Nonoperative care of uncomplicated appendicitis leads to increased resource utilization
Nonoperative management of uncomplicated appendicitis in children entails an increased likelihood of repeat emergency department (ED) visits and hospitalizations compared with appendectomy, a retrospective study has found. Furthermore, close to half of those who receive nonoperative care require subsequent surgical removal of the appendix within the first year.
Six-year data involving 99,001 children with appendicitis (median age 10.9 years; 60.4 percent male; 66.4 percent nonperforated appendicitis) treated at 45 US paediatric hospitals showed an upward trend in the number of nonperforated appendicitis treated nonoperatively, increasing by 20.4 percent from 2010 to 2016 (odds ratio [OR], 1.13; 95 percent CI, 1.04 to 1.23). [Pediatrics 2017;doi:10.1542/peds.2017-0048]
Among the 54,958 of 65,712 nonperforated appendicitis patients with available follow-up data, children managed nonoperatively (2,227 of 4,190) were more likely to undergo additional advanced imaging (absolute risk difference [ARD], 8.9 percent) and to have frequent ED visits (ARD, 11.2 percent) and hospitalizations (ARD, 43.7 percent) compared with those managed operatively (52,731 of 61,522) during the 12 months after the index visit.
The 1-year outcomes of nonoperative management included subsequent appendectomy in 46 percent and appendiceal perforation in 14 percent. Significant predictors of subsequent appendectomy were younger age (OR, 0.93; 0.90 to 0.97) and having a computed tomography study (OR, 3.87; 1.91 to 7.86) and greater doses of parenteral antibiotics (OR, 1.58; 1.03 to 2.44) at the index visit.
Nonoperative management of uncomplicated appendicitis, which involves treatment with antibiotics, is not new, the authors said.
“The surge in interest has grown from the success of antibiotic treatment of complicated appendicitis and other intra-abdominal conditions, the convenience of reliable diagnostic imaging to identify appendicitis and monitor for complications, and the availability of oral broad-spectrum antibiotics,” they continued.
In the present investigation, the authors noted that the increasing number of patients being diagnosed with appendicitis may potentially be a consequence of the option for nonoperative care. They expressed concern regarding the possibility of antibiotic overuse for presumed appendicitis given the lack of clear eligibility criteria or a diagnostic standard.
“As nonoperative treatment becomes more widespread, the consequences of treating a patient with suspected (but unproven) appendicitis with antibiotics would likely be considered more acceptable than a negative appendectomy,” they said.
Given the presence of limitations including the use of administrative data, which prevent accurate identification of reasons for specific management and better explanation of clinical causes of repeat visits, subsequent diagnostic imaging or delayed appendectomies, the findings warrant validation in large prospective clinical studies.
Dr Charles Snyder from the Children’s Mercy Hospital in Kansas City, Missouri, US pointed out in an accompanying editorial that despite the use of administrative data, which are subject to biases related to coding accuracy and do not allow for the assessment of patient-level clinical factors, the author’s points remain valid. [Pediatrics 2017;doi:10.1542/peds.2017-1232]
“Nonoperative management of appendicitis is increasing and may require increased resource utilization which limits its benefits; short- and long-term failure rates are nontrivial and may be higher than anticipated,” Dr Snyder wrote.
He stressed that the risk of complications associated with the current standard of care for children with acute uncomplicated appendicitis—a 30-minute, minimally invasive operation frequently performed on an outpatient basis—is small. Patients who undergo this procedure are unlikely to develop long-term problems related to appendicitis.
“Therefore, the alternative approach, nonoperative management of appendicitis faces an uphill battle to establish noninferiority when compared to surgical management,” he said.