Appendicitis without surgery may be safe option for some kids

By Andrew M. Seaman

NEW YORK (Reuters Health) - Children with simple cases of appendicitis may be safely treated with antibiotics instead of surgery, a new study suggests.

Medical management might not be an option for all kids, researchers say, but just three of 30 children who tried the antibiotics-only route ended up needing surgery during the 30-day follow-up period.

"In this group of patients with uncomplicated appendicitis - in the people we studied, non-operative management with antibiotics alone appears to be a reasonable alternative," lead author Dr. Peter Minneci from Nationwide Children's Hospital in Columbus, Ohio told Reuters Health.

"It used to be that people would operate on appendixes in the middle of the night," he said. "Then we found that it was safe to give them antibiotics and operate on them in the morning."

Doctors began noticing that some of the children were feeling better in the morning after the initial treatment of antibiotics.

"They were hungry and they didn't have pain anymore," Minneci said.

To see whether antibiotics alone might be enough to treat appendicitis, he and his colleagues enrolled 77 children and teens at Nationwide Children's Hospital from October 2012 to October 2013.

All the participants had been diagnosed with uncomplicated acute appendicitis. Their appendixes had not burst, were not overly swollen and imaging did not show a hard piece of stool blocking the appendix.

Those uncomplicated cases represent about one in five appendicitis cases at the hospital, the researchers noted April 12 online in the Journal of the American College of Surgeons.

The participants and their families were allowed to choose between surgery or receiving 24 hours of IV antibiotics in the hospital followed by 10 days of oral antibiotics at home.

"We do believe patients should be admitted to the hospital and watched," Minneci said. "They shouldn't just get antibiotics and be sent home."

Of the 77 participants, 30 chose antibiotics and 47 picked surgery.

Of those who chose the antibiotic option, 93% were feeling better within a day. They also tended to recover faster.

Kids in the antibiotics-only group had an average of three days of recuperation versus 17 days in the surgery group. They were also able to return to school after an average of three days, vs a mean of five days among kids who had surgery.

Three patients in the antibiotic group did require surgery within the 30 days of their first ER visit. None of their appendixes ruptured, however.

Both children and parents rated their quality of life higher in the antibiotics-only group, compared to those who had surgery. But on average, the length of hospital stay was longer at 38 hours for the antibiotics group, compared with 20 hours in the surgery group.

"We really aren't trying to say (patients) shouldn't have an appendectomy," Minneci said. "We're saying there are two reasonable treatment options."

"We chose to perform a non-randomized prospective clinical trial based upon patient choice because we believe that the success of each treatment option partially depends on which outcomes are most important to the patient and their family," the authors wrote in their paper. "For example, although initial nonoperative management of early appendicitis may be safe for most patients, appendectomy may be a better treatment option for patients who live in remote areas or for families who are so fearful of a recurrence that they are likely to return to the emergency department every time their child develops abdominal pain."

The authors also note that a 2009 meta-analysis of nonoperative management of appendicitis in adults found it had "a pooled success rate of 63% at 1 year with significantly lower risks of complications and no difference in the risk of developing complicated appendicitis."

Dr. Mary Brandt said the new study is small and an initial step, but modern surgery is about becoming less and less invasive.

"It's an encouraging first result and definitely means we should continue studying this as an option," said Brandt, a pediatric surgeon at Texas Children's Hospital in Houston who was not involved in the research.

Minneci and his colleagues continue to follow the patients from the original study to see how they do. The researchers are also conducting another trial among patients with more complicated appendicitis.

In addition, the team is working with other hospitals to enroll more than 800 children in a larger trial.

"If that study finds the same thing, then this will probably get adopted as the standard of care," Minneci said.

"Here at Nationwide Children's Hospital, it is now the standard of care," he added.

SOURCE: http://bit.ly/1nEEsUb

J Am Coll Surg 2014.

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