What is the recommended treatment for appendicitis in children, appendectomy or antibiotics (Randomized Controlled Trials)?

Treatment of Appendicitis in Children: Appendectomy versus Antibiotics

For children with acute appendicitis, laparoscopic appendectomy is recommended as the preferred treatment approach over antibiotics alone, as it offers better treatment success rates, lower recurrence rates, and improved quality of life. 1, 2

Surgical Management: The Gold Standard

• Laparoscopic appendectomy is strongly recommended as the preferred approach for both uncomplicated and complicated appendicitis in children, offering significant advantages over open appendectomy including lower postoperative pain, lower incidence of surgical site infection, and higher quality of life 1
• Surgery should be performed within 24 hours of admission for uncomplicated appendicitis, with early appendectomy (within 8 hours) recommended for complicated appendicitis 1, 2
• Conventional three-port laparoscopic appendectomy is preferred over single-incision approaches due to shorter operative times, less postoperative pain, and lower incidence of wound infection 1
• In pediatric patients with favorable anatomy, single incision/transumbilical extracorporeal laparoscopic-assisted appendectomy may be considered as an alternative to traditional three-port laparoscopic appendectomy 1

Non-Operative Management: An Alternative Option

• Non-operative management (NOM) with antibiotics can be discussed as an alternative to surgery in selected children with uncomplicated appendicitis in the absence of an appendicolith 1
• When choosing NOM, patients and families should be advised about the possibility of treatment failure and the risk of misdiagnosing complicated appendicitis 1
• Initial intravenous antibiotics with subsequent conversion to oral antibiotics is recommended based on the patient's clinical condition 1
• Evidence shows that approximately 20% of patients initially treated with antibiotics may require hospitalization for recurrent appendicitis within one year, meaning about two-thirds of patients avoid surgery during this period 3, 4

Comparative Outcomes: Surgery vs. Antibiotics

• Surgery offers higher complication-free treatment success rates (82.3% vs. 67.2%) and better treatment efficacy at 1-year follow-up (93.1% vs. 72.6%) compared to antibiotic therapy 4
• Antibiotic therapy may fail during primary hospitalization in approximately 8% of cases 4
• Antibiotic treatment is associated with fewer immediate complications than surgery (18% vs. 25%), but more subsequent failures requiring later intervention 5
• The rate of complicated appendicitis with peritonitis is not statistically different between antibiotic therapy and surgical treatment (21.7% vs. 12.8%) 4

Special Considerations for Complicated Appendicitis

• For perforated appendicitis in children, early appendectomy within 8 hours is recommended 2
• In selected cases of perforated appendicitis (symptoms >3 days, absence of bowel obstruction, absence of diffuse peritonitis, and presence of appendiceal mass), initial nonoperative treatment with antibiotics and delayed appendectomy can be successful in up to 88% of cases 6
• Prophylactic abdominal drainage after laparoscopic appendectomy for complicated appendicitis in children is not recommended as it does not prevent postoperative complications and may be associated with negative outcomes 1

Technical Aspects of Appendectomy

• Simple ligation of the appendicular stump is recommended over stump inversion in both open and laparoscopic appendectomy, as it is associated with shorter operative times, less postoperative ileus, and quicker recovery 1, 2
• Routine histopathology after appendectomy is recommended to identify unexpected findings 2
• Wound ring protectors are recommended in open appendectomy to decrease the risk of surgical site infection 1

Common Pitfalls and Caveats

• Delaying appendectomy beyond 24 hours from admission for uncomplicated appendicitis or beyond 8 hours for complicated appendicitis may increase the risk of adverse outcomes 1
• When choosing NOM, failure to recognize an appendicolith may lead to higher treatment failure rates 1
• The presence of peritonitis or bowel obstruction are contraindications to non-operative management 6
• In very young children (<5 years), diagnosis may be delayed due to atypical presentation, potentially leading to higher rates of perforation 1