Conservative management was likely to fail in children with appendicitis who had high degree of pain at presentation, suggests a new study reported in JAMA Network Open.1

A subgroup secondary analysis of a prospective, nonrandomized clinical trial of 1068 patients with uncomplicated appendicitis performed between May 1, 2015, and October 31, 2018 was carried out for the present study. The non-randomized trial, conducted at 10 hospitals in the Midwest Pediatric Surgery Consortium, also had a 1-year follow-up comparing nonoperative management with antibiotics vs surgery for uncomplicated appendicitis. Data was analyzed between November 2019 and February 2022.

For the present study, researchers reviewed data from 370 children aged 7 to 17 years (median age 12 years) with uncomplicated appendicitis managed conservatively with antibiotics. The objective of the study was to identify factors associated with the failure of conservative management. Patient satisfaction with the outcomes were also compared.

Out of the 370 patients included in the study, 125 patients had treatment failure at one year; 53 patients underwent appendectomy during their initial hospital admission and 72 patients (19.5%) had delayed treatment failure after discharge from the hospital.

Those who had greater pain at presentation (pain score between 7 and 10) were twice as likely to experience in-hospital treatment failure with relative risk of 2.1 compared to those whose pain scores were between 0 and 2. But they were not at risk of delayed treatment failure after hospital discharge (RR 1.3) or overall treatment failure at 1 year (RR 1.5). Pain duration longer than 24 hours was associated with reduced risk of delayed treatment failure (RR 0.3) but not in-hospital treatment failure (RR 1.2) or treatment failure at 1 year (RR 0.7).

All patients reported high health-related quality of life at 30 days and 1 year, but those who had been successfully managed nonoperatively expressed greater satisfaction with their decision compared to those who experienced treatment failure. No association with treatment failure was noted for factors such as age, white blood cell count, sex, race, ethnicity, presenting symptoms, imaging findings, primary language, insurance status or transfer status.

This secondary analysis has shown that treatment with antibiotics alone is a safe and reasonable approach for children with uncomplicated acute appendicitis. The likelihood of failure of nonoperative management was higher in patients who had severe pain at the time of presentation and those who had longer duration of pain. Those who opted for nonoperative management were satisfied with their decision at both 30 days and 1 year. Parents and/or families of children with uncomplicated acute appendicitis should also be offered the option of conservative management in the appropriate patient. At the same time, they should be educated about the possibility of treatment failure.

Reference

1. Minneci PC, et al. Demographic and clinical characteristics associated with the failure of nonoperative management of uncomplicated appendicitis in children: secondary analysis of a nonrandomized clinical trial. JAMA Netw Open. 2022 May 2;5(5):e229712.