Risk of missed diagnoses when choosing non-operative management of pediatric uncomplicated appendicitis

An antibiotic-only approach to managing uncomplicated appendicitis in children confers the risk of missed diagnoses of alternate pathologies. We aimed to quantify this risk in patients presenting with uncomplicated acute appendicitis at a large tertiary children's hospital and to assess contemporary perioperative clinical outcomes.

A retrospective review of patients who underwent appendectomy for uncomplicated appendicitis between January 1, 2019 and December 31, 2023 was conducted. Pathology reports and perioperative outcomes were analyzed.

Among 5341 patients, 1.1 % had notable alternative pathologies including 31 occult malignancies (0.6 %) and 24 atypical infections (0.5 %). A subgroup analysis demonstrated that patients who underwent interval appendectomy were more likely to have neoplasms (5/128) than those who underwent uncomplicated acute appendectomies (3.9 % vs 0.6 %, respectively; p < 0.001). The median postoperative length of stay was 2.6 h (IQR 2.0-12.5 h). There were 182 (3.4 %) surgery-related emergency center visits post-discharge and 57 (1.1 %) surgery-related readmissions. Seventeen patients (0.3 %) required additional procedures. The negative appendectomy rate was 1.8 %.

A notable number of patients had alternative diagnoses made by pathologic examination, including occult malignancies and atypical infections which required further treatment. The perioperative outcomes of appendectomy were favorable, with low morbidity and a low rate of negative appendectomy. These findings underscore the diagnostic value of surgical specimen evaluation and quantify the added risk of missing alternate pathologies when offering non-operative management.