A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis

Duggan, Eileen; Marshall, Andre P.; Weaver, Katrina L.; Peter, Shawn D. St.; Tice, Jamie; Wang, Li; Choi, Leena; Blakely, Martin L.

doi:10.1007/s00383-016-3897-y

Cited by 34 publications

(27 citation statements)

References 12 publications

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“…Two RCTs have evaluated NOT and appendicectomy for perforated appendicitis in children,47 48 and a recent review evaluated patient-level data from these two RCTs 49. Current data support emergency appendicectomy in children with perforated appendicitis in whom no intra-abdominal abscess is present, but in the presence of an abscess at presentation, comparable outcomes can be achieved with either NOT or surgery 49…”

Section: Non-operative Treatment For Perforated Appendicitis In Childrenmentioning

confidence: 99%

Non-operative management of appendicitis in children

Hall

Eaton

2017

Arch Dis Child

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Whilst appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon's knife. Many as yet unanswered questions remain however before NOT can be considered a realistic and reliable alternative to the surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.

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Section: Non-operative Treatment For Perforated Appendicitis In Childrenmentioning

confidence: 99%

Non-operative management of appendicitis in children

Hall

Eaton

2017

Arch Dis Child

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“…There was no difference in health care charges irrespective of the presence or absence of abscess. 8 Many surgeons, however, continue to utilize an initial nonoperative approach for perforated appendicitis in select children, particularly those presenting with a well-formed abscess. This is driven by concerns about increased operative morbidity and a lack of evidence showing it is more cost effective.…”

Section: Discussionmentioning

confidence: 99%

“…This is often the treatment of choice when a well-formed abscess is present at diagnosis as there may be a greater risk of operative complications, and early appendectomy has not been shown to reduce morbidity or health care charges in this population. 8 Children initially treated nonoperatively are excluded from existing SPs for early appendectomy in complicated appendicitis; thus, it is unclear whether such protocols have a similar benefit in this population, or what an effective SP would entail.…”

Section: Introductionmentioning

confidence: 99%

A Standardized Protocol for Nonoperative Management of Complicated Appendicitis in Children Reduces Resource Utilization

et al. 2020

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Introduction To standardize care and reduce resource utilization, we implemented a standardized protocol (SP) for the nonoperative treatment of complicated appendicitis. Materials and Methods We conducted a prospective, historically controlled, study of patients <21 years with complicated appendicitis managed nonoperatively using an SP from January 2017 to November 2018. The primary outcomes included length of stay (LOS), antibiotic days, peripheral inserted central catheter (PICC) utilization, discharge on intravenous antibiotics, and predischarge imaging. Secondary outcomes were protocol adherence and the rates of adverse events (AE) including return to emergency department (ED), readmission, failure of nonoperative treatment, and interval appendectomy complications. Results Protocol adherence was 67.9%. In total, 741 children were treated for appendicitis of which 58 (30 pre-SP and 28 post-SP) were treated nonoperatively for complicated appendicitis at presentation. Patients were well matched for age, admission white blood cell, sex, body mass index, race, and the proportion requiring percutaneous drainage. After implementing the SP, fewer children had PICCs (100.0 vs. 57.1%, p ≤ 0.001), fewer were discharged on intravenous antibiotics (90.0 vs. 42.9%, p < 0.001), and total antibiotic days were reduced (14.0 vs. 10.0, p = 0.006). There was no difference in LOS (5.5 vs. 6.0 days, p = 0.790) or the proportion undergoing ultrasound (36.7 vs. 39.3%, p = 0.837) or computed tomography scan (16.7 vs. 3.6%, p = 0.195) prior to discharge. There were nonsignificant trends toward reduced AEs (46.7 vs. 35.7%, p = 0.397), returns to ED (40.0 vs. 28.6%, p = 0.360), and readmissions (26.7 vs. 17.9%, p = 0.421). The proportion failing nonoperative treatment (10.0 vs. 3.6%, p = 0.612) and experiencing complications of interval appendectomy (3.3 vs. 3.6%, p = 0.918) were not significantly different. Conclusion Implementing an SP for treating complicated appendicitis nonoperatively reduced resource utilization without negatively affecting clinical outcomes.

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“…In contrast, the optimal treatment timing and strategy in cases of complicated appendicitis are still a matter of debate. In the pediatric population, there is strong evidence that early appendectomy should be employed in cases of perforated appendicitis without abscess . However, there is no consensus on the strategy to adopt in cases of appendicular abscess in either pediatric or adult patients.…”

Section: Introductionmentioning

confidence: 99%

“…In the pediatric population, there is strong evidence that early appendectomy should be employed in cases of perforated appendicitis without abscess. 13 However, there is no consensus on the strategy to adopt in cases of appendicular abscess in either pediatric or adult patients. Two RCTs on the application of NOM and IA in children with appendicular abscess recently reported contrasting results.…”

Section: Introductionmentioning

confidence: 99%

Superior outcomes (but at higher costs) of non‐operative management with interval appendectomy over immediate surgery in appendicitis with abscess: Results from a large adult population cohort

Watanabe

Otsuji

Nakamura

et al. 2019

Asian J Endoscop Surgery

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Introduction The aim of this study was to compare surgical outcomes and hospitalization costs between immediate surgery and non‐operative management followed by interval appendectomy in adults presenting with appendicitis with abscess. Methods From 2003 to 2015, 3316 patients presented with appendicitis, including 101 who presented with appendicular abscess. Between 2003 and 2006, 33 patients with appendicular abscess were managed with emergency operations (emergency group). Non‐operative management followed by interval appendectomy was implemented in 2007 and offered to 68 patients during the study period. Of these patients, 64 patients underwent the procedure (interval group), and 4 patients refused. Results Non‐operative management was successful in 76.6% of cases (49/64 patients) in the interval group. Operative time and length of hospital stay were similar between the emergency and interval groups. In the interval group, blood loss, the need for extended resection, and overall postoperative morbidity were significantly lower than in the emergency group (P < 0.01, respectively). Medical costs for surgery in the interval group were lower than in the emergency group ($4512 vs $6888, P = 0.002), but this group's total medical costs were higher ($9591 vs $6888, P < 0.01). Conclusion The interval strategy is associated with a reduced need for extended resection, lower postoperative morbidity, and a shorter length of hospital stay. However, total medical costs for the interval strategy are higher than those for emergency operations in cases of appendicular abscess in adults.

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A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis

Abstract: While EA appears to improve outcomes in patients without an abscess, the published data support no significant difference in outcomes between EA and IA in patients with an abscess.

Cited by 34 publications

References 12 publications

Non-operative management of appendicitis in children

Non-operative management of appendicitis in children

A Standardized Protocol for Nonoperative Management of Complicated Appendicitis in Children Reduces Resource Utilization

Superior outcomes (but at higher costs) of non‐operative management with interval appendectomy over immediate surgery in appendicitis with abscess: Results from a large adult population cohort

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