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Pediatric patients benefit from elective, nonoperative appendicitis treatment
Patient and family choice is a key component in the effectiveness of nonoperative, antibiotic-based treatment of acute uncomplicated appendicitis among children, according to recent research in JAMA Surgery.
“When chosen by the family, nonoperative management with antibiotics alone is an effective treatment strategy for children with uncomplicated appendicitis,” Peter C. Minneci, MD, MHSc, of the Center for Surgical Outcomes Research at Nationwide Children’s Hospital, and colleagues wrote. “Compared with urgent appendectomy, nonoperative management was associated with fewer disability days and lower health care costs at 1 year and no difference in rates of complicated appendicitis or reported health-related quality of life.”
Minneci and colleagues conducted a prospective study of 102 pediatric patients aged 7 to 17 years with acute uncomplicated appendicitis from October 2012 to March 2013. To determine the impact of patient choice on the success of nonoperative treatment, the researchers studied the safety and efficacy of this approach among the first 77 patients enrolled. After determining that the success of nonoperative treatment was in an acceptable range, the researchers enrolled the remaining study participants. Inclusion criteria included patients experiencing pain for 48 hours or less, with white blood cell counts less than 18,000/ μL and imaging evidence of nonruptured acute appendicitis.
Parents or legal guardians of the patients were counseled on the available treatments and asked to choose either nonoperative management or laparoscopic appendectomy.
Study results showed that 65 patients and families chose surgery; 37 chose nonoperative treatment. The researchers wrote that 89.2% of nonoperative treatments were successful after 30 days, and 75.7% were successful after 1 year.
The researchers learned that children who were treated nonoperatively had fewer disability days than those who underwent surgery (median 8 days vs. 21 days; P < .001). This group also incurred less appendicitis-related health care costs than the surgery group (median, $4,219 vs. $5,029; P = .01).
“Engaging families in shared decision-making in pediatric clinical care has been shown to improve medical outcomes,” Minneci and colleagues wrote. “The patient choice design allows the patient’s and family’s preferences to be aligned with their choice of therapy, thereby minimizing the potential effects of treatment preferences on outcomes.”
In a related editorial, Diana Lee Farmer, MD, FRCS, and Rebecca Anne Stark, MD, of the department of surgery at the University of California Davis School of Medicine, wrote that the researchers successfully defined the subset of patients who benefit most from nonoperative appendicitis treatment. However, Farmer and Stark also emphasized the responsibility of physicians during the decision-making process.
“Demonstrating that different treatment options have equivalent outcomes is the first step in determining whether offering a choice is safe,” Farmer and Stark wrote. “However, balancing the biases of both the physician and the patient is difficult, especially because physician bias is based on personal experience and comfort level and thus may be of more value than the bias of the patient.
“Further study is needed in this arena before we completely abdicate the responsibility for guiding our patient’s decision-making.” – by David Costill
Disclosure: The researchers report no relevant financial disclosures.
