Lack of Blinding: There was no blinding in any of the studies. It would be difficult to conduct a study with a sham surgery group to address this bias.

Antibiotic Regimes: There was no standard antibiotic protocol. While this may be pragmatic, it makes it difficult to know what would be the best antibiotic regimen for acute, uncomplicated pediatric appendicitis.

Safety: While researchers did not report any serious adverse events with NOT, the total number of patients managed nonoperatively is too small to claim safety.

Diagnosis of Acute, Uncomplicated Appendicitis: It is much easier to diagnose complicated appendicitis than uncomplicated appendicitis. In addition, the diagnostic accuracy of ultrasound and CT are not 100 percent.

While NOT of acute, uncomplicated pediatric appendicitis is interesting, there is not enough high-quality evidence to recommend it at this time.

Bottom Line

While NOT of acute, uncomplicated pediatric appendicitis is interesting, there is not enough high-quality evidence to recommend it at this time.

Case Resolution

The surgeon is called, obtains informed consent from Johnny’s parents, and successfully performs an appendectomy.

Thank you to Dr. Ross Fisher from www.ffolliet.com his help with this review. Dr. Fisher is a pediatric surgeon working at Sheffield Children’s Hospital in Sheffield, UK.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References

1. Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910-925.
2. Charles McBurney. Wikipedia website. Accessed June 21, 2017.
3. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ. 2012;344:e2156.
4. Kirby A, Hobson RP, Burke D, et al. Appendicectomy for suspected uncomplicated appendicitis is associated with fewer complications than conservative antibiotic management: a meta-analysis of post-intervention complications. J Infect. 2015;70(2):105-110.