American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Long-term view supports surgery over nonoperative management of appendicitis

OCTOBER 22, 2018
Clinical Congress Daily Highlights, Monday First Edition

The goal of reducing costs while improving outcomes has led to recent interest in nonoperative management (NOM) of uncomplicated appendicitis, such as with antibiotics, as an alternative to surgery. At least seven randomized trials comparing the outcomes of NOM with appendectomy have been conducted. Yet there are few studies examining the long-term costs of appendicitis-related care that account for the lifetime potential of recurrence, the ongoing risk of appendiceal malignancy, or postoperative complications such as small bowel obstruction.  

On Monday, Lindsay Anne Sceats, MD, General Surgery, Stanford (CA) Hospital, presented results from a long-term cost-effectiveness analysis of 58,329 patients evaluating cost and length of index hospitalization, appendicitis-related readmissions, and failure of NOM requiring subsequent appendicitis-related procedure. Within this cohort, 55,709 (95.5 percent) underwent appendectomy while 2,620 (4.5 percent) underwent NOM. She noted the importance of such studies, saying: “It’s really easy to say that nonoperative management is cheaper when you look just at their first visit, but I think it’s important to consider the long-term.”

The study found that on average, patients who underwent appendectomy had slightly shorter hospital stays (1.6 vs. 1.7 days); NOM patients had lower index hospitalization costs of $10,441 compared with $12,286. However, NOM patients were more likely to have appendicitis-related readmissions (2.6 percent vs. 1.2 percent) and to develop an abscess (2.3 percent vs. 1.3 percent). Overall, failure of NOM was low, but nearly half of the failures (44 percent) occurred within one month.

Dr. Sceats noted that the study collected limited data for long-term model parameters and that outpatient NOM parameters were adapted from trials with oral antibiotic strategies. However, she believes that ultimately the data demonstrate that laparoscopic appendectomy is more cost-effective and produces better outcomes compared to outpatient NOM when considered over the lifetime of a young adult patient.

View this study’s abstract online here.

Additional Information

The Scientific Forum presentation, Operative vs Nonoperative Management of Appendicitis: A Long-Term Cost-Effectiveness Analysis, was held October 22 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast, and audio information is available online at

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