Recurrence rates after nonoperative treatment of acute appendicitis in children: long-term follow-up
Emily Hensler*, Debra Watson-Smith, Andrew McCarthy, Melissa Vanover, Francois Luks
Brown University/Hasbro Children's Hospital, Providence, RI
OBJECTIVE: To determine the long-term outcomes associated with nonoperative management of acute appendicitis in children
DESIGN: Children with acute appendicitis enrolled between 2012 and 2015 in a nonrandomized prospective nonoperative management study were evaluated. Patients who had not undergone an appendectomy during the initial study period were followed long-term (endpoints: appendectomy or loss to follow-up).
SETTING: Academic children"ôs hospital.
PATIENTS: Twenty-three patients between 5 and 18 years of age who presented with less than 48 hours of symptoms of acute appendicitis were initially enrolled. Three failed while on treatment, while the remaining twenty patients constitute the current cohort.
INTERVENTIONS: In the initial study period, patients were treated with two doses of piperacillin-tazobactam IV, followed by ampicillin/clavulanate PO for one week. After IRB approval, medical records were consulted and patients/families were contacted to determine whether they remained recurrence-free.
MAIN OUTCOME MEASURE(S): Recurrence-free rate.
RESULTS: Three patients (13%) failed nonoperative management (initial hospitalization or subsequent week-long oral antibiotic therapy). Fourteen of the remaining 20 (70%) have stayed recurrence-free at the time of the most recent follow-up or interval elective appendectomy (2 patients). Median follow-up for this cohort is 74 months (max. follow-up 113 months) (figure 1).
CONCLUSIONS: Nonoperative management of acute appendicitis remains a highly controversial topic. Unfortunately, few long-term studies exist, particularly in children. While the present pilot study is small, it examines the outcome of pediatric patients treated nonoperatively a decade ago. Contrary to earlier predictions and at least one long-term study in adults, recurrent appendicitis in children who underwent initial nonoperative management does not appear to increase substantially over time: two-thirds (4/6) of recurrences occurred in the first year. Seventy percent (14/20) of patients who were successfully treated with nonoperative management on their initial presentation remained recurrence-free at the time of their latest follow-up. The decision to offer nonoperative management of acute appendicitis is contingent on its safety (it appears to be, as very few patients return with complicated appendicitis) and a clear understanding by patients and families of the risks and recurrence rate. This long-term pilot study offers a first glimpse into late recurrence rates. These appear lower than been previously reported, making an argument for large-scale, long-term evaluation of this treatment modality.
Kaplan-Meier curve depicting probability of pediatric patients remaining free of recurrence of appendicitis over time
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