Surgery remains treatment of choice for appendicitis in kids

Last Updated: 2017-08-24

By Scott Baltic

NEW YORK (Reuters Health) - Appendectomy should still be the preferred treatment for uncomplicated appendicitis in children, rather than conservative, antibiotic-based treatment, according to a systematic review and meta-analysis.

Researchers evaluated data from five pertinent studies involving 442 children with uncomplicated appendicitis, 189 treated conservatively with antibiotics and 253 who underwent appendectomies. Their data were published online, August 17, in Archives of Disease in Childhood.

Treatment efficacy - defined as resolution of acute appendicitis without complications - was significantly greater among surgically treated than conservatively treated patients (98% vs.74%; relative risk, 0.77). Surgery outperformed conservative treatment in all five studies.

Conservatively treated patients were also about 7 times more likely to be rehospitalized, and their outcomes were especially poor relative to surgery if they had fecoliths.

Conservatively treated patients without fecoliths had a trend toward fewer complications, a trend toward increased efficacy, and a lower readmission rate, compared to conservatively treated patients with fecoliths. Nonetheless, the conservative approach in patients without a fecolith remained inferior to surgery, in terms of both treatment efficacy and readmission risk.

The authors concluded that no advantage for conservative treatment is evident. They also said that the complication and efficacy rates they found in children differ from those previously found in adults, "where antibiotic treatment for uncomplicated appendicitis seemed to be a valuable option."

They noted, however, "major methodological limitations" in the studies they analyzed, including overall low quality (only one study was randomized), a variety of protocols for conservative treatment, and a range of follow-up periods (from 1 to 4 years).

The authors also stressed the need for further research, noting that because the pathogenesis of appendicitis is still unresolved, conservative treatment that includes antibiotics and bowel rest might provide "a reasonable alternative" to appendectomy in select pediatric patients.

The role of fecoliths in appendicitis is not clear, lead author Dr. Ulf Kessler, of Bern University Hospital, in Switzerland, told Reuters Health by email. He explained that obstruction by fecoliths might be just one causative element in appendicitis, but that not every fecolith necessarily results in appendicitis.

Studies that have evaluated non-operative management of otherwise healthy children with non-ruptured appendicitis found that 80% to 90% of those given antibiotics "get better," Dr. David Rothstein, an associate professor of surgery at the University at Buffalo, in New York State, told Reuters Health by email.

Up to 25% of those patients, however, end up having the appendix removed within a year, whether because of recurrent appendicitis, recurrent pain thought to be appendicitis, or simply parental worry, he said. "The percentage of patients who end up back in the emergency room or pediatrician's office with some sort of abdominal pain is higher undoubtedly" than the 25% figure.

Dr. Rothstein noted that data are still needed on long-term financial and other costs, such as the days lost from school or work, when kids are being evaluated for new belly pain; the additional costs of workup; and potential complications of antibiotic therapy.

He also pointed out that what the appendix does is still not well understood. A few papers during the past 10 to 15 years, he explained, have suggested it serves as a repository of "normal" bacteria so that after diarrheal illness, the appendix can repopulate the gut. "If we had proof, there could be more of an argument to keep the appendix and not remove it surgically," he said. "But we don't."

SOURCE: http://bit.ly/2wrkJp4

Arch Dis Child 2017.