December 9, 2022

Which is best for acute appendicitis?

For uncomplicated acute appendicitis, is nonoperative management with antibiotics as safe as surgery? When nonoperative management is compared to appendectomy, treatment success or the likelihood of major complications are similar, according to results published in JAMA surgery. However, nonoperative management is related to longer hospital stay and higher rate of recurrent appendicitis compared to appendectomy.

The results are based on a systematic review and meta-analysis of 8 randomized clinical trials. The primary outcome was treatment success at 30 days (or longer follow-up period when different time points were reported) as defined in the individual trials, which included resolution of abdominal pain, freedom from complications, and improvement of inflammatory markers.

Previous studies have shown that antibiotic treatment of appendicitis is a safe alternative to appendectomy; however, a wide range of treatment failure rates (7% to 39%) have been observed with nonsurgical management. So, Rocco Ricciardi, MD, MPH, of Massachusetts General Hospital, and colleagues conducted this study to examine whether the results of antibiotic treatment are comparable to those of appendectomy in adult patients with uncomplicated appendicitis.

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Treatment success With antibiotics vs appendectomy

The overall relative risk (RR) for the percentage of appendicitis treatment success at follow-up did not differ between the antibiotic group and the appendectomy group (0.85; 95% CI, 0.66-1.11) . Six of the 8 trials did not find statistically significant differences in the primary outcome between the antibiotic and appendectomy groups. One study reported a statistically significant benefit with surgical treatment, while another showed antibiotic treatment was superior to appendectomy.

Major side effects

A meta-analysis of the 6 trials that reported rates of major adverse events at 30 days showed that antibiotic treatment was associated with a nonsignificant trend toward lower rates of major adverse events compared to appendectomy (RR, 0.72; 95% CI, 0.29-1.79). One study reported a significant superiority of antibiotic treatment, while another reported a superiority of surgical treatment. The other 4 trials showed no statistically significant difference in major adverse effects between the groups. Mortality was low in both groups and in all trials.

“Given the incidence of major adverse effects, our meta-analysis demonstrated relative safety with operative and nonoperative approaches for uncomplicated acute appendicitis,” the researchers noted.

In a meta-analysis of the results of the 3 trials that reported total length of hospital stay, surgical treatment was associated with a significantly shorter length of hospital stay (RR, 1.48; 95% CI , 1.26-1.70).

Rehospitalization rate for appendicitis

According to data from the largest trial in the meta-analysis, the CODA collaborative trial (n=1552), the median rate of rehospitalization for appendicitis was 18%. Thus, “Patients should be informed that despite the promising results of nonoperative management of acute appendicitis, nearly 1 in 5 patients treated nonoperatively in this review eventually experienced recurrent symptoms of appendicitis” , the researchers noted.

They also highlighted the need to consider local infrastructure conditions when selecting antibiotic treatment and close monitoring of patients using serial physical examinations and 24-hour availability. on 24 of imaging, interventional radiology, laboratory tests and rehospitalization, as well as the flexibility to change therapeutic approach if necessary.


by Almeida Leite RM, Seo DJ, Gomez-Eslava B, et al. Nonoperative vs. operative management of uncomplicated acute appendicitis: systematic review and meta-analysis. JAMA Surg. 2022 Jul 27. doi:10.1001/jamasurg.2022.2937