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Pediatric Uncomplicated Acute Appendicitis

Nonoperative vs surgical management

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Nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, and when chosen by patients and families, 3 in 4 children avoided surgery at 1 year. This according to a study of 102 patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital. Participating patients and families gave informed consent and chose between nonoperative management (37 patients) and urgent appendectomy (65 patients). The study found:

• The success rate of nonoperative management was 89.2% at 30 days, and 75.7% at 1 year.

• The incidence of complicated appendicitis was 2.7% in the nonoperative group and 12.3% in the surgery group.

• After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days and lower appendicitis-related health care costs.

Citation: Minneci PC, Mahida JB, Lodwick DL, et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis. [Published online ahead of print December 16, 2015]. JAMA Surg. doi: 10.1001/jamasurg.2015.4534.

Commentary: Nonoperative management using antibiotics for appendicitis would not have been considered when I trained as a resident. Over the last 6 years, a number of randomized trials in adults have shown that nonoperative management of appendicitis is successful about 75% of the time, and surgery can then be performed when medical therapy does not work.1 A recent trial in children showed that there was a 1-year success rate of non-operative management in 66% with no difference in the rate of complicated appendicitis compared to surgery.2 This trial showed that the decision about whether to try nonoperative management of appendicitis vs operative management depends upon patients’ values about aspects of care, such as avoiding an operation, time until recovery, and tolerance for operation at a later date if medical therapy does not work, and that involving patients in this decision is a reasonable approach. —Neil Skolnik, MD

1. DiSaverio S, Sibilio A, Giorgini E, et al. The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg. 2014;260(1):109-117. doi: 10.1097/SLA.0000000000000560.

2. Svensson JF, Patkova B, Almström M, et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg. 2015;261(1):67-71. doi: 10.1097/SLA.0000000000000835.

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