Nonoperative Treatment Of Acute Appendicitis Research Articles

Development and Validation of the Scoring System of Appendicitis Severity 2.0

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.

Non-operative treatment of acute appendicitis in children: clinical efficacy of amoxicillin-clavulanic acid in a retrospective single-centre study

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...

Feasibility of nonoperative treatment of acute appendicitis in children: a prospective cohort study.

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%.

S1050 Clinical Outcomes in Crohn’s Disease Patients With Acute Appendicitis Treated Operatively vs Non-Operatively

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

Appendicular neoplasms and consequences in patients undergoing surgery for suspected acute appendicitis

IntroductionIn patients treated with an appendectomy for acute appendicitis, the specimen is generally sent for histological evaluation. In an era of increasing non-operative treatment for acute appendicitis, it is important to know the incidence, the diagnostic accuracy, and treatment consequences of appendicular neoplasms that are found in acute appendicitis. We hypothesize that pre- and intra-operative parameters might predict an appendicular neoplasm.MethodsData was used from our previous prospective observational cohort study. All patients undergoing surgery for suspected acute appendicitis were included. The primary outcome was the incidence of appendicular neoplasms in patients operated for acute appendicitis. Secondary outcomes were pre-operative diagnostics and imaging outcomes, intra-operative surgical judgment, and postoperative management and outcome. Possible predictors of an appendicular neoplasm were identified and used in multivariable logistic regression. Patients with an appendicular neoplasm were followed for 3 years after initial appendectomy.ResultsA total of 1975 patients underwent surgery for suspected acute appendicitis and in 98.3% (1941/1975) the appendix was removed. In 1.5% (30/1941) of these patients, an appendicular neoplasm was found. Among the malignant neoplasms, the majority were grade 1 neuroendocrine tumors (NET) in 65% (13/20). On pre-operative imaging, there was no suspicion of malignancy. In three cases, there was an intra-operative suspicion of malignancy. Multivariable analysis showed only age as an independent predictor for appendicular neoplasms. No recurrent or new malignancy was found during follow-up.DiscussionThe incidence of appendicular neoplasm in patients undergoing an acute appendectomy is very low and clinical risk factors could not be identified.

The Study of Non Operative Treatment for Acute Appendicitis (NOTA)

The Study of Non Operative Treatment for Acute Appendicitis (NOTA)

Non-operative treatment of acute appendicitis in selected patients

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.

Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

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...

Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis.

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: A feasibility study

PurposeNonoperative treatment of acute appendicitis appears to be feasible in adults. It is unclear whether the same is true for children. MethodsChildren 5–18years with <48h symptoms of acute appendicitis were offered nonoperative treatment: 2 doses of piperacillin IV, then ampicillin/clavulanate ×1 week. Treatment failure (worsening on therapy) and recurrence (after completion of therapy) were noted. Patients who declined enrollment were asked to participate as controls. Cost–utility analysis was performed using Pediatric Quality of Life Scale (PedsQL®) to calculate quality-adjusted life month (QALM) for study and control patients. ResultsTwenty-four patients agreed to undergo nonoperative management, and 50 acted as controls. At a mean follow-up of 14months, three of the 24 failed on therapy, and 2/21 returned with recurrent appendicitis at 43 and 52days, respectively. Two patients elected to undergo an interval appendectomy despite absence of symptoms. Appendectomy-free rate at one year was therefore 71% (C.I. 50–87%). No patient developed perforation or other complications. Cost–utility analysis shows a 0.007–0.03 QALM increase and a $1359 savings from $4130 to $2771 per nonoperatively treated patient. ConclusionDespite occasional late recurrences, antibiotic-only treatment of early appendicitis in children is feasible, safe, cost-effective and is experienced more favorably by patients and parents.

Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial.

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.

Drainage of periappendiceal abscess and removal of free fecalith--extraperitoneal approach.

Treatment of complicated acute appendicitis is controversial. The dilemma is further complicated by presence of free fecalith in a well-circumscribed abscess, which has been repeatedly demonstrated to be a major predicting factor of treatment failure of nonoperative treatment of acute appendicitis complicated with appendiceal abscess. If left behind after drainage of the abscess, further operations for removal of retained fecalith or recurrence of abscess might be required. However, little had been stressed over the significance of removal of the free fecalith when it was first encountered. We report our experience of drainage of appendiceal abscess and removal of free fecalith by taking an extraperitoneal approach. Both of our cases made a smooth recovery without any complication or recurrence after a 2-year follow-up. Treatment with this approach avoids many of the complications associated with formal laparotomy. Unlike image-guided drainage or laparoscopic drainage, this procedure is relatively simple and straightforward and can be performed in any level of hospital, including private practitioners and in less well-developed areas and countries. With proper case selection, we recommend this approach as one of the alternatives in the treatment of late-presenting appendiceal abscess with free fecalith.

A Review of Conservative Treatment of Acute Appendicitis

Appendicitis is a common condition in the pediatric population and appendectomy has been the traditional treatment. Both the urgency of the operation and the need for the appendectomy have recently been challenged. In children, this controversy focuses on operative management of perforated appendicitis and appendix abscesses. In adults, the debate has extended to management of nonperforated appendicitis. This review describes the evidence behind these challenges and updates a per-protocol meta-analysis of randomized controlled trials in adults. In the per-protocol meta-analysis, there was no difference between operative versus nonoperative management in failure of treatment. The complication rate was significantly lower in patients treated nonoperatively. However, in the nonoperative group, 10% of patients needed immediate surgery and 17% developed a recurrence during the 1-year follow-up. Overall, 73% of adults with suspected acute appendicitis may not need operative treatment. There are no data in the literature to support nonoperative treatment of acute appendicitis in children.

Nonoperative treatment of acute appendicitis in children

Background/Purpose Appendicitis is considered by many surgeons to be a surgical emergency for which necessary to avoid perforation of the appendix. Although it has also been treated nonoperatively using antibiotic therapy, experience in such treatment in children with acute appendicitis (AA) is extremely limited. In addition, previous studies on nonoperative treatment (NT) showed it to be a cause of morbidity and mortality. The authors hold that not all appendicitis cases respond to NT because only some of the cases recover. In the present study, 16 of 95 cases with AA were selected for NT according to physical and ultrasound examinations. The clinical and ultrasonographic findings of the cases are presented. Methods The medical records of all children with appendicitis treated between August 2003 and March 2006 were retrospectively reviewed . Patients who had history of abdominal pain for less than 24 hours with localized abdominal tenderness and hemodynamic stability underwent NT. Children were treated with parenteral antibiotics (ampicillin with sulbactam, 100 mg · kg −1 · 24 h −1, divided into 3 doses daily, and ornidasole, 20 mg · kg −1 · 24 h −1, divided intro 2 doses daily), intravenous fluid, and nothing by mouth for at least 48 hours. Results A total of 136 patients with appendicitis were treated. Of the cases, 95 (70%) were AA, and 41 (30%) had perforated appendicitis. Sixteen (16.8%) cases of AA were selected for NT (12 boys and 4 girls; age range, 5-13 years; mean age, 9 years). The mean anteroposterior diameter of the appendix at the presentation was 7.11 ± 1.01 mm (range, 6-9.5 mm). Ultrasound examination was repeated after 48 hours of treatment. The mean diameter of the appendix was 4.64 ± 0.82 mm (range, 3.6-6.8 mm). The difference was statistically significant ( t = 9.63, P < .0001). Nonoperative treatment was successful in 15 (93.7%) of the 16 patients. Conclusion Hyperplasia of the appendiceal lymphoid follicle frequently causes luminal obstruction. Antibiotic therapy probably causes regression of lymphoid hyperplasia because of suppression of bacterial infection and prevents ischemia and bacterial invasion in the early stage of appendicitis. We found that some of the patients who had a history of abdominal pain for less than 24 hours with localized abdominal tenderness and hemodynamic stability could be treated nonoperatively.

Routine Interval Appendectomy Is Not Justified After Initial Nonoperative 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.