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Journal Article Summary

Nonoperative vs Operative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-analysis

Rodrigo Moises de Almeida Leite 1 2Dong Joo Seo 1Barbara Gomez-Eslava 1Sigma Hossain 1Arnaud Lesegretain 1Alexandre Venâncio de Souza 3Camden Phillip Bay 4Bruno Zilberstein 2 5Evaldo Marchi 3Rogerio Bonassi Machado 6Leandro Cardoso Barchi 2 4Rocco Ricciardi 7

Surgery has been the standard treatment for appendicitis regardless of presentation, as appendectomy is generally well-tolerated. However, surgery comes with intraoperative and postoperative risks. For uncomplicated appendicitis, nonoperative management using antibiotic-only treatment has emerged as an attractive option. This approach can avoid surgical scars, reduce postoperative pain, and lead to faster recovery.

Several randomized clinical trials have evaluated the effectiveness of antibiotic treatment compared with surgical approaches. However, the results of these studies have often been confusing and difficult to interpret. The purpose of this study is to perform a meta-analysis to determine whether antibiotic treatment in adults with uncomplicated appendicitis is comparable to surgical treatment. Eight randomized control trials conducted between 1995 and 2021 in Europe and North America were included in the meta-analysis.

The findings indicated that nonoperative treatment was not significantly different from operative treatment in managing acute appendicitis, based on treatment success and major adverse effects. Six clinical trials reported the incidence of major adverse effects after 30 days, with antibiotic treatment showing a trend toward lower percentages of major adverse effects. Four of the trials demonstrated no statistically significant difference between the intervention and comparison groups.

Nonoperative management is a viable alternative strategy for the treatment of acute uncomplicated appendicitis, showing no significant difference in treatment success and major complications when compared to surgical treatment. However, patients should be informed that nearly 1 in 5 patients treated nonoperatively in the review experienced recurrent appendicitis symptoms. Nonoperative management was also associated with a significantly longer hospital stay. Two randomized control trials conducted a subgroup analysis of patients with appendicoliths, with one trial noting a slight increase in conservative treatment failure for patients with appendicoliths. Therefore, patients who choose nonsurgical treatment should have easy access to rehospitalization if necessary. In locations lacking the facilities and personnel to perform the nonoperative approach, the surgical approach should be recommended first.


de Almeida Leite, R. M., Seo, D. J., Gomez-Eslava, B., Hossain, S., Lesegretain, A., de Souza, A. V., Bay, C. P., Zilberstein, B., Marchi, E., Machado, R. B., Barchi, L. C., & Ricciardi, R. (2022). Nonoperative vs Operative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-analysis. JAMA surgery, 157(9), 828–834. https://doi.org/10.1001/jamasurg.2022.2937