Appendiceal Complications Following Nonoperative Management of Complicated Appendicitis: A Retrospective Study of 3,890 Patients
*Zane J. Hellmann MD, *Matthew Hornick MD, Daniel Solomon
Surgery, Yale School of Medicine, New Haven, CT
Background:
In hemodynamically stable, well appearing children with perforated appendicitis and abscess, there is clinical equipoise regarding the preference for upfront nonoperative management. However, the need for, or timing of interval appendectomy remains unsettled. Previous retrospective and prospective trials were limited to individual centers or small multi-institutional trials. Administrative data sets allows for large multi-institutional retrospection to address this controversy.
Study Design:
The Pediatric health information system (PHIS) was queried to identify patients younger than 18 with a ICD-10 diagnosis code for complicated appendicitis who did not undergo appendectomy during their index admission between 2018-2021. These patients were followed until end of 2022, with interval appendectomy identified by CPT or ICD-PCS during a separate admission. Unplanned readmissions for infectious complications were defined by patients receiving four or more doses of antibiotics during a separate admission. Kaplan-Meier survival analysis was performed to determine rates of unplanned readmission following index admission.
Results:
3,890 patients were included in the study for complicated appendicitis. 2,668 (68.6%) patients had an appendectomy, the remaining 1222 did not undergo appendectomy nor were readmitted for complications of recurrent appendicitis. 465 patients required unplanned readmission for antibiotic administration prior to appendectomy (193 patients) or for emergent appendectomy (299 patients, Figure 1). Unplanned readmission rate in the first 50 days following index admission was 8.0% of all patients at risk. This rate decreased to 4.6% of remaining patients from day 50 onwards. There was one patient who was diagnosed with an appendiceal tumor following interval appendectomy, representing 0.02% of all patients who met inclusion criteria for the study.
Conclusions:
The highest likelihood of appendiceal complications following nonoperative management of complicated appendicitis occurs in the first 50 days. After 50 days, pediatric patients who do not undergo interval appendectomy, have a 4.6% rate of readmission. These findings highlight that the standard 6-10 week delay to perform interval appendectomy can be safely extended, and that observation alone may be a safe strategy. This finding is congruent with previous single institution and prospective studies.
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