1. In 8 randomized controlled trials of nonoperative versus operative treatment of uncomplicated acute appendicitis, no significant differences in treatment success and frequency of adverse events were found.
2. Length of hospital stay and recurrent appendicitis were significantly higher in the operative group.
Level of Evidence Valuation: 1 (Excellent)
Study overview: Acute appendicitis is one of the most common etiologies of acute abdomen. Although it has traditionally been treated surgically, new evidence is emerging for nonoperative treatment of acute appendicitis in specific patient populations. Non-operative treatment consists of antibiotics and careful reassessment over time. This systematic review and meta-analysis summarizes recent cross-comparisons of surgical versus nonoperative treatment of uncomplicated acute appendicitis in adult patients.
This review includes a total of 8 studies 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 who received successful treatment after 30 days was not significantly different between surgical and non-surgical patients. No significant difference between the two groups was found in 6 of the 8 studies; in one trial, surgical patients did better and in another the antibiotic group did better. There was a high degree of heterogeneity between studies, as shown by the meta-analysis. There were no significant differences in the rate of adverse events reported in the 6 studies providing this data. Surgical treatment was associated with a significantly shorter hospital stay and a lower recurrence rate of appendicitis.
This systematic review and meta-analysis established that nonoperative treatment of acute appendicitis in adults may be a safe and effective alternative to surgery. Advantages of this work include the in-depth analysis of bias risk and weight of evidence when performing a meta-analysis of randomized controlled trials, although there was a remarkable degree of heterogeneity between the included trials. A limitation of this work was the small number of studies in which differentiating between different surgical techniques was not possible. Future work in this area should attempt to describe clinical decision-making tools to identify which patients are most likely to perform well with nonoperative treatment.
Click here to read this study in JAMA Surgery
Relevant reading: Rate of application and outcome of nonoperative treatment 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 treatment of acute, uncomplicated appendicitis in adults was performed. Patients who received any type of nonoperative antibiotic regimen and any type of surgical appendectomy were included. In particular, patients with complications, haemodynamic instability or appendicoliths were excluded. The risk of bias was assessed using standard methods described by the Cochrane Collaboration and the data were standardized by comparing the relative risk of each study. The primary outcome was treatment success at 30 days as defined by each individual study.
The relative risk for primary outcome between the surgery and antibiotic treatment groups was generally 0.85 (95% confidence interval 0.66-1.11). the me2 value indicating heterogeneity between trials was 85.9%. A subgroup forest plot based on the follow-up period of studies indicated a non-significant trend towards better long-term outcomes in the antibiotic group. Antibiotic use was associated with a trend towards less severe 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 a significantly shorter hospital stay: relative risk 1.48 (95% confidence interval 1.26-1.70). Finally, 4 out of 8 studies reported on the risk of recurrent appendicitis within variable time periods; the median risk of recurrence was 18% (range 7-29%) across several large studies. The overall risk of bias in the included studies appeared to be relatively low.
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