Journal of Pediatric Surgery 49 (2014) 782785

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Non-operative management of early, acute appendicitis in children:

Is it safe and effective?
Jeff Armstrong a, Neil Merritt b, Sarah Jones b, Leslie Scott b, Andreana Btter b,
a
Division of General Surgery, Western University, London Health Sciences Centre, London, Ontario
b
Division of Pediatric Surgery, Western University, Childrens Hospital, London, Ontario

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The purpose of this study was to determine if early, acute appendicitis in children can be safely and
Received 10 February 2014 effectively managed with antibiotics alone.
Accepted 13 February 2014 Methods: A retrospective review was performed of children (b 18 yrs) treated non-operatively (NOM) for
early, acute appendicitis since May 2012. These were compared to patients treated with appendectomy
Key words: between January 2011 and October 2011 (OM). Inclusion criteria included: (a) symptoms b 48 h, (b) localized
Appendicitis
peritonitis, and (c) ultrasound ndings consistent with early, acute appendicitis.
Non-operative management
Antibiotics
Results: Twelve patients (66% female, mean age 12.2,SD = 4.2 yrs) were treated non-operatively, while 12
(50% female, mean age 12.5,SD = 3.2 yrs) were treated operatively. Two NOM children (16.7%) required
initial appendectomy. One patient developed recurrent appendicitis requiring appendectomy 7 months post-
discharge. Four other NOM patients returned with symptoms but did not require admission or surgery. Two
OM patients (8.3%) had hospital visits and admissions related to surgical site infections. Mean length of stay
(LOS) for the rst visit was 1.5 days (SD = 1.0d) (NOM) vs. 1.3 days (SD = 0.5d) (OM) (p = 0.61). Including
rst and subsequent admissions, mean LOS was 1.8 days (SD = 1.1d) (NOM) vs. 1.7 days (SD = 1.5d) (OM)
(p = 0.97).
Conclusion: Early acute appendicitis in appropriately selected children can be successfully treated non-
operatively. Randomized trials with longer follow-up are required.
2014 Elsevier Inc. All rights reserved.

Acute appendicitis (AA) is the most common cause of emergency
surgery in children, with a lifetime prevalence of 7%8% [1]. The
annual incidence in Ontario is 75 per 100,000 population [2].
Since the early 20th century, treatment of acute appendicitis has
been primarily surgical. The surgical management of AA has greatly
reduced the mortality associated with the disease, however the risk of
complications is inherent to surgical treatment. Most commonly,
these risks include wound infection, intra-abdominal abscess forma-
tion, and prolonged ileus. Overall complication rates in adults are
11.1% with open appendectomy and 8.7% laparoscopically [3]. A meta-
analysis of appendectomy complications in pediatric studies was as
follows: 2.6% (laparoscopic) versus 2.7% (open) for non-perforated
disease, and 16.0% (laparoscopic) versus 18.1% (open) in perforated
disease [4].
Recent randomized controlled trials in adults have shown that
primary non-operative treatment with antibiotics alone may decrease
the complications traditionally associated with operative manage-
ment [57]. These suggest an algorithm in which patients are rst
treated with antibiotics, and only progress to surgery if antibiotic
Corresponding author at: Western University, Pediatric Surgeon, Division of Pediatric
Surgery, Childrens Hospital, 800 Commissioners Rd East, Rm B1-188, London, Ontario
N6A 4G5, Canada. Tel.: +1 519 685 8401; fax: +1 519 685 8421.
E-mail address: Andreana.butter@lhsc.on.ca (A. Btter).
therapy fails. This approach is currently utilized in other intra-
abdominal infections, such as uncomplicated diverticulitis in adults,
with good success rates. Conversely, in another randomized trial,
Vons et al. [8] concluded that primary non-operative management
was inferior to surgery, with increased peritonitis and a recurrence
rate of 26%. Other risks of antibiotic therapy alone include, nausea,
diarrhea, allergic reactions and opportunistic infections, such as
Clostridium difcile.
To date, there is very little experience in managing AA non-
operatively in the pediatric population. Abes et al. [9] published a
small retrospective review demonstrating that in select cases of early
AA, non-operative management could be used safely in children.
The objective of our study was to determine if early, uncompli-
cated acute appendicitis in children could safely be managed with
antibiotics alone.
1. Methods
After IRB approval (UWO REB File: 103669), the medical records of
all patients less than 18 years of age treated non-operatively for AA by
a single pediatric surgeon at our institution between May 2012 and
February 2013 were reviewed. During this time, this surgeons
practice was to offer non-operative management to all patients
diagnosed with early, uncomplicated acute appendicitis. Either the

http://dx.doi.org/10.1016/j.jpedsurg.2014.02.071
0022-3468/ 2014 Elsevier Inc. All rights reserved.
 J. Armstrong et al. / Journal of Pediatric Surgery 49 (2014) 782785 783

attending surgeon or the senior resident discussed the benets and Table 1
risks of non operative versus operative management of AA. Inclusion Reasons for exclusion from study groups.

and exclusion criteria were predetermined at the onset of the study NOM OM
period. Patients were included in the non-operative management Screened for inclusion 17 24
arm of the study (NOM) if they met inclusion criteria, including a Excluded 5 (29%) 12 (50%)
classic presentation of appendicitis, less than 48 h of symptoms at Imaging does not support diagnosis 4 7
presentation, and the diagnosis of acute appendicitis was con- Duration of symptoms N48 h 1 2
Other indication for operative intervention 2
rmed with imaging. Patients were excluded if they showed signs
Evidence of perforation on imaging 1
of hemodynamic compromise at presentation or if abscess or
phlegmon was diagnosed on imaging. These criteria were chosen
prior to the study to limit the groups to patients with early,
uncomplicated acute appendicitis. duration greater than 48 h (2 patients), appendectomy per-
The operative management (OM) group was obtained by review- formed electively as part of a larger procedure (2 patients), and
ing charts of all patients who underwent appendectomy for non- evidence of perforation on ultrasound (1 patient). Initial patient
perforated appendicitis by the same surgeon between January and characteristics are presented in Table 2. Median follow-up for the
October 2011. The same inclusion and exclusion criteria as the NOM NOM group was 6.5 months, and OM patients were followed up
group were then applied to this list to arrive at the nal comparison for 6 months after initial presentation.
group. There is a 6 month gap between the 2 groups since the surgeon Two of 12 patients (16.7%) in the NOM group failed initial non-
was on parental leave during that time. operative management of acute appendicitis (Fig. 1). One failed to
NOM patients were treated with intravenous ciprooxacin and improve in hospital, requiring appendectomy within 24 h of admis-
metronidazole or ampicillin, gentamycin and metranidazole while in sion. Another patient showed initial clinical improvement and was
hospital, and prescribed amoxicillin/clavulanic acid on discharge, with discharged home with oral antibiotics the following day. However, a
dosing adjusted for patient weight. Duration of antibiotic therapy was follow-up visit at 6 weeks revealed that the pain had not completely
one week. While in hospital, serial examinations were performed, and resolved, prompting elective appendectomy as an outpatient. The
a clinical decision was made by the attending surgeon to offer patients symptoms resolved following appendectomy. Of note, initial
operative management if the patients condition worsened or failed to imaging for this patient demonstrated the presence of a fecalith. Of
improve over a 24 h observation period. OM patients were treated the remaining 10 patients, 1 developed recurrent appendicitis
with a single dose of preoperative antibiotics, followed by laparo- 7 months post-discharge and required an appendectomy. Finally,
scopic appendectomy. one post-operative complication was seen in the NOM group: a deep
Data collected from the initial presentation included age, gender, surgical site infection requiring readmission but no invasive in-
time since onset of symptoms, leukocyte count ( 10 9l), C-reactive terventions. This complication occurred in the NOM patient who
protein (mgl), appendix diameter on ultrasound (mm), and time underwent appendectomy for failure to improve in hospital within
until management was initiated (hours). Post-treatment data includ- 24 h of admission.
ed length of stay in hospital (LOS), repeat visits to hospital, repeat Two of 12 patients (16.7%) in the OM group developed surgical
admissions, complications, and recurrences. site infections (SSIs), one deep and one supercial. The patient
The primary endpoints were a) failure of initial treatment and b) with a deep SSI required 2 readmissions for pain control and
complications of initial treatment. In the NOM group, this included antibiotics, each admission two days in length. Imaging revealed a
worsening or non-resolution of symptoms of appendicitis requiring small intra-abdominal abscess that was not amenable to percuta-
operation, and perforation while attempting non-operative manage- neous drainage, and the complication was treated with antibiotics.
ment. In the OM group this was dened to include peritonitis The patient with a supercial SSI was found to have an infected
requiring reoperation, and surgical site infections. Secondary end- 5 mm left lower quadrant port site, and was treated with
points included a) length of stay (for the initial visit and all antibiotics as an outpatient. No other surgical complications were
subsequent admissions), b) recurrences, and c) repeat visits to noted in the OM group.
hospital with symptoms. Mean length of stay at the time of the initial visit was 1.5 (SD =
Data were analyzed using IMB SPSS Statistics, version 20. The 1.0) days in the NOM group versus 1.3 (SD = 0.5) days in the OM
mean and standard deviation were used to summarize normally group (p = 0.61) (Table 3). Including subsequent readmissions, total
distributed continuous variables, whereas the median and range mean length of stay per patient was 1.8 (SD = 1.1) days (NOM)
were used for skewed continuous variables. Categorical outcomes versus 1.7 (SD = 1.5) days (OM) (p = 0.97). There were 4 (0.3 per
were reported as percentages. Group differences in continuous patient) repeat visits to the emergency department in the NOM group
variables were compared using the independent samples t-test or the versus 2 (0.2 per patient) in the OM group (Table 3) (p = 0.51).
independent samples MannWhitney U test. The Chi-square test or
Fishers exact test was used to contrast differences in proportions
Table 2
between the two groups. A p value b 0.05 was considered statisti-
Patient characteristics at inclusion.
cally signicant.
Nonoperative Operative management p
management N = 12 N = 12 value
2. Results
Mean SD Mean SD
Of 17 patients treated non-operatively for acute appendicitis, Age (years) 12.2 4.2 12.0 3.2 0.91
12 met the inclusion criteria for the NOM group. Reasons for Female:Male Ratio 8:4 6:6 0.68
exclusion from the study (Table 1) included lack of imaging Hours of symptoms 27.3 9.5 27.5 12.8 0.98
LKC 16.1 4.4 14.0 4.2 0.24
ndings to support the diagnosis (4 patients) and duration of
CRP 13.6 1.294.1 5.4 0.681.6 0.10
symptoms greater than 48 h at presentation (1 patient). Twelve (median) (range) (median) (range)
of 24 patients treated with appendectomy for non-perforated Ultrasound diameter 8.9 1.7 8.9 3.8 0.97
acute appendicitis between January and October 2011 met the (mm)
inclusion criteria for the OM group. Patients were excluded for Follow-up (months) 5.3 2.9 6 0 0.41

lack of imaging to support the diagnosis (7 patients), symptom Values are reported as mean SD unless otherwise noted.
784 J. Armstrong et al. / Journal of Pediatric Surgery 49 (2014) 782785

NOM (12) OM (12)

Successfully Failed NOM (2) Successfully Complications

treated (10) treated (10) (2)

Recurrence (1) Early (1) Late (1) Superficial SSI Deep SSI (1)
(1)

Deep SSI (1)

Fig. 1. Treatment outcomes.

3. Discussion of events considered to represent complications for the purposes of

To our knowledge, this is only the 2nd study reporting on the
non-operative management of early, acute appendicitis in children.
We found that 75% of AA patients in the NOM group were
successfully managed non-operatively, without ever exposing them
to the risks of surgery. In contrast, a recent meta-analysis of
randomised, controlled trials in adults found an overall success rate
of non-operative management of early appendicitis of only 63% at
one year [10].
In our study, all NOM patients requiring appendectomy were
treated laparoscopically. There were no intraoperative evidence of
perforation, and no subjective increased technical difculty with the
surgeries compared to the OM group. In total, there was one post-
operative complication in this group, with the patient requiring
readmission for an abscess, but no invasive intervention. There were
no conversions to open appendectomy in either group.
Complications in the OM group consisted of two surgical site
infections, one deep and one supercial. One patient developed an
intra-abdominal abscess requiring 2 readmissions (2 days each) and
antibiotics, but no invasive interventions. One supercial surgical site
infection was seen in a 5 mm port site, requiring antibiotics. The
complication rate seen in the OM group is higher than those
previously published in the literature. This may be explained by the
small numbers in the study, the lack of a formal protocol for
perioperative antibiotic management, and/or the relatively low acuity
Table 3
Treatment outcomes.
NOM OM
Treatment success 10 (83.3%) 10 (83.3%)
Failures/complications 2 (16.7%) 2 (16.7%)
Recurrences 1 0
Emergency dept visits 4 2
Readmissions 2 (total 3 days) 2 (total 4 days) N/A
LOS initial visit (days), mean (SD) 1.5 (1.0) 1.3 (0.5)
LOS total (days), mean (SD) 1.8 (1.1) 1.7 (1.5)
N/A = not applicable.
this study.
Concerns that increased need for close observation would result in
longer hospital stays for the NOM group appear to be unfounded. No
signicant difference was seen between the two groups. Read-
missions and repeat visits to the emergency department were also
similar between the two groups. Patients undergoing NOM may be
more likely to present to the emergency department with abdominal
pain, fearing recurrent appendicitis. All patients were offered interval
appendectomy following NOM, and all declined the option.
Systematic reviews have shown varied results in adults. Decreased
surgical complications are seen, but treatment efcacy is highly
variable [1015]. Three studies concluded that non-operative treat-
ment is safe and effective [10,11,15], four concluded that appendec-
tomy remains the gold standard [10,1214], and all agree that further
research is needed to determine which subgroups of the population
are most likely to respond to non-operative management [1015].
The NOM approach appears to be safe, although further data are
needed to conrm this. Adult studies suggest no higher rate of
perforated appendicitis in those initially treated non-operatively
when compared to conventionally treated appendicitis [10]. Currently,
there are no clear, high-quality data on postoperative complication
rates in children who have previously failed NOM compared to those in
the general population. Further investigation is needed on the rates of
recurrent appendicitis in the pediatric population, relative severity of
subsequent attacks, and relative difculty of successfully treating
recurrent disease.
Results from this study fall within the range of results in the adult
literature, which show an efcacy of 44%85% for non-operative
management [15]. Certainly different protocols, antibiotic regimens,
and thresholds for operation contribute to the variation in the results.
p-value
The only published pediatric study had a success rate of 93.7% for
0.58 initial treatment, a 13.3% recurrence rate at 1 year, and in total 20% of
N/A patients underwent appendectomy for appendicitis by 1 year post-
N/A
N/A
presentation [9]. Our study had similar results with an initial success
rate of 83.3%, a 10% recurrence rate and a total of 25% of patients
0.61 undergoing appendectomy at a median follow-up of 6 months.
0.97 This study is limited by its small size and relatively short follow-
up. The retrospective design did not allow investigation of other
 J. Armstrong et al. / Journal of Pediatric Surgery 49 (2014) 782785
relevant issues, such as the duration of pain, time until return to
activities and school, and quality of life. Numbers were also too small
to perform a meaningful subgroup analysis or to investigate factors
that may be correlated with increased rates of recurrent appendicitis.
One important factor may be the presence of a fecalith. The only NOM
patient with fecalith identied on imaging required appendectomy
for non-resolution of symptoms. Fecalith was seen in two OM
patients, neither of which suffered any complications. The majority
of previous prior RCTs failed to address the issue of fecaliths in NOM,
and one study demonstrated an increase in failed NOM and
recurrence related to the presence of a fecalith [8]. Larger numbers
would allow us to further investigate the impact on management.
The study design also allows the potential for selection bias. This
was minimized by offering NOM to all patients with early,
uncomplicated AA over the study period. Informed consent was
obtained by the attending surgeon and senior resident following
predetermined inclusion and exclusion criteria.
This study supports the conclusions of recent studies that there
likely is a role for non-operative management of early, acute,
uncomplicated appendicitis in well-selected individuals. This ap-
proach represents a dramatic shift from the traditional approach that
all acute appendicitis patients require immediate operative manage-
ment. Further study is needed to guide the selection of patients who
are appropriate for non-operative management.
Appendectomy following a trial of non-operative management
may come to be viewed not as a complication or failure, but as another
step in the management algorithm of acute appendicitis. This
algorithm may ensure that only those children needing an operation
are exposed to the inherent risks, with the potential to decrease the
overall morbidity related to the disease. A well-designed, large
randomized trial is needed to investigate these issues further.
785
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