Nonoperative treatment versus appendectomy for uncomplicated acute appendicitis.

BackgroundAppendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient...

The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children. A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year. Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination. Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.

Background: Surgical approach for acute appendicitis (AA) is a standard live saving treatment method. The purpose of this study was to assess the feasibility, initial safety and success rate of non-operative treatment of AA in selected patients.Methods: Selected AA patients were enrolled in this prospective study (non-operative treatment). This was based on IV antibiotic therapy and followed up with oral antibiotic. Patients who declined to participate or excluded were managed with appendectomy and considered as controls. The primary goal of the study was to determine the feasibility, initial safety, early and late success rates of non-operative management. Secondary outcomes include hospital length of stay and charge, days of missed works and return to normal activity at home of patients treated non-operatively in comparison to appendectomy group.Results: In non-operative group (36 patients), 7 patients failed to response and managed by appendectomy with early success rate of 80.5%. Three patients experienced recurrent attacks of AA were managed with appendectomy. Late success rate was 72.2%. In appendectomy group (53 patients) one patient with adenocarcinoma of the colon detected during surgery and in ten patients the appendix was perforated. One patient died due to generalized peritonitis. In non-operative group length of stay and hospital charge were lower but only days to resume home activities and days of missed work were shorter and statistically significant as compared to appendectomy group.Conclusions: This study confirms the feasibility, safety and optimum success rate of non-operative treatment of early AA in selected patients.

BackgroundThe success rate of non-operative treatment (NOT) of acute uncomplicated appendicitis (AUA) in children varies from 65% to 95%. There are no recommendations on the appropriate antibiotic therapy.ObjectiveTo determine the...

The management of acute appendicitis is a matter of debate even in contemporary era. Non-operative management is proposed as a valid treatment option for acute appendicitis in children. A prospective cohort study was conducted from April 2020 to September 2021 at the National Institute of Child Health, Jinnah Sindh Medical University, Karachi, Pakistan, in children aged ≤ 12 years who were suspected of having acute appendicitis. Children with diffuse peritonitis and complex mass on ultrasonography were excluded. All children were kept nil per oral and started on intravenous fluid hydration and antibiotics. Statistical analyses were performed using IBM SPSS version 20. Chi-square test and Fisher's exact test were applied to determine the statistical significance. A total of 190 patients were admitted with a diagnosis of acute appendicitis. Thirty-two children with advanced disease underwent surgery. The remaining 158 patients were managed with nonoperative treatment. In 138 (87.3%) patients, resolution of symptoms occurred. Twenty (12.7%) patients underwent operation during the same admission (non-responders). Thirteen (9.4%) patients had recurrence of symptoms and underwent appendectomy. A total of 33 (20.9%) patients had appendectomy either at the primary admission or after discharge. Non-operative treatment was more likely to be successful in patients with symptoms of ≤ 24 h duration ( P = 0.02), total leucocyte count of <12 × 109 cells/L ( P = 0.005) and smaller size of the appendix on ultrasound ( P = 0.001). Among children with uncomplicated acute appendicitis, a non-operative approach resulted in resolution of symptoms in 87.3% of patients at the initial admission. Failure of non-operative treatment and recurrence of disease after discharge from the hospital occurred in 9.4% of patients after successful initial treatment. Thus, the overall success rate at a mean follow-up of 3 months was about 78%.

Second date appendectomy: Operating for failure of nonoperative treatment in perforated appendicitis

When considering nonoperative treatment in a patient with acute appendicitis, it is crucial to accurately rule out complicated appendicitis. The Atema score, also referred to as the Scoring System of Appendicitis Severity (SAS), has been designed to differentiate between uncomplicated and complicated appendicitis but has not been prospectively externally validated. To externally validate the SAS and, in case of failure, to develop an improved SAS (2.0) for estimating the probability of complicated appendicitis. This prospective study included adult patients who underwent operations for suspected acute appendicitis at 11 hospitals in the Netherlands between January 2020 and August 2021. Appendicitis severity was predicted according to the SAS in 795 patients and its sensitivity and negative predictive value (NPV) for complicated appendicitis were calculated. Since the predefined targets of 95% for both were not met, the SAS 2.0 was developed using the same cohort. This clinical prediction model was developed with multivariable regression using clinical, biochemical, and imaging findings. The SAS 2.0 was externally validated in a temporal validation cohort consisting of 565 patients. In total, 1360 patients were included, 463 of whom (34.5%) had complicated appendicitis. Validation of the SAS resulted in a sensitivity of 83.6% (95% CI, 78.8-87.6) and an NPV of 85.0% (95% CI, 80.6-88.8), meaning that the predefined targets were not achieved. Therefore, the SAS 2.0 was developed, internally validated (C statistic, 0.87; 95% CI, 0.84-0.89), and subsequently externally validated (C statistic, 0.86; 95% CI, 0.82-0.89). The SAS 2.0 was designed to calculate a patient's individual probability of having complicated appendicitis along with a 95% CI. In this study, external validation of the SAS fell short in accurately distinguishing complicated from uncomplicated appendicitis. The newly developed and externally validated SAS 2.0 was able to assess an individual patient's probability of having complicated appendicitis with high accuracy in patients with acute appendicitis. Use of this patient-specific risk assessment tool can be helpful when considering and discussing nonoperative treatment of acute appendicitis with patients.

&lt;p dir="ltr"&gt;Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.&lt;/p&gt;&lt;p dir="ltr"&gt;Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.&lt;/p&gt;&lt;p dir="ltr"&gt;Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.&lt;/p&gt;&lt;p dir="ltr"&gt;Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged &lt;18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.&lt;/p&gt;&lt;p dir="ltr"&gt;Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value &lt;0.0001.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Patkova B&lt;/b&gt;, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. &lt;a href="https://doi.org/10.1097/SLA.0000000000003646"&gt;https://doi.org/10.1097/SLA.0000000000003646&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Pátková B,&lt;/b&gt; Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. &lt;a href="https://doi.org/10.1001/jamasurg.2023.2756"&gt;https://doi.org/10.1001/jamasurg.2023.2756&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Patková B&lt;/b&gt;, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]&lt;/p&gt;

&lt;p dir="ltr"&gt;Acute appendicitis is a clinical term for inflammation of the vermiform appendix with a sudden onset. Symptoms depend both on the age of a patient and on the position of appendix intraabdominally. The aetiology remains unknown, although, there are multiple theories. The lifetime risk of acute appendicitis in Western countries has been established as 7-8%, with 8.6% for males and 6.7% for females. The standard treatment has been surgery for many decades, but non-operative treatment, in the form of antibiotics, has more recently come to light as a feasible alternative to appendectomies.&lt;/p&gt;&lt;p dir="ltr"&gt;Aims: The aim of this thesis was to assess intermediate and long-term outcomes of non- operative treatment in both children and adults. This included assessing safety and feasibility of non-operative treatment and its complications. An additional aim was to ascertain the failure rate of non-operative treatment and recurrence of acute uncomplicated appendicitis in children and try to establish the reasons for the treatment failure.&lt;/p&gt;&lt;p dir="ltr"&gt;Methods: Study I was a 5-year follow-up of all participants who underwent surgery or non- operative treatment with antibiotics in a previous randomised controlled pilot trial. Data was extracted from the hospital notes and telephone interviews.&lt;/p&gt;&lt;p dir="ltr"&gt;Study II was a long-term follow-up of adults with acute appendicitis who were involved in two randomised controlled trials, which compared non-operative treatment with appendectomy. The first trial consisted of 40 patients (13 female) and second trial was a multicentre study with 252 male patients. National registers were used to retrieve data at follow up, including the Swedish National Patient Register, the Cancer Register, the Cause of Death Register and Statistics Sweden.&lt;/p&gt;&lt;p dir="ltr"&gt;Study III was a systematic review that was registered in PROSPERO (CRD42024592607) and done according to PRISMA statement. We searched three databases (PubMed, Medline, Web of Science). Eligible studies were randomised controlled trials or prospective cohort studies with children aged &lt;18 years that received non-operative treatment for uncomplicated appendicitis and reporting at least 30 days follow-up. We carried out a meta- analysis.&lt;/p&gt;&lt;p dir="ltr"&gt;Results: In Study I, we followed up all 50 children (26 children in the appendectomy group, 24 children in the nonoperative group) for at least 5 years. The surgical group was without failures and in the nonoperative group there were 11 failures and recurrences. In the first year there were nine failures, two of them had an appendicitis on the histopathology. Another two recurrences, that were histopathologically confirmed appendicitis occurred one to five years after the initial trial. At the 5-year follow-up, 54% of children had been successfully treated nonoperatively with antibiotics alone.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study II, in total, we were able to trace down 259 patients in the Patient Register, 137 patients in the non-operative group and 122 in the surgical group. At the end of follow-up, 82 (60%) patients had had successful non-operative treatment without an appendectomy. In the non-operative group there were 21 (15%) failures during the first admission. Thirty-four recurrences happened after discharge, all with a diagnostic code of acute appendicitis. After successful initial treatment, 82/116 (71%) remained without appendectomy.&lt;/p&gt;&lt;p dir="ltr"&gt;In Study III, through a systematic search we were able to identify 2343 abstracts. Thirty studies were eligible, 8 randomised controlled trials and 22 prospective cohort studies reporting 27 different patient cohorts. An early failure rate occurred in 10% (95% CI 7-14%) and the recurrence rate was 29% (95% CI 24-34%) at the end of follow-up. When analysing studies with faecalith, a failure rate was higher (17% versus 6.4%) with P-value &lt;0.0001.&lt;/p&gt;&lt;p dir="ltr"&gt;Conclusions: Studies I and II demonstrated intermediate- and long-term safety of non- operative treatment alone in children and adults. This treatment does not increase the risk of malignancy and other complications and patients avoid surgery. Study III demonstrated a low initial failure rate and the recurrence rate was 29%. Non-operative treatment was less successful in children with a faecalith, particularly during first admission. These results can be used for discussion about treatment options of uncomplicated appendicitis with child patients and their caregivers.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Patkova B&lt;/b&gt;, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF. Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Ann Surg. 2020 Jun;271(6):1030-1035. &lt;a href="https://doi.org/10.1097/SLA.0000000000003646"&gt;https://doi.org/10.1097/SLA.0000000000003646&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Pátková B,&lt;/b&gt; Svenningsson A, Almström M, Svensson JF, Eriksson S, Wester T, Eaton S. Long-Term Outcome of Nonoperative Treatment of Appendicitis. JAMA Surg. 2023 Oct 1;158(10):1105-1106. &lt;a href="https://doi.org/10.1001/jamasurg.2023.2756"&gt;https://doi.org/10.1001/jamasurg.2023.2756&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Patková B&lt;/b&gt;, Svenningsson A, Jumah S, Wester T, Eaton S. Failure and recurrence of non-operative treatment of uncomplicated appendicitis in children; a systematic review and meta-analysis. [Manuscript]&lt;/p&gt;

Nonoperative treatment (NOT) with antibiotics alone of acute uncomplicated appendicitis (AUA) in children has been proposed as an alternative to appendectomy. To determine safety and efficacy of NOT based on current literature. Three electronic databases. All articles reporting NOT for AUA in children. Two reviewers independently verified study inclusion and extracted data. Ten articles reporting 413 children receiving NOT were included. Six, including 1 randomized controlled trial, compared NOT with appendectomy. The remaining 4 reported outcomes of children receiving NOT without a comparison group. NOT was effective as the initial treatment in 97% of children (95% confidence interval [CI] 96% to 99%). Initial length of hospital stay was shorter in children treated with appendectomy compared with NOT (mean difference 0.5 days [95% CI 0.2 to 0.8]; P = .002). At final reported follow-up (range 8 weeks to 4 years), NOT remained effective (no appendectomy performed) in 82% of children (95% CI 77% to 87%). Recurrent appendicitis occurred in 14% (95% CI 7% to 21%). Complications and total length of hospital stay during follow-up were similar for NOT and appendectomy. No serious adverse events related to NOT were reported. The lack of prospective randomized studies limits definitive conclusions to influence clinical practice. Current data suggest that NOT is safe. It appears effective as initial treatment in 97% of children with AUA, and the rate of recurrent appendicitis is 14%. Longer-term clinical outcomes and cost-effectiveness of NOT compared with appendicectomy require further evaluation, preferably in large randomized trials, to reliably inform decision-making.

Nonoperative treatment of acute appendicitis in children

Non-operative management of acute appendicitis has seen an increasing trend in the management of acute appendicitis, especially after the Covid-19 outbreak. With better imaging modalities like computerized tomography and better broad-spectrum antibiotics, non-operative treatment of acute appendicitis is now considered as an alternative to appendectomy. This article will investigate the role of non-operative treatment of acute appendicitis in adults and children and compare its efficacy and recurrence rate. We will look at the type and duration of antibiotic therapy. The effectiveness of non-operative treatment is also compared with appendectomy in the treatment of acute appendicitis.

The role of interval appendectomy (IA) after an episode of acute appendicitis is debated. Patients treated nonoperatively for acute appendicitis do not require routine IA. Retrospective cohort study using discharge abstract data. Twelve regional Kaiser Permanente hospitals in Southern California. A total of 32 938 patients were hospitalized with acute appendicitis. Appendectomy or nonoperative treatment with or without abscess drainage. Hospitalization for recurrent appendicitis or IA. The type of appendicitis was abscess in 7% of patients, peritonitis in 18%, and no peritonitis or abscess in 75%. Emergency appendectomy was performed in 31 926 (97%) patients. Nonoperative treatment was used initially in 1012 patients (3%). Of these, 148 (15%) had an IA and the remaining 864 (85%) did not. Thirty-nine patients (5%) recurred after a median follow-up of 4 years. Using Cox regression, sex had a slight influence on recurrent appendicitis (hazard ratio males vs females = 0.52, 95% CI, 0.27-0.99, P = .05). Age, Charlson comorbidity index, type of appendicitis, or percutaneous abscess drainage had no influence on recurrence. Median length of hospital stay was 4 days for the admission for recurrent appendicitis compared with 6 days for the IA admission (P = .006). Most patients with acute appendicitis undergo appendectomy initially. For those treated nonoperatively, the recurrence rate is low. Routine IA after initial successful nonoperative treatment is not justified and should be abandoned.

Introduction: The effects of surgical versus medical management of appendicitis in Crohn’s disease (CD) patients remain unknown. Our aim was to evaluate outcomes of CD patients who have undergone operative versus non-operative treatment of acute appendicitis. Methods: We performed a retrospective cohort study of adult CD patients presenting to the University of Minnesota with acute appendicitis between 1/1/2015 and 12/31/2020. Electronic health records were reviewed for demographics, CD classification, medications, disease activity, appendicitis course and subsequent complications and disease outcomes. A t-test was used to compare continuous variables and Fisher’s exact tests were used to compare categorical variables. Univariate logistic regression was used to compare outcomes for those treated with operative versus non-operative management of appendicitis. Results: We identified 24 patients with CD who underwent treatment for appendicitis. Eight patients (33%) received nonoperative management with antibiotics. Sixteen patients (66%) had surgical management. Of those managed with surgery, 4 (25%) were treated with concomitant antibiotics. Crohn’s disease activity, measured using the physician global assessment (PGA), was similar in both groups. Five patients (63%) in the medically managed group had a CD flare on admission compared to one (6%) in the surgically managed group (63% vs 6%, p< 0.01). Four patients (50%) treated with antibiotics eventually required an appendectomy. No differences in length of stay, rate of complications up to 6 months, time to subsequent CD-related surgery or time to CD flare were seen between the two groups. Conclusion: In CD, antibiotic therapy alone can be an effective and safe option for the treatment of acute appendicitis, especially in patients presenting with a concomitant flare. Non-operative management can also help avoid eventual surgery in half of patients. Further data are needed to better characterize individual risk factors and outcomes in this patient population and shared decision making should guide current management. Table 1. - Clinical characteristics of Crohn’s Disease patients presenting with acute appendicitis All Antibiotics (n=8) Surgery (n=16) P-value Sex >0.05 F 10 4 (50%) 6 (37%) M 14 4 (50%) 10 (63%) Physician global assessment score >0.05 Remission 8 1 (13%) 7 (44%) Mild 2 0 2 (12%) Moderate 6 3 (37%) 3 (19%) Severe 8 4 (50%) 4 (25%) Presence of flare during admission < 0.01 Yes 18 5 (63%) 1 (6%) No 6 3 (37%) 15 (94%) Age at appendicitis episode 31 (18-44) 40 (31-49) >0.05 Length of stay 2.5 (1.9-3.1) 2.3 (0.9-3.8) >0.05

Plasma sodium as a predictor of perforation in acute appendicitis: A prospective multi-centre study.