#VisualAbstract: Nonoperative management of uncomplicated acute appendicitis comparable to appendectomy but leads to increased length of stay and disease recurrence

1. No significant differences in treatment success and rate of adverse events were detected in 8 randomized controlled trials of nonoperative versus operative management of uncomplicated acute appendicitis.

2. Length of stay in hospital and recurrent appendicitis were significantly higher in the operative group.

Level of Evidence Rating: 1 (Excellent)

Study Rundown: Acute appendicitis is one of the most common etiologies of acute abdomen. Although it is traditionally treated operatively, new evidence for nonoperative management of acute appendicitis in specific patient populations is emerging. Nonoperative management consists of antibiotics and careful reassessment over time. This systematic review and meta-analysis summarizes recent head-to-head comparisons of surgical versus nonoperative management of uncomplicated acute appendicitis in adult patients.

A total of 8 studies were included in this review from an original search yield of 1504 studies; the most common reasons for exclusion were study design or patient age. The overall percentage of patients experiencing successful treatment at 30 days was not significantly different between surgical and nonsurgical patients. In 6 of 8 trials, no significant difference between the two groups was found; in one trial, surgical patients did better and in another the antibiotic group did better. There was a high degree of heterogeneity amongst the studies as determined by the meta-analysis. There were no significant differences in rates of adverse events reported in the 6 trials which provided this data. Surgical treatment was associated with significantly shorter length of hospital stay as well as lower recurrence rate of appendicitis.

This systematic review and meta-analysis determined that nonoperative management of acute appendicitis in adults can be a safe and effective alternative to surgery. Advantages of this work include the thorough analysis of risk of bias and the strength of evidence in performing a meta-analysis of randomized controlled trials, although there was a notable degree of heterogeneity amongst the included trials. A limitation of this work was the small number of studies which disallowed for discrimination between different surgical techniques. Future work in this area should seek to describe clinical decision-making tools to identify which patients are most likely to do well with nonoperative management.

Click here to read this study in JAMA Surgery

Relevant reading: Rate of application and outcome of non-operative management of acute appendicitis in the setting of COVID-19: a systematic review and meta-analysis

In Depth [systematic review & meta-analysis]: A systematic review and meta-analysis of randomized controlled trials evaluating operative versus nonoperative management of acute, uncomplicated appendicitis in adults was performed. Patients receiving any type of nonoperative antibiotic regime, and any type of surgical appendectomy were included. Notably, patients with complications, hemodynamic instability or appendicoliths were excluded. Risk of bias was assessed using standard methods described by the Cochrane Collaboration and data was standardized by comparing relative risk across each trial. The primary outcome was treatment success at 30 days, as defined by each individual trial.

The relative risk for the primary outcome between the surgery and antibiotic treatment groups was 0.85 (95% confidence interval 0.66-1.11) overall. The I2 value indicating heterogeneity between trials was 85.9%. A subgroup forest plot based on studies’ follow up period indicated a nonsignificant trend towards better long-term outcomes in the antibiotic group. Antibiotic use was associated with a trend towards fewer major adverse events within 30 days, although this was not statistically significant; the relative risk was 0.72 (95% confidence interval 0.29-1.79).

Surgical treatment was associated with significantly shorter length of stay in hospital: relative risk 1.48 (95% confidence interval 1.26-1.70). Finally, 4 of 8 studies reported on risk of recurrent appendicitis within variable time periods; the median risk of recurrence was 18% (range 7-29%) amongst several large trials. Overall risk of bias amongst the included studies was found to be relatively low.

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