Studies show that acute appendicitis accounts for more than 11% of pediatric ED admissions, and more than 70,000 children in the United States are hospitalized for it each year. Appendectomy is curative but invasive procedure that requires general anesthesia. For children, this includes perioperative risks and postoperative pain as well as disability. Research suggests that children can miss up to 2 weeks of activities after undergoing appendectomy, and their caregivers may experience similar disruptions to their normal schedules.
An Alternative Approach
In clinical trials, the rate of perioperative complications in patients undergoing an appendectomy for uncomplicated appendicitis ranges between 5% and 10%. Serious complications, such as reoperations or readmissions, occur in 1% to 7% of these patients. In Europe, several recent randomized clinical trials have shown that taking a non-operative management approach to appendicitis appears to be medically safe and effective in adults, with a success rate ranging between 63% and 85%. Non-operative management approaches to treat appendicitis typically involve intravenous antibiotics until symptom improvement and then a short course of oral antibiotics.
“When making a treatment decision involving either a surgery or a less invasive approach, patients and families may have strong and varying treatment preferences,” explains Peter C. Minneci, MD, MHSc. “Each patient may have different risks and outcomes that are most important to them. Some may value avoiding pain and disability while others may value avoiding general anesthesia. In addition, the success of non-operative management of appendicitis may depend on the patient’s and family’s willingness to accept an ongoing risk for recurrent appendicitis. The pros and cons of these treatment options should be described to patients and their family before a specific treatment option is selected.”
In a study published in JAMA Surgery, Dr. Minneci and colleagues evaluated the overall effectiveness of patient choice in non-operative versus surgical management of uncomplicated acute appendicitis in children aged 7 to 17 in the context of engaging the family in the treatment decision. The authors used a patient choice design and assessed patient-centered outcomes and healthcare costs as well as medical outcomes.
Patients received either urgent appendectomy or non-operative management that involved at least 24 hours of inpatient observation while receiving intravenous antibiotics. For non-operative management, patients needed to demonstrate improvement of symptoms and complete 10 days of oral antibiotic treatment. Of the 102 patients enrolled in the study, 65 patients and families chose appendectomy whereas 37 chose non-operative management.
“The success rate of non-operative management was about 89% at 30 days and nearly 76% at 1 year,” says Dr. Minneci. The incidence of complicated appendicitis was less than 3% in the non-operative group and slightly more than 12% in the surgery group. When compared with the surgery group, children managed without surgery had fewer disability days and lower appendicitis-related healthcare costs after 1 year. The non-operative group had a longer length of stay in the hospital (20 vs 37 hours, respectively), but rates of appendicitis-related medical care within 30 days were similar between the two groups analyzed in the study (Table).
“When chosen by the family, a non-operative management approach with antibiotics alone is an effective treatment strategy for children with uncomplicated appendicitis,” says Dr. Minneci. “The non-operative management strategy also resulted in less morbidity and lower costs than surgery. About three in four patients who chose non-operative management did not undergo an appendectomy when assessed at 1-year follow-up.”
According to Dr. Minneci, results of the analysis can help to further inform the decision-making process of patients and families when faced with the choice between surgery and antibiotics alone. “Research shows that engaging families in shared decision making in pediatric clinical care can improve medical outcomes,” he says. “Our study results reflect the effectiveness of offering non-operative management as an option to patients and their families.” Authors of the study added that the high enrollment rate and alignment of treatment choice with preferences in the analysis allow the results to be generalizable to clinical practice.
Engaging Patients & Families
Accounting for real-life concerns among patients and their families is important in establishing the true effectiveness of a treatment in clinical practice. Dr. Minneci recommends that clinicians strive to use a patient choice design in order to ensure that selected therapies are aligned with preferences of the patient and his or her family. “Making efforts to take this approach may help minimize the potential for negative effects of patient preferences,” he says.
Minneci PC, Mahida JB, Lodwick DL, et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis. JAMA Surg. 2015 Dec 16 [Epub ahead of print]. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=2475977.
Minneci PC, Sulkowski JP, Nacion KM, et al. Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. J AmColl Surg. 2014;219:272-279.
Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomized controlled trials. BMJ. 2012;344:e2156.
Svensson JF, Patkova B, AlmströmM, et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg. 2015;261:67-71.