By managing older, sicker patients’ appendicitis without surgery, US physicians may be increasing their risk for death by a slight but statistically significant degree, data suggest.

“Mortality, we were surprised to find, was significantly higher in the patients managed nonoperatively,” said lead author Isaiah Turnbull, MD, PhD, an assistant professor of surgery at Washington University in Saint Louis, Missouri.

Dr Turnbull presented the finding in a press conference and scientific session here at the American College of Surgeons (ACS) 2017 Clinical Congress.

US physicians have considered surgery the standard of care for appendicitis for a century, Dr Turnbull said.
But more recently, the realization that appendicitis may not always result in perforation led researchers to test treatment with antibiotics. Randomized controlled trials conducted in Europe have shown good results with this approach, and the ACS has advised that “antibiotic treatment might be used as an alternative for specific patients.”

To see how these developments have affected care of appendicitis in the United States, Dr Turnbull and colleagues analyzed 952,443 appendicitis cases recorded in the National Inpatient Sample from 1998 to 2014. They found an accelerating trend toward more nonoperative treatment during the last decade, with the rate doubling from 2.3% to 4.9% during those 16 years.

“This increasing rate of nonoperative management suggests that [these] European data [have] been adopted by US surgeons,” Dr Turnbull said.

Zeroing in on the years 2010 to 2014, they found that patients treated nonoperatively were more likely to die. These patients were also older, more likely to be diagnosed with peritonitis, had more total diagnoses, and had more comorbidities as measured by the Elixhauser-van Walraven comorbidity index. The differences were all statistically significant (P < .001).

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