Thursday, March 8, 2018

More negative data about the nonoperative management of simple appendicitis

If you think I am the only one urging restraint in the adoption of nonoperative management of patients with uncomplicated appendicitis, you are wrong. A pediatric surgeon and a research fellow from Harvard and Massachusetts General Hospital have recently published their thoughts on the matter online in Annals of Surgery.

They call their opinion piece “Ulysses Syndrome” because they liken the fate of those undergoing nonoperative management to the “10-year ordeal filled with unexpected peril and ample misfortune” that befell Ulysses while attempting to go home.

Here are a few highlights.

The authors cited a 2017 study from Boston Children’s Hospital in the journal Pediatrics which looked at data from 45 pediatric hospitals in the United States and reported that in the previous six years, the incidence of nonoperative management of non-perforated appendicitis has increased significantly by 20.4%. The paper also found that in the year after nonoperative management, children who underwent nonoperative management were subjected to more advanced imaging, more emergency department visits, and more hospitalizations, and a whopping46% eventually underwent an appendectomy.

A small randomized controlled trial compared 26 children who underwent immediate surgery for simple appendicitis to 24 patients manage with antibiotics alone. All of the patients in the immediate surgery group had appendicitis with no significant complications after surgery. Of the 24 patients managed nonoperatively, 9 (37.5%) eventually underwent an appendectomy. Five of them had surgery for recurrent abdominal pain and one at the request of the parents. Of note is that all six had normal appendices.

Despite the high rate of subsequent surgery, the authors of that paper put a positive spin on their conclusion which claimed “that nonoperative treatment of acute appendicitis in children is feasible and safe.”

Two other papers found longer lengths of hospital stay for patients undergoing nonoperative management when subsequent hospitalizations were included.

Several randomized prospective trials comparing surgery to nonoperative management are in progress. Detailed descriptions of them can be found at

The largest study, posted at in June 2016, is a multicenter trial looking to enroll more than 1500 patients with an estimated end date of March 2021.

The verdict about the outcomes of nonoperative management of appendicitis is not yet in. Physicians should be aware of the shortcomings of nonoperative management in order to better inform patients and families.


Anonymous said...

Is there any set of circumstances in which you would opt for nonoperative treatment (e.g. poor operative risk)?

Skeptical Scalpel said...

It's hard to say never. If I were the only surgeon at the South Pole and I thought I had appendicitis, I would go with antibiotics.

A laparoscopic cholecystectomy is not much of an insult to a patient's physiology but it does require general or fairly high spinal or epidural anesthesia. I suppose there might be a patient who simply could not tolerate such an anesthetic.

Just a thought said...

I think it allows for patients to wait out certain life events. Star quarterback playing at a state championship or the patient on blood thinners. I think I would still plan an interval appy. Also what about the looming cancer in the appendix that would have come out, if you had only taken the appendix.

That is was I think the evidence shows I can do it safely in the right context. I need 5-10 year follow out to see how many have problems after “conservative” treatment.

Skeptical Scalpel said...

An NHL player had a laparoscopic appendectomy a couple of years ago and was back playing in a week.

I agree none of the studies have followed patients long enough. I can’t understand why so many people have jumped on the bandwagon.

artiger said...

Nonoperative management has its (few) places, but I can't understand their definition of "feasible and safe".

Korhomme said...

Perhaps I posted this sort of comment before. I read a paper about what happened to people on nuclear submarines who developed RIF pain. There was no surgeon available; they were treated with antibiotics. No shortish-term problems. Some might not have had appendicitis, some probably did. So away from proper medical facilities, non-operative treatment is reasonable.

Pye's Surgical Handcraft was the manual issued to ships' captains; IIRC, it described how to do an appendicectomy. I once saw a (Russian) sailor who had undergone an appendictomy by the ship's captain. In those days, there wasn't much alternative.

Today, I'd opt for the antibiotics (though my appendix was removed as an encore during a laparotomy for an intussception.)

Skeptical Scalpel said...

Artiger, feasible yes. Safe, I don't know yet.

Kor, I agree. If there's no surgeon, use antibiotics.

Anonymous said...

As a chief resident, I woke one Thursday morning with localized RLQ tenderness after spending the previous 30ish hours with generalized malaise, nausea, abdominal discomfort, but still able to get work done. Now clear that I had appendicitis, I operated that morning and kept myself NPO and then notified my superiors I needed to talk to the abdominal surgeons. A few hours later, I was in recovery after my appendectomy, and the next morning, I drove myself home from the hospital. Saturday I was back in the hospital rounding.

Someone remind me why we are looking hard for an alternative treatment? What could be more simple, effective, definitive?

Skeptical Scalpel said...

Great story. I wish everyone was as motivated as you are. It’s a great example of the magic of surgery.

rotator said...

Reminds me of the US olympic team swimmer ~40 yrs ago who had his appendix out less than a week before the olympics started that year. He was back in the pool within 3 days and IIRC was on a medalling relay.
It googles up easily along with a 2018 variant:

Skeptical Scalpel said...

Rotator, thanks for the link. I had not seen that story. It's a good one.

Rugger said...

As goes the old saying "To cut, is to cure"

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