Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: A randomized controlled trial

Abstract

Objectives: To compare the outcome of non-operative treatment (NOT) with antibiotics versus surgical management of uncomplicated appendicitis in children.
 Methods: This randomized clinical trial (NCT 04030741) was carried out in Pediatric Surgery Department, Mayo Hospital from September 2018 to September 2019. Total sample size was 180, and after informed consent patients were randomly allocated in two groups. All children between 5 and 15 years of age and having pediatric appendicitis score (PAS) ≥7 were included. Patients with previous abdominal surgery, peritonitis, appendicular mass, or intra-abdominal abscess were excluded. Children in NOT group (Group A) were given intravenous Meropenem and Metronidazole for 48 hours and after starting oral, antibiotics were continued orally for 7 days. In Group B, children underwent appendectomy. Failure of NOT was labeled if there was abscess formation or peri-appendiceal fluid collection on ultrasound, development of peritonitis or recurrence of appendicitis.
 Results: In Group A, mean age was 9.56±1.8 years and in Group B 10.11±1.8 years. There were 123 male and 57 female patients. Group B had 100% successful outcome. NOT (Group A) had successful outcome in 75 patients (83.3%) and failure was noted in 15 (16.7%). Five needed operation within 48 hours, all had appendicolith, and 10 patients presented within 6 months. Raised total leukocyte count (p value < 0.0001) and C reactive protein (p value < 0.04) levels were noted with failure of NOT.
 Conclusions: In this study, success of NOT was 84% so a trial of NOT in cases of uncomplicated appendicitis should be considered in children.
 doi: https://doi.org/10.12669/pjms.37.5.4016
 How to cite this:Sajjad MN, Naumeri F, Hina S. Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: A randomized controlled trial. Pak J Med Sci. 2021;37(5):---------. doi: https://doi.org/10.12669/pjms.37.5.4016
 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A Systematic Review Comparing Nonoperative Management to Appendectomy for Uncomplicated Appendicitis in Children

“…This review found that there is a scarcity of relevant evidence in children, which is consistent with previous findings. Our study is the first to incorporate two RCTs in its analysis; the pilot trial with 50 participants and the article with 180 patients done by Sajjad et al [33]. The objective of this study was to systematically review available literature in the pediatric population and compare the efficacy and recurrence between initial nonoperative treatment strategy and appendectomy in children with uncomplicated appendicitis.…”

“…Also, three of nine patients with recurrence in the study by Mudri et al had fecalith [31]. However, Sajjad et al noticed no association; they noted that none of their ten patients with recurrence had appendicolith [33].…”

“…Patients in the appendectomy group got preoperative antibiotics, which were continued for at least 24 hours following surgery in certain studies. Initial failure rate associated with appendicolith: Five studies demonstrated that appendicolith was related to a significant likelihood of initial treatment failure [22,25,27,30,33]. Sajjad et al noted that all five patients (100%) who failed initial treatment had appendicolith [33].…”

“…Initial failure rate associated with appendicolith: Five studies demonstrated that appendicolith was related to a significant likelihood of initial treatment failure [22,25,27,30,33]. Sajjad et al noted that all five patients (100%) who failed initial treatment had appendicolith [33]. Mahida et al reported three cases of treatment failure with appendicolith on imaging [27].…”

“…In addition, Sajjad et al discovered a higher initial failure rate in individuals with elevated C-Reactive protein and leukocyte counts [33].…”