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Appendectomy or antibiotics?

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Appendicitis is a common diagnosis in ED, and once it is confirmed clinically or on ultrasound, the patient usually goes pretty quickly to theatre for an appendectomy. But is a course of antibiotics just as effective as taking these kids to theatre?

A recent article accepted for publication in the Journal of the American College of Surgeons (Feb 2014) investigated this question in a prospective, non-randomised trial comparing urgent appendectomy with antibiotic management of acute appendicitis in children.

Minneci PC, Sulkowski JP, Nacion KM, Mahida JB, Cooper JN, Moss RL, Deans KJ, Feasibility of a Nonoperative Management Strategy for Uncomplicated Acute Appendicitis in Children, Journal of the American College of Surgeons (2014), DOI: 10.1016/j.jamcollsurg.2014.02.031.

Who were the patients?

Eligible children who presented to the author’s hospital (in the USA) were:

  • 7-17 years old
  • Less than 48 hours of abdominal pain
  • WCC < 18 000
  • US or CT confirming non-ruptured appendicitis (appendix <1.1cm, no phlegmon, abscess or faecolith)
  • Surgical review confirming clinical appendicitis

Exclusion criteria:

  • Diffuse peritonitis
  • Positive pregnancy test
  • Chronic abdominal pain

There were 77 patients in the study.

What was the intervention?

Enrolled patients could opt for surgical management or non-operative management. Of the 77 patients: 47 chose surgery and 30 chose non-operative management.

The surgical group went straight for an appendectomy, with antibiotics prior to surgery (these were discontinued post-op).

The non-operative group had:

  • Minimum 24 hours of piperacillin/tazobactam
  • Minimum of 12 hours nil by mouth and then could start a diet if the pain was improving
  • Pain relief PRN
  • Switched to oral amoxicillin once tolerating oral diet and once discharged should have completed a total of 10 days of antibiotics

Doesn’t this seem a bit dangerous?

Patients were removed from the non-operative group if they did not show clinical improvement within 24 hours of antibiotics; or if they returned with abdominal pain after discharge.

What was the follow-up?

Patients were followed up for 30 days to look at outcomes which included: non-operative management; length of hospital stay; disability days; quality of life.

So what happened?

After 30 days, 27 out of the 30 patients had successful non-operative management. Of the three that failed:

  • One had an appendectomy within the first 24 hours due to failure to improve and had acute appendicitis
  • One had an appendectomy within the first 24 hours due to failure to improve and had appendicitis secondary to a tumour
  • One had an appendectomy after representation one-day post-discharge and the appendix was normal

In the non-operative group, there was a longer hospital stay, but a shorter time to return to normal activity. Quality of life scores were higher at 30 days in the non-operative group.

Previously most studies on the conservative management of appendicitis have been on adults, and this study in children provides some promising preliminary results (although it is on quite a small sample). The main risk from missed appendicitis would be from a perforated appendix, and none of the patients in this study went on to have a perforated appendix within 30 days.

However, longer-term issues would be recurrent abdominal pain which could have a significant impact on the lives of these families; and also the eventual outcome of appendectomy as this would negate the benefit of the delay. The authors are aiming to follow up in 1 year so we should keep an eye out for the next article from this group of authors.

About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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