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Nonoperative management of appendicitis offers short-term benefits, but long-term risks
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Although nonoperative management could offer patients with acute uncomplicated appendicitis an alternative to surgery, the long-term complications and costs that come with it could make it undesirable as a first-line therapy, according to research published in JAMA Surgery.
Lindsay A. Sceats, MD, of the Stanford-Surgery Policy Improvement Research and Education Center, and colleagues wrote that while appendectomy has long been considered the best treatment for appendicitis, it does not come without risks.
“Long-term complications may occur, including incisional hernias and small-bowel obstructions,” they wrote. “Due to sheer volume, appendectomy is the sixth leading cause of morbidity and mortality owing to emergency general surgery in the United States.”
Previous trials have shown that nonoperative management could be a viable alternative, and researchers set out to determine if it could have comparable outcomes, as well as if the overall cost ended up being less than that of an appendectomy.
Investigators analyzed data from 58,329 patients admitted with uncomplicated appendicitis between January 2008 and December 2014. Most patients underwent appendectomy (n = 55,709; 95.5%) compared with nonoperative management (n = 2,620; 4.5%). They assessed both short-term (emergency department visits, hospital readmission, abdominal abscess and Clostridium difficile infections) and long-term (small-bowel obstructions, incisional hernias and appendiceal cancer) clinical outcomes as primary endpoints, as well as secondary outcomes of follow-up visits, length and costs of index hospitalization and total cost of appendicitis-associated care.
Sceats and colleagues found that patients in the nonoperative cohort had a lower rate of treatment failure (3.9%) than previously reported. However, these patients were more likely to have appendicitis-related readmissions (adjusted OR = 2.13; 95% CI, 1.63–2.77) and more likely to develop an abscess (aOR = 1.42; 95% CI,1.05–1.92).
While patients in the nonoperative arm had lower index hospitalizations costs, they required more follow-up visits, resulting in a higher overall appendicitis-related cost of care (unadjusted mean [SD] $14,934 [$31,122] vs. $14,186 [$10,889]; P = .003).
“Taken together, these data do not support the use of nonoperative management as first-line therapy for uncomplicated appendicitis until more conclusive randomized clinical trial data become available,” Sceats and colleagues wrote.
In an accompanying editorial, Katherine M. Reitz, MD, and Brain S. Zuckerbraun, MD, both of the department of surgery at the University of Pittsburgh, wrote that while the study’s findings would generally support the continued use of nonoperative management, surgeons need to balance the short and long-term consequences of surgery for each patient.
“The onus is on surgeons to consider and educate patients about all aspects and costs of care associated with each option,” they wrote. “The findings of Sceats et al should be considered in the conversation between surgeon and patient, and the subsequent recommendation for operative or nonoperative management should be tempered by whichever strategy is most likely to achieve the additional goals and priorities of the patient beyond cure.” – by Alex Young
Disclosures: The authors report no relevant financial disclosures.
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