Delayed appendectomy as part of a nonoperative treatment strategy does not increase postoperative complications in children with simple appendicitis-A secondary analysis from a randomized controlled trial (Antibiotics Versus Primary Appendectomy in Children trial)
In brief
Delayed appendectomy had an 8.7% complication rate, similar to surgery-first care
In children with simple appendicitis, complications occurred in 4 of 46 who had delayed surgery after initial nonoperative treatment, compared with 11 of 143 who had surgery first. The secondary analysis found no significant difference in complication rates or severity, but the small delayed-surgery group leaves uncertainty about how closely outcomes compare.
- Journal
- Surgery (Q1)
- Published
- 9 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Said Bachiri, Paul van Amstel, Merel D Adolfsen, Max Knaapen, Rik van Eekelen, Willem A Bemelman, et al.
- PMID
- 42976577
- DOI
- 10.1016/j.surg.2026.110750
Why clinicians should know about it
- Picked for Surgery (paper of the day, 4 November 2026): Compares complications after primary versus delayed appendectomy
Abstract
BACKGROUND: Recently, nonoperative treatment has been investigated in children with acute simple appendicitis. This strategy involves a step-up approach, starting with intravenous antibiotics and reserving appendectomy for cases of clinical nonimprovement or recurrent appendicitis, referred to as delayed appendectomy. Delayed appendectomy as part of a nonoperative treatment strategy in children might be associated with worse outcomes compared with primary appendectomy. We aimed to compare the proportion of participants with postoperative complications between primary appendectomy and delayed appendectomy after initial nonoperative treatment in children with simple appendicitis. METHODS: A secondary analysis was performed on data gathered in the Antibiotics Versus Primary Appendectomy in Children trial (a noninferiority randomized controlled trial) investigating the outcomes of children (7-17 years old) randomized to primary appendectomy or a nonoperative treatment strategy for imaging-confirmed acute simple appendicitis with 1-year follow-up. In this analysis, we compared children in the primary appendectomy group with children who underwent delayed appendectomy (because of early treatment failure, recurrent appendicitis, or interval appendectomy caused by persistent abdominal complaints) in the nonoperative treatment strategy group. The primary outcome was the proportion of children with postoperative complications. Secondary outcomes included the total number and severity of complications. RESULTS: In the Antibiotics Versus Primary Appendectomy in Children trial, 143 children underwent primary appendectomy, and 48 underwent delayed appendectomy in the nonoperative treatment strategy group. Two children were lost to follow-up in the delayed appendectomy group and excluded from the primary outcome analysis. No statistically significant difference was observed in terms of the proportion of participants with complications, which occurred in 11 of 143 (7.7%) children in the primary appendectomy group and in 4 of 46 (8.7%) children in the delayed appendectomy group (absolute risk difference, -1.0; 95% confidence interval, -13.1 to 6.6). One participant in the primary appendectomy group developed 2 complications, resulting in a total of 12 complications in this group. Also, no difference was observed in complication severity between groups. CONCLUSION: The proportion of participants with complications in the primary appendectomy and delayed appendectomy groups (as part of the nonoperative treatment strategy) in children with imaging-confirmed simple appendicitis did not significantly differ. These findings do not support the hypothesis that delayed appendectomy as part of the nonoperative treatment strategy is associated with worse outcomes in terms of complications.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.