Appendectomy may be best for appendicitis in the short term

Last Updated: 2018-11-23

By Marilynn Larkin

NEW YORK (Reuters Health) - Nonoperative management of uncomplicated appendicitis is associated with worse short-term outcomes than appendectomy, an analysis of claims data suggests.

"Our retrospective study assessed how nonoperative management of appendicitis performs in the 'real world' for everyday patients, outside of the specialized conditions of randomized trials," said Dr. Lindsay Sceats of Stanford University in California, in an email to Reuters Health.

Among the 58,329 patients with uncomplicated appendicitis studied by Dr. Sceats and colleagues (mean age, 32; 52.7% men), 95.5% underwent appendectomy.

As reported online November 14 in JAMA Surgery, patients managed nonoperatively were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13) and to develop an abscess (aOR, 1.42). They also required more follow-up visits in the year after index admission (unadjusted mean, 1.6 vs. 0.3 visits).

Although the nonoperative group had a lower index hospitalization cost (unadjusted mean, $11,502 vs. $13,551), the total cost of appendicitis care was higher when follow-up care was included (unadjusted mean, $14,934 vs. $14,186).

During a mean 3.2 years of follow-up, nonoperative management failed in 101 patients (3.9%); these individuals later underwent appendectomy, hemicolectomy or percutaneous drain placement. The median time to appendicitis recurrence was 42 days, with 44 patients experiencing failure within 30 days.

"These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis," the authors conclude.

Dr. Sceats noted, "There are likely (patient-related) factors which determine whether or not a nonoperative approach will be successful. We analyzed these factors to the best of our ability, but due to the limitations inherent in working with claims data, we can't say which factors should influence that decision."

"Clinical trials that collect granular data are required to determine which clinical factors would be associated with success," she added. "Until definitive data are available, clinicians should consider the patient they have in front of them. For example, if a patient is a high-risk surgical candidate, nonoperative management may still be the least risky option for them."

Dr. Brian Zuckerbraun of the University of Pittsburgh Medical Center, coauthor of a related editorial, commented, "The possibility of avoiding a surgical procedure for appendicitis is appealing to many patients (and) the findings demonstrate that non-operative management of appendicitis continues to be a viable option for this disease."

"Societal costs, including days away from work and daily life activities, were not considered in this study, and are important considerations for most people," he said in an email to Reuters Health. "The patient should be informed of all aspects related to the decision to consider non-operative management, including direct and indirect costs."

"The results of this study need to be interpreted with the findings of other studies comparing non-operative to operative treatment of appendicitis and presented to patients so they can make the best personal decision," he added. "When treating patients with acute uncomplicated appendicitis I present both options."

"Moving forward," he said, "when asked by my patients 'what would you recommend if it was your family member?,' I will acknowledge my bias and continue to explain that when I take into account the risks of immediate surgical treatment versus the risks of failure of non-operative management, and when considering all other aspects related to care with each option (hospital stays, readmissions, duration of antibiotics, complications, doctors office visits, and costs), I do not believe that there is equipoise."

"I would recommend surgical treatment in most cases," Dr. Zuckerbraun said. "Younger and healthy patients are likely to do well with either operative or non-operative treatment."

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JAMA Surg 2018.