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Nonoperative Treatment of Acute Appendicitis in Children; A Feasibility Study
Joseph Hartwich, Debra Watson-Smith, *Arlet G. Kurkchubasche, *Christopher S. Muratore, Hale E. Wills, *Thomas F. Tracy Jr, *Francois I. Luks
Hasbro Children's Hospital, Providence, RI

Objective: Nonoperative treatment of acute appendicitis seems feasible in adults. It is unknown whether the same is true for children.

Design: Non-randomized controlled trial

Setting: Children's Hospital Emergency Room

Patients: Children 5-18 years with <48 h symptoms of acute appendicitis were offered nonoperative treatment: 2 doses of piperacillin IV, then ampicillin clavulanate x1 wk. Exclusion criteria included penicillin allergy, clinical/radiologic suspicion of advanced appendicitis, and inability (or unwillingness) to comply with the study. Treatment failure (worsening on therapy) and recurrence (after completion of therapy) were noted. Patients who declined enrollment were asked to participate as controls.

Intervention(s): Patients in the treatment arm were treated with antibiotics only, discharged after 8 hours of observation if pain was improved and patient was tolerating a diet. Patients are offered an interval appendectomy in 6-8 weeks if desired. Controls received a standard appendectomy (laparoscopic or open) and were treated according to standard therapy

Main Outcome Measure(s): Early failure, defined as progression of or worsening symptoms while on antibiotics. Late failure, defined as recurrence of symptoms (presumed appendicitis) after antiobiotics completed. Quality of life months were calculated based on a standard for age PedsQL questionairre and compared. Lastly a cost comparison between antibiotic therapy and standard appendectomy for early appendicitis was generated.

Results: Over 18 months, 308 children presented with appendicitis: 148 with perforation, 44 who met exclusion- and 116 who met inclusion criteria. Fifty-six were excluded for clinical or noncompliance reasons. Twenty-four patients agreed to undergo nonoperative management and 50 acted as controls. At a mean follow-up of one year, three of the 24 failed on therapy, and 2/21 returned with recurrent appendicitis at 43 and 52 days, respectively. Two patients elected to undergo an interval appendectomy despite absence of symptoms. Appendectomy-free rate at one year was therefore 71% (C.I. 44-86%) – not significantly different from adults (73%, C.I. 67-79% in a meta-analysis of >300 patients; P=0.77, ?2 analysis). No patient developed perforation or other complications. Based on PedsQL® results, appendectomy was assigned a value of 0.854-0.856 QALM and successful nonoperative treatment 0.928-0.992 QALM. Cost/utility analysis shows a 0.007-0.03 QALM increase and an \,299 = saving, from \,130 to \,831 per nonoperatively treated patient.

Conclusions: Despite the occurrence of late recurrences, antibiotic-only treatment of early appendicitis in children is feasible and safe. In a cost-utility analysis, attempted nonoperative treatment of early appendicitis results in \,878-197,084 saved for each quality-adjusted life month (QALM) increase.

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