Quick Appendectomy for Kids Beats Waiting
Surgery day after perforation gets kids on their feet faster, researchers say.
Feb. 21, 2010— -- Surgery within a day for children with a perforated appendix reduced the time before they returned to normal activities compared with waiting until peritoneal contamination cleared up, researchers reported.
Early appendectomy was also safer than the so-called interval appendectomy, in which the procedure is planned for up to eight weeks after diagnosis, according to Dr. Martin Blakely of the University of Tennessee Health Science Center in Memphis, and colleagues.
The finding -- which "definitively favors early appendectomy" -- comes from a single-center randomized trial of the two options, the researchers reported online in Archives of Surgery.
The study "may put an end to a long-standing controversy," according to Dr. Marty Makary, an associate professor of surgery and public health at Johns Hopkins University School of Medicine in Baltimore, who was not part of the study.
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It "provides strong evidence to operate as soon as possible," Makary commented in an e-mail to MedPage Today and ABC News. "Removing the appendix as the source of an infection can often provide instant relief and sometimes dramatic improvements in the patient's well-being."
Although there is consensus that immediate surgery is the right choice unperforated appendix, there has been no similar agreement on the correct approach to a perforated appendix, seen in about 30 percent of appendicitis cases in children in the U.S., Blakely and colleagues noted.
On one hand, the early appendectomy relieves the disorder within 24 hours of diagnosis, at the risk of missing alternative diagnoses, they noted. On the other hand, waiting allows peritoneal contamination to resolve, with a potential for improved outcomes.
To test the issue, they studied 131 patients under 18 with a diagnosis of perforated appendix, with 64 randomly assigned to early and 67 to interval appendectomy.
Getting Kids Back on Their Feet
Since mortality in such cases is rare and almost all children return to a pre-illness level of activity, the main interest of parents and children is how soon that will take place, Blakely and colleagues noted.
For that reason, the primary outcome of the study, they reported, was time to resumption of normal activities, with a difference of five days considered to be clinically significant. Secondary outcomes included adverse events.
"We found that those treated with early appendectomy return to normal activities an average of five days earlier," the researchers reported. "Because a child's time away from normal activities limits parents' abilities to work, we believe it is an important outcome from a patient and family perspective."
Blakely and colleagues cautioned that the study was conducted in a single center, so that the result might not apply in all situations.
They added that there is no accepted standard way to determine the time when a child has returned to normal activities.
The method used in the study was a combination of objective elements, such as time in the hospital, and subjective factors, determined by talking with patients and their families. It was applied to both groups, the researchers reported.
Johns Hopkins' Makary cautioned that immediate surgery might not be appropriate in all situations. If an abscess has formed, he said, draining it "and waiting for the infection to settle down is often prudent."
Another outside expert, Dr. William Berquist of Stanford University School of Medicine in Stanford, Calif., called the report "important" but also cautioned that one approach may not work in all situations.
"I would keep in mind that both patient factors (age, other illness, duration of symptoms, status at time of diagnosis, response to antibiotics) and surgical factors (large versus small abscess) play a role so there really is a spectrum of disease severity," he said in an e-mail to MedPage Today and ABC News.