Acute Appendicitis and Non-operative Management

This month we will be enjoying the company of our pediatric EM colleagues. We will be looking at non-operative management of pediatric patients with acute appendicitis. Annually, in the U.S., there are over 250,000 cases of acute appendicitis in children, the majority of whom undergo operative intervention. Interestingly, in 1911, a paper was published in CMAJ advocating non-operative management of acute appendicitis (Rudolph). Early pediatric articles described non-operative or delayed appendectomy in kids with perforation and noted no increase in complication rate (Nadler).  A systematic review published by Cochrane in 2011 (Wilms), demonstrated a higher complication rate in non-operative management that was confirmed in a subsequent meta-analysis in 2012 (Mason). Recently, there have been some additional data published including two RCT’s that we will be reviewing. Factors often not addressed in these papers include economic costs to patients and family members, loss of school days, harms from hospital admission etc. Does the data suggest that non-operative management of acute appendicitis is a reasonable option and should it be included in a patient-centered decision making discussion? Should make for a very interesting topic. Hope to see you there!  Charlie

Svensson JF et al.  Nonoperative treatment with antibiotics versus surgery for acute non-perforated appendicitis in children: a pilot randomized controlled trial. Ann Surg. 2015 Jan;261(1):67-71   Appraisal

Minneci PC et al. Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. J Am Coll Surg. 2014 Aug;219(2):272-9.    Appraisal

Armstrong J et al., Non-operative management of early, acute appendicitis in children: is it safe and effective?  J Pediatr Surg. 2014 May;49(5):782-5.   Appraisal

Salminen P et al., Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015 Jun 16;313(23 Appraisal