From the Journals

Nonoperative management of pediatric appendicitis appears feasible

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Appendectomy remains standard of care

This is the first data synthesis on the effectiveness of nonoperative management compared with appendectomy in children, and it shows that the evidence at this time is simply insufficient to warrant a change in clinical practice. Appendectomy remains the standard of care for this disease.

Despite the high early “success rate” for nonoperative treatment, patients in this group were nearly nine times more likely to have “treatment failure” than those who underwent immediate appendectomy.

The nonoperative approach remains an experimental proposition and should be offered only under protocol in a clinical trial setting. It clearly merits ongoing consideration, but much more data from high-quality clinical trials are needed.

Monica E. Lopez, MD, and David E. Wesson, MD, are both with the division of pediatric surgery at Baylor College of Medicine and the department of surgery at Texas Children’s Hospital, both in Houston. They reported having no relevant financial disclosures. Dr. Lopez and Dr. Wesson made these remarks in an editorial accompanying Dr. Huang’s report (JAMA Ped. 2017 Mar 27. doi: 10.1001/jamapediatrics.2017.0056).



Nonoperative management of uncomplicated acute appendicitis in the pediatric population appeared feasible and didn’t raise the risk of complications in the first metaanalysis to examine this approach, investigators reported March 27 in JAMA Pediatrics.

Nonoperative management, based on antibiotic treatment and close monitoring of the patient, is accepted as safe and effective in adults but has not been well studied in children and adolescents. “Owing to specific anatomical and pathophysiologic features of children, the clinical scenario of acute appendicitis in pediatric patients is different from that in adults, and treatment decisions for children are more difficult,” said Libin Huang, MD, of West China Hospital and Sichuan University, Chengdu, and his associates.

The few clinical trials that have been performed in children have had small sample sizes, so the investigators performed a meta-analysis to pool the results for 404 patients aged 5-18 years. They analyzed data from four single-center prospective but nonrandomized controlled trials and one single-center randomized controlled trial to compare outcomes between 168 patients initially treated with antibiotics and 236 who underwent immediate appendectomy.

Sixteen patients in the nonoperative group (9.5%) had treatment failure, defined as appendectomy within 48 hours (11 patients) or within 1 month of follow-up (5 patients). Three of these patients developed a complication (perforated appendicitis). In comparison, none of the surgery group had treatment failure, and one developed a complication requiring reoperation. Thus, the rate of success in the nonoperative group was 152 of 168 patients, or 90.5%, and the rate of complications was not significantly different between the two study groups, Dr. Huang and his associates said (JAMA Ped. 2017 Mar 27. doi: 10.1001/jamapediatrics.2017.0057).

During the following year, 27 patients in the nonoperative group had a histopathologically confirmed recurrence of appendicitis and underwent appendectomy; another 8 had the surgery because of parents’ requests. Nonoperative management was significantly more likely to fail in patients who had an appendicolith, so this approach should be considered inappropriate for this subgroup of patients, the investigators said.

Larger clinical trials with a randomized design, standardized criteria for antibiotic therapy, and longer follow-up are needed to confirm these preliminary findings, they added.

No sponsor was cited for this study. Dr. Huang and his associates reported having no relevant financial disclosures.

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