Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Non-Operative Management of Appendicitis: 2018 Pediatric Surgery Practice Gap #2
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Drs. Todd Ponsky, Alex Casar, Alex Gibbons, and Rae Hanke review 2018 Practice Gap #2: Wilms Tumor Protocol Violations, as identified by the APSA Professional Development Committee.
video1:21 · Jun 2019
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
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In this session, Dr. Jose Campos leads us through the top publications that are not in the Journal of Pediatric Surgery.
Articles referenced:
1. IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children T
video27:50 · Sep 2022
Quick Literature Updates Episode 11
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We’re back with eleventh episode of "Quick Literature Updates" the podcast series that delivers the latest updates in pediatric surgery literature in a quick and digestible format. This episode, we will review three articles covering the mo
video · Jul 2023
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Non-operative management of perforated appendicitis represents an established alternative to immediate surgery, with equivalent outcomes but a 15% one-year recurrence risk and advantages in reduced hospital stays and disability days. The choice between operative and non-operative approaches remains individualized, with APSA declining to issue blanket recommendations despite increasingly clear data. Antibiotic selection remains controversial: a multi-institutional RCT stopped early showed piperacillin-tazobactam reduced intra-abdominal abscesses versus ceftriaxone-metronidazole (OR 4.8, NNT 5.7), yet results were driven entirely by one center's experience, and NSQIP-P national data shows no difference between regimens. Adjunctive gabapentin in postoperative management decreased both opioid consumption and length of stay in a single-center retrospective cohort. The evidence base continues to evolve, with institutional variation suggesting local factors—microbiology, surgical technique, patient selection—may outweigh protocol-level differences.
- Non-operative management achieves equivalent outcomes to surgery with 15% recurrence at one year, shorter stays, and less disability.[e1462-c2][e1462-c3][e1462-c4][e1462-c5]
- Piperacillin-tazobactam reduced abscesses (NNT 5.7) in one RCT, but single-center effect and conflicting NSQIP-P data limit generalizability.[e5819-c2][e5819-c3][e5819-c4][e5819-c5][e5819-c6]
- Gabapentin as multimodal adjunct decreased postoperative opioid use and length of stay in one retrospective cohort.[e6954-c6][e6954-c7][e6954-c8]
- APSA has not issued blanket recommendations for non-operative management; choice remains individualized based on risks and benefits.[e1462-c6][e1462-c7][e1462-c9]
- Institutional variation in antibiotic trial outcomes suggests local factors may outweigh protocol differences in abscess prevention.[e5819-c5][e5819-c6]
For patients & families
Doctors have known for a long time that perforated appendicitis—when the appendix bursts—can sometimes be treated without surgery. Recent studies show that using antibiotics alone can work just as well as operating right away, with shorter hospital stays and less time away from normal activities. However, about 15 out of 100 children treated this way may have appendicitis come back within a year. The medical community agrees this is a real option families can consider, but it's not the right choice for everyone—doctors weigh the pros and cons for each child. When surgery is needed, research shows that the choice of antibiotics matters: one combination called piperacillin-tazobactam led to fewer abscesses (pockets of infection) after surgery compared to the older standard combination, though some hospitals saw different results. Doctors also found that a medication called gabapentin, given after surgery, helped children need less pain medicine and go home sooner.
Doctors have known for a long time that perforated appendicitis—when the appendix bursts—can sometimes be treated without surgery. Recent studies show that using antibiotics alone can work just as well as operating right away, with shorter hospital stays and less time away from normal activities. However, about 15 out of 100 children treated this way may have appendicitis come back within a year. The medical community agrees this is a real option families can consider, but it's not the right choice for everyone—doctors weigh the pros and cons for each child. When surgery is needed, research shows that the choice of antibiotics matters: one combination called piperacillin-tazobactam led to fewer abscesses (pockets of infection) after surgery compared to the older standard combination, though some hospitals saw different results. Doctors also found that a medication called gabapentin, given after surgery, helped children need less pain medicine and go home sooner.
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Non-Operative Management of Appendicitis: 2018 Pediatric Surgery Practice Gap #2
Non-operative management of perforated appendicitis has been known for a long time.
clinical0:19 ↗
Treating appendicitis with antibiotics had equal outcome measures compared to initial operative management.
clinical0:19 ↗
There was a 15% risk of recurrence of appendicitis at one-year follow-up with non-operative management.
clinical0:35 ↗
Non-operative management resulted in decreased hospital stays compared to operative management.
clinical0:35 ↗
Non-operative management resulted in decreased days of disability compared to operative management.
clinical0:35 ↗
Non-operative management of appendicitis is an option with risks and benefits that need to be taken into account.
guideline0:52 ↗
APSA was not making a flat out recommendation to start doing non-operative appendicitis.
opinionGibbons1:08 ↗
The data on non-operative appendicitis management is becoming more clear.
opinionGibbons1:14 ↗
The choice between operative and non-operative appendicitis management remains dealer's choice.
opinionGibbons1:06 ↗
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
The Chilean Society of Pediatric Surgery screens approximately 1,200 articles each month from non-pediatric surgical journals to identify the 3% relevant to pediatric surgery.
clinicalJose Campos1:38 ↗
A multi-institutional prospective randomized trial comparing piperacillin-tazobactam to ceftriaxone-metronidazole for perforated appendicitis was stopped at 75% enrollment when interim analysis favored the piperacillin-tazobactam group.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position4:40 ↗
Intra-abdominal abscess formation was significantly lower in the piperacillin-tazobactam group with an odds ratio of 4.8.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position5:30 ↗
The number needed to treat with piperacillin-tazobactam to prevent one intra-abdominal abscess was 5.7.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position5:50 ↗
One participating hospital in the appendicitis antibiotic trial did not see a difference in abscess rates between the two antibiotic regimens in their cohort, while the overall study results were driven entirely by Phoenix Children's Hospital's experience.
clinicalShawn St. Peter7:04 ↗
NSQIP-P national data shows no difference in abscess rates between ceftriaxone-metronidazole and piperacillin-tazobactam across much larger patient numbers.
epidemiologicalShawn St. Peter7:45 ↗
Necrotizing enterocolitis treated surgically is associated with high mortality rates and poor neurodevelopmental outcomes.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position10:30 ↗
Two previous randomized controlled trials comparing surgical techniques for NEC both failed to enroll enough patients to answer the clinical question.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position10:50 ↗
A 20-center randomized controlled trial by Marty Blakely comparing initial laparotomy versus peritoneal drainage for NEC randomized 310 premature newborns.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position11:05 ↗
At 18 to 22 months of corrected age, the composite outcome of death and neurodevelopmental impairment was similar in both the laparotomy and peritoneal drainage groups in frequentist analysis.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position11:25 ↗
Bayesian analysis of the NEC trial showed a high probability of laparotomy being superior to peritoneal drainage.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position11:40 ↗
In the NEC trial, there was significant surgeon intention to treat, with most patients who received initial peritoneal drainage going to laparotomy shortly after drain placement.
clinicalShawn St. Peter12:40 ↗
Peritoneal drainage for NEC often serves as a temporizing measure to stabilize septic patients before laparotomy rather than as definitive therapy.
opinionShawn St. Peter13:42 ↗
In the original papers by Ziggy Hein on peritoneal drainage for NEC, approximately one-third of patients died, one-third received laparotomy, and one-third were managed with drainage alone.
Host summaryThe host summarizing the discussion — not the host's own clinical position13:51 ↗
Peritoneal drainage started as a temporizing measure for NEC but morphed into a definitive management strategy in approximately 40-50% of surgeons' minds.
opinion14:10 ↗
The original description of percutaneous endoscopic gastrostomy (PEG) was done by Todd Ponsky Sr.
clinicalJose Campos15:50 ↗
A systematic review examining gastrostomy insertion techniques reviewed 900 publications, with 58 being used for final recommendations.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position18:20 ↗
Twelve studies directly compared outcomes between laparoscopic and percutaneous endoscopic gastrostomy, showing major complication rates were significantly less common with laparoscopic placement.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position18:50 ↗
The number needed to treat to prevent one major complication from PEG (by using laparoscopic approach instead) is 24.
Host summaryJose Campos summarizing the discussion — not the host's own clinical position19:20 ↗
PEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button.
clinicalMeera Kotagal20:29 ↗
The article by Todd Ponsky Sr. and Mike Goddard on PEG tube placement remains the most cited article in the history of the Journal of Pediatric Surgery, with approximately three times the citations of the number two article.
clinicalTodd Ponsky17:36 ↗
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