Comparison Between Immediate Appendectomy Versus Nonoperative Management For Pediatric Perforated Appendicitis With Intraabdominal Abscess

Abstract

Introduction: The impact of nonoperative management (NOM) on children with perforated appendicitis compared to immediate appendecomy (IA) remains unclear. This study identifies factors associated with NOM and compares outcomes between NOM and IA. Methods: Children 1-18 y/o with perforated appendicitis and intraabdominal abscess were extracted from California's Patient Discharge Database,1999-2006. NOM was defined as drainage for appendiceal abscess and no appendectomy within 2 days of admission. NOM failures required operations within 4 weeks of presentation. Patient and hospital characteristics, initial hospital course, and readmissions were compared between NOM and IA. Hospital volumes were stratified into quartiles, where the “top” and “bottom” quartiles were labeled as “high” and “low” volume hospitals respectively. P<0.01 was considered significant. Results: Overall, 17,039 children with perforated appendicitis were treated at 359 different hospitals with volumes ranging from 1-117 cases/yr. Only 408 (2.4%) underwent NOM, while 16.631 (97.6%) had IA. NOM rate increased from 1.6% in 1999 to 4.4% in 2006 (p<0.001). NOM had longer initial (7.5 vs 5.4 days, p<0.001) and cumulative (9.3 vs 5.8 days, p<0.001) length of stay, higher cumulative hospital charges ($40k vs $31k, p<0.001), and more home health assistance (9 vs 2%, p<0.001). Furthermore, NOM had higher readmission rates (57 vs 11%, p<0.001), and more serious complications (14 vs 9%, p<0.005). Postoperative infection rate (3 vs 6%, p=NS) and readmit abscess drainage rate (2 vs 5%, p=NS) were similar. Multivariate analysis demonstrated children who had NOM compared to IA were more likely to be white (33 vs 27%, OR 1.49, p<0.005), girls (52 vs 38%, OR 1.75, p<0.001), with private insurance (45 vs 37%, OR 1.51, p<0.001), and to be treated at a high volume (48 vs 32%, OR 2.45, p<0.001) and children's hospitals (46 vs 26%, OR 2.50, p<0.001). NOM failure occurred in 148 (37%), 18% failed during the initial hospitalization. There were 79 children who underwent interval appendectomy (19%), and 181 (44%) did not undergo appendectomy. The rate of extensive bowel resections at appendectomy was similar (1 vs 1%, p=NS). The rate of laparoscopy was higher in the NOM group (51 vs 31%, p<0.001). Conclusions: Although the use of NOM increased steadily over time, there is no clear advantage of NOM compared to IA. NOM had longer hospitalizations, higher charges, more readmissions, and a higher complication rate. The rates of bowel resections were similar between the two groups. Large prospective randomized trials are needed to identify unique patient populations that would benefit from NOM vs. IA.