SGEM #384: Take Me Out Tonight, I Don’t Want to Perforate My Appendix Alright

Date: November 16th, 2022 Reference: Lipsett SC, Monuteaux MC, Shanahan KH, et al. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022 Dr. Angelica DesPain Guest Skeptic: Dr. Angelica DesPain is an Assistant Professor of Pediatrics and a pediatric emergency medicine physician at the Baylor College of Medicine Children’s Hospital of San Antonio in San Antonio, TX. Case: A 10-year-old boy comes into the emergency department (ED) with right lower quadrant (RLQ) pain for the past two days. He also has had nausea, vomiting, loss of appetite but no fevers. You order an ultrasound and find that he has acute appendicitis without evidence of perforation or appendicolith. His white blood cell count is 11,000 and his C reactive protein (CRP) is mildly elevated. After you tell the family the news, the parents express concern about their child having surgery. They ask you and the surgeon, “Does he absolutely need surgery, or can we treat this medication alone?” Background: The SGEM has covered diagnosing appendicitis using speed bumps (SGEM#23), a clinical decision instrument (SGEM#155) and point of care ultrasound (SGEM#274). The current standard of care for nonperforated acute appendicitis is immediate laparoscopic appendectomy. However, over the last decade nonoperative treatment of appendicitis (NOTA) with antibiotics alone has become an alternative treatment option for non-perforated acute appendicitis. These authors call this alternative nonoperative management of uncomplicated acute appendicitis (NOM). The SGEM has looked at the evidence for NOTA/NOM in adults a few times including SGEM#115, SGEM#256 and SGEM#345. We have also looked at it specifically in children with pediatric general surgeon and rock star Dr. Ross Fisher with an episode called: The First Cut is the Deepest (SGEM#180). In adults, randomized control trials suggest that nonoperative management with antibiotics alone may be a reasonable treatment approach for individuals without appendicolith [1-3]. Although, up to 39% of patients may experience failure by the five-year mark [4]. In children, there have been two randomized and several nonrandomized prospective trials. Most recently, the two prospective pediatric studies published their 5-year data and observed a similar five-year failure rate of nonoperative management of 30-40% [5-6]. The shift from immediate operative management to now up to 3 in 10 cases being treated with IV antibiotics leaves a lot of questions as to whether nonoperative management is an appropriate option for nonperforated pediatric acute appendicitis.  Clinical Question: How do the risks and complications compare between nonoperative management vs immediate operative intervention for acute nonperforated appendicitis?  There are actually four questions these authors are trying to address with this paper. What are the trends in NOM of nonperforated acute appendicitis? What are the early and late treatment failure rates with NOM? How does subsequent healthcare utilization compare between children undergoing immediate operative management and those undergoing NOM? How do the rates of perforated appendicitis and postsurgical complications compare between children undergoing immediate operative management and those who experience failure of NOM? Reference: Lipsett SC, Monuteaux MC, Shanahan KH, et al. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022 Population: <19 years of age seen across 47 EDs in the Pediatric Health Information System (PHIS) database from January 2011 through March 2020 who were ascribed a primary diagnosis of appendicitis based on ICD-9 and 10 codes. To increase the specificity of the case definition, the study only included patients who either underwent appendectomy or received a parenteral antibiotic during the index visit. Excluded: complex chronic condition and those with a previous visit with a diagnosis of appen...