I would say no! There are several problems

1.Creating a potentially recurrent disease needs re-hospitalization several times.2.Creating antibiotic resistance3.No cost efficiency definitely longer hospital stay4.Reported to have higher rate of morbidity and mortality compared to surgery

I doubt there is any point even trying it.

Well, it is possible to get some degree of symptom resolutions in some patients especially, those with low Alvarado's score. But bear in mind that no sooner or later that patient might present with same or worse complains.

As I type, a patient of mine age 16 years,was managed conservatively for recurrent appendicitis 4 weeks ago but presented today to the emergency with same symptoms.  She is now being schedule for an appendectomy.

Hello Dear colleagues,

I truly appreciate your opinion and I also agree with some of your arguments.

I terms of self efficacy, it is possible that the cost to treat appendicitis nonoperatively do not differ from the total cost to treat appendicitis surgically because of potential recurrence rate. I do agree with that!!

Looking at from another point of view " avoiding surgery" a recent study is suggesting otherwise. They found ... I quote:

" twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted"

Even thought it seems interesting, I anticipate that my biggest concern about this study is the total sample size (Even though this is only a pilot, I still believe it is small). It is a small RCT - 50pts - 26 randomly selected to have surgery and 24 only antibiotics.

In terms of creating antibiotics resistance. It is important to remember that even the operative group receive antibiotic therapy before surgery. As it is part of the standardized treatment of care.

quote: "All patients allocated to surgery received preoperative antibiotic prophylaxis with 20 mg/kg of metronidazole. Further antibiotic treatment in this group depended on the severity of appendicitis in accordance with institutional practice."

I share your concerns, but I believe that a stronger RCT should be developed.

Best regards

Well, this is a good question. The best answer would be derived from a randomised controlled trial (RCTs). In adults at least, findings from recent RCTs show that patients without an appendicolith may be successfully treated conservative with antibiotics. However this does not necessary apply to children. Of course, RCTs in children are difficult for ethical reasons, but this study design could only answer your question without confounders or bias. 

What do you think? 

Thank you Dimitri for your answer. I agree and we are also considering to develop an index to predict whether some patients would be more appropriate for non surgical treatment than others. In that case, the one who are not appropriate, would undergo appendectomy. 

I like the idea on an index. This has to based on unbiased data derived from an international multicentric randomised controlled trial. The problem is that the best way to exclude an appendicolith in adults at least is CT. Ultrasound may be an alternative to kinds. This is important for the diagnosis as there is no point treating a patient with appendicitis in the presence of an appendicolith.  

The answer is Yes. You can treat your paediatric patients with non-complicated acute appendicitis without surgery by giving intravenous antibiotics. The indicators you use for monitoring of success must be clear. Follow up your own cohort of patients to see if recurrence occur including those with faecolith in the appendix.

Thank you Ossama and Dayang Anita,

I will read the recommended article. It is good to see similar studies previously done with similar expected results.

Dear Dr KAMARY

I suggest to read this paper;

Antibiotics alone versus appendectomy to treat uncomplicated acute appendicitis in adults: what do meta-analyses say?

Rocha LL, Rossi FM, Pessoa CM, Campos FN, Pires CE, Steinman M.

World J Emerg Surg. 2015 Oct 31;10:51. doi: 10.1186/s13017-015-0046-1. eCollection 2015. Review.

PMID: 26526329 Free PMC Article

It is indeed possible to get some symptom resolutions in some patients. Antibiotic treatment is not the golden standard jet. Don´t forget that recurrent disease needs re-hospitalization and an operative intervention.

Sometimes it is possible to treat the case conservative with heavy course of antibiotics under closed observation as inpatient. 

From my personal experience I would say that for the time being antibiotic therapy as a first line stand alone therapy does not meet a positive risk/benefit balance at all.

But, how is based my expertise? Partly on the "eminence" level of 3 decades of working and partly on the evidence level of myriads of publications dealing with this topic. And- the best surgery is the "no scalpel" surgery, still.

So to answer this question there will be a large prospective multi center study necessary, don´t you think so?

All those dealing with pediatric surgical patients know that non-surgical tratment of uncomplicated appendicitis can lead to devastating consequences, particularly in young kids.

  If you considerer that children with non-perforated cases are treated in our area laparoscopically, in a one-day stay basis, with minimun disconfort and early recovery, we hardly find any place for a risky treat-and-see policy  apart from those children with comorbidities or anesthetic risk.

    Long term prospective randomized studies IN CHILDREN are needed before changing our policy.

The answer is a resounding yes!  The evidence from prospective observational trials from as early as 1957, through the experience of the submarine program in the Navy, to multiple recent randomized trials.  

The more important question is which approach, first-line appendectomy vs. first-line antibiotic therapy is better.  Risk profiles differ; cost estimates differ.  Each is dependent on where the emphasis is placed and how the process works.

Can there be a benefit to avoiding an unnecessary operation. Of course. There are systematic reports that identify everything from surgical site infection to death.  Anecdotally, I have seen multiple devastating injuries related to anesthesia, exsanguinating blood loss, urethral injury, and others.

Is it possible that the disease could recur. Of course.  We don't give this a second thought in patients with simple diverticulitis.

This debate is clouded by a complete misunderstanding of the natural history and pathogenesis of appendicitis. Fitz' proposal of obstruction does not go far enough to explain the documented outbreaks and clusters of appendicitis. Families have shown several fold increases in the incidence of appendicitis.  Further, it cannot explain the non random distribution of cases world wide.

We should be working to understand why one individual gets the disease and another does not.  Why does patient A perforate in 24 hours while patient B has 11 days of symptoms and shows resolving inflammation in a non-perforated appendix.

Finally, the appendix has a function. It may be critical to maintaining the gut microbiome which has been linked to conditions as disparate as asthma, inflammatory bowel disease, alzheimer's disease, coronary artery disease and cancer. Is there a long term consequence of removing the appendix? if there is, then it might be in a patient's best interest to keep their appendix as long as possible.

 Hello Kurosh Paya, Yes, I do agree, and a multicenter RCT will be in place soon.

Kamary

Hello Adam,

"The more important question is which approach, first-line appendectomy vs. first-line antibiotic therapy is better"

Yes this is a very interesting idea. Because there is no standardized antibiotic used. In fact, even within the same institution this decision varies between surgeons.

This is very interesting topic as you are rightfully trying to expand the current discussion of a possible paradigm change for the disease of appendicitis to children. My main struggle with the results of recent, well conducted RCTs in adults is that it is not at all clear to me how we should be able to expand their findings to the general, population of patients presenting with appendicitis. As Dimitri pointed out, we would first have to establish if they have an appendicolith or not. This is not at all trivial, as CTs whilst displaying highest sensitivities for appendicitis, are not a standard diagnostic tool in most countries. Furthermore, there is a false-negative rate diagnostic rate even when integrating all modalities that requires consideration as well. Then there are other factors that require consideration, which in an RCT-setting are usually exclusion criteria: comorbidities, immunosuppression, previous surgeries, and and and. Then also, in a regular every day setting, you would want to provide the patient with a treatment and discharge them, but with appendicitis and conservative therapy, we tend to keep them in extremely close follow-up, which might even prove less cost-effective than uncomplicated surgery with discharge within 24 hours. Finally, one must never forget, that RCTs represent highly selected patient populations and therefore any 'effect-size' seen in an RCT will most often be 'watered down' when the same approach is applied to the more general population. In this case, I would assume failure rates of antibiotic treatment alone to increase if this were to become the new 'gold-standard'. Thus, with all of these issues in mind - how should we even conceive taking this debate to children already? Whilst I strongly support trying to answer this important question in a paediatric RCT, I still think there's quite a bit of work left to do with this disease in adults. 

¿Pueden los pacientes pediátricos con apendicitis aguda no complicada (no perforada) ser tratados con éxito sin cirugía?

es posible que si,  pero es mejor tratarlos con cirugia

Hola! Mi amigo,

Gracias por responder a la pregunta, incluso en español. Sí, estoy de acuerdo que la cirugía y sigue siendo la mejor opción de tratamiento para la apendicitis. Pero antes de pasar por alto completamente antibióticos como un posible tratamiento conservador, un ensayo clínico multicéntrico aleatorizado debe hacerse.

Por favor, perdona mi español