A role for conservative antibiotic treatment in early appendicitis in children

Non-operative treatment for simple acute appendicitis (NOTA) in children during the COVID-19 era: new lessons from the pandemic

Coronavirus (COVID-19) was a pandemic disease that was affecting our medical and surgical daily practice badly. The surgical management of acute appendicitis was the gold standard, but new studies suggest the safety of antibiotic treatment alone. Non-operative treatment for simple acute appendicitis (NOTA) avoids surgery, the risks of general anesthesia, and long hospital stays. It also decreases the risk of exposure to coronavirus. We aimed to study the cost-effectiveness and outcome of NOTA during the COVID-19 pandemic and compared it to single-incision pediatric endo-surgery appendectomy (SIPESA). A prospective cohort study for NOTA of patients from 6 to 12 years old in the COVID-19 pandemic period from April 1st, 2020, to April 30th, 2021, patients were divided into two groups: Group S was managed by SIPESA, and Group N was managed by NOTA. Family education and assurance with detailed explanation were done for early detection of any complications, and we continue monitoring the patients until their complete recovery. Group S had 24 cases (40%), mean age 9.3 years. Group N had 36 cases (60%), mean age 9.1 years. Six cases (17%) in group N were converted to surgical management in the first 6 months of the study. The mean cost dropped from $2736/day to $400/day. The mean psychological stress for the children improved from 4.4 in April to 2 in September. The mean follow-up was 3.5 months. NOTA is a feasible, cost-effective approach, and we recommend it, as we have learned this lesson during the COVID-19 pandemic days.

Non-operative treatment of acute appendicitis in children: clinical efficacy of amoxicillin-clavulanic acid in a retrospective single-centre study

BACKGROUND

The success rate of non-operative treatment (NOT) of acute uncomplicated appendicitis (AUA) in children varies from 65% to 95%. There are no recommendations on the appropriate antibiotic therapy.

OBJECTIVE

To determine the clinical efficacy of amoxicillin-clavulanic acid for NOT of AUA in children.

METHODS

Design: Cross-sectional study in a single medical centre.

SETTINGS

Emergency department and Paediatric Visceral Surgery department of the Children Hospital in Toulouse, France.

PATIENTS

Patients 5-15 years old who were diagnosed with appendicitis, (1) With abdominal pain and a first episode of acute appendicitis, (2) With no radiological or ultrasound evidence of appendicolith, appendiceal perforation, pelvic abscess nor peritonitis, and (3) With non-septic general aspect, were included.

INTERVENTIONS

NOT consisted of hospital admission. The antibiotic treatment was a combination of amoxicillin and clavulanic acid (80 mg/kg/day of amoxicillin): intravenous regimen during 48 hours followed by oral route during 7 days.

MAIN OUTCOME MEASURE

Success rate of amoxicillin-clavulanic acid NOT in children with AUA at 2 years.

RESULTS

The initial success rate of amoxicillin-clavulanic acid NOT in children with AUA was 100% (104/104 patients). The success rate at 2 years was 85.6% (89/104) at discharge. None of the 15 patients who underwent surgery after recurrence of appendicitis presented with peritonitis, appendiceal perforation nor pelvic abscess.

CONCLUSION

Narrowed antibiotic therapy with amoxicillin and clavulanic acid seems to be an alternative to surgery in children with AUA. It is necessary to wait for the results of ongoing studies to confirm these results.

Appendicitis in Children

The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.

Follow-up ultrasonographic findings among children treated conservatively for uncomplicated acute appendicitis

BACKGROUND

Ultrasound is an accurate tool for diagnosing acute appendicitis. Conservative treatment for uncomplicated acute appendicitis is feasible and safe in children. However, no sonographic follow-up results from children with nonoperatively managed acute appendicitis have been reported.

OBJECTIVE

To describe the sonographic appearance of the appendix at follow-up ultrasound and to attempt to identify signs predictive of recurrent acute appendicitis.

MATERIALS AND METHODS

Children diagnosed with uncomplicated acute appendicitis and treated conservatively in our hospital from 2014 to 2019, and who presented for follow-up ultrasound at 3, 6 and 9 months, were included in our study. Clinical, laboratory and ultrasound data were recorded.

RESULTS

By the end of follow-up, 29 (14.2%) of 204 children in the cohort had developed recurrent acute appendicitis and 175 had recovered uneventfully. On follow-up ultrasound, appendiceal diameter measured > 6 mm in 56/204 (27.5%) cases at 3 months and in 9/26 (34.5%) at 6 months. After 3 months, 102/204 (50%) children had normal appendiceal diameter on ultrasound. Appendiceal diameter > 6 mm was associated with intraluminal fluid or sludge in the appendiceal lumen at 3- and 6-month follow-up (P < 0.001, P = 0.002, respectively). Comparing cases with and without recurrence, at 3-month follow-up, appendiceal diameter > 6 mm was found in 17/29 (58.6%) cases vs. 39/175 (22.3%), respectively (P < 0.001). Appendiceal diameter returned to normal in 12/19 (63.2%) cases in the nonrecurrent acute appendicitis group compared with 2/7 (28.6%) in the recurrent acute appendicitis group (P = 0.05) at the 6-month follow-up. Intraluminal fluid or sludge was detected more frequently in the recurrent acute appendicitis versus the nonrecurrent acute appendicitis group at 3- (P < 0.001) and 6-month (P = 0.001) follow-up.

CONCLUSION

Progressive normalization of appendiceal diameter was noted on follow-up ultrasound. The prevalence of both appendiceal diameter > 6 mm and intraluminal fluid or sludge were found to be increased in children who later developed recurrent acute appendicitis. Ultrasound appears to be a useful tool for follow-up in children with conservatively treated uncomplicated acute appendicitis and possibly might help predict recurrence.

Effectiveness of nonsurgical antibiotic treatment in the experimental appendicitis model in rats

Background

In this study, we aimed to demonstrate efficacy and laboratory follow-up criteria of nonsurgical antibiotic treatment in uncomplicated acute appendicitis. We established an experimental appendicitis model in rats, and antibiotic treatment was evaluated by biochemical and immunohistochemical changes.

Materials and method

In the study, 28 rats were divided into 4 groups. Group 1 constituted the group of sham; group 2 was the control group that appendicitis model was created and did not receive any treatment. Group 3 was created as an appendicitis model and was given regular antibiotic treatment. In group 4, appendicitis model was created, and appendectomy was performed on the 2nd day. Blood samples were taken from the rats on the 0, 2nd, and 7th days in all groups. Rats in groups 1, 2, and 3 underwent appendectomy with laparotomy under anesthesia on the 7th day. Serum C-reactive protein (CRP), procalcitonin, and leukocyte levels were measured for biochemical analysis. In immunohistochemical evaluation, inflammation severity of the tissue samples taken from appendices was evaluated. Also, tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) levels of tissue samples were evaluated.

Results

A statistically significant difference in CRP values was observed between groups 1 and 2 on the 7th day (p = 0.046), between groups 1 and 4 on 0 and 2nd days (p = 0.004, p = 0.004), between groups 2 and 3 on 0, 2nd, and 7th days (p = 0.018, 0.013, 0.025), between groups 2 and 4 on 0, 2nd, and 7th days (p = 0.002, p = 0.002, p = 0.009), and between groups 3 and 4 on 0 and 2nd days (p = 0.013, p = 0.025). There was a significant difference in procalcitonin values between groups 1 and 3 on the 7th day (p = 0.032) and between groups 1 and 4 on day 0 (p = 0.019). A significant difference was also observed in TNF-α and IL-6 inflammation between groups 2 and 3 (p = 0.031, p = 0.018) and between groups 2 and 4 (p = 0.031, p = 0.01).

Conclusion

Acute uncomplicated and early appendicitis may be treated with antibiotics. According to our results, CRP levels are useful as follow-up criterion in experimental appendicitis model. Clinical studies on the assessment of CRP levels in the course of nonsurgical treatment in the patients with acute appendicitis will reveal out the effectiveness of this marker.

Uses of Antibiotics Alone in Case of Uncomplicated Appendicitis

The frequent abdominal surgical emergency is acute appendicitis with a significantly less lifelong risk. One of the most common surgeries manifested is an appendectomy, but with recent advances, non-operative management has evolved using antibiotics. In adult patients with simple appendicitis, we identified the role of surgical and non-surgical therapy. One of the most common surgeries manifested is an appendectomy, but with recent advances, non-operative management has evolved using antibiotics. In adults suffering from mild appendicitis, we identified the role of surgical and non-surgical therapy. The analysis indicated that the Antibiotics versus Primary Appendectomy in Children (APAC) did not establish non-inferiority of antibiotics vs. appendectomy with a pre-specified small margin.

In contrast to the majority of appendectomies that are carried out laparoscopically, the surgeries were almost usually open. Appendectomies, both laparoscopic and open, are not the same procedure. Antibiotic therapy is effective in about 60% of cases of simple appendicitis. A surgery-only strategy would reduce antibiotic exposure, a factor to consider in these days of antimicrobial stewardship. Therefore, studies are being conducted on whether to shift alone on antibiotics or with appendectomy to have better results with fewer complications. Future studies should focus on appendicitis features and long-term unfavorable consequences, including antibiotic resistance or Clostridium difficile colitis, most responsive to antibiotics by utilizing laparoscopic procedures as controls. Using it along with appendectomy may change the outcome showing a better prognosis.

New Criteria Could Improve the Success Rate of Non-operative Management of Acute Appendicitis in Children

Background: Most studies addressing non-operative management for acute appendicitis have focused on adults, and there are limited data available for children. We aimed to evaluate the results of successful non-operative management in children with acute uncomplicated appendicitis with our “additional criteria” and find which factors could be affecting the success rate and which cases could be candidates for non-operative management.

Materials and methods: A total of 54 patients who were diagnosed with acute uncomplicated appendicitis and received non-operative management were re-evaluated retrospectively. Defining uncomplicated appendicitis was based on the duration of symptoms (<24 hours), clinical history, and radiologic findings. The radiologic evaluation was based on ultrasonography and computed tomography. The patients received an intravenous antibiotic combination (sulbactam/ampicillin, gentamicin, clindamycin) for five days at the hospital; the treatment was completed after 10 days with an oral antibiotic combination (amoxicillin/clavulanate, metronidazole). The cases have a follow-up period of up to two years.

Results: The mean patient age and follow-up time were 13.0 ± 4 years and 41.6 ± 13 months, respectively. The mean leukocyte count, C-reactive protein (CRP), and appendix diameter values were 15.48 ± 6.4 × 109/L, 11.79 ± 24.5 mg/dL, and 7.76 ± 1.4 mm on admission, and 6.86 ± 12.4 × 109/L, 4.17 ± 10.3 mg/dL, and 5.82 ± 1.6 mm on the second day, respectively. This decrease in WBC/CRP values and appendix diameter was statistically significant (p < 0.001). None of the patients had an early failure, complication, or adverse event. Recurrent appendicitis occurred in only five cases (9%) that were treated by laparoscopic appendectomy during the follow-up.

Conclusion: Non-operative management for acute uncomplicated appendicitis in children regarding long-term outcomes with our criteria was satisfactory and initial success rates were excellent.

Nonoperative Management of Uncomplicated Appendicitis

BACKGROUND AND OBJECTIVES

Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking.

METHODS

We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis.

RESULTS

We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period.

CONCLUSIONS

NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.

Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT

BACKGROUND

Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking.

OBJECTIVES

The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children.

DESIGN

This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set.

SETTING

This study was set in three specialist NHS paediatric surgical units in England.

PARTICIPANTS

Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set.

INTERVENTIONS

Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial.

DATA SOURCES

Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews.

RESULTS

Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol.

LIMITATIONS

Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time.

CONCLUSIONS

A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres.

FUTURE WORK

Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15830435.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.

Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children

Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.

Nonoperative treatment for nonperforated appendicitis in children: a systematic review and meta-analysis

Acute appendicitis is the most common surgical emergency in children. Nonoperative treatment of nonperforated acute appendicitis in children is an alternative to appendectomy. The purpose of this systematic review and meta-analysis was to determine the outcomes of nonoperative treatment of nonperforated acute appendicitis in children in the literature. Databases were searched to identify abstracts, using predefined search terms. The abstracts were reviewed by two independent reviewers and articles were selected according to inclusion and exclusion criteria. Data were extracted by the two reviewers and analyzed. The literature search yielded 2743 abstracts. Twenty-one articles were selected for analysis. The study design was heterogenous, with only one randomized controlled study. The symptoms resolved in 92% [95% CI (88; 96)] of the nonoperatively treated patients. Meta-analysis showed that an additional 16% (95% CI 10; 22) of patients underwent appendectomy after discharge from initial hospital stay. Complications and length of hospital stay was not different among patients treated with antibiotics compared with those who underwent appendectomy. Nonoperative treatment of nonperforated acute appendicitis children is safe and efficient. There is a lack of large randomized controlled trials to compare outcomes of nonoperative treatment with appendectomy.

Indications for Nonoperative Management of Uncomplicated Appendicitis in Children: A Prospective Analysis at a Single Institution

Aim: To assess nonoperative management (NOM) of uncomplicated appendicitis (UC-appy) in children to determine factors influencing prognosis and review the literature. Materials and Methods: All UC-appy cases presenting younger than 16 years between 2015 and 2018 who had NOM (one dose of intravenous analgesia and intravenous piperacillin/tazobactam 112.5 mg/kg 8 hourly) and were followed up for at least 3 months were reviewed prospectively (n = 146). Perceived pain and fever were assessed 12 hourly, biochemistry daily. If predetermined cutoff results were not achieved at each assessment, NOM was abandoned and urgent laparoscopic appendectomy (ULA) performed. Results: NOM succeeded in 48.6% (S-NOM; n = 71) and failed in 51.4% (F-NOM; n = 75). Mean age at presentation (10.7 ± 2.5 versus 8.6 ± 3.7 years old; P < .0001) and duration of preadmission fever (1.0 ± 0.9 versus 2.1 ± 1.2 days; P < .0001) were the only significantly different criteria between S-NOM and F-NOM. Optimal cutoff values using receiver operating characteristic curve analysis were 7.0 years old (32% sensitivity and 93% specificity) and 1.0 day (95% sensitivity and 25% specificity), respectively. NOM was abandoned for persistent pain, prolonged fever, or raised white blood count at 12 hours in 20/75 (26.7%), 24 hours in 31/75 (41.3%), 36 hours in 14/75 (18.7%), and 48-72 hours in 10/75 (13.3%). At ULA, perforation was identified in 14/75 (18.7%). Complications arising within 3 months of ULA were residual abscess (n = 7/75; 9.3%) and transient ileus (n = 1/75; 1.3%). Conclusion: It would appear that surgery may be more appropriate for children with UC-appy when they are younger and febrile before admission for longer.

Factors influencing choice of medical vs. surgical treatment of pediatric appendicitis

PURPOSE

To examine what proportion of caregivers, if given a choice, would choose medical versus surgical treatment of appendicitis and what factors would be important in their decision.

METHODS

A survey was devised and given to the caregivers of children presenting to the pediatrician for a routine visit in community and academic pediatric clinics. The survey presented a summary of outcomes after medical (non-operative) and surgical treatment of uncomplicated appendicitis. Participants were then asked to choose medical versus surgical treatment if their child were to develop appendicitis. They were also asked to rate the importance of certain factors in their decision -1 being "not important" and 5 being "very important".

RESULTS

Four hundred surveys were distributed with an 86.2% (345/400) response rate. Six percent (21/342) of respondents reported a history of appendicitis and 49.4% (168/340) reported having known someone who had appendicitis. The majority of respondents, 85.3% (284/333), were mothers. A minority of respondents, 41.7% (95% CI: 36.7, 47.0), chose medical treatment over surgery for appendicitis. There was no statistical difference in the proportion of mothers (41.6%) versus fathers who chose medical treatment (41.3%). Caregivers who chose medical treatment were more likely to rate time in hospital (p = .008) and time out of school (p = 05) as important in decision making when compared with those who chose surgery. Those who chose surgical treatment were more likely to rate risk of recurrent appendicitis (p < .001) as important to decision making. In the multivariate analysis, those who rated time in hospital as very important had more than twice the odds of choosing medical therapy (OR 2.20, p = 0.02) when compared with those who rated it as less important. Not knowing someone who has had appendicitis was significantly associated with choosing medical therapy when compared with those who do know someone who has had appendicitis, OR 2.3, p = .002. Rating pain as very important was also significantly associated with choosing medical therapy, when compared to those rating pain 1-3, OR 3.38, p = .03.

CONCLUSIONS

In this survey of caregivers of children presenting for routine care, 41.7% would choose medical, or non-operative, therapy for their children with acute appendicitis. The risk of recurrence, time in hospital, and time out of school, pain, and knowing someone who has had appendicitis were all important factors that families may consider when making a decision. These data may be useful for surgeons counseling patients on which treatment to pursue.

Effects of a Patient Activation Tool on Decision Making Between Surgery and Nonoperative Management for Pediatric Appendicitis: A Randomized Clinical Trial

Importance

Strategies to activate and engage patients and caregivers in shared decision making in the acute care setting may result in improved outcomes.

Objective

To determine whether a patient activation tool (PAT) can improve decision-making and patient-centered outcomes among pediatric patients and their caregivers who choose between surgery and nonoperative management for their child's appendicitis.

Design, Setting, and Participants

This single-blind, randomized clinical trial collected data from a single tertiary children's hospital from March 1, 2014, through April 30, 2016, with 1-year follow-up completed on May 1, 2017. Two hundred of 236 eligible children and adolescents aged 7 to 17 years with uncomplicated appendicitis enrolled with their caregivers. After receiving the randomized clinical intervention, caregivers chose surgery or nonoperative management. Data were analyzed from March 1, 2014, through May 1, 2017.

Interventions

Randomization to a scripted standardized surgical consultation that emphasized patient choice or a scripted standardized surgical consultation plus the PAT (a tablet-based tool that presents each treatment, encourages participation in medical decision making, and aims at alleviating decisional uncertainty).

Main Outcomes and Measures

Decisional self-efficacy immediately after treatment decision, health care satisfaction at discharge, and disability days for the child at 1-year follow-up.

Results

Among 200 participants (median age, 12 years [interquartile range (IQR), 9-15 years]; 120 [60.0%] male), 98 were randomized to the PAT and 102 to the standardized consultation groups. The percentages choosing nonoperative management were similar (standardized consultation group, 42 of 102 [41.2%]; PAT group, 31 of 98 [31.6%]; P = .19). Immediate decisional self-efficacy was similar in the standardized consultation and PAT groups (median score, 100 [IQR, 97.7-100] vs 100 [IQR, 95.5-100]; P = .03), which was not significant at the planned significance level of P = .02. Total scores on health care satisfaction at discharge were similar (median, 99 [IQR, 94.7-100] vs 98 [IQR, 91.7-100]; P = .27). Disability days at 1-year follow-up were also similar (median, 6 [IQR, 2-11] vs 5 [IQR, 2-15]; P = .67). No difference in the failure rate of nonoperative management at 1 year (13 of 38 [34.2%] vs 11 of 30 [36.7%]; P > .99) or in the rate of complicated appendicitis 30 days after discharge (7 of 68 [10.3%] vs 9 of 71 [12.7%]; P = .79) occurred.

Conclusions and Relevance

In this study, a technology-based PAT did not improve measures of decision making for pediatric patients and caregivers needing to make an urgent treatment decision between surgery and nonoperative management for appendicitis. However, the overall high scores in both groups suggest that pediatric patients and caregivers can process information in the acute care setting and effectively participate in an informed shared decision-making process around the need for surgery.

Trial Registration

ClinicalTrials.gov identifier: NCT02110485.

Comparison of conservative treatment with appendectomy for acute uncomplicated pediatric appendicitis: a meta-analysis

Aim: We aimed to compare conservative treatment with surgery for uncomplicated pediatric appendicitis to estimate effectiveness and safety. Methods: Data recorded until September 2018 were searched, and relevant academic articles from PubMed, EMBASE, the Cochrane Library and other libraries were selected. STATA version 13.0 (Stata Corporation, TX, USA) was used for statistical analysis. Results: We identified nine eligible papers. The study reported a significant difference in the success rate of treatment in 1 month and in 1 year, and no difference in the incidence of complications. The patients with fecaliths showed low treatment efficacy in conservative treatment group (p < 0.05). Conclusion: Standardized conservative treatment as inpatients for pediatric appendicitis is safe and feasible. Appendectomy was the better choice for patients with fecaliths.

Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review

BACKGROUND

Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist.

METHODS

PUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

RESULTS

Thirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success.

CONCLUSION

While further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management.

LEVEL OF EVIDENCE

Systematic review, level II.

Clinical trials

Clinical trials can be used to generate data on safety, efficacy, and/or effectiveness of treatments. They can be classified based on their purpose, phase, or design. Key components of clinical trial design include: identifying the study question and population; clearly defining the treatment and comparison groups; choosing the method of treatment group allocation; defining the primary and secondary outcomes; performing a power analysis; outlining an analytic plan; and reporting results. Critical issues to consider when either designing a trial or interpreting the results of a trial include evaluating the validity and generalizability of the results and assessing the appropriateness of the control group. Designing and implementing clinical trials in pediatric surgery is challenging, but well-constructed and executed trials are instrumental in improving clinical care.

Outcome of initially nonoperative treatment for acute simple appendicitis in children

PURPOSE

To compare the outcome of initially nonoperative treatment with immediate appendectomy for simple appendicitis in children.

METHODS

Between September 2012 and June 2014 children aged 7-17 years with a radiologically confirmed simple appendicitis were invited to participate in a multicentre prospective cohort study in which they were treated with an initially nonoperative treatment strategy; nonparticipants underwent immediate appendectomy. In October 2015, their rates of complications and subsequent appendectomies, and health-related quality of life (HRQOL) were assessed.

RESULTS

In this period, 25 children were treated with an initially nonoperative treatment strategy and 19 with immediate appendectomy; median (range) follow-up was 25 (16-36) and 26 (17-34) months, respectively. The percentage [95%CI] of patients experiencing complications in the initially nonoperative group and the immediate appendectomy group was 12 [4-30]% and 11 [3-31]%, respectively. In total 6/25 children (24%) underwent an appendectomy; none of the 6 patients operated subsequently experienced any postappendectomy complications. Overall, HRQOL in the nonoperative treatment group was similar to that of healthy peers.

CONCLUSIONS

Outcome of initially nonoperative treatment for acute simple appendicitis in children is similar to the outcome in those who undergo immediate appendectomy. Initially nonoperative management seems to be able to avoid appendectomy in 3 out of 4 children.

LEVEL OF EVIDENCE

2 (prospective comparative study). This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Are antibiotics a safe and effective treatment for acute uncomplicated appendicitis?- First update

UPDATE

This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in January 2016.

INTRODUCTION

Appendicitis is a typical cause of acute abdominal pain and the most frequent cause of emergency abdominal surgery. In the last two decades, increasing evidence has been published about the use of antibiotics as an exclusive treatment for acute appendicitis.

METHODS

To answer this question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained through searches from multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, reanalyzed the data from the primary studies, performed a meta-analysis and prepared a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified 23 systematic reviews including 28 primary studies, of which eight were randomized trials. We concluded the exclusive use of antibiotics for the treatment of uncomplicated acute appendicitis could be less effective than appendectomy, but it might be associated with a lower rate of complications.

Non-operative management of appendicitis in children

While appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades, there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon's knife. Many as yet unanswered questions remain, however, before NOT can be considered a realistic and reliable alternative to surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.

CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial

BACKGROUND

Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial.

METHODS/DESIGN

The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery.

DISCUSSION

In this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design.

TRIAL REGISTRATION

ISRCTN15830435 . Registered on 8 February 2017.

Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible

PURPOSE

Appendectomy versus conservative antibiotic treatment (CAT) for children with acute uncomplicated appendicitis (AUA) remains unresolved, with concerns regarding the practicality of CAT. We analyzed our center's experience with CAT for AUA, using a protocol with strict inclusion, exclusion and treatment criteria.

METHODS

Non-randomized, prospective cohort study included all children admitted betwee 2014 and 2016, with clinical and laboratory tests suspicious for AUA. Data collected included clinical signs and symptoms; laboratory, ultrasound and pathology results. Follow-up was conducted through clinic visits, telephone conversations and national registry analysis.

RESULTS

Included in CAT: 362 children, 19 underwent appendectomy within 1-2 days. Overall, 75 were readmitted for recurrent acute appendicitis during 22 months (6-43) follow-up. Thirty were treated successfully with antibiotics a second time. The remaining 45 had appendectomy. Overall, 86.8% underwent CAT with no surgery. Histology of all recurrent AUA revealed no perforations.

CONCLUSION

We confirm the feasibility of conservative management of AUA in children. A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile. CAT does not compete with surgery or render appendectomy unnecessary. It is a safe alternative to surgery in selected cases.

Nonoperative Management of Appendicitis

We evaluated the outcomes for nonoperative management (NOM) of all children with suspected nonperforated appendicitis, including those patients with an appendicolith. Parents of all children with suspected nonperforated appendicitis were offered NOM versus laparoscopic appendectomy. NOM included administration of intravenous antibiotics and hospital admission. If no improvement within 24 hours, laparoscopic appendectomy was performed. Primary outcomes were initial success rate and recurrence rate. Fifty patients selected NOM. The initial failure rate for NOM was 20%. Of the 10 who failed, 7 had complicated appendicitis. The recurrence rate was 13%. Overall, 34 (68%) patients avoided appendectomy. Patients with an appendicolith had a higher initial failure rate (37%) compared to patients without an appendicolith (10%; P < .05). NOM is feasible and effective in pediatric nonperforated appendicitis. The presence of an appendicolith was associated with a higher failure rate but is not an absolute contraindication for NOM.

Five lessons in uncomplicated appendicitis: Can we remove the surgery?

Appendicectomy has remained the treatment of choice for appendicitis for over a century and is the most commonly performed emergency operation in children. However, emerging evidence suggests that appendicectomy may not always be necessary in uncomplicated appendicitis, with early paediatric trials demonstrating that antibiotic-only therapy can be safe and effective. Further rigorously designed and appropriately powered studies are necessarily to establish the place of non-operative management of uncomplicated appendicitis in the future.

Expanding the inclusion criteria for nonoperative management of uncomplicated appendicitis: Outcomes and cost

BACKGROUND

Carefully selected children with early appendicitis may be managed nonoperatively. However, it is unknown whether nonoperative management (NOM) is applicable to all patients with uncomplicated appendicitis. The purpose of this study was to evaluate the outcomes of NOM of uncomplicated appendicitis with expanded inclusion criteria.

METHODS

A prospective, nonrandomized patient-preference study comparing NOM versus laparoscopic appendectomy (LA) was performed in children with radiographic/clinical evidence of uncomplicated appendicitis.

RESULTS

Demographics, laboratory values, and clinical presentation were similar between the NOM (n=51) and LA (n=32) groups. Initial failure rate was 31%. The outcomes were similar between groups, except that NOM had fewer days of pain medication. Patients who failed NOM had a longer duration of symptoms prior to admission. Patients with appendicolith had a failure rate of 50% compared to 24% without appendicolith. The recurrence rate was 26%. Overall, 51% avoided appendectomy. Costs were similar between NOM and LA.

CONCLUSIONS

When expanding the inclusion criteria for children with presumed uncomplicated appendicitis, NOM was associated with high failure and recurrence rates. These high rates may be because of the inclusion of patients with complicated appendicitis and patients with an appendicolith. Even in this setting of less-restrictive exclusion criteria, NOM remained cost neutral.

LEVEL OF EVIDENCE

LEVEL II (Treatment Study: Prospective Comparative Study).

Nonoperative management in children with early acute appendicitis: A systematic review

PURPOSE

Appendectomy has remained the gold standard treatment of acute appendicitis for more than 100years. Nonoperative management (NOM) has been shown to be a valid treatment alternative for acute uncomplicated appendicitis in adults. A systematic review of available evidence comparing operative management (OM) and NOM in children with acute uncomplicated appendicitis was performed.

METHODS

Systematic searches of MedLine, Embase, and a clinical trial register (https://clinicaltrials.gov/) were performed in March 2016. Only articles that studied NOM for uncomplicated appendicitis in children were included. Data generation was performed independently by two authors, and quality was assessed using the rating schema by the Oxford Centre for Evidence-Based Medicine.

RESULTS

15 articles were selected: four retrospective analyses, four prospective cohort studies, four prospective nonrandomized comparative trials and one randomized controlled trial (RCT). Initial success of the NOM groups (a cure within two weeks of intervention) ranged from 58 to 100%, with 0.1-31.8% recurrence at one year.

CONCLUSION

Although present literature is scarce, publications support the feasibility of further studies investigating NOM of acute uncomplicated appendicitis in children. Higher quality prospective RCTs with larger sample sizes and robust randomization methods, studying the noninferiority of NOM with antibiotics compared with OM are required to establish its utility.

LEVEL OF EVIDENCE

This manuscript is a systematic review and thus assigned the lowest evidence used from the manuscripts analyzed which is a Level IV.

C-reactive Protein may Predict the Recurrence of Appendicitis in Children Formerly with Appendiceal Mass after Successful Non-operative Treatment

BACKGROUND

This study identified factors associated with the recurrence of appendicitis in children with appendiceal masses after successful nonsurgical treatment.

METHODS

In this retrospective study, children who were diagnosed as having appendiceal masses after undergoing conservative treatment between 2000 and 2014 were enrolled and the medical records of those who did not undergo an interval appendectomy were reviewed. The clinical features and outcomes of patients with and those without recurrent appendicitis were compared. Regression analysis was used to identify risk factors of appendicitis recurrence.

RESULTS

Seventy patients were included and successfully discharged after receiving nonsurgical treatment for appendiceal masses. Of the patients, 35 (50.0%) developed recurrent appendicitis and 85.7% (30/35) recurrences developed within 3 months. Multivariate analyses showed that patients with a higher serum C-reactive protein (CRP) level and peritonitis more frequently developed recurrence. The appendicitis recurrence rate was significantly higher in the patients with CRP levels of ≥103 mg/L with an odds ratio of 16.9 or in those with peritonitis with an odds ratio of 4.9.

CONCLUSION

Children with appendiceal masses who develop peritonitis or have CRP levels of ≥103 mg/L have a higher recurrence rate of appendicitis and should undergo an interval appendectomy.

The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children

BACKGROUND

Several studies have demonstrated the safety and short-term success of nonoperative management in children with acute, uncomplicated appendicitis. Nonoperative management spares the patients and their family the upfront cost and discomfort of surgery, but also risks recurrent appendicitis.

METHODS

Using decision-tree software, we evaluated the cost-effectiveness of nonoperative management versus routine laparoscopic appendectomy. Model variables were abstracted from a review of the literature, Healthcare Cost and Utilization Project, and Medicare Physician Fee schedule. Model uncertainty was assessed using both one-way and probabilistic sensitivity analyses. We used a $100,000 per quality adjusted life year (QALY) threshold for cost-effectiveness.

RESULTS

Operative management cost $11,119 and yielded 23.56 quality-adjusted life months (QALMs). Nonoperative management cost $2277 less than operative management, but yielded 0.03 fewer QALMs. The incremental cost-to-effectiveness ratio of routine laparoscopic appendectomy was $910,800 per QALY gained. This greatly exceeds the $100,000/QALY threshold and was not cost-effective. One-way sensitivity analysis found that operative management would become cost-effective if the 1-year recurrence rate of acute appendicitis exceeded 39.8%. Probabilistic sensitivity analysis indicated that nonoperative management was cost-effective in 92% of simulations.

CONCLUSIONS

Based on our model, nonoperative management is more cost-effective than routine laparoscopic appendectomy for children with acute, uncomplicated appendicitis.

LEVEL OF EVIDENCE

Cost-Effectiveness Study: Level II.

Outcomes of Nonoperative Management of Uncomplicated Appendicitis

BACKGROUND AND OBJECTIVES

Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization.

METHODS

Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up.

RESULTS

99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy.

CONCLUSIONS

A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy.

Nonoperative management of appendicitis in children

PURPOSE OF REVIEW

The aim of this review is to summarize the recent literature investigating nonoperative management of uncomplicated and complicated appendicitis and highlight recent data establishing its safety and efficacy.

RECENT FINDINGS

Recent studies and clinical trials have demonstrated the efficacy of nonoperative treatment of both uncomplicated and complicated appendicitis, defined as perforated appendicitis with or without formed abscess or phlegmon. Nonoperative management of uncomplicated appendicitis has been reported to be effective in approximately 71-94% of cases. In complicated appendicitis, treatment with antibiotics alone or antibiotics with interval appendectomy has been shown to be a well tolerated and reasonable treatment alternative.

SUMMARY

Appendicitis is one of the most common surgical diagnoses in children. The standard of care for many years has been surgical appendectomy; however, it carries with it risks including bleeding, wound complications, injury to surrounding structures, and the potential need for reoperation. Nonoperative management of both uncomplicated and complicated appendicitis in children is well tolerated and efficacious in select populations.

Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

BACKGROUND

Appendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient and parental interest in non-operative treatment of acute appendicitis with antibiotics as opposed to surgery. To date no multicentre randomised controlled trials that are appropriately powered to determine efficacy of non-operative treatment (antibiotics) for acute appendicitis in children compared with surgery (appendectomy) have been performed.

METHODS

Multicentre, international, randomised controlled trial with a non-inferiority design. Children (age 5-16 years) with a clinical and/or radiological diagnosis of acute uncomplicated appendicitis will be randomised (1:1 ratio) to receive either laparoscopic appendectomy or treatment with intravenous (minimum 12 hours) followed by oral antibiotics (total course 10 days). Allocation to groups will be stratified by gender, duration of symptoms (> or <48 hours) and centre. Children in both treatment groups will follow a standardised treatment pathway. Primary outcome is treatment failure defined as additional intervention related to appendicitis requiring general anaesthesia within 1 year of randomisation (including recurrent appendicitis) or negative appendectomy. Important secondary outcomes will be reported and a cost-effectiveness analysis will be performed. The primary outcome will be analysed on a non-inferiority basis using a 20% non-inferiority margin. Planned sample size is 978 children.

DISCUSSION

The APPY trial will be the first multicentre randomised trial comparing non-operative treatment with appendectomy for acute uncomplicated appendicitis in children. The results of this trial have the potential to revolutionise the treatment of this common gastrointestinal emergency. The randomised design will limit the effect of bias on outcomes seen in other studies.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov: NCT02687464. Registered on Jan 13th 2016.

Conservative treatment in uncomplicated acute appendicitis: reassessment of practice safety

The success rate of conservative treatment for children with uncomplicated appendicitis was prospectively evaluated among 197 children. All who received intravenous antibiotics for 3-5 days, and if symptoms resolved, were discharged home on oral antibiotics for 5 days. Failure rate, symptoms, laboratory signs, and sonographic findings were evaluated for prognostic markers of treatment failure. Children were followed for 18 months. The success rate of conservative treatment was 87%, with shorter hospital stays compared to children who eventually needed surgery (72 [60-84] vs. 84 h [72-126], P = 0.001). Vomiting and/or nausea and intraluminal fluid on sonography were the only prognostic signs of failed treatment (P = 0.028 and P = 0.0001, respectively). After multi-regression analysis, intraluminal fluid was the only prognostic sign for failed treatment (odds ratio = 10.2; 95% CI 3.3-31.8, P = 0.001). Patients who failed conservative treatment were successfully operated without significant morbidity. Pathology findings were compatible with acute or subacute inflammation in 94% of operated AA, with no perforated appendices.

CONCLUSION

When applying rigorous criteria for children with uncomplicated appendicitis, a high success rate can be achieved with conservative treatment. Those who fail conservative treatment have a benign medical course without serious complications. Intraluminal fluid may increase risk for conservative treatment failure. What is Known: • Conservative treatment in uncomplicated acute appendicitis is a reasonable alternative to appendectomy. What is New: • Using rigorous criteria for conservative treatment in uncomplicated acute appendicitis is safe and feasible. • Intraluminal fluid should be considered a contraindication to conservative treatment.

Pediatric appendicitis: state of the art review

Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.

Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis

CONTEXT

Nonoperative treatment (NOT) with antibiotics alone of acute uncomplicated appendicitis (AUA) in children has been proposed as an alternative to appendectomy.

OBJECTIVE

To determine safety and efficacy of NOT based on current literature.

DATA SOURCES

Three electronic databases.

STUDY SELECTION

All articles reporting NOT for AUA in children.

DATA EXTRACTION

Two reviewers independently verified study inclusion and extracted data.

RESULTS

Ten articles reporting 413 children receiving NOT were included. Six, including 1 randomized controlled trial, compared NOT with appendectomy. The remaining 4 reported outcomes of children receiving NOT without a comparison group. NOT was effective as the initial treatment in 97% of children (95% confidence interval [CI] 96% to 99%). Initial length of hospital stay was shorter in children treated with appendectomy compared with NOT (mean difference 0.5 days [95% CI 0.2 to 0.8]; P = .002). At final reported follow-up (range 8 weeks to 4 years), NOT remained effective (no appendectomy performed) in 82% of children (95% CI 77% to 87%). Recurrent appendicitis occurred in 14% (95% CI 7% to 21%). Complications and total length of hospital stay during follow-up were similar for NOT and appendectomy. No serious adverse events related to NOT were reported.

LIMITATIONS

The lack of prospective randomized studies limits definitive conclusions to influence clinical practice.

CONCLUSIONS

Current data suggest that NOT is safe. It appears effective as initial treatment in 97% of children with AUA, and the rate of recurrent appendicitis is 14%. Longer-term clinical outcomes and cost-effectiveness of NOT compared with appendicectomy require further evaluation, preferably in large randomized trials, to reliably inform decision-making.

Pediatric Appendicitis

Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.

Acute uncomplicated appendicitis study: rationale and protocol for a multicentre, prospective randomised controlled non-inferiority study to evaluate the safety and effectiveness of non-operative management in children with acute uncomplicated appendicitis

INTRODUCTION

This article presents an overview of a prospective randomised controlled non-inferiority study designed to evaluate the safety and effectiveness of non-operative management (NOM) with operative management in children with acute uncomplicated appendicitis (AUA). Here, we present the study protocol for this APRES study, a multicentre Australian study. The rationale and details of future analysis, in particular, non-inferiority calculations, cost-effectiveness, feasibility and acceptability of each intervention.

DESIGN

A multicentre, prospective randomised controlled clinical trial, conducted in 2 Australian tertiary paediatric hospitals.

PARTICIPANTS

Children who meet the inclusion criteria of an age between 5 and 15 years and a clinical diagnosis of AUA will be invited to participate, and after consent will be randomised via a computer-based program into treatment groups. The study started in June 2016, and the target recruitment is 220 patients.

INTERVENTIONS

Children in the control group will be treated with prophylactic antibiotics and appendicectomy, and those in the intervention group will be treated with antibiotic therapy alone. Primary outcome measures include unplanned or unnecessary operation and complications at 30 days. Secondary outcomes include longer term complications within 1 year, length of stay, time off work and school analgesic requirements and cost.

ANALYSIS

Data analyses will be on the intention-to-treat principle using non-inferiority analysis. Analysis will include the Pearson χ2 test for categorical variables and independent sample t-test or Mann-Whitney test for continuous variables. Non-inferiority for NOM will be tested using 1-sided Wald tests with an α level of 0.05.

ETHICS AND DISSEMINATION

The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospital Network. In addition, results will be reported through academic journals, seminars and conference presentations.

TRIAL REGISTRATION NUMBERS

NCT02795793; ACTRN12616000788471.

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management

STUDY OBJECTIVE

Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics-first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics-first, including outpatient management, with appendectomy.

METHODS

Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics-first-treated participants older than 13 years could be discharged after greater than or equal to 6-hour emergency department (ED) observation with next-day follow-up. Outcomes included 1-month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics-first appendectomy rate.

RESULTS

Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics-first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/μL (range 6,200 to 23,100/μL), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic-treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics-first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics-first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics-first-treated participants had less pain and disability. During median 12-month follow-up, 2 of 15 antibiotics-first-treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group.

CONCLUSION

A multicenter US trial comparing antibiotics-first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.