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Operation versus antibiotics––The “appendicitis conundrum” continues: A meta-analysis

Sakran, Joseph V. MD, MPH, MPA; Mylonas, Konstantinos S. MD; Gryparis, Alexandros PhD; Stawicki, Stanislaw P. MD, MBA; Burns, Christopher J. MD; Matar, Maher M. MD; Economopoulos, Konstantinos P. MD, PhD

Journal of Trauma and Acute Care Surgery: June 2017 - Volume 82 - Issue 6 - p 1129–1137
doi: 10.1097/TA.0000000000001450
Review Articles
EAST Journal Club

Background Acute appendicitis continues to constitute a diagnostic and therapeutic challenge. The aim of this study was to synthesize evidence from randomized controlled trials (RCTs) comparing nonoperative versus surgical management of uncomplicated acute appendicitis in adult patients.

Methods A systematic literature search of the PubMed, Cochrane, and Scopus databases was performed with respect to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement (end-of-search date: January 29, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. The random-effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when substantial heterogeneity was encountered; otherwise, the fixed-effects (Mantel-Haenszel) model was implemented. Quality assessment of included RCTs was performed using the modified Jadad scale.

Results Five RCTs were included in this review. Overall, 1,430 adult patients with uncomplicated acute appendicitis underwent either nonoperative (n = 727) or operative management (n = 703). Treatment efficacy at 1-year follow-up was significantly lower (63.8%) for antibiotics compared with the surgery group (93%) (risk ratio [RR], 0.68; 95% confidence interval [CI], 0.60–0.77; p < 0.001). Overall complications were significantly higher in the surgery group (166/703 [23.6%]) compared with the antibiotics group (56/727 [7.7%]) (RR, 0.32; 95% CI, 0.24–0.43; p < 0.001). No difference was found between the two treatment modalities in terms of perforated appendicitis rates (RR, 0.52; 95% CI, 0.14–1.92), length of hospital stay (weighted mean difference [WMD], 0.20; 95% CI, −0.16 to 0.56), duration of pain (WMD, 0.22; 95% CI, −5.30 to −5.73), and sick leave (WMD, −2; 95% CI, −5.2 to 1.1).

Conclusions Conservative management of uncomplicated appendicitis in adults warrants further study. Addressing patients’ expectations via a shared decision-making process is a crucial step in optimizing nonoperative outcomes.

LEVEL OF EVIDENCE Systematic review, level II.

Supplemental digital content is available in the text.

From the Department of Surgery (J.V.S.), Johns Hopkins University, Baltimore, Maryland; Surgery Working Group (K.S.M., K.P.E.), Society of Junior Doctors, Athens, Greece; Division of Pediatric Surgery, Department of Surgery (K.S.M.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Institute of Preventive Medicine, Environmental & Occupational Health (A.G.), Prolepsis, Athens, Greece; Department of Hygiene, Epidemiology and Medical Statistics (A.G.), Medical School, National and Kapodistrian University of Athens, Athens, Greece; Department of Research & Innovation (S.P.S.), St Luke's University Health Network, Bethlehem, Pennsylvania; Department of Surgery (C.J.B.), Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery (M.M.M.), Medical University of South Carolina, Charleston, South Carolina; and Department of Surgery (K.P.E.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Submitted: October 29, 2016, Revised: February 4, 2017, Accepted: February 27, 2017, Published online: March 23, 2017.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Website (

Address for reprints: Joseph V. Sakran, MD, MPH, MPA, Department of Surgery, Johns Hopkins University, The Johns Hopkins Hospital, 1800 Orleans Drive, Sheikh Zayed Tower, Suite 6107B Baltimore, MD 21287; email:

© 2017 Lippincott Williams & Wilkins, Inc.