Are Appendectomies a Thing of the Past?

Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: a meta-analysis. JAMA Pediatr. Published online March 27, 2017. doi:10.1001/jamapediatrics.2017.0057.

Acute appendicitis is a very common pediatric emergency. In the past 10 years, there have been significant advances in surgical technology and imaging modalities that have allowed for more accurate diagnostics. Simultaneously, several randomized controlled trials have proven the safety and effectiveness of non-operative treatment of appendicitis with antibiotics in adults. Until now, a similar a meta-analysis had yet to be completed in the pediatric population. Huang and colleagues aimed to compare antibiotic treatment with appendectomy for the treatment of uncomplicated acute appendicitis in pediatric patients, with particular attention to safety and efficacy.

This meta-analysis initially screened 527 articles, with 5 eventually included in the study. A total of 404 patients with uncomplicated appendicitis were included, all aged 5-15 years, with 168 patients assigned to the antibiotic treatment group and 236 patients assigned to the appendectomy group. Diagnosis was suspected appendicitis and was obtained from history, presentation, radiographic evidence, and increased inflammatory markers, though imaging was used to confirm diagnosis in all 5 studies. Successful non-operative treatment was defined by a resolution of symptoms within 48 hours without the need for surgery and/or the recurrence of appendicitis within 1 month. Successful treatment within the appendectomy group was considered with an operation without negative pathology findings and/or the need for re-operation.

Non-operative treatment was effective in 152 of 168 patients (90.5%). In the patients where this method was not successful, 11 went on to have an appendectomy, and 5 experienced recurrence of symptoms. Three of these patients had a perforated appendix.

Interestingly, a subgroup analysis showed that the risk for treatment failure increased in those patients with appendicolith with higher rates of recurrence. While the initial treatment data appears promising, the follow-up data within 1 year is worth examining. In total, 45 patients (28.6%) of the 168 patients underwent appendectomy within 1 year, most often due to recurrent appendicitis. At least 8 of these 45 patients did in fact have histopathologically normal appendixes. There were several appendectomies that occurred due to parental choice. In the appendectomy group, 1 patient required re-operation.

Other secondary outcomes examined included complications, cost, length of hospitalization, and length of disability. There was not a significant difference noted in complication rates between the 2 groups. The cost was noted to be decreased in the antibiotic group. There was a significantly longer hospital stay (a difference of about 14 hours) for the antibiotic group. The mean length of disability between the groups was more notable, which was reported as 8 days (IQ range, 5-18 days) for the antibiotic group and 21 days (IQ range, 15-25 days) in the appendectomy group.

There are a few limitations to this study. The antibiotics used in these various studies differ in terms of duration, type, and dose. It would be helpful to create standard criteria to further study this as a treatment modality. Also, as only 5 studies were included in this meta-analysis, more data would be helpful.

This research is an excellent starting point to consider antibiotic treatment for uncomplicated appendicitis. Antibiotic treatment can be quite effective, has lower length of disability, and is significantly lower in cost. It does still have a higher risk for treatment failure, though it is not clear from the results of this study how much of that increase was due to the presence of appendicolith. It does seem that surgery is suggested for uncomplicated appendicitis with appendicolith. Appendectomies do not appear to be a thing of the past, but larger studies will be needed to further delineate treatment guidelines to determine when other options may be more desirable.

Jessica Tomaszewski, MD, is an Assistant Clinical Professor of Pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware. 

Charles A. Pohl, MD—Series Editor, is a Professor of Pediatrics, Senior Associate Dean of Student Affairs and Career Counseling, and Associate Provost for Student Affairs at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.