Optimal Care of Complicated Appendicitis

This is a single center, prospective study to compare early appendectomy vs. non-operative management of immunocompetent patients with complicated appendicitis, and then to compare interval appendectomy vs. no interval appendectomy in those managed with the initial non-operative approach. Patients who choose early appendectomy will have surgery within 24 hours of diagnosis and be discharged once they are afebrile for 24 hours, have a normal WBC count, and can tolerate a diet. They will be discharged with 5 days of oral ciprofloxacin and metronidazole and follow-up in clinic 2-4 weeks later. Patients who choose non-operative management will receive piperacillin-tazobactam with or without abscess drainage until they are afebrile 24 hours with a normal WBC count and are tolerating a diet, followed by 5 days of oral ciprofloxacin and metronidazole upon discharge. These patients will then be seen in clinic in 2-4 weeks, at which time they will be given the choice of whether or not to undergo interval appendectomy at least 8 weeks from initial presentation. Those in the interval appendectomy group will follow-up one month post-operatively. Patients in both groups will be contacted 3 months and 2 years following initial presentation.

{{{While 40 participants were enrolled as intended, and some data was collected from them, a combination of staff turnover and subsequent resource constraints did not permit the analysis originally intended. Thus, results data is shown comparing the early appendectomy participants against the other two arms combined.}}}}

• Early Appendectomy (Procedure): Removal of the appendix within 24 hours of admission
• Interval Appendectomy (Procedure): Removal of the appendix after initial antibiotic treatment and at least 6 weeks of recovery.
• Antibiotics (Drug), also known as Zosyn (piperacillin/tazobactam); ciprofloxacin; metronidazole: Zosyn will be administered unless the patient has a penicillin allergy, in which case patients will receive both ciprofloxacin and metronidazole.

Primary outcomes

• Overall Cost of Care [The original intention was to gather cost data for 2 years per person following admission. As no cost data was able to be procured, there is no time frame to which it applies.]: Total health care cost starting from time of admission was the intention of this outcome measure. However, the institutions potentially involved were unwilling to provide access to any cost data so this could not be analyzed for any length of time.

Secondary outcomes

• Complications [During index/initial hospitalization (generally not more than 5-6 weeks)]: Number of persons who experience any of a number of specified complications, including new/recurrent abscess, wound infection, small bowel obstruction, or need for a larger operation
• Parents Away From Work [During index/initial hospitalization (generally not more than 5-6 weeks)]: Parents away from work measured in days is presented here. The intention was to collect "missed activity days" for children as well as missed parent work days. However, the question to capture this information referred to school and was determined to be too inconsistent with the way the question may have been interpreted when the survey was given to code reliably.
• Duration of Antibiotic Therapy [During index/initial hospitalization (generally not more than 5-6 weeks)]: Duration of antibiotic therapy measured in days
• Length of Stay [During index/initial hospitalization (generally not more than 5-6 weeks)]: Length of all hospital stays measured in days
• Number of Percutaneous Drainage Procedures [During index/initial hospitalization (generally not more than 5-6 weeks)]: Number of persons with differing numbers of percutaneous drainage procedures
• Number of Radiographic Imaging Studies [During index/initial hospitalization (generally not more than 5-6 weeks)]: Number of radiographic imaging studies including ultrasound, CT, and MRI
• Quality of Life (PedsQL) [1 month; for GI QOL; 2 years for Peds QL]: Original QOL outcome measure listed was: Quality of life measured by PedsQL 2 years following discharge. Two year data collected was insufficient to allow for any analysis. One month GI QOL data collected, also listed in the protocol, is shown below. GI QoL is a validated measure with scores ranging from 0 to 100, where lower scores mean worse quality of life and higher scores mean better quality of life. Peds QL is a validated measure with scores ranging from 0 to 100, where lower scores mean worse quality of life and higher scores mean better quality of life.
• Recurrent Appendicitis [2 years; (Although this appears longer than trial duration, study completion date is based on last 2 year survey turned in, and medical record analysis looked a full two years per participant which extended a bit longer.)]: Number of persons who experience recurrent appendicitis requiring hospitalization. Because the early appendectomy arm participant by definition have no appendix to infect after surgery, they are not shown below.

Sex: All, ages: 5 Years to 17 Years

Inclusion criteria

1. At least 1 of the following CT or MRI findings:

   1. Peri-appendicular abscess
   2. Extruded appendicolith
   3. Visible hole in appendiceal wall
   4. Free peritoneal air

   OR
2. CT or MRI read with phlegmon or diffuse/extensive inflammation/free fluid plus 1 of 3 of the following (with CT) or 2 of 3 of the following (with MRI) *:

   1. White blood cell count (WBC) >15
   2. Peritonitis (involuntary right lower quadrant (RLQ) guarding, + Rovsing sign, percussion tenderness, and/or rebound tenderness)
   3. Temperature > 38.0 C *>90% specificity for complicated appendicitis based on unpublished institutional data

Exclusion Criteria

1. Immunocompromized state
2. History of major abdominal operation
3. Previous appendicitis
4. Major comorbidities that preclude safe operation
5. Inability to follow-up or appropriately consent
6. Pregnant women
7. Allergy to penicillin plus any one of the following:

   1. Hypersensitivity to ciprofloxacin and/or metronidazole
   2. Pregnant/lactating women
   3. Patients taking theophylline
   4. Patient taking tizanidine

Participant flow

Outcome results

• Overall Cost of Care (Primary)
• Complications (Secondary), Count of participants, Participants: Early Appendectomy 9; Interval Appendectomy 6; No Appendectomy 1
• Parents Away From Work (Secondary), Mean, days: Early Appendectomy 7.6 (1 to 21); Interval Appendectomy 9.3 (1 to 16); No Appendectomy 3.5 (3 to 4)
• Duration of Antibiotic Therapy (Secondary), Mean, days: Early Appendectomy 6.3 (5 to 17); Interval Appendectomy 5.1 (2 to 6); No Appendectomy 5.4 (5 to 10)
• Length of Stay (Secondary), Mean, days: Early Appendectomy 7.8 (0 to 26); Interval Appendectomy 7.4 (2 to 32); No Appendectomy 3.5 (2 to 5)
• Number of Percutaneous Drainage Procedures (Secondary), Count of participants, Participants: Early Appendectomy 4; Interval Appendectomy 4; No Appendectomy 1
• Number of Radiographic Imaging Studies (Secondary), Mean, number of imaging procedures/participant: Early Appendectomy 1.96 (1 to 6); Interval Appendectomy 2.04 (1 to 6); No Appendectomy 1.88 (1 to 5)
• Quality of Life (PedsQL) (Secondary), Mean, score on a scale: Early Appendectomy 80.18 (61 to 100); Interval Appendectomy 88.4 (79 to 94); No Appendectomy 87.25 (76 to 97)
• Recurrent Appendicitis (Secondary), Count of participants, Participants: Interval Appendectomy 2; No Appendectomy 0

Adverse events

Time frame: Three months

Serious adverse events by term

Other adverse events by term

• Study Protocol and Statistical Analysis Plan (PDF, 2017-04-05)

• Steven W. Bruch, M.D., Principal investigator, University of Michigan