My Child has Acute Appendicitis. Should We Operate ?

This is a modern-day study relevant to many parents who bring their child to an emergency room. Almost every parent knows the signs and symptoms of acute appendicitis, right lower quadrant pain, nausea and vomiting, and fever.  

In the emergency department, the physicians formulate a quick differential diagnosis to determine the alternatives.  Some viral infections cause similar or even identical symptoms and signs.

The appendix is a normal part of the digestive tract located at the junction of the small intestine where it enters into the ascending colon. Along with symptoms of acute appendicitis, the signs of right lower quadrant point tenderness strengthen the possibility of acute appendicitis. Viral gastroenteritis is very common in children and can mimic appendicitis.

A ruptured appendix can lead to an abscess or diffuse peritonitis, which could lead to sepsis be a life-threatening complication. A one time this decision was critical when powerful antibiotics were not always readily available.  Complications and disability were much more common.


There have been articles contrasting the safety and efficacy of nonsurgical treatment from 2014. More recently in 2017 a study revealed some changes in outcomes. The 2017 group included over 1000 patients enrolled in a randomized group of patients assigned by the physicians doing the study.  Although making this study more accurate it created difficulties for parents to enroll their children.

How to find McBurney's Point

 Conclusions

Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was a substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not me

Limitations

This study has several limitations. First, the results of this study are only applicable to a limited percentage of children who present with acute appendicitis. Due to the inclusion-exclusion criteria, only 19.3% of patients with appendicitis treated at the participating sites qualified for this study. These criteria were intentionally selected based on the available data in the literature related to the safety and efficacy of nonoperative management for children and to ensure consensus across the participating institutions. Also, all the participating sites are tertiary children’s hospitals whose patient population may include a lower proportion of children meeting eligibility criteria. Second, the nonrandomized treatment allocation potentially allows for treatment selection bias, where treatment may be affected by participant characteristics, and those choosing nonoperative management differ, on average, from those choosing surgery. However, several steps to minimize this were taken including the use of a standardized enrollment script and decision aid, specific inclusion and exclusion criteria, standardized treatment protocols and algorithms, and obtaining agreement to participate from all participating surgeons prior to beginning the study. Furthermore, treatment decision-making in clinical practice is affected by the biases of patients, families, and surgeons, suggesting that a patient choice treatment allocation may be more reflective of current practice. Moreover, robust inferential methods to aid in accounting for treatment confounding bias were used. Third, the generalizability of the results may be limited by the substantial rates of incomplete follow-up.

ref:

Cash  CL, Frazee  RC, Abernathy  SW,  et al.  A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis.   J Am Coll Surg. 2012;215(1):101-105. doi:10.1016/j.jamcollsurg.2012.02.024PubMedGoogle Scholar
5.
Kocataş  A, Gönenç  M, Bozkurt  MA, Karabulut  M, Gemici  E, Alış  H.  Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis: a prospective randomized clinical trial.   Ulus Travma Acil Cerrahi Derg. 2013;19(3):200-204. doi:10.5505/tjtes.2013.58234PubMedGoogle Scholar
6.
Minneci  PC, Mahida  JB, Lodwick  DL,  et al.  Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis.   JAMA Surg. 2016;151(5):408-415. doi:10.1001/jamasurg.2015.4534
ArticlePubMedGoogle Scholar
7.
Salminen  P, Paajanen  H, Rautio  T,  et al.  Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial.   JAMA. 2015;313(23):2340-2348. doi:10.1001/jama.2015.6154
ArticlePubMedGoogle Scholar
8.
Fitzmaurice  GJ, McWilliams  B, Hurreiz  H, Epanomeritakis  E.  Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence.   Can J Surg. 2011;54(5):307-314. doi:10.1503/cjs.006610PubMedGoogle Scholar



Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis | Emergency Medicine | JAMA | JAMA Network