R. C. Brady2, L. S. Burkhalter1, R. I. Renkes1, R. Huang1, A. C. Alder1,2 1Children’s Medical Center,Division Of Pediatric Surgery/Department Of Surgery/UT Southwestern,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA
Introduction:
Although acute appendicitis has traditionally been treated with urgent appendectomy, initial nonoperative treatment with antibiotics and abscess drainage has gained wide acceptance when patients present with a complicated appendicitis associated with periappendiceal abscess or phlegmon. Data suggest that adjuncts, such as percutaneous drains, allow for more rapid resolution of symptoms. Following successful nonoperative treatment, an interval appendectomy (IA) is traditionally routinely recommended to eliminate the risk of recurrent appendicitis. Surgeons have questioned the benefit of appendectomy after successful nonoperative management of complicated appendicitis.
Methods:
A retrospective review of children managed nonoperatively for complicated appendicitis between June 2009 and December 2012 at Children’s Medical Center in Dallas was performed. Patients were assessed for the development of recurrent symptoms of appendicitis. Demographic data, presenting symptoms, imaging, treatment, clinical course and outcome were analyzed to identify potential associations with recurrent symptoms.
Results:
A consecutive series of 100 children treated nonoperatively out of 3491 patients (2.8%) diagnosed with appendicitis during the study period were included. Eighteen patients (18%) experienced recurrent symptoms requiring admission or emergency department visit prior to scheduled IA within a median of 16.1 days from diagnosis (range 6.9 – 73.7d). Seven patients did not undergo an appendectomy.
There were no significant associations between gender, age, obesity status, race, or ethnicity and recurrent appendicitis symptoms. The presence of a fecalith or well-defined abscess on imaging was not predictive of recurrence. Similarly, analysis revealed no significant difference in recurrence rates or rehospitalization following treatment with aspiration, drain, or neither (i.e. antibiotics alone).
While the length of stay during the initial diagnostic admission was comparable, the cumulative length of stay, including readmissions and appendectomy, was significantly increased in the recurrence group when compared to the no-recurrence group (R median 242h, range 103-400h; NR median 166h, range 23-760h p=0.009).
Conclusion:
Significantly increased total hospitalization is associated with recurrent appendicitis. As no significant associations can be made between the clinical and demographic factors analyzed and risk of recurrence, we could not identify any predictors of recurrent symptoms. Similarly, recurrence risk did not appear to be significantly influenced by the use of a drain during nonoperative management in contrast to previous reports. We did not have sufficient numbers of patients who did not undergo IA to make any relevant conclusions. Additional study investigating the risk factors of recurrent symptoms in children managed nonoperatively for complicated appendicitis may help predict which patients will benefit from interval appendectomy.