- ED —
- emergency department
- NOM —
- nonoperative management
The current standard of care for children with acute uncomplicated appendicitis is a 30-minute, minimally invasive operation that is frequently done on an outpatient basis. The risk of operative complications is small and it is unlikely that patients will develop long-term problems related to appendicitis. Therefore, the alternative approach, nonoperative management (NOM) of appendicitis faces an uphill battle to establish noninferiority when compared to surgical management.
In this timely study, Bachur et al1 reviewed data from the Pediatric Health Information System database over nearly 7 years, identifying 4190 children who met the following criteria for NOM: an emergency department (ED) visit with the diagnostic code for uncomplicated acute appendicitis, treatment with antibiotics, no procedure codes for appendectomy during the index visit, and no history of a previous appendectomy or appendicitis in the past year. The comparison group of 61 522 children had a diagnostic code for uncomplicated acute appendicitis and the procedure code for an appendectomy. The use of administrative data provides the benefit of large numbers. However, administrative data are subject to biases related to coding accuracy and do not allow for the assessment of patient-level clinical factors.
The authors found that the use of NOM was increasing. Resource utilization (ED visits, diagnostic imaging, and hospitalizations) after the index encounter was increased for NOM when compared with conventional appendectomy. The NOM group had an appendectomy rate of 46% within 1 year and 14% of patients were eventually found to have complicated (perforated) appendicitis.
The 1-year appendectomy rate of 46% is somewhat higher than commonly reported in pediatric or adult studies,1,2 and this rate excludes early inpatient failures of NOM: children who were admitted, received antibiotics, and then worsened; children who failed to improve; or families who changed their minds and requested an appendectomy during the index visit. The early inpatient failure rate of NOM is ∼10%.2
The proportion of patients eventually found to have complicated appendicitis was also higher than previous reports (14% vs <3%),1,2 suggesting that perhaps some in the NOM group were actually undergoing interval appendectomy.
The median time to failure of NOM was just 1 day, although early inpatient failure of antibiotic-only therapy was excluded, potentially suggesting a problem with the data or the interpretation of the data. 942 out of 4191 patients who received NOM were discharged from the ED after parenteral antibiotics but without hospital admission. To counter the concern that these children were not truly receiving NOM for appendicitis, the authors cite a 2016 report of adults and children over 13 years of age who underwent outpatient NOM of appendicitis.3 However, there were only 16 outpatients in this study, and ED discharge of children with acute appendicitis, even by strong proponents of NOM, seems highly unusual.
An alternative explanation is that children with suspected appendicitis in the ED were given a dose of antibiotics and were diagnosed (provisionally) as having appendicitis. These children would be more frequently sent for diagnostic evaluations (ultrasound and computerized tomography) because the diagnosis was less than clear. The administrative data indicate when a study was done but do not provide the results of the study. Some children may have been discharged from the hospital if radiographic studies showed negative or equivocal results. These children would be counted in this study as having nonoperatively managed appendicitis, artificially raising the incidence of appendicitis. Some patients would return (potentially for a scheduled follow-up or if their condition were worsening) for appendectomy, increasing the failure rate of NOM and potentially increasing the incidence of perforated appendicitis, as noted in the study.
Even with these concerns, the authors’ points remain valid: NOM of appendicitis is increasing and may require increased resource utilization which limits its benefits; short- and long-term failure rates are nontrivial and may be higher than anticipated. Identification of subgroups in whom NOM is more likely to succeed is needed. Well-controlled randomized studies, several of which are underway,4–7 are the most appropriate vehicle for evaluating the utility and efficacy of this approach.
- Accepted April 17, 2017.
- Address correspondence to Charles L. Snyder, MD, Department of Surgery, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-0048.
- Bachur RG,
- Lipsett S,
- Monuteaux M
- Rentea RM,
- Peter SD,
- Snyder CL
- Talan DA,
- Saltzman DJ,
- Mower WR, et al; Olive View–UCLA Appendicitis Study Group
- Children’s Mercy Hospital Kansas City
- Nationwide Children’s Hospital
- Rhode Island Hospital
- Xu J,
- Liu YC,
- Adams S,
- Karpelowsky J
- Copyright © 2017 by the American Academy of Pediatrics