'Antibiotics, not surgery, best for child appendicitis' says study

“Operating on children with acute appendicitis may be unnecessary in many of cases,” the Mail Online reports.

The headline is a little misleading as the researchers were specifically looking at a type of appendicitis known as “appendix mass”. This is where a lump develops inside the appendix.

The most common treatment approach for an appendix mass is to treat it first with antibiotics and then use surgery to remove the appendix to stop the problem from reoccurring.

In this study, researchers wanted to see if the second stage of surgical treatment was actually required.

The study included over 100 children from the UK, Sweden and New Zealand with appendicitis treated with antibiotics and found that later removal of the appendix could be avoided in many cases.

While the risk of complications following surgery is low, they can be serious. So if a condition can be treated without resorting to surgery,  this is usually for the best. 

This was a well-designed trial including over 100 children. But it does have some limitations, such as the short follow-up period (one year) for detecting the risk of recurrent appendicitis.

However, the findings of the trial are interesting and useful for clinicians and parents faced with a decision about treating this type of appendicitis: antibiotics followed by active surveillance, or antibiotics followed by surgery?

Guidelines for these sorts of issues are never set in stone. So it could be the case that this evidence will “add to the mix” for evolving theories of best practice for treatment.

Where did the story come from?

The study was carried out by researchers from the University of Southampton and was funded by the BUPA Foundation. The study was published in the peer-reviewed medical journal The Lancet.

Mail Online has provided an accurate report of the trial and also included the details of other studies that have been done around treatment options for appendicitis.

As mentioned, the headline did not mention “appendix mass”, but this is understandable as the phrase would mean little to most people.

What kind of research was this?

This was a randomised controlled trial (RCT) that compared the “interval” removal (surgical removal of the appendix following antibiotic treatment) of the appendix with active observation in children who had previously received non-operative treatment for appendicitis with a lump on the appendix (appendix mass).

Appendicitis is the most common general surgical emergency in children. Around 9% of children have an appendix mass that is treated with antibiotics as the risk of complications from surgery can be high.

However as the appendix is still in place it is possible that the child could have recurrent problems.

According to a 2009 survey of paediatric surgeons in the UK, it was reported that 68% routinely recommend removal of the appendix for all children after non-operative treatment of an appendix mass.

However, a systematic review published in 2011 suggested that the risk of recurrence after successful non-operative treatment of an appendix mass in children was 20%, and the incidence of complications after surgery was 3%.

What did the research involve?

The researchers recruited children to take part in the CHildren’s INterval Appendicectomy (CHINA) study from 19 specialist paediatric surgery centres, 17 in the UK, one in Sweden, and one in New Zealand.

Children included were aged 3 to 15 years and had successful non-operative treatment for acute appendicitis with a mass. Children were excluded from the study if they had existing gastrointestinal disease, another medical condition or an immune system problem.

The included children were randomly assigned to either receive interval appendectomy (removal of the appendix), where they were followed up at an outpatient clinic at around six weeks after surgery and again at one year after randomisation.

The other group of children went under active observation where they were reviewed every three months in the outpatient clinic for one year after randomisation.

The two main outcomes of interest were the proportion of children that developed acute appendicitis or recurrent appendix mass within one year following previous successful treatment in the active observation group, and the occurrence of severe complications related to interval appendectomy.

What were the basic results?

A total of 106 children were included in the trial, 52 children were assigned to interval appendectomy and 54 to active observation, (average age 8.5 years).

Following randomisation only 44 children in the interval appendectomy group had surgery and two children in the active observation group became ineligible after randomisation.

During the follow-up period six children (12%, 95% confidence interval [CI] 5 to 23) in the active observation group had recurrent acute appendicitis and three children (6%, 95% CI 1 to 17) in the interval appendectomy group had severe complications.

The severe complications related to interval appendectomy in three children were:

• one child had a hernia where the surgery was performed
• two children had a wound infection

Of the active observation group, 12 (23%) of these children underwent appendectomy during the follow-up period.

How did the researchers interpret the results?

The researchers conclude: “More than three-quarters of children could avoid appendectomy during early follow-up after successful non-operative treatment of an appendix mass. Although the risk of complications after interval appendectomy is low, complications can be severe. Adoption of a wait-and-see approach, reserving appendicectomy for those who develop recurrence or recurrent symptoms, results in fewer days in hospital, fewer days away from normal daily activity, and is cheaper than routine interval appendicectomy. These high-quality data will allow clinicians, parents, and children to make an evidence-based decision regarding the justification for interval appendicectomy.”

Conclusion

This was a randomised controlled trial (RCT) that compared the removal of the appendix with active observation in children who had previously received non-operative treatment for an appendix mass.

The researchers found that appendectomy could be avoided in many cases.

Perhaps actively keeping an eye on the child’s symptoms and only operating on those that develop appendicitis could be an approach worth considering.

This was a well-designed trial and efforts were made to reduce the risk of bias. For example, allocation to groups was concealed at the point of assignment. The trial was also performed at multiple centres, which increases the generalisability of the findings.

However there are also limitations.

• Due to the interventions being compared blinding was not possible in this trial, but objective outcomes were assessed as far as possible.
• As no formal definition of appendicitis or of a mass was used, the diagnosis was made by the surgeon in charge of the child’s care – this can be subject to bias as each surgeon’s opinion is subjective.
• The active observation group was followed up for only one year, which may not have been long enough to get a true estimate of the risk of recurrent appendicitis.

The findings of this trial are interesting as there have been some confusion over the benefits of interval appendectomy and provides useful information for parents and surgeons faced with this decision.

Read more about the treatment options for appendicitis.

Links To The Headlines

Why removing your child’s appendix could be a waste of time: Study finds that antibiotics could be just as effective. Mail Online, February 9 2017

Links To Science

Hall NJ, Eaton S, Stanton MP, et al. Active observation versus interval appendicectomy after successful non-operative treatment of an appendix mass in children (CHINA study): an open-label, randomised controlled trial. The Lancet – Gastroenterology & Hepatology. Published online February 6 2017