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Comment & Response
July 22, 2019

Medical Overuse and Appendicitis Treatment—Reply

Author Affiliations
  • 1Division of Pediatric Inpatient Medicine, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City
  • 2Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
JAMA Pediatr. 2019;173(9):892-893. doi:10.1001/jamapediatrics.2019.2399

In Reply We appreciate Goldstein and Raval’s letter to the editor regarding our review of the pediatric overuse literature1 and the opportunity to further consider the benefits and harms of nonoperative treatment of acute uncomplicated appendicitis. The principal advantage of the nonoperative (antibiotic) approach is that it avoids the risks associated with anesthesia and surgery. While these risks are low in the hands of pediatric surgeons using a laparoscopic technique for appendectomy, the risk is not zero, and surgical complications are higher in centers without access to pediatric and laparoscopic expertise.2 There are also potential downstream consequences to the operative approach including exposure to opioids and missed time from school. For example, a 2019 study3 found that children undergoing uncomplicated laparoscopic appendectomy by pediatric and general surgeons were prescribed a median of 59 and 90 oral morphine equivalents, respectively. While differences in time away from school were not measured in the pediatric meta-analyses,4 an adult trial found that patients randomized to a nonoperative approach used 11 fewer days of sick leave compared with patients treated operatively.4 Finally, the cost of nonoperative treatment is substantially lower, even when including costs associated with recurrent appendicitis and interval appendectomy.5

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