Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

Systematic Review and Meta-analysis to Compare the Short- and Long-term Outcomes of Non-operative Management With Early Operative Management of Simple Appendicitis in Children After the COVID-19 Pandemic

BACKGROUND

Non-operative management (NOM) of simple appendicitis is becoming an increasingly researched treatment option. This systematic review aims to describe the short and long-term failure rates of NOM and the complication rate of appendicectomy in children with simple appendicitis.

METHODS

The systematic review was registered a priori (CRD42022322149). Study inclusion criteria are: participants aged ≤ 18 years of age; groups undergoing both NOM and appendicectomy for simple appendicitis; outcomes including one or more of: NOM failure rate at 30 days or 1 year and beyond; study design: RCT or case control study. Four databases were searched and 3 reviewers determined study eligibility and data extraction. Risk of bias was assessed and meta-analysis was performed using Stata.

RESULTS

The database search identified 2731 articles, 14 studies met the inclusion criteria; 4 RCTs and 10 case controlled studies. All studies had moderate-serious risk of bias. There were no deaths in either group in any study. Meta-analysis demonstrated a 30 day failure rate of 20 % (95 % CI 11-29 %) and 11 studies reported failure rate at 1 year or beyond at 32 % (95 % CI 25-38 %). Rates of significant complications of appendicectomy was 1 % (95 % CI 0-1 %).

CONCLUSIONS

Non-operative management of simple appendicitis in children is safe, with moderate early success. The failure rate increases over time, resulting in eventual appendicectomy in a third of the children diagnosed with appendicitis. These data will enable clinicians to have an informed discussion with children and their parents about their treatment options for simple appendicitis.

LEVEL OF EVIDENCE

II.

I Walk the Line: Between Basic Science and Paediatric Surgery

The role of a basic scientist working with paediatric surgeons is not an obvious one. However, there are several levels at which science can contribute to the speciality, and also ways that scientists can learn useful lessons from paediatric surgery. As most conditions treated by paediatric surgeons have low case numbers, we need to find ways of defining optimal treatment and developing novel therapies within a challenging number of patients.

A meta-analysis and trial sequential analysis comparing nonoperative versus operative management for uncomplicated appendicitis: a focus on randomized controlled trials

BACKGROUND

The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis.

METHODS

A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs.

RESULTS

Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61-1.04, P = 0.07, I2 = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I2 = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I2 = 81%) participants. There was no difference in LOS (mean difference - 0.58 days 95% confidence interval - 1.59 to 0.43, p = 0.26, I2 = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence.

CONCLUSIONS

As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes.

Non-operative treatment for simple acute appendicitis (NOTA) in children during the COVID-19 era: new lessons from the pandemic

Coronavirus (COVID-19) was a pandemic disease that was affecting our medical and surgical daily practice badly. The surgical management of acute appendicitis was the gold standard, but new studies suggest the safety of antibiotic treatment alone. Non-operative treatment for simple acute appendicitis (NOTA) avoids surgery, the risks of general anesthesia, and long hospital stays. It also decreases the risk of exposure to coronavirus. We aimed to study the cost-effectiveness and outcome of NOTA during the COVID-19 pandemic and compared it to single-incision pediatric endo-surgery appendectomy (SIPESA). A prospective cohort study for NOTA of patients from 6 to 12 years old in the COVID-19 pandemic period from April 1st, 2020, to April 30th, 2021, patients were divided into two groups: Group S was managed by SIPESA, and Group N was managed by NOTA. Family education and assurance with detailed explanation were done for early detection of any complications, and we continue monitoring the patients until their complete recovery. Group S had 24 cases (40%), mean age 9.3 years. Group N had 36 cases (60%), mean age 9.1 years. Six cases (17%) in group N were converted to surgical management in the first 6 months of the study. The mean cost dropped from $2736/day to $400/day. The mean psychological stress for the children improved from 4.4 in April to 2 in September. The mean follow-up was 3.5 months. NOTA is a feasible, cost-effective approach, and we recommend it, as we have learned this lesson during the COVID-19 pandemic days.

Non-operative treatment of acute appendicitis in children: clinical efficacy of amoxicillin-clavulanic acid in a retrospective single-centre study

BACKGROUND

The success rate of non-operative treatment (NOT) of acute uncomplicated appendicitis (AUA) in children varies from 65% to 95%. There are no recommendations on the appropriate antibiotic therapy.

OBJECTIVE

To determine the clinical efficacy of amoxicillin-clavulanic acid for NOT of AUA in children.

METHODS

Design: Cross-sectional study in a single medical centre.

SETTINGS

Emergency department and Paediatric Visceral Surgery department of the Children Hospital in Toulouse, France.

PATIENTS

Patients 5-15 years old who were diagnosed with appendicitis, (1) With abdominal pain and a first episode of acute appendicitis, (2) With no radiological or ultrasound evidence of appendicolith, appendiceal perforation, pelvic abscess nor peritonitis, and (3) With non-septic general aspect, were included.

INTERVENTIONS

NOT consisted of hospital admission. The antibiotic treatment was a combination of amoxicillin and clavulanic acid (80 mg/kg/day of amoxicillin): intravenous regimen during 48 hours followed by oral route during 7 days.

MAIN OUTCOME MEASURE

Success rate of amoxicillin-clavulanic acid NOT in children with AUA at 2 years.

RESULTS

The initial success rate of amoxicillin-clavulanic acid NOT in children with AUA was 100% (104/104 patients). The success rate at 2 years was 85.6% (89/104) at discharge. None of the 15 patients who underwent surgery after recurrence of appendicitis presented with peritonitis, appendiceal perforation nor pelvic abscess.

CONCLUSION

Narrowed antibiotic therapy with amoxicillin and clavulanic acid seems to be an alternative to surgery in children with AUA. It is necessary to wait for the results of ongoing studies to confirm these results.

Feasibility of nonoperative treatment of acute appendicitis in children: a prospective cohort study

Introduction

The management of acute appendicitis is a matter of debate even in contemporary era. Non-operative management is proposed as a valid treatment option for acute appendicitis in children.

Methods

A prospective cohort study was conducted from April 2020 to September 2021 at the National Institute of Child Health, Jinnah Sindh Medical University, Karachi, Pakistan, in children aged ≤ 12 years who were suspected of having acute appendicitis. Children with diffuse peritonitis and complex mass on ultrasonography were excluded. All children were kept nil per oral and started on intravenous fluid hydration and antibiotics. Statistical analyses were performed using IBM SPSS version 20. Chi-square test and Fisher's exact test were applied to determine the statistical significance.

Results

A total of 190 patients were admitted with a diagnosis of acute appendicitis. Thirty-two children with advanced disease underwent surgery. The remaining 158 patients were managed with nonoperative treatment. In 138 (87.3%) patients, resolution of symptoms occurred. Twenty (12.7%) patients underwent operation during the same admission (non-responders). Thirteen (9.4%) patients had recurrence of symptoms and underwent appendectomy. A total of 33 (20.9%) patients had appendectomy either at the primary admission or after discharge. Non-operative treatment was more likely to be successful in patients with symptoms of ≤ 24 h duration (P = 0.02), total leucocyte count of <12 × 109 cells/L (P = 0.005) and smaller size of the appendix on ultrasound (P = 0.001).

Conclusion

Among children with uncomplicated acute appendicitis, a non-operative approach resulted in resolution of symptoms in 87.3% of patients at the initial admission. Failure of non-operative treatment and recurrence of disease after discharge from the hospital occurred in 9.4% of patients after successful initial treatment. Thus, the overall success rate at a mean follow-up of 3 months was about 78%.

The Management of Pediatric Acute Appendicitis-Survey among Pediatric Surgeons in Romania

Background and Objectives: To assess the current practice pattern in the management of pediatric acute appendicitis in Romania. Materials and Methods: A questionnaire was emailed to all the members of the Romanian Society of Pediatric Surgery between June-July 2022. Results: 118 answers were received, 79.7% responses being from permanent staff members. In the diagnosis of appendicitis, complete blood count, C-reactive protein and abdominal ultrasound are the most commonly used diagnostic tools, while appendicitis scores are not widely used (25% of surgeons). In the case of simple appendicitis, 49.2% of surgeons prefer the conservative approach-oral/intravenous antibiotics. Those who choose the operative approach begin preoperative antibiotics in 56.7% of patients. In case of a stable patient, only 16.7% of surgeons will operate during the night. Laparoscopic approach is chosen by 51.7% of surgeons. In the case of a complicated appendicitis, 92.4% of surgeons will perform the appendectomy, prescribing preoperative antibiotics in 94% of the cases and continuing the therapy postoperatively in 98.2%. Laparoscopic approach is used by 28.8% of surgeons in case of complicated appendicitis. In presence of appendicular mass, 80% prefer a conservative approach with a delayed appendectomy within 6 months. Appendicular abscesses are managed operatively in 82.2% of the cases. The appendix is sent for histological analysis by 95.8% of surgeons. If the peritoneal cavity is contaminated, 95% of the respondents will take a sample for microbiological analysis, 71% will always place a drainage and 44% will always irrigate (71.9%-saline). Conclusions: Clearly, there seems to be a lack of consensus regarding several aspects of the management of acute appendicitis in children. In addition, minimally invasive surgery is not as widely used as reported, despite literature support.

Remote ischemic conditioning in necrotizing enterocolitis: study protocol of a multi-center phase II feasibility randomized controlled trial

PURPOSE

Remote ischemic conditioning (RIC) is a maneuver involving brief cycles of ischemia reperfusion in an individual's limb. In the early stage of experimental NEC, RIC decreased intestinal injury and prolonged survival by counteracting the derangements in intestinal microcirculation. A single-center phase I study demonstrated that the performance of RIC was safe in neonates with NEC. The aim of this phase II RCT was to evaluate the safety and feasibility of RIC, to identify challenges in recruitment, retainment, and to inform a phase III RCT to evaluate efficacy.

METHODS

RIC will be performed by trained research personnel and will consist of four cycles of limb ischemia (4-min via cuff inflation) followed by reperfusion (4-min via cuff deflation), repeated on two consecutive days post randomization. The primary endpoint of this RCT is feasibility and acceptability of recruiting and randomizing neonates within 24 h from NEC diagnosis as well as masking and completing the RIC intervention.

RESULTS

We created a novel international consortium for this trial and created a consensus on the diagnostic criteria for NEC and protocol for the trial. The phase II multicenter-masked feasibility RCT will be conducted at 12 centers in Canada, USA, Sweden, The Netherlands, UK, and Spain. The inclusion criteria are: gestational age < 33 weeks, weight ≥ 750 g, NEC receiving medical treatment, and diagnosis established within previous 24 h. Neonates will be randomized to RIC (intervention) or no-RIC (control) and will continue to receive standard management of NEC. We expect to recruit and randomize 40% of eligible patients in the collaborating centers (78 patients; 39/arm) in 30 months. Bayesian methods will be used to combine uninformative prior distributions with the corresponding observed proportions from this trial to determine posterior distributions for parameters of feasibility.

CONCLUSIONS

The newly established NEC consortium has generated novel data on NEC diagnosis and defined the feasibility parameters for the introduction of a novel treatment in NEC. This phase II RCT will inform a future phase III RCT to evaluate the efficacy and safety of RIC in early-stage NEC.

It's time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone

BACKGROUND

Published data demonstrate that management of uncomplicated pediatric appendicitis with antibiotics-alone is safe and frequently successful. Randomized controlled trials (RCT) comparing antibiotics-alone to appendectomy are lacking, alongside insight into drivers of failure. We sought to validate the antibiotics-alone approach and identify barriers to success using an RCT design.

METHODS

Patients aged 6-17 years with uncomplicated appendicitis were randomized to appendectomy or intravenous piperacillin/tazobactam for 24-48 h followed by 10 days of oral ciprofloxacin/metronidazole. Enrollment required symptoms <48 h, WBC<18, appendiceal diameter <11 mm, and radiographic absence of perforation. Lack of clinical improvement or persistently elevated WBC resulted in appendectomy. Primary outcomes were 1-year success rate of antibiotics-alone and quality-of-life measures.

RESULTS

Among 39 children enrolled over 31 months, 20 were randomized to antibiotics-alone and 19 to surgery. At 1 year, 6 nonoperative patients underwent appendectomy (70% success). Four cases were not true antibiotic failures but instead reflected "pragmatic" challenges to executing nonoperative algorithms. Only 2 cases represented recurrent/refractory appendicitis, suggesting a 90% adjusted 1-year success rate. Parental PedsQL™ scores were similar between treatment cohorts (91.3 vs 90.2, P = 0.32). Children treated with antibiotics-alone had faster return to activity (2.0 vs 12 days, P = 0.001) and fewer parental missed work days (0.0 vs 2.5, P = 0.03).

CONCLUSIONS

These data corroborate findings from non-randomized studies suggesting 70-90% of uncomplicated pediatric appendicitis can be treated with antibiotics-alone, with fewer disability days. Failures appear multifactorial, often reflecting practical hurdles and not antibiotic limitations. As surgeons consider nonoperative protocols for uncomplicated appendicitis, these data further inform the variability of treatment success.

LEVEL OF EVIDENCE

1; randomized controlled trial.

Management of Acute Appendicitis in Children During COVID-19 and Perspectives of Pediatric Surgeons From South Asia: Survey Study

BACKGROUND

Nonoperative treatment (NOT) of pediatric appendicitis as opposed to surgery elicits great debate and is potentially influenced by physician preferences. Owing to the effects of the COVID-19 pandemic on health care, the practice of NOT has generally increased by necessity and may, in a post-COVID-19 world, change surgeons' perceptions of NOT.

OBJECTIVE

The aim of this study was to determine whether the use of NOT has increased in South Asia and whether these levels of practice would be sustained after the pandemic subsides.

METHODS

A survey was conducted among pediatric surgeons regarding their position, institute, and country; the number of appendicitis cases they managed; and their mode of treatment between identical time periods in 2019 and 2020 (April 1 to August 31). The survey also directly posed the question as to whether they would continue with the COVID-19-imposed level of NOT after the effect of the pandemic diminishes.

RESULTS

A total of 134 responses were collected out of 200 (67.0%). A significant increase in the practice of NOT was observed for the entire cohort, although no effect was observed when grouped by country or institute. When grouped by position, senior physicians increased the practice of NOT the most, while junior physicians reported the least change. The data suggest that only professors would be inclined to maintain the COVID-19-level of NOT practice after the pandemic.

CONCLUSIONS

Increased practice of NOT during the COVID-19 pandemic was observed in South Asia, particularly by senior surgeons. Only professors appeared inclined to consider maintaining this increased level of practice in the post-COVID-19 world.

Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: A randomized controlled trial

Objectives:

To compare the outcome of non-operative treatment (NOT) with antibiotics versus surgical management of uncomplicated appendicitis in children.

Methods:

This randomized clinical trial (NCT 04030741) was carried out in Pediatric Surgery Department, Mayo Hospital from September 2018 to September 2019. Total sample size was 180, and after informed consent patients were randomly allocated in two groups. All children between 5 and 15 years of age and having pediatric appendicitis score (PAS) >7 were included. Patients with previous abdominal surgery, peritonitis, appendicular mass, or intra-abdominal abscess were excluded. Children in NOT group (Group A) were given intravenous Meropenem and Metronidazole for 48 hours and after starting oral, antibiotics were continued orally for 7 days. In Group B, children underwent appendectomy. Failure of NOT was labeled if there was abscess formation or peri-appendiceal fluid collection on ultrasound, development of peritonitis or recurrence of appendicitis.

Results:

In Group A, mean age was 9.56±1.8 years and in Group B 10.11±1.8 years. There were 123 male and 57 female patients. Group B had 100% successful outcome. NOT (Group A) had successful outcome in 75 patients (83.3%) and failure was noted in 15 (16.7%). Five needed operation within 48 hours, all had appendicolith, and 10 patients presented within 6 months. Raised total leukocyte count (p value < 0.0001) and C reactive protein (p value < 0.04) levels were noted with failure of NOT.

Conclusions:

In this study, success of NOT was 84% so a trial of NOT in cases of uncomplicated appendicitis should be considered in children.

Nonoperative management of appendicitis in children

Appendicitis is a common condition in childhood and adolescence that frequently requires urgent surgical intervention. For almost two centuries appendicitis has been recognized as a medical problem with a surgical solution. Currently the appendix can be removed with a minimally invasive approach, low anesthetic and surgical risk, and swift hospital discharge. Despite these advances, surgery and anesthesia have associated risks including postoperative infection, bleeding, hernia and organ injury among others. In addition, surgery requires time off of school and work to recover and associated healthcare costs can be significant. In both adult and pediatric populations, quality data suggesting a nonoperative approach is suggesting a change to the traditional surgical paradigm. Adults studies have demonstrated both safety and efficacy in the nonoperative management of acute appendicitis. In selected children with uncomplicated appendicitis, initial nonoperative management has been shown to be safe with fewer complications, fewer disability days and less healthcare costs while avoiding the risks inherent to surgery. Ongoing randomized controlled clinical trials in both the United States and Europe seek to further demonstrate the safety of nonoperative management and assist physicians with educating patients about the risk profile of their treatment decision. In complicated appendicitis presenting with abscess or acute appendiceal phlegmon, an initial nonoperative strategy with or without abscess drainage followed by interval appendectomy is the current state of the art though the utility of interval appendectomy is questioned.

Diagnostic accuracy of Leucine-rich α-2 glycoprotein (LRG) as a urinary biomarker in pediatric appendicitis: a prospective observational pilot study from Eastern India

Background

Recently, several serum and urinary biomarkers have been investigated for diagnosis of acute appendicitis. Urinary biomarkers seem to be advantageous in children as it is non-invasive, painless, and easy to perform. Leucine-rich α-2-glycoprotein (LRG) is regarded as a reliable urinary biomarker for the diagnosis of pediatric appendicitis. A prospective observational pilot study was conducted in children presenting with abdominal pain. Assessment of pediatric appendicitis score (PAS), routine blood tests, and measurements of urinary LRG was done. The present study aimed to evaluate the diagnostic accuracy of urine LRG in appendicitis in Indian children and to assess the concentration of urine LRG at which it will guide the management.

Results

LRG had a receiver operating characteristic (ROC) area under the curve (AUC) of 0.586 (95% CI 0.407–0.766). There was no specific cut-off identified using Youden’s index. ROC analysis of the PAS score resulted in an AUC of 0.821 (95% CI 0.691–0.952). Using Youden’s index, the cut-off for PAS scoring was identified as 6.5 with the sensitivity of 80%, the specificity of 76.2%, positive predictive value 76.19%, negative predictive value as 80%, and diagnostic accuracy of 78%.

Conclusions

LRG could not show better diagnostic performance compared to routine blood tests and PAS scores. There was no specific cut-off value at which it will differentiate mesenteric adenitis and acute appendicitis and guide their management. With 78% diagnostic accuracy, PAS score (> 6) is still a better tool for the diagnosis of acute appendicitis.

Trial registration

Clinical Trials Registry Government of India, CTRI/2018/01/011182, Registered on: 08 Jan 2018.

Predictive Value of Alvarado Score and Pediatric Appendicitis Score in the Success of Nonoperative Management for Simple Acute Appendicitis in Children

INTRODUCTION

 During the past decade, nonoperative management (NOM) for simple acute appendicitis (SAA) in children has been proven safe with noninferior complications rate. The aim of this study was to examine Alvarado score and pediatric appendicitis score (PAS) together with other factors in predicting failure of NOM in children presenting with SAA.

MATERIALS AND METHODS

 Patients aged 5 to 18 years admitted to our department between 2017 and 2019 diagnosed with SAA were given a choice between surgical management and NOM. We divided the NOM patients into two groups: successful treatment and failed NOM, comparing their files for Alvarado score and PAS and other clinical and demographic factors, with a mean follow-up of 7 months. Failure was determined as need for appendectomy following conservative treatment due to any reason.

RESULTS

 A total of 85 patients answered criteria and chose NOM. Overall failure rate was 32.9%. We found no difference in the mean Alvarado score and PAS as well as in each component of both scores between success and failed NOM groups. However, when using the risk classification of the scores, we found a significant correlation between high-risk Alvarado score and failed NOM. After adjusting for age, gender, duration of symptoms, diagnosis of tip appendicitis, and presence of appendicolith, the odds of failure were four times higher among high-risk Alvarado group.

CONCLUSION

 Alvarado score of 7 or higher, older age, and diagnosis of an appendicolith on imaging are possible predictors for failure of NOM for SAA in children.

Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT

BACKGROUND

Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking.

OBJECTIVES

The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children.

DESIGN

This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set.

SETTING

This study was set in three specialist NHS paediatric surgical units in England.

PARTICIPANTS

Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set.

INTERVENTIONS

Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial.

DATA SOURCES

Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews.

RESULTS

Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol.

LIMITATIONS

Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time.

CONCLUSIONS

A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres.

FUTURE WORK

Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15830435.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.

CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT)

OBJECTIVE

To establish the feasibility of a multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy in children with uncomplicated acute appendicitis.

DESIGN

Feasibility randomised controlled trial with embedded qualitative study to inform recruiter training to optimise recruitment and the design of a future definitive trial.

SETTING

Three specialist paediatric surgery centres in the UK.

PATIENTS

Children (aged 4-15 years) with a clinical diagnosis of uncomplicated acute appendicitis.

INTERVENTIONS

Appendicectomy or a non-operative treatment pathway (comprising broad-spectrum antibiotics and active observation).

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of eligible patients recruited. Secondary outcomes evaluated adherence to interventions, data collection during follow-up, safety of treatment pathways and clinical course.

RESULTS

Fifty per cent of eligible participants (95% CI 40 to 59) approached about the trial agreed to participate and were randomised. Repeated bespoke recruiter training was associated with an increase in recruitment rate over the course of the trial from 38% to 72%. There was high acceptance of randomisation, good patient and surgeon adherence to trial procedures and satisfactory completion of follow-up. Although more participants had perforated appendicitis than had been anticipated, treatment pathways were found to be safe and adverse event profiles acceptable.

CONCLUSION

Recruitment to a randomised controlled trial examining the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy for the treatment of uncomplicated acute appendicitis in children is feasible.

TRIAL REGISTRATION NUMBER

ISRCTN15830435.

Outcomes after appendectomy in children with acute appendicitis treated at a tertiary paediatric centre: results from a retrospective cohort study

PURPOSE

In general, an appendectomy is presumed to have a limited burden of disease. However, in current literature, reported complication rates vary. This study aims to provide additional insights in the incidence of post-appendectomy complications in children with acute appendicitis.

METHODS

This retrospective cohort study included children (0-17 years old) that underwent appendectomy at our tertiary referral centre for suspected acute appendicitis (January 2011-December 2018). Children referred to our centre, and those that underwent non-operative treatment were excluded. Post-appendectomy complications were recorded from electronic medical charts using predefined definitions and classified as severe (Clavien-Dindo III-IV) or less severe (Clavien-Dindo I-II).

RESULTS

A total of 131 children were included. Simple and complex appendicitis was diagnosed in 66 (50%) and 60 (46%) children, respectively. A non-inflamed appendix was seen in five (4%) children. One or more complications were identified in 33 (25%) patients. Eight (12%) children with simple appendicitis developed a complication, three of these were severe. In children with complex appendicitis, 23 (38%) children developed a complication, 14 of these were severe.

CONCLUSION

This study shows a high rate of complications compared with current literature, both in children with simple and complex appendicitis. This is probably the result of our definition of complications and being a tertiary referral centre receiving more severe appendicitis cases. However, these results still show that appendectomy is not always a routine procedure with only few complications. Substantiating the need to keep optimizing treatment for children with appendicitis.

The Understated Malignancy Potential of Nonoperative Acute Appendicitis

Cancer of the appendix is rare and is most commonly found incidentally on pathology after an appendectomy for uncomplicated appendicitis (UA). The medical management alternative with antibiotics and observation remains an ongoing debate. The purpose of our study was to develop modern epidemiological data for adult patients completing an appendectomy for UA secondary to an appendiceal neoplasm (AN). ACS-NSQIP database was queried (2005–2016) to identify patients completing an appendectomy. Cohorts of patients who were diagnosed with UA and an AN were included in the study. Relevant perioperative clinical and outcomes data were collected. Type of AN, surgical procedure, and mortality were analyzed. A total of 239,615 UA patients were identified, of whom 2,773 (1.2%) met the inclusion criteria of AN. Patients with AN were predominantly white (79.5%), with a mean age of 54.5 ± 15.9 years, and 54.6 per cent were females. AN pathology findings included malignant neoplasm (64.5%), malignant carcinoid (17.3%), benign carcinoid (9.3%), and benign neoplasm (8.8%). The overall reported incidence was 1.2 per cent and the mortality rate was 0.7 per cent. Our study emphasizes surgical intervention in adult UA maintains a 1 per cent incidence of AN, and treatment with antibiotics alone will presumably lead to a delay in surgical treatment and progression of disease.

Management of complicated acute appendicitis in children: Still an existing controversy

Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.

Enhancing communication, informed consent and recruitment in a paediatric urgent care surgical trial: a qualitative study

Background

Recruiting patients to paediatric trials can be challenging, especially in trials that compare markedly different management pathways and are conducted in acute settings. We aimed to enhance informed consent and recruitment in the CONTRACT trial (CONservative TReatment of Appendicitis in Children a randomised controlled Trial; ISRCTN15830435) – a feasibility trial that compared non-operative treatment (antibiotics) versus appendicectomy for uncomplicated acute appendicitis.

Methods

Qualitative study embedded within CONTRACT and conducted across three UK children’s hospitals. Data were transcribed audio-recordings of 85 CONTRACT recruitment consultations with 58 families; and semi-structured interviews with 35 health professionals and 28 families (34 parents, 14 children) invited to participate in CONTRACT. Data analysis drew on thematic approaches. Throughout CONTRACT, we used findings from the ongoing qualitative analysis to inform bespoke communication training for health professionals recruiting to CONTRACT. Before and after training we also examined qualitative changes in communication during consultations and quantitative changes in recruitment rates.

Results

Bespoke communication training focussed on presenting the trial arms in a balanced way, emphasising clinical equipoise, exploring family treatment preferences and managing families’ expectations about the trial’s treatment pathways. Analysis of recruitment consultations indicated that health professionals’ presentation of treatment arms became increasingly balanced following training, (e.g. avoiding imbalanced terminology) and recruitment rose from 38 to 62%. However, they remained reluctant to explore families’ treatment preferences and respond with further information to balance these preferences. Analyses of interviews identified the time constraints of the urgent care setting, concerns about coercion, and reservations about exposing children to conversations about treatment risks as reasons for this reluctance. Interviews with families indicated the importance of clear explanations of trial treatment timings and sensitive communication of treatment allocation for both recruitment and retention.

Conclusions

Following bespoke training based on the qualitative analyses, health professionals presented CONTRACT to families in clearer and more balanced ways and this was associated with an increase in the recruitment rate. Despite training, health professionals remained reluctant to explore families’ treatment preferences. We provide several recommendations to enhance communication, informed consent, recruitment and retention in future trials in urgent care settings.

Indications for Nonoperative Management of Uncomplicated Appendicitis in Children: A Prospective Analysis at a Single Institution

Aim: To assess nonoperative management (NOM) of uncomplicated appendicitis (UC-appy) in children to determine factors influencing prognosis and review the literature. Materials and Methods: All UC-appy cases presenting younger than 16 years between 2015 and 2018 who had NOM (one dose of intravenous analgesia and intravenous piperacillin/tazobactam 112.5 mg/kg 8 hourly) and were followed up for at least 3 months were reviewed prospectively (n = 146). Perceived pain and fever were assessed 12 hourly, biochemistry daily. If predetermined cutoff results were not achieved at each assessment, NOM was abandoned and urgent laparoscopic appendectomy (ULA) performed. Results: NOM succeeded in 48.6% (S-NOM; n = 71) and failed in 51.4% (F-NOM; n = 75). Mean age at presentation (10.7 ± 2.5 versus 8.6 ± 3.7 years old; P < .0001) and duration of preadmission fever (1.0 ± 0.9 versus 2.1 ± 1.2 days; P < .0001) were the only significantly different criteria between S-NOM and F-NOM. Optimal cutoff values using receiver operating characteristic curve analysis were 7.0 years old (32% sensitivity and 93% specificity) and 1.0 day (95% sensitivity and 25% specificity), respectively. NOM was abandoned for persistent pain, prolonged fever, or raised white blood count at 12 hours in 20/75 (26.7%), 24 hours in 31/75 (41.3%), 36 hours in 14/75 (18.7%), and 48-72 hours in 10/75 (13.3%). At ULA, perforation was identified in 14/75 (18.7%). Complications arising within 3 months of ULA were residual abscess (n = 7/75; 9.3%) and transient ileus (n = 1/75; 1.3%). Conclusion: It would appear that surgery may be more appropriate for children with UC-appy when they are younger and febrile before admission for longer.

Management of pediatric appendiceal carcinoid: a single institution experience from 5000 appendectomies

AIM OF THE STUDY

Appendiceal carcinoid (neuroendocrine tumor or NET) is a rare neuroendocrine neoplasm often found incidentally following appendectomy for appendicitis. Surgery for appendicitis is currently under scrutiny and children are increasingly managed conservatively with antibiotics alone. Herein, we aimed to review our experience with the management of appendiceal carcinoids at our institution.

METHODS

Following ethical approval, we reviewed the charts of all patients who underwent appendectomy for appendicitis at our institution between 2000 and 2018. The pathology registry was consulted to identify children diagnosed with appendiceal carcinoid. Outcome measures included incidence, demographics, and management.

MAIN RESULTS

During the study period, 32 children (23 female) had an appendiceal carcinoid confirmed at pathology. Of these, 13 were initially treated with appendectomy (total of 5,059 appendectomies: 0.3% incidence). The other 19 had an appendectomy elsewhere by an adult general surgeon and were referred to our institution for further management. Overall, the mean age at diagnosis was 13 ± 2.7 years and all patient had a preoperative diagnosis of appendicitis, none of suspected carcinoid. Most children (75%) had acute non-perforated appendicitis. The overall mean size of the lesion was 1 ± 0.9 cm, with a > 2 cm lesion in 3 patients. Following diagnosis, 12 children (38%) underwent an ileocolic resection, due to carcinoid size, invasiveness, and margin clearance.

CONCLUSIONS

In our cohort, the incidence of appendiceal carcinoid among children with appendicitis is very low. Most carcinoids are small, located at the tip, associated with non-perforated appendicitis, and present in girls. Most were treated with appendectomy alone, with more extensive surgery performed in one third of children.

Diagnosis and classification of pediatric acute appendicitis by artificial intelligence methods: An investigator-independent approach

Acute appendicitis is one of the major causes for emergency surgery in childhood and adolescence. Appendectomy is still the therapy of choice, but conservative strategies are increasingly being studied for uncomplicated inflammation. Diagnosis of acute appendicitis remains challenging, especially due to the frequently unspecific clinical picture. Inflammatory blood markers and imaging methods like ultrasound are limited as they have to be interpreted by experts and still do not offer sufficient diagnostic certainty. This study presents a method for automatic diagnosis of appendicitis as well as the differentiation between complicated and uncomplicated inflammation using values/parameters which are routinely and unbiasedly obtained for each patient with suspected appendicitis. We analyzed full blood counts, c-reactive protein (CRP) and appendiceal diameters in ultrasound investigations corresponding to children and adolescents aged 0–17 years from a hospital based population in Berlin, Germany. A total of 590 patients (473 patients with appendicitis in histopathology and 117 with negative histopathological findings) were analyzed retrospectively with modern algorithms from machine learning (ML) and artificial intelligence (AI). The discovery of informative parameters (biomarker signatures) and training of the classification model were done with a maximum of 35% of the patients. The remaining minimum 65% of patients were used for validation. At clinical relevant cut-off points the accuracy of the biomarker signature for diagnosis of appendicitis was 90% (93% sensitivity, 67% specificity), while the accuracy to correctly identify complicated inflammation was 51% (95% sensitivity, 33% specificity) on validation data. Such a test would be capable to prevent two out of three patients without appendicitis from useless surgery as well as one out of three patients with uncomplicated appendicitis. The presented method has the potential to change today’s therapeutic approach for appendicitis and demonstrates the capability of algorithms from AI and ML to significantly improve diagnostics even based on routine diagnostic parameters.

Falling through the worm hole: an exploration of the imaging workup of the vermiform appendix in the pediatric population

Despite the thousands of articles discussing appendicitis in the literature, the dilemma of how to best diagnosis and manage pediatric appendicitis remains unsettled. Over the past decade, evidence has been mounting about the use of antibiotics as the sole therapy in uncomplicated appendicitis in the adult population. This debate has even recently bled over into the lay press. While this change in practice pattern is still in its infancy for the pediatric population, radiologists should be aware of this change in therapy and how it can impact the imaging work-up and relevant findings. This article concisely summarizes the imaging findings and various imaging pathways to arrive at the diagnose of appendicitis with an emphasis of how to best be of use to our surgical colleagues in this evolving paradigm. It also highlights venues for further research, namely increasing accuracy of differentiating complicated from uncomplicated appendicitis.

Sonographic differentiation of complicated from uncomplicated appendicitis

OBJECTIVE

This study aims to differentiate acute uncomplicated and complicated appendicitis, by investigating the correlation between sonographic findings and histological results in different types of paediatric appendicitis.

METHODS

This is a retrospective study of 1017 paediatric patients (age < 18 years) who underwent ultrasound by paediatric radiologists before appendicectomy at our institution between 2006 and 2016. Histologically, uncomplicated appendicitis was primarily associated with transmural infiltration of neutrophil granulocytes, while complicated appendicitis was characterised by transmural myonecrosis. Logistic regression analyses were used to investigate the association between sonographic and histological findings.

RESULTS

Out of 566 (56%) male and 451 (44%) female patients with a mean age of 10.7 years, uncomplicated appendicitis was histologically diagnosed in 446 (44%) children and complicated appendicitis was diagnosed in 348 (34%) cases. The following ultrasound findings were significantly associated with complicated appendicitis in multivariate regression: an increased appendiceal diameter (OR = 1.3, p < .001), periappendiceal fat inflammation (OR = 1.5, p = 0.02), the presence of an appendicolith (OR = 1.7, p = 0.01) and a suspected perforation (OR = 6.0, p < .001) by the pediatric radiologist. For complicated appendicitis, an appendiceal diameter of more than 6 mm had the highest sensitivity (98%), while a sonographically suspected perforation showed the highest specificity (94%).

CONCLUSION

Abdominal sonography by paediatric radiologists can differentiate between uncomplicated and complicated appendicitis in paediatric patients by using an increased appendiceal diameter, periappendiceal fat inflammation, the presence of an appendicolith and a suspected perforation as discriminatory markers.

ADVANCES IN KNOWLEDGE

This paper demonstrates expanded information on ultrasound, which is not only an essential tool for diagnosing appendicitis, but also a key method for distinguishing between different forms of appendicitis when performed by paediatric radiologists. Compared with previous studies, the crucial distinction features in our analysis are 1) the definition of gangrene and not primarily perforation as an acute complicated appendicitis enabling early decision-making by sonography and 2) a large number of patients in a particularly affected age group.

Improving outcome reporting in clinical trial reports and protocols: study protocol for the Instrument for reporting Planned Endpoints in Clinical Trials (InsPECT)

Background

Inadequate and poor quality outcome reporting in clinical trials is a well-documented problem that impedes the ability of researchers to evaluate, replicate, synthesize, and build upon study findings and impacts evidence-based decision-making by patients, clinicians, and policy-makers. To facilitate harmonized and transparent reporting of outcomes in trial protocols and published reports, the Instrument for reporting Planned Endpoints in Clinical Trials (InsPECT) is being developed. The final product will provide unique InsPECT extensions to the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) reporting guidelines.

Methods

The InsPECT SPIRIT and CONSORT extensions will be developed in accordance with the methodological framework created by the EQUATOR (Enhancing the Quality and Transparency of Health Research Quality) Network for reporting guideline development. Development will consist of (1) the creation of an initial list of candidate outcome reporting items synthesized from expert consultations and a scoping review of existing guidance for reporting outcomes in trial protocols and reports; (2) a three-round international Delphi study to identify additional candidate items and assess candidate item importance on a 9-point Likert scale, completed by stakeholders such as trial report and protocol authors, systematic review authors, biostatisticians and epidemiologists, reporting guideline developers, clinicians, journal editors, and research ethics board representatives; and (3) an in-person expert consensus meeting to finalize the set of essential outcome reporting items for trial protocols and reports, respectively. The consensus meeting discussions will be independently facilitated and informed by the empirical evidence identified in the primary literature and through the opinions (aggregate rankings and comments) collected via the Delphi study. An integrated knowledge translation approach will be used throughout InsPECT development to facilitate implementation and dissemination, in addition to standard post-development activities.

Discussion

InsPECT will provide evidence-informed and consensus-based standards focused on outcome reporting in clinical trials that can be applied across diverse disease areas, study populations, and outcomes. InsPECT will support the standardization of trial outcome reporting, which will maximize trial usability, reduce bias, foster trial replication, improve trial design and execution, and ultimately reduce research waste and help improve patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3248-0) contains supplementary material, which is available to authorized users.

Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study

Non-operative treatment of uncomplicated appendicitis in children is gaining ground. Pending definitive evidence regarding its effectiveness, there is a call to evaluate clinical recovery after non-operative treatment. In this study, we analyzed data collected during initial admission of a multicenter prospective cohort in which children, 7-17 year, were treated non-operatively for uncomplicated appendicitis. During admission clinical parameters (pain and gastro-intestinal symptoms), inflammation parameters and sequential abdominal ultrasound were recorded. In total, 45 children were included, 42(93%) were discharged without the need for appendectomy; median [IQR] pain scores on admission were 5 [4-7], decreasing to 2 [0-3] after 1 day of treatment. Initially, 28/42 (67%) reported nausea and 19/42 (45%) vomiting; after 1 day, this was 3/42 (7%) and 1/42 (2%), respectively. White blood cell count declined from a median [IQR] of 12.9 [10.7-16.7] 10E9/L on admission to 7.0 [5.8-9.9] 10E9/L on day 1. Median [IQR] C-reactive protein levels increased from 27.5 [9-69] mg/L on admission to 48 [22-80] mg/L on day 1, declining to 21.5 [11-42] mg/L on day 2. Follow-up ultrasound showed no signs of complicated appendicitis in any of the patients.Conclusion: Clinical symptoms resolved in most children after 1 day of non-operative treatment. This suggests that non-operative treatment is a viable alternative to appendectomy regarding clinical recovery.Trail registration: NCT01356641 What is Known: • Non-operative treatment of uncomplicated appendicitis in children is safe and its use around the world is gaining ground, however high quality evidence from adequately designed randomized trials is still lacking. • Concerns have been raised regarding the potentially prolonged clinical recovery associated with non-operative treatment. What is New: • Most clinical symptoms resolve after 1 day of non-operative treatment in the majority of children.

Conservative treatment of acute appendicitis

Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.

Conservative therapy for appendicitis in children

Question A 10-year-old girl who was seen in my office last week with acute-onset abdominal pain and fever was referred to an emergency department, was diagnosed with appendicitis, and was treated conservatively with antibiotics, without surgery. Has the paradigm for treating appendicitis changed, and which is the preferred treatment of appendicitis in children: antibiotics or appendectomy?Answer For more than 100 years, surgical management was the principal treatment of acute appendicitis. Potential adverse events associated with appendectomy include bleeding, surgical site infection, and ileus, as well as stress for children and their parents. The option of treating appendicitis with antibiotics has been known for decades, which has led to consideration of antibiotics alone as a therapeutic alternative to surgery for uncomplicated appendicitis. While there is a reasonable body of evidence in support of this practice in adults, the accumulation of evidence of the safety and effectiveness of non-operative management in children is ongoing. Large studies are still needed, and those are being conducted at this time, with results expected in the next few years.

Non-operative management of appendicitis in children

While appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades, there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon's knife. Many as yet unanswered questions remain, however, before NOT can be considered a realistic and reliable alternative to surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.

CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial

BACKGROUND

Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial.

METHODS/DESIGN

The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery.

DISCUSSION

In this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design.

TRIAL REGISTRATION

ISRCTN15830435 . Registered on 8 February 2017.

Initial non-operative management of uncomplicated appendicitis in children: a protocol for a multicentre randomised controlled trial (APAC trial)

INTRODUCTION

Based on epidemiological, immunological and pathology data, the idea that appendicitis is not necessarily a progressive disease is gaining ground. Two types are distinguished: simple and complicated appendicitis. Non-operative treatment (NOT) of children with simple appendicitis has been investigated in several small studies. So far, it is deemed safe. However, its effectiveness and effect on quality of life (QoL) have yet to be established in an adequately powered randomised trial. In this article, we provide the study protocol for the APAC (Antibiotics versus Primary Appendectomy in Children) trial.

METHODS AND ANALYSIS

This multicentre, non-inferiority, randomised controlled trial randomises children aged 7-17 years with imaging-confirmed simple appendicitis between appendectomy and NOT. Patients are recruited in 15 hospitals. The intended sample size, based on the primary outcome, rate of complications and a non-inferiority margin of 5%, is 334 patients.NOT consists of intravenous antibiotics for 48-72 hours, daily blood tests and ultrasound follow-up. If the patient meets the predefined discharge criteria, antibiotic treatment is continued orally at home. Primary outcome is the rate of complications at 1-year follow-up. An independent adjudication committee will assess all complications and their relation to the allocated treatment. Secondary outcomes include, but are not limited to, delayed appendectomies, QoL, pain and (in)direct costs.The primary outcome will be analysed both according to the intention-to-treat principle and the per-protocol principle, and is presented with a one-sided 97.5% CI. We will use multiple logistic and linear regression for binary and continuous outcomes, respectively, to adjust for stratification factors.

ETHICS AND DISSEMINATION

The protocol has been approved by the Medical Ethics Review Committee of the Academic Medical Center, Amsterdam. Data monitoring is performed by an independent institute and a Data Safety Monitoring Board has been assigned. Results will be presented in peer-reviewed academic journals and at (international) conferences.

TRIAL REGISTRATION NUMBER

NCT02848820; NTR5977; Pre-results.

Five lessons in uncomplicated appendicitis: Can we remove the surgery?

Appendicectomy has remained the treatment of choice for appendicitis for over a century and is the most commonly performed emergency operation in children. However, emerging evidence suggests that appendicectomy may not always be necessary in uncomplicated appendicitis, with early paediatric trials demonstrating that antibiotic-only therapy can be safe and effective. Further rigorously designed and appropriately powered studies are necessarily to establish the place of non-operative management of uncomplicated appendicitis in the future.