Modern medicine is amazing. Our oldest grandson had surgery to remove his appendix just a year ago, and now there is a new study that antibiotics may be an alternative to anesthesia and surgery. The Study, found on line December 16, 2015, “Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis,” compares surgery with a non surgical administering of antibiotics and the medical and non medical (“family’s perspective, goals, and expectations”) variables and consequences, “.
Appendicitis is caused by a bacterial infection of the appendix. According to the authors, “[a]cute appendicitis accounts for 11.4% of pediatric emergency department admissions, with more than 70,000 children hospitalized for it annually in the United States.” The concern for parents is the anesthesia and risks: “[a]lthough curative, appendectomy is an invasive procedure requiring general anesthesia with associated perioperative risks and postoperative pain and disability. Children may miss up to 2 weeks of activities and their caregivers may experience a similar disruption to their normal schedule.” Appendicitis is the leading reason for emergency surgeries in children, so the study is worth reading and knowing.
The objective of the study was “to determine the effectiveness of patient choice in nonoperative versus surgical management of uncomplicated acute appendicitis in children,” and the patients were ages 7 -16, who presented at a single acute care hospital with acute uncomplicated appendicitis. “Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy.”
So, what did the nonoperative management consist of?
“Patients choosing nonoperative management were admitted to the hospital for observation and to receive intravenous antibiotics (piperacillin sodium-tazobactam sodium or ciprofloxacin hydrochloride and metronidazole hydrochloride if allergic) for a minimum of 24 hours. After having oral food and fluids withheld for at least 12 hours, patients with clinical improvement (decreased reported pain or decreased tenderness on examination) had their diet advanced. When tolerating a regular diet, patients were switched to oral amoxicillin-clavulanate potassium (or ciprofloxacin and metronidazole if allergic) with the first dose given as an inpatient to ensure tolerance. Patients were subsequently discharged with oral antibiotics to complete a 10-day total course. Showing signs of clinical worsening (increased pain or systemic signs of sepsis) or failure to show clinical improvement within 24 hours (decreased pain or tenderness, resolution of nausea/emesis, or improvement in fever curve) was considered a failure and resulted in prompt laparoscopic appendectomy. After discharge, any patient who returned with abdominal pain and had clinical workup or evaluation findings consistent with recurrent appendicitis underwent urgent laparoscopic appendectomy. Follow-up was performed at 2 to 5 days, 10 to 14 days, 30 days, 6 months, and 1 year after discharge.”
So, what did surgical management consist of?
“Surgical management consisted of admission to the hospital with prompt initiation of intravenous antibiotics and laparoscopic appendectomy within 12 hours. All appendectomies were performed by pediatric surgeons with anesthesia administered by pediatric anesthesiologists. Patients were instructed to resume activities as tolerated, with resumption of heavy activity or sports (eg, weight lifting, football) 2 weeks postoperatively. Follow-up was performed at 30 days and 1 year after discharge.”
These children did not have a ruptured appendix and the appendix inflammation had to have certain criteria, so the choice to use the non surgical option may not be available in all circumstances. When the child was a candidate and used the nonoperative management with antibiotics alone, the study found that this management “is an effective treatment strategy for children with uncomplicated appendicitis. It incurs less morbidity and lower costs than surgery. By 1-year follow-up, 75.7% of patients who chose nonoperative management did not undergo an appendectomy. There was no difference in the rate of complicated appendicitis between those who had undergone appendectomy secondary to failure of nonoperative management and those who chose surgery initially. The study clearly showed, “. . . that an initial nonoperative management strategy is associated with fewer disability days and lower costs at 1 year than urgent appendectomy.”
So, where does the difference in outcome for the child involve the “family’s perspective, goals, and expectations?”
This is very interesting from the study: “For families who do not want to accept the risk of recurrent appendicitis, nonoperative management may potentially harm the child. For example, if a family is so afraid of a recurrence that they visit the emergency department every time their child has abdominal pain, then their child will likely undergo increased imaging and will eventually undergo an appendectomy. In this case, letting them choose an appendectomy up front may be the better choice for that child.”
So, the important consideration to note by virtue of this study is that a family has a choice. If the parents are concerned about anesthesia and surgery, and the child is a candidate, the family now can consider this option. This is great news. If the family is concerned about the nonsurgical option, the family can opt for surgery. Appendicitis surgery is usually lapraroscopic. According to Wikipedia,“[l]aparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5-1.5 cm) elsewhere in the body.” Our grandson recovered in three days and went on vacation with his family ten days after appendicitis surgery.
More choices for family is wonderful. But, do not wait to share this study until there is acute appendicitis. Remember that appendicitis is the leading reason for emergency surgeries in children.
Joy,
Mema
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