a randomized clinical trial. JAMA Netw Open. 2019;2(6):e195009.

Apfeld JC, Cooper JN, Minneci PC, Deans KJ. Pediatric patient and caregiver values in treatment decision-making for uncomplicated appendicitis. JAMA Pediatr. 2020:3;e202289.