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Original Investigation |

Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis

Peter C. Minneci, MD, MHSc1,2; Justin B. Mahida, MD, MBA1,2; Daniel L. Lodwick, MD, MS1,2; Jason P. Sulkowski, MD1,2; Kristine M. Nacion, MPH1; Jennifer N. Cooper, PhD, MS1; Erica J. Ambeba, PhD, MPH1; R. Lawrence Moss, MD1,2; Katherine J. Deans, MD, MHSc1,2
[+] Author Affiliations
1Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
2Department of Surgery, Nationwide Children’s Hospital, Columbus, Ohio
JAMA Surg. 2016;151(5):408-415. doi:10.1001/jamasurg.2015.4534.
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Importance  Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient’s and family’s perspective, goals, and expectations.

Objective  To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children.

Design, Setting, and Participants  Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy.

Interventions  Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics.

Main Outcomes and Measures  The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery.

Results  A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01).

Conclusions and Relevance  When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.

Trial Registration  clinicaltrials.gov Identifier: NCT01718275

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Figure 1.
Study Flow Diagram

CRP indicates C-reactive protein; WBC, white blood cell (to convert WBC count to ×109 per liter, multiply by 0.001).

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Figure 2.
Kaplan-Meier Curve for the Success Rate of Nonoperative Management of Acute Appendicitis
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