Initial Non-operative Treatment Strategy Versus Appendectomy Treatment Strategy for Simple Appendicitis in Children

Study Overview
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Brief Summary
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OBJECTIVE The aim of this study is to compare the effectiveness of initial non-operative treatment strategy (reserving appendectomy for those not responding or with recurrent disease) with immediate appendectomy in children from 7 to 17 years old, inclusive, with acute simple appendicitis in terms of complications, health-related QOL and costs. Main research question: What is the difference in proportion of patients experiencing complications within 1 year between both strategies in children from 7 to 17 years old, inclusive, with acute simple appendicitis?

Detailed Description
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Initial non-operative treatment of acute simple appendicitis has recently been investigated in both the adult as the paediatric population. In the adult population, six Randomised Controlled Trial (RCTs) showed that an appendectomy could be avoided in 40-76% of the patients at the end of their follow-up period. Despite the fact that some patients need to undergo a delayed appendectomy, it has been demonstrated in systematic reviews that non-operative treatment strategy is associated with a significant reduction in complications, faster recovery and return to work, less pain duration and analgesic medication consumption. In children only pilot data is yet available. Short-term success rates of this strategy (including of the investigators own pilot cohort study) are between the 83-92%. Long-term results (one-year follow-up) are available from two studies; 62-75% did not require an appendectomy. No large RCT have yet been conducted in the paediatric population. It is therefore essential to generate high quality empirical evidence regarding this strategy in this subset of patients.

Official Title
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Initial Non-operative Treatment Strategy Versus Appendectomy Treatment Strategy for Simple Appendicitis in Children Aged 7-17 Years Old - Antibiotics Versus Primary Appendectomy in Children With Simple Appendicitis: APAC Study

Conditions
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Appendicitis

Intervention / Treatment
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* Drug: Augmentin + Gentamicin
* Procedure: Appendectomy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 7-17 years Radiologically confirmed simple appendicitis, defined as: Clinical findings: Unwell, but not generally ill Localized tenderness in the right iliac fossa region Normal/hyperactive bowel sounds No guarding No mass palpable Ultrasonography: Incompressible appendix with an outer diameter of ≥6 mm Hyperaemia within the appendiceal wall Without faecolith Infiltration of surrounding fat No signs of perforation No signs of intra-abdominal abscess/phlegmon Exclusion Criteria: Generalized peritonitis, complex appendicitis or sepsis (based upon predefined criteria and scoring system). Scoring system: As scoring system was developed determining the risk of complex appendicitis based upon five pre-operative variable. Points have been awarded to each variable. In case the total score is less than 4 points, the patient is likely to have a simple appendicitis. In case the score is 4 or more points, the chance of having complex appendicitis is significant and those children will be excluded from this study. Variables: Diffuse abdominal guarding (3 points) C-Reactive Protein level more than 38 mg/L (2 points) Signs on ultrasound indicative of complex appendicitis (2 points) More than one day abdominal pain (2 points) Temperature: more than 37.5 degree Celsius (1 point) Faecolith (ultrasound) Serious co-morbidity Recurrent appendicitis Suspicion of an underlying malignancy or inflammatory bowel disease Documented type 1 allergy to the antibiotics used.

Ages Eligible for Study
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Minimum Age: 7 Years
Maximum Age: 17 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Augmentin + Gentamicin<br>Initial non-operative treatment strategy reserving an appendectomy for those not responding or with recurrent disease. It consist of: Clinical observation for 48 hours with administration of Intravenous administration of amoxicillin/clavulanic acid 25/2.5mg 6-hourly (total 100/10 mg/kg daily; maximum 6000/600mg a day) and gentamicin 7mg/kg once daily for 48 hours. If after 48 hours the patient fulfils the predefined discharge criteria, the antibiotics will be switched to oral amoxicillin/clavulanic acid 50/12.5 mg/kg 8-hourly (max 1500/375mg a day) for in total 7 days and discharge. An appendectomy is reserved for those patients with clinical deterioration, non-improvement after 72 hours or recurrent appendicitis. Pain medication according to national protocol. | Drug: Augmentin + Gentamicin<br>* Amoxicillin/clavulanic acid (Augmentin) 25/2.5mg 6-hourly (total 100/10 mg/kg daily; maximum 6000/600mg a day) intravenously for 48 hours Oral amoxicillin/clavulanic acid 50/12.5 mg/kg 8-hourly (max 1500/375mg a day) for in total 7 days Gentamicin 7mg/kg once daily for 48 hours<br>* Other names: Amoxicillin/clavulanic acid (Augmentin) + Gentamicin;|
| Active Comparator: Operative treatment strategy<br>Clinical observation and semi-urgent appendectomy. Pre-, peri- and postoperative care according to local protocol. No routine postoperative antibiotics. Discharge if the patient fulfils the predefined discharge criteria. Pain medication according to national protocol. | Procedure: Appendectomy<br>* Pre-, peri- and postoperative care according to local protocol. No routine postoperative antibiotics<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients experiencing complications |  | One year follow up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of days absent from school, social or sport events |  | 7 days, 1,6,12 months | 
| Number of days absent from work |  | 7 days, 1,6,12 months | 
| Total number of extra visits (not the already scheduled ones) to the outpatient clinic, general practitioners office or emergency department for abdominal pain. |  | 7 days, 1,6,12 months | 
| Total length of hospital stay during the follow-up period for strategy related treatment or complications |  | 7 days, 1,6,12 months | 
| Total days of analgesics medication use. |  | one month | 
| Pain score measured by the Visual Analogue Scale (VAS) |  | Clinical phase (up to 7 days) | 
| Proportion of patients with missed diagnosis of complex appendicitis with risk of peritonitis |  | 7 days, 1,6,12 months | 
| Proportion of patients not having to undergone appendectomy |  | 7 days, 1,6,12 months | 
| Proportion of patients experiencing recurrent appendicitis |  | 7 days, 1,6,12 months | 
| Proportion of patients experiencing early failure of initial non-operative treatment. |  | 7 days, 1,6,12 months | 
| Proportion of patients that undergo interval appendectomy. |  | 7 days, 1,6,12 months | 
| Quality of life questionnaire (CHQ-CF87, EQ-5d-Youth, EQ-5d-Proxy) |  | 7 days, 1,6,12 months | 
| Medical and non-medical costs (Health and Labor questionnaire) |  | 1,6,12 months | 
| Quality adjusted life years (QALY's). Calculating using outcome 13 and 14 |  | 1,6,12 months | 
| Patient satisfaction questionnaire (PSQ-18 & Net promotor score) |  | 7 days, 1,6,12 months | 
| Promoting and obstructing factors of implementability measured by questionnaires |  | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Appendicitis, Appendectomy, Antibiotics