Antibiotics versus surgery for uncomplicated acute appendicitis in adults: a meta-analysis of long-term outcomes and risk factors for failure
Salman, Mohamed AbdAlla Elewa, Ahmed Tourky, Mohamed Ali, Mahmoud Emechap, Evelyn Nkem Elserafy, Amr Salman, Ahmed
Salman, Mohamed AbdAlla
Elewa, Ahmed
Tourky, Mohamed
Ali, Mahmoud
Emechap, Evelyn Nkem
Elserafy, Amr
Salman, Ahmed
Affiliation
Cairo University; NHS Ayrshire; National Hepatology and Tropical Medicine Research Institute Cairo; Great Western Hospital NHS Foundation Trust; United Lincolnshire Teaching Hospitals NHS Trust; University Hospitals Birmingham NHS Foundation Trust
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Publication date
2025-12-15
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Abstract
Background: Acute uncomplicated appendicitis has traditionally been managed surgically, but recent trials suggest nonoperative treatment with antibiotics may be effective in selected adults. This meta-analysis compares long-term outcomes of antibiotics versus surgery and evaluates predictors of treatment failure, including the presence of an appendicolith.
Methods: We systematically searched MEDLINE, Embase, CENTRAL, and clinical trial registries up to July 2024. We included randomized controlled trials (RCTs) comparing antibiotics versus appendectomy in adults with imaging-confirmed uncomplicated appendicitis. The primary outcome was 1-year treatment success. Secondary outcomes included complication rates, recurrence, and subgroup analysis by appendicolith. A meta-regression explored the relationship between appendicolith prevalence and treatment failure.
Results: Seven RCTs (n=3164) were included. The 1-year treatment success rate was significantly lower in the antibiotics group (73.8%) versus surgery (98.1%) (RR 0.78, 95% CI: 0.73-0.84). Complication rates were comparable (RR 0.57, 95% CI: 0.29-1.12). Patients with appendicolith had a significantly higher failure rate (up to 46%). Meta-regression confirmed a positive correlation between appendicolith prevalence and antibiotic failure.
Conclusions: Antibiotics can be effective in selected patients, but recurrence and treatment failure remain concerns, particularly in the presence of appendicolith. Appendectomy remains the definitive treatment. This meta-analysis, including the most recent trials and a novel meta-regression, provides timely insights for shared decision-making.
Citation
Salman MA, Elewa A, Tourky M, Ali M, Emechap EN, Elserafy A, Salman A. Antibiotics Versus Surgery for Uncomplicated Acute Appendicitis in Adults: A Meta-analysis of Long-term Outcomes and Risk Factors for Failure. Surg Laparosc Endosc Percutan Tech. 2025 Dec 15. doi: 10.1097/SLE.0000000000001425. Epub ahead of print.
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