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

The findings are based on a systematic review and meta-analysis of 8 randomized clinical trials. The primary outcome was treatment success at 30 days (or the longest period of follow-up when different time points were reported) as defined in the individual trials, which included resolution of abdominal pain, no 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%) was found with nonoperative management. Thus, Rocco Ricciardi, MD, MPH, of Massachusetts General Hospital, and colleagues conducted this study to examine whether outcomes of antibiotic treatment are comparable with that of appendectomy in adult patients with uncomplicated appendicitis. 

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Treatment Success With Antibiotics vs Appendectomy

The overall risk ratio (RR) for the percentage of successful treatment for appendicitis 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 that antibiotic treatment was superior to appendectomy.

Major Adverse Effects

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

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

In a meta-analysis of findings from the 3 trials that reported total hospital length of stay, operative 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 promising outcomes with nonoperative management of acute appendicitis, nearly 1 of 5 patients treated nonoperatively in this review eventually experienced recurrent appendicitis symptoms,” the researchers noted.

They also emphasized the need to consider local infrastructure conditions when selecting antibiotic treatment and for close monitoring of patients using serial physical examinations and round-the-clock availability of imaging, interventional radiology, laboratory testing, and rehospitalization, as well as the flexibility to change treatment approach if needed.


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