Expanding the inclusion criteria for nonoperative management of uncomplicated appendicitis: Outcomes and cost

Background: Carefully selected children with early appendicitis may be managed nonoperatively. However, it is unknown whether nonoperative management (NOM) is applicable to all patients with uncomplicated appendicitis. The purpose of this study was to evaluate the outcomes of NOM of uncomplicated appendicitis with expanded inclusion criteria.

Methods: A prospective, nonrandomized patient-preference study comparing NOM versus laparoscopic appendectomy (LA) was performed in children with radiographic/clinical evidence of uncomplicated appendicitis.

Results: Demographics, laboratory values, and clinical presentation were similar between the NOM (n=51) and LA (n=32) groups. Initial failure rate was 31%. The outcomes were similar between groups, except that NOM had fewer days of pain medication. Patients who failed NOM had a longer duration of symptoms prior to admission. Patients with appendicolith had a failure rate of 50% compared to 24% without appendicolith. The recurrence rate was 26%. Overall, 51% avoided appendectomy. Costs were similar between NOM and LA.

Conclusions: When expanding the inclusion criteria for children with presumed uncomplicated appendicitis, NOM was associated with high failure and recurrence rates. These high rates may be because of the inclusion of patients with complicated appendicitis and patients with an appendicolith. Even in this setting of less-restrictive exclusion criteria, NOM remained cost neutral.

Level of evidence: LEVEL II (Treatment Study: Prospective Comparative Study).