Nonoperative treatment promising for acute appendicitis, but more study needed

Last Updated: 2017-02-17

By Megan Brooks

NEW YORK (Reuters Health) – For children with uncomplicated acute appendicitis, nonoperative treatment with antibiotics alone appears to be safe and likely effective, based on the existing evidence, researchers say.

“However, we need to be aware of the limitations of the data and in particular the fact that high-quality studies comparing non-operative treatment to current standard of care, that is appendectomy, have not yet been performed,” Dr. Nigel J. Hall of the University of Southampton and Southampton Children's Hospital told Reuters Health. “So we cannot yet say for sure which of these treatments is better or even in fact how non-operative treatment really compares with surgery.”

Dr. Hall and colleagues did a meta-analysis of 10 studies reporting on 413 children receiving nonoperative treatment for acute uncomplicated appendicitis. Six studies (one randomized controlled trial) compared nonoperative treatment with appendectomy. The other four reported outcomes of children receiving nonoperative treatment without a comparison group.

Nonoperative treatment was effective as initial treatment in 97% of children, the researchers report in Pediatrics, online February 17.

At final reported follow-up, which ranged from eight weeks to four years, nonoperative treatment remained effective (no appendectomy performed) in 79% of children and the rate of recurrent appendicitis was 14%.

Complications and total length of hospital stay during follow-up were similar for nonoperative treatment and surgery. No serious adverse events related to nonoperative treatment were reported.

The researchers caution that the “lack of prospective randomized studies limits definitive conclusions to influence clinical practice. Longer-term clinical outcomes and cost-effectiveness of nonoperative treatment compared with appendicectomy require further evaluation, preferably in large randomized trials, to reliably inform decision-making.”

Dr. Hall told Reuters Health, “We believe these findings do not call for any change in practice at present but they do support ongoing research studies to fully evaluate nonoperative treatment for this group of children and importantly to compare nonoperative treatment with surgery in clinical trials. We believe strongly that until nonoperative treatment has been fully evaluated that it should only be used in properly designed research studies.”

In related research published online February 6 in The Lancet Gastroenterology & Hepatology, Dr. Hall and colleagues report results of the CHINA study, which suggests that more than three-quarters of children could avoid appendectomy during early follow-up after successful nonoperative treatment of an appendix mass.

“Despite a scarcity of supporting evidence, most surgeons recommend routine interval appendicectomy after successful nonoperative treatment of an appendix mass in children,” they point out.

The open-label randomized CHINA study compared routine interval appendectomy with active observation after successful nonoperative treatment of an appendix mass in 106 children aged 3 to 15 years treated at 19 specialist pediatric surgery centers.

Two of the 52 children in the interval appendectomy group were withdrawn due to withdrawal of consent and two of the 54 in the active-observation group were withdrawn because they became ineligible after allocation.

Within one year of randomization, the incidence of histologically proven recurrent appendicitis in children under active observation was 12%, and more than 75% of children avoided appendectomy. Severe complications related to interval appendectomy occurred in 6% of patients.

“This study has provided prospectively collected, high-quality data with which clinicians, parents, and children can, for the first time to our knowledge, make an evidence-based decision regarding the justification for interval appendicectomy,” write the researchers.

“Adoption of a wait-and-see approach, reserving appendicectomy for those who develop recurrence or recurrent symptoms, results in fewer days in hospital and days away from normal daily activity, and is cheaper than routine interval appendicectomy,” they note.

This study “makes a substantial contribution to present pediatric and pediatric surgical literature,” writes Dr. Anette Jacobsen, of the Department of Pediatric Surgery, KK Women's and Children's Hospital in Singapore, in a linked comment.

“We have suspected for some time that the reports are true: we do not need to operate on all cases of acute appendicitis,” Dr. Jacobsen told Reuters Health by email. “This was previously reserved for simple cases, but this paper has sought to prove categorically with evidence-based data from a carefully crafted and well-structured protocol, that this approach also applies to appendicitis where a mass has formed.”

“This current paper proves the application in children. It is important to note that it does not mean that patients will not require monitoring; while under antibiotic treatment, some will still require an appendectomy, and the patients need to be followed up to ensure appropriate clinical management,” said Dr. Jacobsen.

She added, “Clinical practice currently dictates that all patients with a diagnosis of acute appendicitis or an appendicular mass require surgery. The clinical implication now is that majority (but NOT all) can be treated conservatively with antibiotics, even the patients who have an appendicular mass. This will imply a potential cost savings for the payer, and also – perhaps more importantly, quicker return to normal activities for the patient. This applies now in adults as well as in children.”

SOURCE: http://bit.ly/2lqLu6J, http://bit.ly/2lXx0sb and http://bit.ly/2lc1A1P

Pediatrics 2017. Lancet Gastroenterol Hepatol 2017.