Pediatric Appendicitis – Is Non-Op Management Safe?

Written by Denrick Cooper

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Nonoperative management (NOM) for uncomplicated appendicitis has become more common over the past 10 years in the pediatric population. Although many children do well, those who have recurrences have higher rates of surgical complications and hospitalizations.

Why does this matter?
The real JF connoisseurs know we have been following NOM for appendicitis for a while ( here, here and here ). NOM of uncomplicated appendicitis in adults is a feasible treatment modality. Although the rate of NOM in the pediatric population has increased drastically, there are few large trials supporting it. This study examines NOM in children from 2011 – 2021.

POP goes the appendix
This study was a retrospective cohort analysis of 63,150 children who underwent operative management, compared to 10,394 children who underwent NOM. ICD codes were used to define case presentations. Treatment failure was defined as a subsequent encounter with an ICD code of appendectomy or perforated appendicitis.

Among the children treated with NOM, 2,084 (20.1%) had treatment failure. Children who failed NOM had a higher chance of perforated appendicitis (45.7% vs 37.5% , p < .001), higher rates of ED visits (8.0 % vs 5.1%, p < .001), and more hospitalizations (4.2% vs 1.4%, p<001) compared to children who had operative management.

This study documents a lower treatment failure rate than previous literature (42 % vs 20.1%). However, it was not randomized, excluded appendicitis cases with appendicoliths, and relied on ICD case definitions. Although there was a high complication rate in children who failed NOM, a subset of children exists who seem to do well with NOM. The problem is we do not know exactly who those children are. We may not be doing the surgery, (thank God for EM and shift work!), but we do have a responsibility to act as patient advocates and participate in shared decision making. Larger scale randomized studies must be done before NOM can widely be used in children.

Source
Nonoperative Management of Uncomplicated Appendicitis. Pediatrics. 2022 Apr 18;e2021054693. doi: 10.1542/peds.2021-054693. Online ahead of print.

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