Non-operative management of uncomplicated acute appendicitis which is comparable to appendectomy but results in increased length of stay and disease recurrence.

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

2. Duration of hospital stay and recurrent appendicitis was significantly higher in the surgical group.

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Study rundown: Acute appendicitis is one of the most common causes of an acute abdomen. Although it is conventionally treated surgically, there is new evidence for the non-operative management of acute appendicitis in specific patient populations. Nonsurgical management consists of antibiotics and careful reassessment over time. This systematic review and meta-analysis summarize recent comparisons between surgical versus nonsurgical management of acute uncomplicated appendicitis in adult patients.

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

This systematic review and meta-analysis determined that non-operative management of acute appendicitis in adults could be a safe and effective alternative to surgery. Advantages of this work include comprehensive analysis of risk of bias and strength of evidence in performing a meta-analysis of randomized controlled trials, although there is a notable degree of heterogeneity between the included trials. A limitation of this work was the small number of studies that did not allow a distinction between different surgical techniques. Future work in this field should seek to describe clinical decision-making tools to identify patients who are most likely to do well with nonsurgical management.

Click here to read this study at JAMA Surgery

Related reading: Application rate and outcome of the 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 the surgical versus non-operative management of uncomplicated acute appendicitis in adults was performed. Patients receiving any type of non-surgical antibiotic regimen and any type of surgical appendectomy were included. Notably, patients with complications and hemodynamic instability or appendicitis were excluded. Risk of bias was assessed using standard methods described by the Cochrane Collaboration and data were standardized by comparing relative risks across each trial. The primary outcome was treatment success at 30 days, as determined in each individual trial.

The relative risk for primary outcome between the surgery and antibiotic treatment groups was 0.85 (95% confidence interval 0.66–1.11) overall. I2 The value indicating heterogeneity between trials was 85.9%. A sub-forest plot based on the studies’ follow-up period indicated a non-significant trend toward 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% CI 0.29-1.79).

Surgical treatment was associated with a significantly shorter hospital stay: RR 1.48 (95% CI 1.26–1.70). Finally, 4 of 8 studies reported a risk of recurrent appendicitis over variable time periods. The median risk of recurrence was 18% (range 7-29%) among several large trials. The general risk of bias among the included studies was found to be relatively low.

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