The last decade or so featured a rather notable increase in palatability for the conservative management of appendicitis. Why undergo surgery for a condition antibiotics can cure? You wouldn’t take out your bladder for a urinary tract infection, would you?
This latest randomized trial adds to the evidence surrounding the “antibiotics first” strategy for appendicitis by expanding it to children. The failure rates at one year for the “antibiotics first” strategy in adults have been established at roughly 30%, as confirmed in another recent individual patient meta-analysis. At long-term follow-up, the failure rate approaches 50%.
In this trial of nearly 1,000 children across Canada, the USA, Finland, Sweden, and Singapore, virtually the same failure rate was seen, at 34%. Approximately half of the failures occurred at the index hospitalization, whereas the remainder occurred over the one year of follow-up. Conversely, the “negative appendectomy rate”, the measure of failure for those in the surgery arm, was 7%. Adverse events were low and similar across each group.
It is fairly clear the “antibiotics first” strategy, when it works, is superior. These children spent less time in the hospital, were back to normal activity sooner, and required less analgesia. I would suspect, overall, it is also less expensive – whether those costs are born by individual families, or by the health systems in total. However, the observed failure rate – and extrapolating to higher, longer term failures, as with adults – remains a vexing issue. The authors probably summed it up most accurately themselves
“… we suspect that this difference will continue to be interpreted from opposite viewpoints. Those most interested in avoiding an operation will see these data as providing hope, whereas those most interested in avoiding initial treatment failure or recurrence will see the failure rate as unacceptably high.”
Importantly, though, even if these data refuse to give us a solid answer, these do finally give us robust data in children to assist in those shared decision-making conversations.
“Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial”
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02420-6/fulltext