BACKGROUND AND PURPOSE:

• Recent RCTs have suggested that nonoperative management may be a reasonable alternative to surgery for uncomplicated appendicitis
• Significant limitation of previous studies include relatively small sample size
• Sceats et al. (JAMA Surgery, 2018) compared the outcomes of nonoperatively managed appendicitis versus appendectomy

METHODS:

• National retrospective cohort study (2008-2014)
• Participants
  • Patients admitted with uncomplicated appendicitis
• Patients classified in to two groups
  • Appendectomy
  • Nonoperative management
• Primary outcome: Clinical outcome differences between the two groups, including
  • Short term (<30 days) complications: Emergency department visits | All-cause readmissions | Appendicitis-associated readmissions | Abdominal abscess | Clostridium difficile diagnoses
  • Long term (≥30 days) complications: Readmission for small-bowel obstruction | Diagnosis of incisional hernia | Diagnosis of appendiceal cancer
• Nonoperative management failure
  • Hospital readmission with appendicitis diagnosis
  • Appendicitis-associated operation or procedure
• Secondary outcomes
  • Number of follow-up visits | Length and cost of index hospitalization | Total cost of appendicitis-associated care

RESULTS:

• 58,329 patients were included
  • 47.3% women
  • Mean age, 31.9 years
• 55,709 (95.5%) appendectomy group | 2620 (4.5%) nonoperative group
• Patients in the nonoperative management group were more likely to
  • Undergo appendicitis-associated readmissions (adjusted odds ratio (OR) 2.13; 95% CI, 1.63-2.77; P < .001)
  • Develop an abscess (aOR, 1.42; 95% CI, 1.05-1.92; P = .02)
  • Require more follow-up visits in the year after index admission (unadjusted mean 1.6 vs 0.3 visits; adjusted +1.11 visits; P < .001)
• Nonoperative group hospitalization costs
  • Index admission lower vs surgical group
    • Unadjusted mean $11,502 vs $13,551
    • Adjusted mean −$2117 (P < .001),
  • Total cost of appendicitis care was higher vs surgical group
    • Unadjusted mean $14,934 vs $14,186
    • Adjusted mean +$785 (P = .003)
  • During a mean follow up of 3.2 years
    • Failure of nonoperative management occurred in 3.9%
    • Median time to recurrence was 42 days
    • Among the patients who experienced treatment failure, 44 did so within 30 days

CONCLUSION:

• Nonoperative management was associated with higher rates of significant complications such as abscess and readmission as well as higher overall costs of care when follow-up was taken in to account

Learn More – Primary Sources:

Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients

Related ObG Topics:

Antibiotic Treatment Instead of Appendectomy for Uncomplicated Appendicitis – Long-Term Outcomes at 5 Years

Pelvic Inflammatory Disease – CDC Treatment Guidelines