Surgery Not Always Necessary for Appendicitis in Children

October 3, 2016

Acute appendicitis is the most common surgical emergency in children, with more than 70,000 patients younger than 18 undergoing the procedure each year in the United States. But, a recent shift in treatment protocols means that some children presenting to the hospital with appendicitis will never need to see the inside of an operating room.

“Operative appendectomy has been the gold standard treatment for acute appendicitis for more than 100 years. At present, the procedure is performed with very low risk and few negative outcomes,” said Francois Luks, MD, interim pediatric-surgeon-in-chief of Hasbro Children’s Hospital. “However, non-operative treatment of early uncomplicated appendicitis could, if successful, help avoid surgery altogether.”

The traditional emergency surgical management of appendicitis has been reevaluated in recent years. In a 2012 survey of members in the American Pediatric Surgical Association (APSA), only 4 percent of physicians polled considered a non-perforated appendix – or one that has not “burst” – to be an emergent procedure. Rather, most indicated that “urgent surgery within a day” was a reasonable approach to treatment. Supporting this outlook are several studies that demonstrated no increase in negative outcomes from appendicitis, and no increase in perforation, when appendectomy was postponed overnight.

Christopher Muratore, MD

This shift away from the emergent surgical nature of appendicitis has allowed doctors to be much more precise, and has dramatically reduced the “negative appendectomy” rate – or, operations for what was thought to be an inflamed appendix, when the appendix turned out to be normal. On average, fifteen percent of cases were found to not be appendicitis, and with the new, more thoughtful treatment protocol, the negative appendectomy rate is less than two percent today.

“If you asked most parents what happens if their child gets appendicitis, the usual response would be, ‘they would need surgery to remove the appendix.’ For a long time that was true,” said Christopher Muratore, MD, a pediatric surgeon at Hasbro Children’s Hospital. “We want parents to know now that, if your child comes to the hospital with an early case of appendicitis, it may not automatically result in surgery anymore. In select cases, we may actually be able to fully resolve the appendicitis with antibiotics alone.”

A study in children at Hasbro Children’s Hospital, published earlier this year, demonstrated that non-operative treatment is 90 percent successful in eliminating the signs and symptoms of early appendicitis. Of course, not all cases of appendicitis are “early” – in fact, this approach may only apply to approximately 20 percent of patients with confirmed acute appendicitis.

Patients were hospitalized for less than a day and could return to their regular routine within a few days. The experience was rated more positively by patients and parents than those who underwent either laparoscopic or open appendectomy.

Luks 2
Francois Luks, MD

“Any surgical intervention is associated with pain, discomfort and the risk of complications - it affects the overall quality of life for children,” said Luks. “But also, because of the high prevalence of appendicitis in children, this represents a significant healthcare burden. These new non-surgical measures have 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.”

Luks added that it is important to understand that appendicitis, if ignored or improperly treated, can still be a dangerous disease. Therefore, any treatment, whether with surgery or antibiotics alone, must be performed in a hospital setting under close supervision of surgeons and other specialists.

Even if successful, antibiotic treatment must be administered intravenously in a hospital. Only if there are clear signs of improvement can a patient be discharged home on an oral regimen.