1. Non-operative management of “the” classic surgical disease?

2. Patient D.R. 7-year-old girl.
Several days of malaise, low grade fever at home, nausea.
Sent home from school.
WBC = 15k
PMNs = 96%
CRP < 0.8
Appetite in the ED.
Focal RLQ tenderness without involuntary guarding.

3. Patient D. R.
9 mm in widest dimension.
Peri-appendiceal fat stranding
At least two appendicoliths.

4. Patient D.R.
At operation (laparoscopic appendectomy) she was found to have an inflamed appendix with no perforation and a tiny amount of turbid fluid in the abdomen.
Path: areas of “marked mucosal disruption with ulceration and moderately intense mixed neutrophil-rich inflammation that extends through the muscular wall to the serosa. A perforation site is not appreciated.”

5. Patient D.R. No complications and she went home the next day.
Follow up phone call found her doing well. Rash thought related to oxycodone, so she was taking ibuprofen and Tylenol only.

6. Q: why would we consider non-operative management of acute appendicitis?
A: The luxury of 24-hour pediatric surgical consultation or even general surgery consultation is not available everywhere.

7.  

8. Data on non-operative management of acute appendicitis.

9. Suspected perforations were excluded.
2007 RCT in Sweden.
Multicenter.
Prosepective.
Randomized.
Male patients only.
18 – 50 year olds only.
Patients were asked whether they wished to participate prior to randomization.
Suspected perforations were excluded.
By study protocol, patients randomized to abx went to surgery if they were not improved within 24 hours of starting abx.
All suspected recurrences underwent surgery.
Antibiotics protocol: IV cefotaxime and tinidazole for 48 hours then PO abx (ofloxacin and tinidazole for ten days).
Styrud,J et al. Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prospective Multicenter Randomized Controlled Trial. World Journal of Surgery

10. 124 patients randomized to surgery
Results
124 patients randomized to surgery
128 patients randomized to antibiotics
Acute appendicitis was found in 97% of those who had surgery.
Of the 128 patients randomized to abx, 15 patients (12%) were operated on within the first 24 hours. 14 had appendicitis (one had terminal ileitis).
113 patients were sent home “successfully.”
1 year follow-up:
17 complications (14%) in surgery group (most were wound infections).
Recurrence rate was 15% (16 patients) within one year in the abx group. Five of these patients had a perforation at operation.
So: overall need for surgery was 27% in this study; or 63% treated non-op.
Hospital stay, sick leave, time off from work were not significantly different.
Styrud,J et al. Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prospective Multicenter Randomized Controlled Trial. World Journal of Surgery

11. 2010 Meta-analysis from a group in Nottingham, UK:
Three RCTs (including the one just discussed)
All with some methodological problems.
Total of 661 patients in the study.
Overall, 68% patients were treated successfully with antibiotics on first admission without a substantial increase in complications (indeed this paper sites a trend in the risk ratio towards less complications with non-op management).
HOWEVER, 15% of those sent home on antibiotics recurred (and most were then managed surgically).
Data is roughly similar to findings in study by Styrud et al.
Varadhan, K et al. Antibiotic Therapy Versus Appendectomy for Acute Appendicitis. A Meta-Analysis. World Journal of Surgery

12. Seattle Children’s Pathways
For the most part all acute appendicitis gets an operation: - normal: no abx, home next day - appendicitis, no perf: 3 doses IV abx and home if doing well the next day. - appendicitis equivocal perf: 48 hours IV abx and then home if doing well, or if cont’d signs of infection, switch to perf’d pathway - perforation: 5 days IV zosyn then re-assessment: [1] if clinically improved and normal CBC, home on PO abx; [2] if clinically well but abnormal CBC, home on IV abx and re-eval at POD 10 and POD 15; [3] if cont’d clinical signs of infection, remains in-house and continue IV zosyn and consider imaging on POD#7.

13. My conclusions:
In resource-rich health care settings no compelling data to support non-operative management of acute appendicitis.
In resource-limited health care settings, triage by initial 24 hour response to resuscitation and IV antibiotic therapy could safely identify those children who require transfer to regional or central hospitals.