Forgoing surgery to remove the appendix may not be
an option for all kids, researchers say, but just three of 30
children who tried the antibiotics-only route ended up needing
"In this group of patients with uncomplicated appendicitis — in the
people we studied, non-operative management with antibiotics alone
appears to be a reasonable alternative," Dr. Peter Minneci told
He is the study's lead author, from Nationwide Children's Hospital
in Columbus, Ohio.
Appendicitis is when the appendix, a small tube-shaped extension of
the colon, becomes inflamed and filled with puss. The appendix may
burst without treatment and cause a widespread infection.
Although the cause of appendicitis is not known, Minneci said it may
often occur when a piece of feces blocks the appendix and allows
bacteria to proliferate. Other inflamed tissues may also block the
appendix and cause the condition.
"It used to be that people would operate on appendixes in the middle
of the night," he said. "Then we found that it was safe to give them
antibiotics and operate on them in the morning."
Doctors began noticing that some of the children were feeling better
in the morning after the initial treatment of antibiotics.
"They were hungry and they didn't have pain anymore," Minneci said.
To see whether antibiotics alone might be enough to treat
appendicitis, he and his colleagues enrolled 77 children and teens
brought to the emergency room at Nationwide Children's Hospital from
October 2012 to October 2013.
All the participants had been diagnosed with uncomplicated acute
appendicitis. Their appendixes had not burst, were not overly
swollen and imaging did not show a hard piece of stool blocking the
Those uncomplicated cases represent about one in five appendicitis
cases at the hospital, the researchers note in the Journal of the
American College of Surgeons.
The participants and their families were allowed to choose between
surgery or receiving 24 hours of intravenous antibiotics in the
hospital followed by 10 days of antibiotics in pill form after they
"We do believe patients should be admitted to the hospital and
watched," Minneci said. "They shouldn't just get antibiotics and be
Of the 77 participants, 30 chose antibiotics and 47 picked surgery.
Of those who chose the antibiotic option, 93 percent were feeling
better within a day. They also tended to recover faster.
Kids in the antibiotics-only group had an average of three days of
recuperation versus 17 days in the surgery group. They were also
able to return to school after three days, versus five days among
kids who had surgery.
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Three patients in the antibiotic group did require surgery to
remove their appendix within the 30 days following their first ER
visit. None of their appendixes burst, however.
Both children and parents rated their quality of life higher in the
antibiotics-only group, compared to those who had surgery. But on
average, the length of hospital stay was longer at 38 hours for the
antibiotics group, compared with 20 hours in the surgery group.
"We really aren't trying to say you shouldn't have an appendectomy,"
Minneci said. "We're saying there are two reasonable treatment
options and you have to choose which is appropriate for you and your
Dr. Mary Brandt said the new study is small and an initial step,
but modern surgery is about becoming less and less invasive.
"It's an encouraging first result and definitely means we should
continue studying this as an option," said Brandt, a pediatric
surgeon at Texas Children's Hospital in Houston who was not involved
in the research.
Minneci and his colleagues continue to follow the patients from the
original study to see how they do. The researchers are also
conducting another trial among patients with more complicated
In addition, the team is working with other hospitals to enroll more
than 800 children in a larger trial.
"If that study finds the same thing, then this will probably get
adopted as the standard of care," Minneci said.
"Here at Nationwide Children's Hospital, it is now the standard of
care," he added.
Journal of the American College of Surgeons, online April 12, 2014.
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