Risk-adjusted Comparison of Operative and Non-Operative Management for Perforated Appendicitis in Children: Impact of Initial Treatment Approach on Overall Cost

ObjectiveManagement of perforated appendicitis remains controversial. Non-operative and immediate operative strategies are employed. We hypothesize that initial non-operative management is associated with higher overall costs... [ view full abstract ]

Objective

Management of perforated appendicitis remains controversial. Non-operative and immediate operative strategies are employed. We hypothesize that initial non-operative management is associated with higher overall costs and worse outcomes compared to immediate operation.

Methods

Following IRB approval, 718 patients undergoing appendectomy between 2012-2015 underwent chart review. One hundred and forty five patients underwent immediate operation for perforated appendicitis and 83 were treated non-operatively. Patients with perforated appendicitis were defined by evidence of perforation on imaging. Patients initially treated at an outside facility, with perforated appendicitis initially managed under a non-perforated clinical pathway, with organ failure, or VP shunts were excluded. The immediate operative group underwent appendectomy within 24 hours of admission. Non-operative management was determined by individual surgeon preference. Univariate and multivariate analyses were performed.

Results

Compared to immediate operative patients, non-operative patients incurred higher overall costs, greater LOS, more readmissions, complications, PICC lines, IR drains, and unplanned clinic and ED visits (p<0.0001 for all). By multivariate analysis adjusting for days of symptoms, admission CRP and WBC, and age, non-operative management was independently associated with increased costs (OR 1.35, 1.12 – 1.62, 95% CI).

Conclusion

Our study shows that non-operative management of perforated appendicitis is independently associated with higher overall costs, total length of stay, and complications and supports the immediate operative intervention for patients with perforated appendicitis.