Non-Operative Management of Early Acute Appendicitis in Children: Interim Results From a Prospective Clinical Study

Sunday, October 27, 2013: 10:08 AM
Windermere Ballroom W (Hyatt Regency Orlando, formerly the Peabody)
Peter C. Minneci, MD, MHSc, Jason P. Sulkowski, MD, Kristine M. Nacion, MPH, Jennifer N. Cooper, PhD, R. Lawrence Moss and Katherine J. Deans, MD, MHSc, Department of Surgery, Nationwide Children's Hospital, Columbus, OH

Purpose

Urgent operation has been considered the only appropriate management of acute appendicitis in children for decades.  This study reports the interim results of an ongoing study investigating the safety and feasibility of non-operative management of acute appendicitis in children.

Methods

This prospective non-randomized single center study investigating non-operative management for early acute appendicitis in children began in October 2012.   Inclusion criteria are age 7-17 years, symptoms ≤ 48 hours, absence of generalized peritonitis, white blood cell (WBC) count ≤ 18,000, and imaging consistent with acute appendicitis without evidence of rupture or appendicolith.  After informed consent, eligible patients/caregivers choose either non-operative management or operation.  The non-operative management protocol requires ≥24 hours of intravenous antibiotics and inpatient observation until resolution of symptoms, resumption of a regular diet, and discharge with oral antibiotics to complete a 10 day course. Failure to improve within 24 hours prompts appendectomy. These patients will be followed until 18 years of age.  Patients choosing operation receive preoperative intravenous antibiotics, undergo urgent appendectomy, and are followed for 30 days.

Results

Thirty patients have been enrolled with 13 choosing non-operative management and 17 choosing operation. The mean age of enrolled patients was 12 years. There were no differences in age, gender, duration of symptoms, or pre-operative WBC count between the groups. In the non-operative group, 1 patient required appendectomy prior to discharge for failure to resume a regular diet despite symptom improvement (pathology: acute appendicitis) and two patients returned with abdominal pain after discharge and underwent appendectomy per study protocol (pathology: one acute appendicitis, one normal appendix). No patient managed non-operatively had progression of their appendicitis to rupture or gangrene. Patients managed non-operatively had a longer hospital length of stay (44 hours vs. 28 hours, p=0.001) but a shorter time period to return to normal activities (4 days vs. 18 days, p=0.01).

Conclusion

Our interim results suggest that non-operative management of early acute appendicitis in children appears to be safe and feasible with a current rate of success of 77%. No patient managed non-operatively has had progression to more advanced disease. These findings warrant a more comprehensive study of non-operative management of early acute appendicitis including  evaluation of patient and caregiver satisfaction and cost-effectiveness.