No surgery for acute appendicitis?

You may not need to operate on every child with acute appendicitis. New research suggests that antibiotics and inpatient observation may be all that are required.

For decades we’ve believed that surgery is the only appropriate management of acute appendicitis in children. Now interim results from an ongoing study indicate that nonoperative management, including a combination of intravenous (IV) and then oral antibiotics and in-hospital observation, may suffice for many children.

The researchers from Nationwide Children’s Hospital in Columbus, Ohio, conducted a prospective, nonrandomized, single-center study involving children aged between 7 and 17 years. To participate, the children had to have symptoms for 48 hours or less, no generalized peritonitis, a white blood cell count ≤18,000, and imaging studies indicating acute appendicitis without evidence of rupture or appendicolith.

The researchers then gave caregivers the choice to pursue surgical or nonsurgical treatment. The nonoperative route consisted of at least 24 hours of IV antibiotics; hospitalization until symptoms resolved and a regular diet resumed; and a 10-day course of oral antibiotics upon hospital discharge.

Of the 30 participants, 13 pursued nonoperative management and 17 chose surgery. The mean age of the participants was 12 years.

The investigators reported the success rate of the nonsurgical approach to be 77%. One child in the nonoperative group required appendectomy prior to discharge for failure to resume a regular diet despite improvement in symptoms, and 2 children returned with abdominal pain after discharge and underwent appendectomy. One had acute appendicitis, but the other had a normal appendix.

None of the nonsurgical group progressed to rupture or gangrene. Although they had almost twice as long of a hospital stay as those in the surgical group (44 hours vs 28 hours), they resumed normal activities far faster (4 days vs 18 days).

The investigators presented their findings during the recent annual meeting of the American Academy of Pediatrics held in Orlando, Florida, October 26 to 29.

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