Appendectomy or antibiotics?

Appendicitis is a common diagnosis in the ED, and once it is confirmed clinically or on ultrasound, the patient usually goes pretty quickly to the theatre for an appendectomy. But is a course of antibiotics just as effective as taking these kids to theatre?

A recent article accepted for publication in the Journal of the American College of Surgeons (Feb 2014) investigated this question in a prospective, non-randomised trial comparing urgent appendectomy with antibiotic management of acute appendicitis in children.

Minneci PC, Sulkowski JP, Nacion KM, Mahida JB, Cooper JN, Moss RL, Deans KJ, Feasibility of a Nonoperative Management Strategy for Uncomplicated Acute Appendicitis in Children, Journal of the American College of Surgeons (2014), DOI: 10.1016/j.jamcollsurg.2014.02.031.

Who were the patients?

Eligible children who presented to the author’s hospital (in the USA) were:

• 7-17 years old
• Less than 48 hours of abdominal pain
• WCC < 18 000
• US or CT confirming non-ruptured appendicitis (appendix <1.1cm, no phlegmon, abscess or faecolith)
• Surgical review confirming clinical appendicitis

Exclusion criteria:

• Diffuse peritonitis
• Positive pregnancy test
• Chronic abdominal pain

There were 77 patients in the study.

What was the intervention?

Enrolled patients could opt for surgical management or non-operative management. Of the 77 patients, 47 chose surgery, and 30 chose non-operative management.

The surgical group went straight for an appendectomy, with antibiotics prior to surgery (these were discontinued post-op).

The non-operative group had:

• Minimum 24 hours of piperacillin/tazobactam
• Minimum of 12 hours nil by mouth, and then could start a diet if the pain was improving
• Pain relief PRN
• Switched to oral amoxicillin once tolerating an oral diet and once discharged, should have completed a total of 10 days of antibiotics

Doesn’t this seem a bit dangerous?

Patients were removed from the non-operative group if they did not show clinical improvement within 24 hours of antibiotics or if they returned with abdominal pain after discharge.

What was the follow-up?

Patients were followed for 30 days to assess outcomes, including non-operative management, length of hospital stay, disability days, and quality of life.

So what happened?

After 30 days, 27 out of the 30 patients had successful non-operative management. Of the three that failed:

• One had an appendectomy within the first 24 hours due to failure to improve and had acute appendicitis
• One had an appendectomy within the first 24 hours due to failure to improve and had appendicitis secondary to a tumour
• One had an appendectomy after representation one day post-discharge and the appendix was normal

In the non-operative group, there was a longer hospital stay but a shorter time to return to normal activity. Quality-of-life scores were higher at 30 days in the non-operative group.

Previously, most studies on the conservative management of appendicitis have been on adults, and this study in children provides some promising preliminary results (although it is on quite a small sample). The main risk from missed appendicitis would be from a perforated appendix, and none of the patients in this study went on to have a perforated appendix within 30 days.

However, longer-term issues would be recurrent abdominal pain, which could have a significant impact on the lives of these families and also the eventual outcome of appendectomy, as this would negate the benefit of the delay. The authors aim to follow up in one year, so we should keep an eye out for their next article.