A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues? RETRACTED ARTICLE: Conservative Management of Acute Appendicitis Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. Antibiotics‐First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. Acute nonperforating appendicitis. Efficacy of brief antibiotic prophylaxis. Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible Prophylactic antibiotics in uncomplicated appendicitis during childhood--a prospective randomised study. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis Retraction Note to: Conservative Management of Acute Appendicitis [Preventive use of single dose antibiotics in acute appendicitis. Results of a prospective randomized clinical study]. Expanding the inclusion criteria for nonoperative management of uncomplicated appendicitis: Outcomes and cost. Nonperforative appendicitis: a continuing surgical dilemma. Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children.
Introduction : The management approach for acute appendicitis has been challenged in recent years , with numerous r and omized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment , with lower complication rates . Methods : A national survey of all consultant general surgeons evaluating their practice s was performed . Reasons for changed practice s , choice of antibiotics and follow-up investigations were evaluated . In addition , the role of interval appendicectomy and conservative management in the pediatric population was also assessed . Results : The response rate for this survey was 74.7 % ( n = 74/99 ) . Over one-fifth ( n = 17 , 22.9 % ) routinely treat acute appendicitis conservatively , while another 14.8 % ( n = 11 ) consider this approach in selected cases . Main reasons for modified practice s included the presence of inflammatory phlegmon ( 75 % ) , delayed presentation ( 64 % ) , and recent evidence -based medicine developments ( 46 % ) . Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management ( 53 % ) . Alternatively , combinations of antibiotics were also utilized . One-third felt interval appendicectomy was warranted , while one-fifth supported conservative management in the paediatric setting . The overwhelming majority ( > 95 % ) advocate follow-up colonoscopy ± computed tomography in any patient aged > 40 years managed conservatively . Conclusion : Considerable variation in management of uncomplicated appendicitis  remains in Irel and despite growing evidence suggesting that the non-operative approach is safe . Reasons for adopting a conservative management practice have been identified and reflect the exp and ing literature on this subject Background The acute appendicitis is the most common abdominal emergency , and the primary treatment has been appendicectomy . Antibiotics are started preoperatively and continued postoperatively as needed . Methods This prospect i ve study was carried out at Sher-i-Kashmir Institute of Medical Sciences , Soura , Srinagar , Kashmir , India to determine the role of antibiotics as the only treatment in acute appendicitis and the analgesic consumption needed . Total of 80 patients were included in the study with a duration of abdominal pain less than 72 h. Out of 80 patients , 40 patients received antibiotics intravenously for 2 days followed by oral treatment for 7 days , while another 40 patients considered as controls were r and omized to surgery . Results Patients managed conservatively were discharged within 3 days except for two— patients who required surgery after 12 and 24 h , respectively , because of peritonitis due to perforated appendicitis . Four patients were readmitted within 1 year as a result of recurrent appendicitis and had to undergo surgery when appendicitis was confirmed . The diagnostic accuracy within the operated group was 90 % . Two patients had perforated appendicitis at operation . Conclusion Our conclusion is that antibiotic treatment in the patients with acute appendicitis is quite effective , and these patients may not need surgery . The patients managed conservatively with antibiotics alone experience less pain and require less analgesia but have high recurrent rate OBJECTIVE The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children . METHODS A pilot r and omized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children . Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were r and omized either to treatment with antibiotics or to surgery . Follow-up was for 1 year . RESULTS Fifty patients were enrolled ; 26 were r and omized to surgery and 24 to nonoperative treatment with  antibiotics . All children in the surgery group had histopathologically confirmed acute appendicitis , and there were no significant complications in this group . Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis . Another 6 patients have had an appendectomy due to recurrent abdominal pain ( n = 5 ) or parental wish ( n = 1 ) during the follow-up period ; none of these 6 patients had evidence of appendicitis on histopathological examination . CONCLUSIONS 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 Uncomplicated appendicitis may resolve spontaneously or require treatment with antibiotics or appendicectomy . The aim of this r and omized trial was to compare the outcome of a non‐antibiotic management strategy with that of antibiotic therapy in uncomplicated appendicitis BACKGROUND Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial . We studied the results of initial conservative treatment ( antibiotics and percutaneous drainage if necessary , with or without interval appendectomy ) compared with immediate surgery . METHODS We undertook an observational , retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon , treated in our hospital between January 1997 and March 2009 . Patients younger than 14 , with severe sepsis or with diffuse peritonitis were excluded . A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment . A control group was composed of the other patients , who all underwent  urgent appendectomy  , matched for age and later r and omized 1:1 . The infectious risk stratification was established with the National Nosocomial Infections Surveillance System ( NNIS ) index . Dependent variables were hospital stay and surgical site infection . Analysis was with SPSS , with p < 0.05 considered significant . RESULTS Interval appendectomy  was performed in 7 study group patients . Surgical site infection episodes were more frequent in the control group ( 6 vs. 0 , p < 0.001 ) . A greater percentage of high risk patients ( NNIS ≥ 2 ) was identified in the control group ( 80 vs. 28.7 % , p < 0.03 ) , mostly related with contaminated or dirty procedures in this group ( p < 0.001 ) . No significant difference between groups was found in hospital stay . CONCLUSION Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon Study objective R and omized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics‐first is safe . No trial has evaluated outpatient treatment and no US r and omized trial has been conducted , to our knowledge . This pilot study assessed feasibility of a multicenter US study comparing antibiotics‐first , including outpatient management , with appendectomy . Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were r and omized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole . Stable antibiotics‐first‐treated participants older than 13 years could be discharged after greater than or equal to 6‐hour emergency department ( ED ) observation with next‐day follow‐up . Outcomes included 1‐month major complication rate ( primary ) and hospital duration , pain , disability , quality of life , and hospital charges , and antibiotics‐first appendectomy rate . Results Of 48 eligible patients , 30 ( 62.5 % ) consented , of whom 16 ( 53.3 % ) were r and omized to antibiotics‐first  and 14 ( 46.7 % ) to appendectomy . Median age was 33 years ( range 9 to 73 years ) , median WBC count was 15,000/&mgr;L ( range 6,200 to 23,100/&mgr;L ) , and median computed tomography appendiceal diameter was 10 mm ( range 7 to 18 mm ) . Of 15 antibiotic‐treated adults , 14 ( 93.3 % ) were discharged from the ED and all had symptom resolution . At 1 month , major complications occurred in 2 appendectomy participants ( 14.3 % ; 95 % confidence interval [ CI ] 1.8 % to 42.8 % ) and 1 antibiotics‐first participant ( 6.3 % ; 95 % CI 0.2 % to 30.2 % ) . Antibiotics‐first participants had less total hospital time than appendectomy participants , 16.2 versus 42.1 hours , respectively . Antibiotics‐first‐treated participants had less pain and disability . During median 12‐month follow‐up , 2 of 15 antibiotics‐first‐treated participants ( 13.3 % ; 95 % CI 3.7 % to 37.9 % ) developed appendicitis and 1 was treated successfully with antibiotics ; 1 had appendectomy . No more major complications occurred in either group . Conclusion A multicenter US trial comparing antibiotics‐first to appendectomy , including outpatient management , is feasible to evaluate efficacy and safety 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 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 A prospect i ve , r and omized , double-blind clinical study was performed to determine the efficacy of perioperative systemic antibiotics in preventing infection after appendectomy for acute nonperforating appendicitis . One hundred three patients received three doses of either placebo ( saline , n = 52 ) or cefoxitin sodium ( n = 51 ) . The two groups were similar with regard to age distribution , sex ratio , duration of operation , pathologic condition of appendix , and hospital stay . Postoperative wound infections were detected in 9.6 % of the placebo-treated patients , whereas none occurred in the cefoxitin group . All but one infection appeared after discharge . Cost analysis identified a net savings of $ 84 per patient with the use of prophylactic antibiotics . Septic morbidity after appendectomy for nonperforating appendicitis is significantly reduced by systemic antibiotics , and brief administration of a single broad-spectrum agent ( cefoxitin ) is effective prophylaxis Purpose Appendectomy versus conservative antibiotic treatment ( CAT ) for children with acute uncomplicated appendicitis ( AUA ) remains unresolved , with concerns regarding the practicality of CAT . We analyzed our center ’s experience with CAT for AUA , using a protocol with strict inclusion , exclusion and treatment criteria . Methods Non-r and omized , prospect i ve cohort study included all children admitted betwee 2014 and 2016 , with clinical and laboratory tests suspicious for AUA . Data collected included clinical signs and symptoms ; laboratory , ultrasound and pathology results . Follow-up was conducted through clinic visits , telephone conversations and national registry analysis . Results Included in CAT : 362 children , 19 underwent appendectomy within 1–2 days . Overall , 75 were readmitted for recurrent acute appendicitis during 22 months ( 6–43 ) follow-up . Thirty were treated successfully with antibiotics a second time . The remaining 45 had appendectomy . Overall , 86.8 % underwent CAT with no surgery . Histology of all recurrent AUA revealed no perforations . Conclusion We confirm the feasibility of conservative management of AUA in children . A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile . CAT does not compete with surgery or render appendectomy unnecessary . It is a safe alternative to surgery in selected cases 544 children operated upon for uncomplicated appendicitis were r and omised into three groups . Group I received no antibiotics , patients in Group II were administered one single pre-operative dose of metronidazole ( 10 mg/kg ) and patients in Group III received both both metronidazole ( 20 mg/kg ) and cefuroxime ( 50 mg/kg ) in a single preoperative dose . The rate of infectious complications in Group I was 6.3 % but only 2.1 and 2.3 in Groups II and III , respectively . Among patients with a normal appendix or patients with simple appendicitis there was no difference in the rate of post-operative infections between the three different groups . However , in patients with gangrenous appendicitis the rate of postoperative infections was significantly lower in the two groups who received preoperative antibiotics ( 1.8 % and 3.0 % respectively ) than in the group receiving no prophylactic antibiotics ( infection rate 14 % ) . It is concluded that a single preoperative dose of metronidazole significantly decreases the rate of postoperative infectious complications in children with appendicitis . No further improvement could be demonstrated if cefuroxime against aerobic organisms was added 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 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 ) A prospect i ve r and omized clinical trial was performed to determine the efficiency of single-dose antibiotic prophylaxis in preventing septic complications after appendectomy . The infection rate increased significantly in the control group without antibiotic prophylaxis ( 9.3 % to 20.3 % ) . Older patients with severe appendicitis had more advantages from the prophylaxis than younger ones . We have suggested to perform antibiotic prophylaxis individually only in those patients with high risk of septic complications after appendectomy BACKGROUND Carefully selected children with early appendicitis may be managed nonoperatively . However , it is unknown whether nonoperative management ( NOM ) is applicable to all patients with uncomplicated appendicitis . The purpose of this study was to evaluate the outcomes of NOM of uncomplicated appendicitis with exp and ed inclusion criteria . METHODS A prospect i ve , nonr and omized patient-preference study comparing NOM versus laparoscopic appendectomy ( LA ) was performed in children with radiographic/ clinical evidence of uncomplicated appendicitis . RESULTS Demographics , laboratory values , and clinical presentation were similar between the  NOM ( n=51 ) and LA ( n=32 ) groups . Initial failure rate was 31 % . The outcomes were similar between groups , except that NOM had fewer days of pain medication . Patients who failed NOM had a longer duration of symptoms prior to admission . Patients with appendicolith had a failure rate of 50 % compared to 24 % without appendicolith . The recurrence rate was 26 % . Overall , 51 % avoided appendectomy . Costs were similar between NOM and LA . CONCLUSIONS When exp and ing the inclusion criteria for children with presumed uncomplicated appendicitis , NOM was associated with high failure and recurrence rates . These high rates may be because of the inclusion of patients with complicated appendicitis and patients with an appendicolith . Even in this setting of less-restrictive exclusion criteria , NOM remained cost neutral . LEVEL OF EVIDENCE LEVEL II ( Treatment Study : Prospect i ve Comparative Study ) Acute appendicitis continues as a medical challenge with newer approaches failing to improve diagnostic accuracy . The role of antibiotics in acute nonperforative appendicitis ( NPA ) remains unclear . In 175 patients studied at two hospitals , preoperative guidelines were used to exclude perforative appendicitis . Nevertheless , 14 % of patients were found to have this condition . Surgeon 's reports significantly underestimated the diagnosis when compared with the pathologists ' reports . Antibiotic prophylaxis in 122 patients with NPA was studied prospect ively comparing ceftizoxime ( CTZ ) , cefam and ole ( CFM ) , and placebo ( PLA ) . Ceftizoxime decreased the infection rate compared with PLA ( 0 vs. 8 ; P less than .01 ) . Use of antibiotics ( CTZ or CFM ) result ed in decreased infections when compared with PLA ( 3 vs. 8 ; P less than .01 ) and fewer days of hospitalization ( 3.8 vs. 5.4 d , P less than .005 ) . Analysis of infection risk factors showed no correlations except for failure to administer antibiotics and the finding of a gangrenous appendix . Operative culture results had no predictive value for either infection or pathogen identification . It is recommended that all patients undergoing surgery for NPA be given 1 d of antibiotic prophylaxis 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
Although pain was a common criterion for nonresponse and appendectomy , analgesic regimens were poorly described .
BACKGROUND Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery .
However , guidance as to specific management does not exist .