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Comment & Response
November 2017

Nonoperative Treatment of Appendicitis—Reply

Author Affiliations
  • 1Department of Surgery, Texas Children’s Hospital, Houston
  • 2Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
JAMA Pediatr. 2017;171(11):1127. doi:10.1001/jamapediatrics.2017.2943

In Reply We thank Minneci and Deans for their comment on our Editorial. We agree that the two 2017 meta-analyses of nonoperative treatment of pediatric appendicitis indeed have demonstrated the feasibility and initial success of this approach. While Huang et al1 did not report a pooled estimate for risk of treatment failure at 1 year, Georgiou et al2 found an overall nonoperative treatment efficacy of 82% at final reported follow-up, with both studies yielding similar histopathological appendicitis recurrence rates of 14% to 16%.1,2 In comparison, two 2017 meta-analyses of adult data, demonstrated an overall treatment effectiveness at 1 year of 64%3 and 73%,4 with Harnoss et al4 reporting a complication-free treatment success for nonoperative treatment at 1 year of 68% vs 90% for the operative treatment.4 The conclusions drawn from the pediatric meta-analyses published to date generate consensus that nonoperative treatment is “feasible and effective,” albeit a higher risk for treatment failure compared with appendectomy, especially in the setting of acute appendicitis with appendicolith,1 and that further evaluation by means of large randomized trials is needed with regard to longer-term clinical outcomes and cost-effectiveness.2 In fact, Georgiou et al2 recommend that nonoperative treatment of children with acute uncomplicated appendicitis “be reserved for those participating in carefully designed research studies.” We regret that Minneci and Deans have focused their contention on only 1 aspect of our conclusion in which we state that “nonoperative treatment remains an experimental proposition meriting ongoing consideration as a treatment strategy” for this condition and that “this therapeutic option should only be offered to pediatric patients under protocol in the setting of a clinical trial.”5 We stand by our recommendation that future studies should have attention “to longer follow-up and patient-centered outcomes, cost utility, and shared decision making.”5 This last area is essential as we attempt to understand how to align patients’ wishes, values, and their particular circumstances with their treatment plan. We commend Minneci and Deans on their ongoing work with preference-based trials and look forward to their long-term results. Their findings will provide critical information as we build a repository of evidence addressing all the previously mentioned categories so that we can provide patients’ families complete information to aid in their decision making. In spite of ongoing debates as to what the best study design is to establish superiority and to balance internal vs external validity, the current available evidence does not support routine nonoperative treatment of uncomplicated acute appendicitis in general practice.

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