Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

doi:10.1016/j.jpedsurg.2006.09.005

Journal of Pediatric Surgery

Volume 42, Issue 1, January 2007, Pages 19-24

https://doi.org/10.1016/j.jpedsurg.2006.09.005 Get rights and content

Abstract

Background

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

Methods

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using χ², Fisher exact, and Student t tests.

Results

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain).We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 ± 5.7 vs 8.8 ± 6.7 days, P = .08).

Conclusions

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.

Section snippets

Methods

A multicenter case control study was designed and conducted at 4 geographically diverse, academic, tertiary care children's medical centers. Institutional review board approval was received from all institutions before study initiation.

Data were collected for all children ages 1 to 18 who presented to these four hospitals between May 1998 and June 2003 with a diagnosis of perforated appendicitis. For the purposes of this study, perforated appendicitis was defined as evidence on preoperative

Results

Data were collected for 313 patients. Forty-eight were treated by nonoperative management. Five (10.4%) patients failed nonoperative management and required appendectomy within 3 weeks. These patients “failed” because of persistent fevers despite antibiotic treatment, abscess development believed to require operation, or ongoing and worsening symptoms. These 5 children subsequently had long hospitalizations, with a mean stay of 17.6 ± 12.4 days (range, 6-32 days). There were no significant

Discussion

Thirty to sixty percent of children with appendicitis have developed a perforation by the time the child presents to a surgeon [11], [12]. The management options for the surgeon include immediate appendectomy vs nonoperative management with or without drainage of a periappendicular abscess. When nonoperative treatment is successful, defined as return of the child to normal diet and activity, some surgeons suggest elective IA, while others do not.

In this study, we sought to define the

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Cited by (53)

Early versus interval appendicectomy for localised perforated appendicitis in children: A best evidence review
2020, Annals of Medicine and Surgery
A best evidence topic in general surgery was written according to a structured protocol. The question addressed was whether early or interval appendicectomy provides a superior clinical outcome for children presenting with localised perforated appendix. Altogether 204 papers were found using the search strategy reported below; of which 5 were identified to provide the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We concluded that for children presenting with localised perforated appendix without abscess formation, early appendicectomy provides better clinical outcome in terms of lower complication and re-admission rate and shorter length of hospital stay.
Comparison of Appendectomy for Perforated Appendicitis With and Without Abscess: A National Surgical Quality Improvement Program Analysis
2020, Journal of Surgical Research
Outcomes of appendectomy stratified by type of complicated appendicitis (CA) features are poorly researched, and the evidence to guide operative versus nonoperative management for CA is lacking. This study aimed to determine laparoscopic-to-open conversion risk, postoperative abscess risk, unplanned readmission risk, and length of hospital stay (LOS) associated with appendectomy in patients with perforated appendicitis without abscess (PA) and perforated appendicitis with abscess (PAWA) compared with a control cohort of nonperforated appendicitis (NPA).
The 2016-2017 National Surgical Quality Improvement Program Appendectomy-targeted database identified 12,537 (76.1%) patients with NPA, 2142 (13.0%) patients with PA, and 1799 (10.9%) patients with PAWA. Chi-squared analysis and analysis of variance were used to compare categorical and continuous variables. Binary logistic and linear regression models were used to compare risk-adjusted outcomes.
Compared with NPA, PA and PAWA had higher rates of conversion (0.8% versus 4.9% and 6.5%, respectively; P < 0.001), postoperative abscess requiring intervention (0.6% versus 4.8% and 7.0%, respectively; P < 0.001), readmission (2.8% versus 7.7% and 7.6%, respectively; P < 0.001), and longer median LOS (1 day versus 2 days and 2 days, respectively; P < 0.001). PA and PAWA were associated with increased odds of postoperative abscess (odds ratio [OR]: 7.18, 95% confidence interval [CI]: 5.2-9.8 and OR: 9.94, 95% CI: 7.3-13.5, respectively), readmission (OR: 2.70, 95% CI: 2.1-3.3 and OR: 2.66, 95% CI: 2.2-3.3, respectively), and conversion (OR: 5.51, 95% CI: 4.0-7.5 and OR: 7.43, 95% CI: 5.5-10.1, respectively). PA was associated with an increased LOS of 1.7 days and PAWA with 1.9 days of LOS (95% CI: 1.5-1.8 and 1.7-2.1, respectively).
Individual features of CA were independently associated with outcomes. Further research is needed to determine if surgical management is superior to nonoperative management for CA.
Pathology findings following interval appendectomy: Should it stay or go?
2020, Journal of Pediatric Surgery
Interval appendectomy following nonoperative management of complicated appendicitis remains controversial. The aim of this study was to evaluate surgical pathology and clinical outcomes after pediatric interval appendectomy.
Pathology results from children with complicated appendicitis who underwent interval appendectomy at a single children's hospital from 2010 to 2017 were reviewed. The primary outcome was pathology results. Secondary outcomes included complications and readmission following initial treatment and after interval appendectomy.
Among 149 patients (median age 11 years; range, 1–18), all had evidence of persistent inflammation on surgical pathology, 25 (17%) had an appendicolith, and no neoplasms were identified. Median duration of the initial admission was 8 days (range, 2–28) and 70% received a percutaneous drain prior to appendectomy. Interval appendectomy was performed at a median of 7.5 weeks (range, 2.9–29.1). Thirty-six (24%) returned to the hospital prior to their scheduled appendectomy and 6 (4%) required appendectomy earlier than planned. Nine patients (6%) experienced a complication following interval appendectomy, of which superficial surgical site infection was the most common (n = 4).
All children had evidence of ongoing inflammation on surgical pathology. While the clinical implications of persistent inflammation remain uncertain, these findings suggest that interval appendectomy is an appropriate treatment following medical management of complicated appendicitis in children.
IV, Case series with no comparison groups.
Appendicitis
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Acute appendicitis is one of the most common surgical conditions afflicting children and adults. Approximately 250,000 cases occur annually in the United States, with the highest incidence in patients 10 to 19 years of age. The lifetime risk of developing appendicitis has been estimated at 8.6% for males and 6.7% for females, with a lifetime risk of undergoing an appendectomy estimated at 12% for males and 23% for females. Appendiceal perforation in the pediatric population is more common than in adults, occurring in up to 50% of patients. In children younger than 5 years of age, the perforation rate is 65%, and 95% in children younger than 2 years of age. A thorough understanding of this common surgical condition is important for all health care providers, who should be able to recognize and refer patients with possible appendicitis to be further evaluated promptly in order to avoid complications related to delayed diagnosis.
Early appendectomy vs. conservative management in complicated acute appendicitis in children: A meta-analysis
2019, Journal of Pediatric Surgery
Citation Excerpt :
Furthermore, after successful NOM, once the child is returned to normal activity, many surgeons suggest DA. Several observational studies [8,11,5,24,21,7,12,18,20,9,15,14,19,22,1,6,16,17], two RCTs [10,13] and some meta-analysis [24,23,28,29] compared NOM vs OM in children, but no definitive data exist about which is the best option and for which patients. In the meta-analysis by Vaos about CAA, OM was associated with shorter LOS, while overall complication rates and wound infection declined significantly with NOM, but there was significant heterogeneity among studies [23].
No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children (CAA). Existing studies present heterogeneity of data and only few studies analyzed free perforated appendicitis (FPA) separately from appendicular abscess (AAb) and appendicular phlegmon (AP).
Studies which have been judged eligible for this systematic review and consequent meta-analysis are those comparing non-operative management (NOM) with operative management (OM) in children with CAA. Studies were subgrouped between those analyzing mixed patients with CAA, those focusing on patients with AAb/AP and those focusing on patients with FPA.
Fourteen studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 1288 patients. In the fixed-effects model the complication rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.07, 95%CI = 0.02–0.27) and to the OM arm for the FPA subgroup (RR = 1.86, 95%CI = 1.20–2.87); the re-admission rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.35, 95%CI = 0.13–0.93) and to the OM arm for the FPA subgroup (RR = 1.49, 95%CI = 1.49–7.44). There was no statistical heterogeneity for the two subgroups of patients. The costs weren't significantly different between NOM and OM. The length of stay was favorable to OM. The pooled proportion rate of NOM success was 90%, the pooled relapse rate of appendicitis was 15.4%.
Children with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM.
II
Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis
2019, Journal of Pediatric Surgery
This study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment (CT) of complicated acute appendicitis (CAA) in children.
Systematic literature research was performed for relevant studies published from 1969 to date. Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of hospital stay (LOS).
Fifteen trials were studied (1.243 patients). CT achieved better rates of any complication type (odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40 [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]: 0.25 [95% CI: 0.07, − 0.43], p = 0.007).
IS was associated with shorter LOS, while overall complication rates and wound infection declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized controlled trials (RCTs) to discover safe management of CAA in children.
Type of study: Meta-analysis.

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^☆: This research was funded by an OHSE grant from the Department of Surgery, Yale University School of Medicine.

: Presented at the 37th Annual Meeting of the American Pediatric Surgical Association, May 20–24, 2006, Hilton Head, SC.

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APSA PaperMatched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis☆,

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Am Coll Surg

Am J Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Role of interval appendectomy in the management of complicated appendicitis in children

World J Surg

APSA Paper
Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis☆,