Outcomes 1 year after non-operative management of uncomplicated appendicitis in children: Children with AppendicitiS during the CoronAvirus panDEmic (CASCADE) study
Authors: Bethell George S , Rees Clare M , Sutcliffe Jonathan , Hall Nigel J ,   CASCADE study collaborators, Long Anna-May , Djendov Florin , Emordi Victor , Peter Mark , Staight Sarah , Jackson Andrew , Cleeve Stewart , Kelay Arun , Terry Michael , Major Christina , Croysdale Oscar , Patel Bhavik , Nelson Mike , Cusick Eleri , Rhodes Hannah , King Juliette , Lewis Sophie , Driver Chris , Winter Gillian , Wilson Michael , Robertson Rachael , Rutherford Duncan , McGivern Kieran , Jafarli Ilhama , Curkovic Selena , Jackson Raef , Jadhav Bhushanrao , Conroy Maeve , Raymond Thomas , Gangalam Vijay , Selvakumar Deepak , Elmalik Khalid , Habak Reda , Abdullah Muslim , Osama Mohamed Ahmed , Gopal Milan , Phillips Laura , Asanai Khlud , Gabra Hany , Naidoo Kamil , Zafar Noman , Lewis Sophia , Kashora Florence , Thakrar Dixa , Rex Dean , Budzanowski Annita , Binnington Jennifer , Timbrell Simon , Ridgeway Megan , Chan Shirley , Asour Amani , Aderombi Adetayo , Kocsis Anna Maria , Menzies Donald , Murtada Ali , Dragu Corina , Quan Vincent , Askari Alan , Patel Krashna , Zuberi Sharukh , Ebrahim Saarah , McHoney Merrill , Patel Hetal , Hotonu Sesi , Meikle Ashley , Dass Raj , Beamish Andrew , Codd Rhodri , Ooi Rucira , Tang Alethea , Taylor Luke , Belgaumkar Ajay , Oyewole Bankole , Narayan Prabhat , Hollyman Marianne , Kosti Angeliki , Badenoch Thomas , Rakin Asef , Khan Hamad , Goulder Frances , Siggens Katie , Peters Kizzie , Kirkham-Wilson Fiona , Bowyer Sophie , Jamnadass Enakshee , Froggatt Paul , Lai Karen , Navarro Cristina , Chandrabose Dorinda , Awolaran Olugbenga , Toh Simon , Darbyshire Alex , Towers Ashley , Tan Christine , Miles Joanna , Jester Ingo , Martin Ben , Merwe Elmarie Van Der , Patel Hetal N , Gemmill Elizabeth , Lenzi Elisa , Egan Richard , Soanes Keira , Dilworth Mark , Stamatiou Dimitrios , Macmillan Alasdair , McIntyre Joshua , Clyde Danielle , Rashid Majid , Srinivas Gandrapu , Christopoulos​ Petros , Majeed Talal , Buckley Katherine , Smith Darren , Ahmed Salma , Dowson Henry , Singh Gautam , Kerans George , Ghorpade Ashwini , Tobbal Muhammad , Bylapudi Seshu Kumar , Phillips Louise , Hallam Kimberley , Clemente Marisa , Gala Tanzeela , Pal Karol , Dick Lachlan , Ninkovic-Hall George , Paul Emila , Abdalla Ahmed , Pelly Theo , Vance-Daniel Joe , Kanakala Venkatesh , Nevins Edward J. , Dixon James , John Michael , Prince Jude , Rajput Kunal , Clifford Rachael , Kumar Siddhant , Vimalachandran Dale , Karagiannidis Georgios , Youssef Fahed , Samlalsingh Suzette , Ozone Chrsitine , Bouhelal Amina , Handa Siddhartha , Mitchell Andrew , Rajeev Sathasivam , Ross Ellen , Wadah Ali , Bradnock Tim , Hallett John , Arthur Felicity , Tewari Shirish , Shah Vinay , Gupta Vivek , Reay-Jones Nick , Bodla Salman , Yassin Nuha , Corbett Harriet , Chhabra Sumita , Tyraskis Athanasios , Allin Benjamin , Fitchie Angus , Samra Benjamin , Stanton Michael , Fouad Dina , Brown Joshua , Vipond Mark , Dean Harry , Boal Matthew , Brown Oliver , Goring Jonathan , Marei Mahmoud , Verhoef Christian , Ducey Jonathan , Rees Clare , Mushonga Chipo , Frith Dan , Ram Ashok , Boam Tristan , Gabriel Melissa , Mohamed Ferzine , Williams David , Cross Katie , Dyar Nadine , MacMahon Rick , Fakhrul-Aldeen Mohammed , Bain Iain , Bunting David , Branagan Graham , Carten Rachel , Lai Chee Wan , Longstaff Lydia , West Charles , Doyle Lucinda , Niyogi Anindya , Koh Claudia , John Michael , Fox Christian , Gerrie Brooke , Thakkar Hemanshoo , Loukogeorgakis Stavros , Curry Joe , Cross Kate , Sivaraj Jayaram , Marven Sean , Jancauskaite Milda , Please Helen , Fradley Wayne , Welsh Fenella , Jitsumara Maki , Walsh Caoimhe , Hassett Sinead , Muntean Ancuta , Stoica Ionica , Yassin Sarah , O’Brien Lukas , Mortell Alan , Hughes Kris , Conroy Maeve , Asanai Khlud , Lawther Suzanne , Colvin David , Durand Ciaran , Lim Adrian , Eltom Mohamed , Yardley Iain , Brennan Kirsty , Chong Clara , Pointon Joshua , Mukhtar Hasan , Khalil Hany , Clark Stephanie , Iskandarani Mohamad , Desai Ashish , Woodward Ben , Gozzini Sara , Muntean Ancuta , Saxena Amulya , Cave Joshua , Sorensen Eva , Sharples Alistair , Meilak Joseph , Shah Ankur , Rai Sujata , Pangeni Anang , Shrestha Ashish Kiran , Tanwar Astha , Hamal Milord , Youssef Marco , Al-Hamid Zaid , Ahmed Salma , Zaver Vasudev , Sutcliffe Jonathan , Elfar Hazem , Stephenson Lucy , Hannon Ed , Jones Gregory , Hodgkinson Jonathan , Chadha Radhika , Dale James , Pilpel Timothy 
Published: June 2023

Abstract

Background
A major shift in treatment of appendicitis occurred early in the SARS-CoV-2 pandemic with non-operative management used commonly outside research protocols and in units with limited previous experience. This study aims to compare real-world outcomes of surgery versus non-operative management of uncomplicated appendicitis in children with 1-year follow-up.

Method
A prospective multicentre observational study of children treated for uncomplicated appendicitis at 74 hospitals in the UK and Ireland from 1 April to 31 July 2020 was performed. Propensity-score matched analysis was conducted using age, sex, C-reactive protein at diagnosis and duration of symptoms as covariates. Primary outcomes were success of non-operative management defined as achieving 1-year follow-up without undergoing appendicectomy due to recurrent appendicitis or ongoing symptoms, and occurrence of any predefined complication (intra-abdominal collection, wound infection, bowel obstruction or reintervention).

Results
Of 1464 children with presumed uncomplicated appendicitis, 1027 (70.2 per cent) underwent surgery and 437 (29.9 per cent) underwent non-operative management. Ninety-four children (21.5 per cent) treated by initial non-operative management required appendicectomy during the index hospital admission while recurrent appendicitis after discharge occurred in 25 (10.4 per cent) children within 1 year. The overall success rate of non-operative management at 1 year was 63.1 per cent (95 per cent c.i. 58.0 to 68.3 per cent). For propensity-score matched analyses, 688 children undergoing surgery and 307 undergoing non-operative management were included. Any predefined complication occurred in 50 (7.3 per cent) children undergoing surgery and in four (1.3 per cent) children undergoing non-operative management (OR 5.9 (95 per cent c.i. 2.1 to 16.6)) in the propensity-score matched cohort. There was no mortality or stoma formation.

Conclusion
Non-operative management is a safe and valid alternative to appendicectomy in children with uncomplicated appendicitis.