Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Is nonoperative treatment of appendicitis in children safe?

Skeptical Scalpel, MD
Conditions
March 25, 2017
Share
Tweet
Share

After writing my 21st post about appendicitis back in November, I swore I would not write about it again for the foreseeable future.

Well, the future is now because investigators from the United Kingdom and Canada just published a meta-analysis including ten papers and 413 children about the efficacy and safety of nonoperative treatment for appendicitis in children.

They concluded that nonoperative management is effective in 96 percent of children with acute uncomplicated appendicitis during their initial hospitalizations with just 17 (4 percent) children requiring appendectomy before discharge. An additional 68 (16.4 percent) developed recurrent appendicitis later, and 19 of these patients were treated with the second course of antibiotics. The other 49 underwent appendectomy with histologic evidence of recurrent appendicitis.

Another 11 patients underwent appendectomy in the follow-up period for various reasons. In all, 77 (18.6 percent) patients initially treated with antibiotics eventually underwent appendectomy.

Although the initial hospital length of stay for appendectomy was shorter than that of patients treated with antibiotics, complication rates were similar.

These findings were met with headlines like “Antibiotics, not surgery, could treat appendicitis in children, study suggests” from the Guardian and “Is Surgery Always Needed for Kids’ Appendicitis?” from US News.

What are the problems with this paper?

After searching the literature, the authors identified the ten studies they deemed suitable — seven prospective and three retrospective. Four involved only nonoperative treatment. It is unclear how one could perform a meta-analysis comparing the nonoperative treatment of appendicitis with antibiotics to appendectomy if 40 percent of the studies did no such comparison.

Of the ten papers, only one was a randomized controlled trial, and it was a pilot study in which patients, parents, and surgeons were not blinded regarding treatment allocation. The lack of blinding obviously taints the results. The proper way to do this study is to blind the patients, the parents, and the surgeons by obtaining consent for enrollment before knowing which treatment group each patient was randomly assigned to.

The authors of the meta-analysis also pointed out that the randomized trial “was not powered to provide definitive evidence of the efficacy of nonoperative treatment vs. appendectomy.”

In the five other studies, surgery and antibiotics were discussed with the parents, and they were allowed to choose which treatment their child would undergo, hardly an objective research method.

Other than saying it varied, the meta-analysis was vague regarding how the diagnosis of acute uncomplicated appendicitis was made in each of the reviewed studies. An unknown number of children may have been diagnosed by clinical criteria only. Therefore, some may not have had appendicitis at all. If they never had appendicitis, they were not likely to get a recurrence no matter what the treatment was.

The combined average length of follow-up for patients in the ten studies is not stated but ranged from as little as two months to 51 months, and seven of the studies had follow-up lengths of less than two years.

ADVERTISEMENT

The authors had an epiphany about this stating, “Although we have not formally analyzed it, we noted a tendency for long-term efficacy to be lower in studies with longer duration of follow-up.” The short duration of follow-up is an issue with all studies of nonoperative treatment of appendicitis.

No studies used the same intravenous antibiotic regimen, and the duration of IV antibiotics was any one of the following: 2 doses, 24 hours, 48 hours, 72 to 120 hours, until abdominal tenderness resolved, and until C-reactive protein was less than 5 mg/dL. The oral antibiotic protocols were almost as varied.

I can agree with one conclusion of the meta-analysis. The authors called for larger and proper randomized controlled trials and said, “Until such studies are completed, we would recommend that nonoperative treatment of children with acute uncomplicated appendicitis be reserved for those participating in carefully designed research studies.”

This should ease the conscience of any surgeon not involved in a randomized controlled trial who believes appendectomy is still the treatment of choice for children with appendicitis.

“Skeptical Scalpel” is a surgeon who blogs at his self-titled site, Skeptical Scalpel.  

Image credit: Shutterstock.com

Prev

The new generation of physicians will reconcile the patient-provider relationship

March 25, 2017 Kevin 1
…
Next

How a mathematician developed an algorithm to help treat diabetes

March 25, 2017 Kevin 1
…

Tagged as: Surgery

Post navigation

< Previous Post
The new generation of physicians will reconcile the patient-provider relationship
Next Post >
How a mathematician developed an algorithm to help treat diabetes

ADVERTISEMENT

More by Skeptical Scalpel, MD

  • The hospital CEO who made a surgical incision. What happened?

    Skeptical Scalpel, MD
  • Medical error is not the third leading cause of death

    Skeptical Scalpel, MD
  • Should speed-eating contests be banned?

    Skeptical Scalpel, MD

Related Posts

  • Stop stigmatizing medication-assisted treatment

    Brandon Jacobi
  • When celebrities attack children with food allergies

    Lianne Mandelbaum, PT
  • Bullying immigrant children in the name of politics

    Linda Girgis, MD
  • Hospital administrators thinking about no-cost treatment which really helps patients

    John Corsino, DPT
  • A disturbing study about children and guns

    Christopher Johnson, MD
  • Separating children at the border is a danger to their health

    Oscar J. Benavidez, MD

More in Conditions

  • Why PSA levels alone shouldn’t define your prostate cancer risk

    Martina Ambardjieva, MD, PhD
  • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

    Olumuyiwa Bamgbade, MD
  • America’s ER crisis: Why the system is collapsing from within

    Kristen Cline, BSN, RN
  • Why timing, not surgery, determines patient survival

    Michael Karch, MD
  • Why psychotherapy works and why psychotherapy fails

    Peggy A. Rothbaum, PhD
  • How oral health silently affects your heart, brain, and body

    Charles Reinertsen, DMD
  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Why point-of-care ultrasound belongs in every emergency department triage [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why PSA levels alone shouldn’t define your prostate cancer risk

      Martina Ambardjieva, MD, PhD | Conditions
    • How to handle chronically late patients in your medical practice

      Neil Baum, MD | Physician
    • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

      Olumuyiwa Bamgbade, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • Why medicine must evolve to support modern physicians

      Ryan Nadelson, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 4 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Why point-of-care ultrasound belongs in every emergency department triage [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why PSA levels alone shouldn’t define your prostate cancer risk

      Martina Ambardjieva, MD, PhD | Conditions
    • How to handle chronically late patients in your medical practice

      Neil Baum, MD | Physician
    • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

      Olumuyiwa Bamgbade, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • Why medicine must evolve to support modern physicians

      Ryan Nadelson, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Is nonoperative treatment of appendicitis in children safe?
4 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...