Pediatric Surgical Services at Hasbro Children's Hospital
Study Tests Nonsurgical Treatment as Viable Option for Acute Appendicitis
by Francois Luks, MD, pediatric surgeon-in-chief, and Thomas Chun, MD, pediatric emergency medicine physician, Hasbro Children's Hospital
Acute appendicitis is the most common surgical emergency in the pediatric population. In the U.S. more than 300,000 appendectomies are performed each year, with 70,000 of those operations in patients younger than 18 years. Operative appendectomy has been the gold standard treatment for acute appendicitis for more than 100 years. Surgical therapy has transformed a previously potentially fatal condition to a commonplace illness with a mortality rate close to zero. Most recent reports suggest that the morbidity rates in children are approximately 2.7% in nonperforated (nonruptured) and 16% in perforated appendicitis.
Current trends in modern medicine and surgery include a push to drive down even single digit morbidity percentages and to maximize cost effectiveness in medical care. This has caused a new analysis of the treatment of many medical and surgical diseases. Nonoperative treatment of early uncomplicated appendicitis could, if successful, help reduce health care costs and avoid many emergency surgical interventions.
In a 2012 survey of members in the American Pediatric Surgical Association, only 4% of 484 physicians considered nonperforated appendicitis to be an emergent procedure; most indicated that “urgent surgery within a day” was a reasonable approach to treatment. Supporting this paradigm shift are several studies that demonstrated no increase in morbidity and mortality of appendicitis, and no increase in perforation, when appendectomy was postponed overnight. This shift away from emergent surgical treatment has enabled the consideration of alternative management strategies for the treatment of acute nonperforated appendicitis. Initial nonoperative treatment of perforated appendicitis has been well reported in children and has demonstrated equivalence in efficacy (if not always in cost). Nonsurgical treatment of early, uncomplicated appendicitis, however, has not been considered until very recently.
Nonoperative treatment of early uncomplicated appendicitis could, if successful, help reduce health care costs and avoid many emergency surgical interventions.
Recently, six small studies have attempted to emulate the adult experience with antibiotic-only treatment of acute appendicitis. Initial success ranged from 75 to 90% but long-term data is lacking. In addition, these studies largely fail to find a statistically significant difference in overall cost when compared with operative management. This is likely owing to a combination of the study design, variable alteration of hospitalization and prolonged course of intravenous antibiotics.
In a small nonrandomized study in children at Hasbro Children’s Hospital (HCH), we demonstrated that nonoperative treatment is 88% successful in eliminating the signs and symptoms of early appendicitis in patients with confirmed acute appendicitis (approximately 20% of patients with appendicitis). Patients were hospitalized for less than a day and could return to their regular routine within days. The experience was rated more positively by patients and parents than that of patients who underwent either laparoscopic or open appendectomy. When successful, the overall cost of nonoperative treatment was less than half that of urgent appendectomy ($1,365 versus $4,130). Initial failure of nonoperative treatment was 12% - similar to that of other pediatric and adult surgeries.
A legitimate concern with nonoperative studies is whether the correct diagnosis is being treated. The false positive rate of appendicitis has fallen dramatically. No longer is a 10 to 15% normal appendectomy rate acceptable, as the risk of missed appendicitis is not the potentially lethal complication it was a century ago. Today, the false positive rates of 4 to 5% in children are accepted as the norm. In a recent study, we demonstrated that the negative appendectomy rate could be reduced below 2% using a combination of clinical exam, imaging and leukocytosis. Thus, the current management of appendicitis in children at HCH allows the diagnosis of early disease with near 100% accuracy.
Nevertheless, any surgical intervention is associated with pain, discomfort and the risk of complications. It affects the overall quality of life and, because of the high prevalence of appendicitis in children, represents a significant health care burden. With the creation of incentives like the Patient Centered Outcome Research Institute in 2010, an intentional shift is being made towards greater patient input in complex medical decisions.
In 2017, Dr. Thomas Chun and Dr. Francois Luks, both at Hasbro Children’s Hospital, were awarded a 1-year planning grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in preparation of a large, nationwide multi-institution randomized control trial to determine whether children with early appendicitis can be offered a trial of nonoperative management. The proposed study capitalizes on the expertise and infrastructure of the NIDDK, in close cooperation with the Pediatric Emergency Care Applied Research Network, and the geographic and patient diversity of its member institutions. This unique partnership ensures acceptance of the protocol at all levels of pediatric care and wide applicability of its results. Given its prevalence, there is the potential to radically reduce the burden of appendicitis, not only on patients and their families, but on society and health care systems as well.
References: Chau DB, et al, Patient-centered outcomes research in appendicitis in children: Bridging the knowledge gap, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.10.029 Hartwich J, et al, Nonoperative treatment of acute appendicitis in children: A feasibility study, J Pediatr Surg (2015), http://dx.doi.org/10/1016/j.jpedsurg.2015.10.024.