The surgeons at Nationwide Children’s Hospital noticed something strange about some of their young patients. If kids with appendicitis got to the hospital in the middle of the night, they were put on antibiotics until they could be wheeled into surgery early the next morning — at which point many patients were feeling better.
“Their parents began to question whether they needed surgery,” said Dr. Peter Minneci, a pediatric surgeon at Nationwide in Columbus, Ohio.
Minneci decided to answer the question with a controlled study. Over a five-month period, he and his colleagues asked parents of children with uncomplicated appendicitis if they wanted to be treated with antibiotics alone, or first with antibiotics and then with surgery, as is now standard practice. Of the 102 participating families, 37 chose just antibiotics, while 65 opted for both antibiotics and surgery. It was the first study of its kind in the United States, and the first in the world to look at this question in children.
In a paper published Wednesday in the journal JAMA Surgery, Minneci and his team reported that it may be possible to use antibiotics alone to treat kids with appendicitis, instead of always surgically removing the child’s inflamed organ. The findings support the conclusions of a June study from Finland, which tested the “antibiotics only” strategy in more than 500 adults.
“For over a hundred years, we’ve thought that we needed to treat appendicitis with surgery,” said Dr. Paulina Salminen, a surgeon at the Turku University Hospital who led the Finnish study. “The idea and treatment paradigm is probably changing.”
Minneci’s team found that three-quarters of those who went without surgery did not need to have an appendectomy within the next year, and that their medical bills for appendicitis were typically lower. “They got back to normal daily life faster, and their quality of life was better, which isn’t surprising, because they didn’t have to have surgery,” said Minneci.
But for Dr. Shawn Rangel, a surgeon at Boston Children’s Hospital, this study is hardly conclusive, mainly because the researchers chose eligible cases from over 600 patients screened, which means that the results don’t apply to most kids who walk into the ER with appendicitis.
Even when excluding so many of the more severe cases, families were probably biased to choose a certain course of treatment depending on the extent of their child’s pain, he explained. “If your kid looks fairly good, you’re much more likely to do the antibiotics,” he said. But, he added, if a child is writhing in pain and unable to walk even after intravenous morphine, chances are you’ll choose surgery, to deal with the problem once and for all.
Many of the children who went without surgery might not have even had appendicitis in the first place, he said, noting: “Unless you take out the appendix, you really don’t know if a patient has appendicitis or not.”
Dr. Katherine Deans, a surgeon at Nationwide and a co-author of the study, acknowledges that the wait-and-watch approach to cutting out the appendix might only be appropriate in a small number of kids with mild disease.
Still, the findings emphasize the importance of patient preference. “We don’t want everyone to use [antibiotics], we don’t want it to replace surgery,” she said. “It’s a reasonable choice. It’s a point of discussion with your doctor.”