title: Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. Progress in the Diagnosis of Appendicitis: A Report From Washington State's Surgical Care and Outcomes Assessment Program Comparison of operative and non operative management of acute appendicitis. Retraction Note to: Conservative Management of Acute Appendicitis Improving Outcomes After Laparoscopic Appendectomy: A Population-Based, 12-year Trend Analysis of 7446 Patients The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm.
abstract: BACKGROUND For decades , urgent operation has been considered the only appropriate management of acute appendicitis in children . The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children . STUDY DESIGN A prospect i ve nonr and omized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy  was performed . The primary result was 30-day success rate of nonoperative management . Secondary outcomes included comparisons of disability days , missed school days , hospital length of stay , and measures of quality of life and health care satisfaction . RESULTS Seventy-seven patients were enrolled during October 2012 to October 2013 ; 30 chose nonoperative management and 47 chose surgery . There were no significant differences in demographic or clinical characteristics . The immediate and 30-day success rates of nonoperative management were 93 % ( 28 of 30 ) and 90 % ( 27 of 30 ) . There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed . Compared with the surgery group , the nonoperative group had fewer disability days ( 3 vs 17 days ; p < 0.0001 ) , returned to school more quickly ( 3 vs 5 days ; p = 0.008 ) , and exhibited higher quality of life scores in both the child ( 93 vs 88 ; p = 0.01 ) and the parent ( 96 vs 90 ; p = 0.03 ) , but incurred a longer length of stay ( 38 vs 20 hours ; p < 0.0001 ) . CONCLUSIONS Nonoperative management of uncomplicated acute appendicitis in children is feasible , with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores . Additional follow-up will allow for determination of longer-term success rate , safety , and cost effectiveness IMPORTANCE Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe , but overall effectiveness is determined by combining medical outcomes with the patient 's and family 's perspective , goals , and expectations . OBJECTIVE To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1 , 2012 , through March 6 , 2013 . Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy . INTERVENTIONS Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and , on demonstrating improvement of symptoms , completion of 10 days of treatment with oral antibiotics . MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year success rate of nonoperative management . Successful nonoperative management was defined as not undergoing an appendectomy . Secondary outcomes included comparisons of the rates of complicated appendicitis , disability days , and health care costs between nonoperative management and surgery . RESULTS A total of 102 patients were enrolled ; 65 patients /families chose appendectomy ( median age , 12 years ; interquartile range [ IQR ] , 9 - 13 years ; 45 male [ 69.2 % ] ) and 37 patients /families chose nonoperative management ( median age , 11 years ; IQR , 10 - 14 years ; 24 male [ 64.9 % ] ) . Baseline characteristics were similar between the groups . The success rate of nonoperative management was 89.2 % ( 95 % CI , 74.6%-97.0 % ) at 30 days ( 33 of 37 children ) and 75.7 % ( 95 % CI , 58.9%-88.2 % ) at 1 year ( 28 of 37 children ) . The incidence of complicated appendicitis was 2.7 % in the nonoperative group ( 1 of 37 children ) and 12.3 % in the surgery group ( 8 of 65 children ) ( P = .15 ) . After 1 year , children managed nonoperatively compared with the surgery group had fewer disability days ( median [ IQR ] , 8 [ 5 - 18 ] vs 21 [ 15 - 25 ] days , respectively ; P < .001 ) and lower appendicitis-related health care costs ( median [ IQR ] , $ 4219 [ $ 2514-$7795 ] vs $ 5029 [ $ 4596-$5482 ] , respectively ; P = .01 ) . CONCLUSIONS AND RELEVANCE When chosen by the family , nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis , incurring less morbidity and lower costs than surgery . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01718275 The Alvarado score was assessed as to its accuracy in the preoperative diagnosis of  acute appendicitis .  A series of 49 consecutive patients was studied prospect ively over a period of 9 months in two hospitals ( Gateshead and Sunderl and ) . The presence of a high score was found to be an easy and satisfactory aid to early diagnosis of appendicitis in children and men . However , the false-positive rate for appendicitis in women was unacceptably high BACKGROUND In 2012 , a protocol for routine  outpatient laparoscopic appendectomy for uncomplicated appendicitis was published reflecting high success , low morbidity , and significant cost savings . Despite this , national data reflect that the majority of laparoscopic appendectomies are performed with overnight admission . This study up date s our experience with outpatient appendectomy  since our initial report , confirming the efficacy of this approach . METHODS In July 2010 , a prospect i ve protocol for outpatient  laparoscopic appendectomy  was adopted at our institution . Patients were dismissed from the postanesthesia recovery room or day surgery if they met predefined criteria for dismissal . Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management . An institutional review board – approved retrospective review of patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2012 was performed to analyze success of outpatient management , postoperative morbidity and mortality , as well as readmission rates . RESULTS Three hundred forty-five patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame . There were 166 men and 179 women , with a mean age of 35 years . Three hundred five patients were managed as out patients , with a success rate of 88 % . Forty patients ( 12 % ) were admitted for preexisting comorbidities ( 15 patients ) , postoperative morbidity ( 6 patients ) , or lack of transportation or home support ( 19 patients ) . Twenty-three patients ( 6.6 % ) experienced postoperative morbidity . There were no mortalities . Four patients ( 1 % ) were readmitted for transient fever , nausea/vomiting , partial small bowel obstruction , and deep venous thrombosis . CONCLUSION Outpatient laparoscopic appendectomy can be performed with a high rate of success , a low morbidity , and a low readmission rate . This study reaffirms our original pilot study and should serve as the basis for a change in the st and ard of care for appendicitis . LEVEL OF EVIDENCE Therapeutic study , level In a prospect i ve controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated . Of 40 patients admitted with a duration of abdominal pain of less than 72 h , 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were r and omized to surgery . All patients treated conservatively were discharged within 2 days , except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis . Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery , when appendicitis was confirmed . The diagnostic accuracy within the operated group was 85 per cent . One patient had perforated appendicitis at operation .  Antibiotic treatment  in patients with  acute appendicitis was as effective as surgery . The patients had less pain and required less analgesia , but the recurrence rate was high IMPORTANCE An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis . OBJECTIVE To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography ( CT ) . DESIGN , SETTING , AND PARTICIPANTS The Appendicitis Acuta ( APPAC ) multicenter , open-label , noninferiority r and omized clinical trial was conducted from November 2009 until June 2012 in Finl and . The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan . Patients were r and omly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period . INTERVENTIONS Patients r and omized to antibiotic therapy received intravenous ertapenem ( 1 g/d ) for 3 days followed by 7 days of oral levofloxacin ( 500 mg once daily ) and metronidazole ( 500 mg 3 times per day ) . Patients r and omized to the surgical treatment group were assigned to undergo st and ard open appendectomy . MAIN OUTCOMES AND MEASURES The primary end point for the surgical intervention was the successful completion of an appendectomy . The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period . RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group . Of 273 patients in the surgical group , all but 1 underwent successful appendectomy , result ing in a success rate of 99.6 % ( 95 % CI , 98.0 % to 100.0 % ) . In the antibiotic group , 70 patients ( 27.3 % ; 95 % CI , 22.0 % to 33.2 % ) underwent appendectomy within 1 year of initial presentation for appendicitis . Of the 256 patients available for follow-up in the antibiotic group , 186 ( 72.7 % ; 95 % CI , 66.8 % to 78.0 % ) did not require surgery . The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0 % ( 95 % CI , -31.6 % to ∞ ) ( P = .89 ) . Given the prespecified noninferiority margin of 24 % , we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery . Of the 70 patients r and omized to antibiotic treatment who subsequently underwent appendectomy , 58 ( 82.9 % ; 95 % CI , 72.0 % to 90.8 % ) had uncomplicated appendicitis , 7 ( 10.0 % ; 95 % CI , 4.1 % to 19.5 % ) had complicated acute appendicitis , and 5 ( 7.1 % ; 95 % CI , 2.4 % to 15.9 % ) did not have appendicitis but received appendectomy for suspected recurrence . There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients r and omized to antibiotic treatment . CONCLUSIONS AND RELEVANCE Among patients with CT-proven , uncomplicated appendicitis , antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy . Most patients r and omized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period , and those who required appendectomy did not experience significant complications . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01022567 Background and Objectives : Studies suggest that computed tomography and ultrasonography can effectively diagnose and rule out appendicitis , safely reducing negative appendectomies ( NAs ) ; however , some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis . The Surgical Care and Outcomes Assessment Program ( SCOAP ) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes . Since 2006 , accurate diagnosis of appendicitis has been a priority for SCOAP . The objective of this study was to evaluate the association between imaging and NA in the general community . Methods : Data were collected prospect ively for consecutive appendectomy patients ( age > 15 years ) at nearly 60 hospitals . SCOAP data are obtained directly from clinical records , including radiological , operative , and pathological reports . Multivariate logistic regression models were used to examine the association between imaging and NA . Tests for trends over time were also conducted . Results : Among 19,327 patients ( 47.9 % female ) who underwent appendectomy , 5.4 % had NA . Among patients who were imaged , frequency of NA was 4.5 % , whereas among those who were not imaged , it was 15.4 % ( P < 0.001 ) . This association was consistent for men ( 3 % vs 10 % , P < 0.001 ) and for women of reproductive age ( 6.9 % vs 24.7 % , P < 0.001 ) . In a multivariate model adjusted for age , sex , and white blood cell count , odds of NA for patients not imaged were 3.7 times the odds for those who received imaging ( 95 % CI : 3.0–4.4 ) . Among SCOAP hospitals , use of imaging increased and NA decreased significantly over time ; frequency of perforation was unchanged . Conclusions : Patients who were not imaged during workup for suspected appendicitis had more than 3 times the odds of NA as those who were imaged . Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations . Programs such as SCOAP improve care through peer-led , benchmarked practice change BACKGROUND In this prospect i ve study , operative and nonoperative management of acute appendicitis were evaluated regarding their safety and cost effectiveness . METHODS Two hundred ninety patients presenting to our Emergency Department between March 2005 and March 2006 with acute appendicitis were included in this prospect i ve study . Nonoperative medical therapy was performed in 107 patients ( Group 1 ) , and 183 patients were treated surgically ( Group 2 ) . Routine follow-up controls were done on the 10th day , at the 3rd and 6th months and at the first year after discharge in Group 1 . Both groups were compared regarding age , gender , mean hospital stay , modified Alvarado score , morbidity , mortality , and cost effectiveness . RESULTS The male/female ratio of Groups 1 and 2 were 65/42 ( mean age : 30.98+/-1.30 ) and 125/58 ( mean age : 26.25+/-0.79 ) , respectively . In Group 1 , 19 patients were operated . Operation indications were resistance to therapy , patient 's request , and operation in another hospital . Although the mean hospital stay of Group 1 was statistically significantly longer than Group 2 , the mean cost of the therapy was $ 559 in Group 2 and $ 433 in Group 1 . Morbidity rates were similar , with no mortality in either group . CONCLUSION With its high success rate and cost effectiveness , medical treatment seems to be a good alternative to the gold st and ard therapy of surgery in management of acute appendicitis The editors of the Journal of Gastrointestinal Surgery as well as the SSAT Board of Directors have retracted the article Malik , A.A. & Bari , S.U. Conservative management of  acute appendicitis . J Gastrointest . Surg 13 , 966–970 ( 2009 ) since significant portions of the article were published earlier in the following articles : Eriksson , S. & Granstrom , L. R and omized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis . Br J Surg 82 , 166–169 ( 1995 ) . Horton , M.D. , Counter , S.F. , Florence , M.G. & Hart , M.J. A prospect i ve trial of computed tomography and ultrasonography for diagnosing  appendicitis in the atypical patient . Am J Surg 179 , 379–381 ( 2000 ) OBJECTIVE Laparoscopic appendectomy for acute appendicitis has become increasingly used over the past decade . The objective of this trend analysis is to assess whether clinical outcomes after laparoscopic appendectomy have improved over the past 12 years . METHODS This analysis is based on the prospect i ve data base of the Swiss Association of Laparoscopic and Thoracoscopic Surgery . All patients undergoing emergency laparoscopic appendectomy for acute appendicitis from 1995 to 2006 were included . The following outcomes were assessed for each of the 12 years : conversion rates , intraoperative complications , surgical postoperative complications , general postoperative complications , rate of reoperations , and length of hospital stay . Unadjusted and risk-adjusted multivariable analyses were performed . Statistical significance was set at a level of P < 0.05 . All statistical tests were 2-sided . RESULTS Data from 7446 patients undergoing laparoscopic appendectomy for acute appendicitis were prospect ively collected . Over the period of observation , the conversion rate decreased significantly from 2.2 % to 1.2 % ( P(trend ) < 0.001 ) , as did intraoperative complications ( from 3.1 % to 0.7 % ; P(trend ) < 0.001 ) , surgical postoperative complications ( from 6.1 % to 1.9 % ; P(trend ) < 0.001 ) , general postoperative complications ( from 4.9 % to 1.5 % ; P(trend ) < 0.001 ) , and rates of reoperations ( from 3.4 % to 0.7 % ; P(trend ) < 0.001 ) . Average postoperative length of hospital stay also significantly decreased from 4.9 to 3.5 days ( P(trend ) < 0.001 ) . CONCLUSIONS Our investigation provides compelling evidence that intraoperative complications , surgical and general postoperative complications , conversion rates , rates of reoperations , and average length of hospital stay have significantly decreased over the past decade in patients undergoing surgery for acute appendicitis . The present trend analysis is the first one in the literature encompassing more than a decade and reporting clinical outcomes after laparoscopic appendectomy for acute appendicitis , which represents an important quality control PURPOSE Although many patients receive antibiotic therapy for uncomplicated appendicitis , the relatively high treatment failure and recurrence rates are problematic . We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm , have better outcomes . The purpose of this prospect i ve non-r and omized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm . METHODS Over 2 years , we enrolled 119 patients who initially received antibiotic therapy .  The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis . Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively . We evaluated the rates of treatment failure , peritonitis , and recurrence . RESULTS Nine patients ( 7.6 % ) failed to respond to initial antibiotic therapy , and 6 had true appendicitis after subsequent surgery . Two patients had complicated appendicitis ( peritonitis ) , but no patient displayed intra-abdominal abscess postoperatively . During a median follow-up period months of 14 months , 14 patients ( 12.7 % ) experienced recurrence . CONCLUSIONS Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm
target: The need for crossover in management and recurrent appendicitis were low among all studies .
  For those patients who ultimately required surgery , no increased complications were observed .
  Antibiotics may be safely recommended in patients with high surgical risk , such as the elderly or those with multiple comorbidities
background: AIM To review outcomes of  surgical and antibiotic management of acute appendicitis .